Wound care protocol-primary care provider

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 Initiate the plan of care for the wound as per NE CCAC Wound Care Protocol & Integrated Clinical Pathways



Note: All wound categories require an appropriate cover dressing; foam is suggested unless stated otherwise. Gauze is also an acceptable cover dressing, where appropriate.

  1. Principles of wound bed preparation MUST be adhered to:

    1. Debridement of dead tissue, except in dry diabetic gangrene and ischemia. Proper equipment and training for debridement are ESSENTIAL for professionals treating wounds.

    2. Moisture balance.

    3. Bacterial balance: Infected wounds require antimicrobial products for localized infection and antibiotics for systemic infections.

  2. All dressing are to be done using aseptic technique.

  3. All diabetic wounds require antimicrobial products.

  4. Optimize wound health by attention to nutrition, blood supply avoiding smoking, offloading pressure, pain control, etc. (Treat the whole person)

  5. Diagnose etiology of wound-May be multifactorial, e.g. traumatic, diabetic and/or ischemic.

Clinical Pathways



Select Desired Pathway :

 Diabetic Foot Ulcer

 Surgical Wound

 Pressure Ulcer

 Venous Leg Ulcer

 Chronic Maintenance Wound

 Infected Surgical Wound

 Pilonidal Sinus/Incision & Drainage

 Trauma Wound

*Integrated Clinical Pathways (ICPs) can be found on the CCAC portal.
 Atypical wound

Frequency of visits and treatment products may change at the discretion of the nurse or wound care therapist, as per clinical assessment, in accordance with the ICPs. Treatment will be taught to the patient/caregiver when appropriate.

The following wound descriptors can be used to select the appropriate dressing protocols. If no selection is made, the nurse will initiate the plan of care as per ICPs and communicate on the status of the wound to the primary care provider:

Superficial Granulating Wound

Minimum Exudate:

Moderate to Severe Exudate:

 Hydrocolloid Full Thickness (Every 3-7 days)

 Hydrogel + Jelonet/Adaptic (Every 3 days)

 Hydrofibre (Every 3-7 days)

 Foam Dressing (Every 3-7 days)

Cavity Wound

Minimum exudate

Moderate to Severe exudate

 PHMB  Ribbon  Gauze  Kerlix Roll(Every 3 days)

 Hydrogel + Jelonet/Adaptic + Appropriate Gauze Packing

(Every 2-3 days)

 Hydrofibre/Calcium Alginate (Every 3-7 days)

 Foam Cover Dressing (Every 3-7 days)

Burn Wound

 Nanocrystalline Silver (Every 3 days)

 Hydrofibre with Silver - Change cover dressing and non-adhered hydrofibre (Every 3-5 days)

 Calcium Alginate with Silver – Change cover dressing and non-adhered alginate (Every 3-5 days)

 Flamazine - Requires Physician Rx (Twice a day)

 Burns to face – Polysporin (Patient to apply Three times a day)

Chronic Non-healing Wound

(Exclude: cancer, foreign bodies, granulomatous diseases, fungi)

 Hydrofibre with silver (Every 3-7 days)

 PHMB  Ribbon  Gauze  Kerlix Roll (Every 3 days)

 Cadexomer Iodine – e.g. Iodosorb + Gauze (Every 3 days)

 Delayed release Iodine dressing (Inadine) (Every 3 days)

 Silver (Every 3-7 days); Specify type:      

Pressure Ulcer

See Infected wound, Cavity Wound, or Superficial Wound.

INITIALS:       DATE:      

Infected Wound

 Cadexomer Iodine dressing – e.g. Iodosorb (Every 3 days)

 Delayed release Iodine dressing (Inadine) (Every 3 days)

 Hydrogel with Silver (Every 2-3days)

 Hydrofibre with silver (Every 3-7 days)

 Calcium Alginate with silver (Every 3 days)

 PHMB  Ribbon  Gauze  Kerlix Roll (Every 3 days)

 Gentian Violet + Methylene Blue (Hydrofera Blue) (Every 3-7 days)

 Pseudomonas infection: acetic acid (vinegar) 2.5% (5% diluted 1:1 with saline or water) Soaked gauze BID x5 days, then revert to appropriate dressing for infected wound.


 Textile with Silver- Interdry Ag in Skin folds- can be hand-washed, hung to dry and reused, if appropriate, apply as the sole product (ie. No creams or ointments)

 PHMB  Ribbon  Gauze  Kerlix Roll (Antimicrobial dressing - apply dry as the sole product – Every 3 days)

Venous Stasis Ulcer

(ABPI or vascular study required prior to initial treatment, ABPI may not be accurate in diabetic and renal patients – Vascular studies required, and patients must be followed by wound care specialist.)

Compression is the cornerstone of treatment; Life long compression is necessary once ulcers heal.

 Compression bandage – Coban II if ABPI 0.8-1.2 Coban lite if ABPI is <0.8 but >0.5

 Elastic tubular bandage (Surgigrip) toes to knee if ABI 0.6-0.8

-If exudative:

 Calcium Alginate with silver

 Hydrofiber with Silver

 PHMB  Ribbon  Gauze Kerlix Roll

 Cadexomer Iodine
Change dressing weekly unless strikethrough/slipping of the bandage.


Moderate to heavily exudating wounds

All must be referred to local specialist or wound clinic

Wound dressing

-- Size Small Medium  Large

-- Filler  White Foam  Black Foam


-Every 3 days (cannot be left in place longer than 3 days. If VAC malfunctions, must be assessed immediately or changed to conventional dressing if VAC is not available at that time)

 Priority case

 High exudate

 Necrotizing fasciitis

 Orthopedic with hardware


Light to moderate exudating wounds

Wound dressing

-- Size Small Medium  Large

-- Filler:      

-Change maximum twice per week

Necrotic Wound

- If Eschar is loose, remove or trim Loose eschar only

 Hydrogel for autolytic debridement (CONTRAINDICATED IN ISCHEMIC WOUNDS. Vascular assessment necessary. Sharp debridement is CONTRAINDICATED without vascular assessment)

 Cadexomer Iodine (Iodosorb) at the margins of dry eschar

 Dry ischemic wounds: Paint with Betadine solution daily, cover with dry gauze PRN



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