Does the wound need cleansing? 

• Only cleanse if there is visible debris on the wound bed that needs removed. 
• Use warm potable tap water or warmed sterile solutions if immunocompromised such as saline 0.9%.
• PHMB if infected, colonised. 

• Document type of wound, location, duration. Measure wound length, width, depth and undermining and tracking as applicable. 

• Document peri-wound skin condition, pain or any clinical signs of infection. 
• Do not estimate. 
• Use a scale such as: 
  • tracing, disposable ruler for length and/or width 
  • wound swab stick, wound probe for depth and/or undermining  
  • wound photography with appropriate consent

A. What tissue type and levels of exudate does the wound have? 

• Dressing choice must accommodate tissue type, exudate level, odour, expected wear time, peri-wound skin, area to be dressed, pain at dressing change and patient/client need. 
• Consider intrinsic and extrinsic factors also – past medical history, age, and cognitive ability.  

B. Select secondary dressing if required. 

• See Step 3A above.

Document in wound chart

A wound chart must be completed for every patient/client with a wound. 

Points to remember: 

• Know the action and possible side effects of any dressing you apply. 
• Know how to apply and remove any dressing correctly, eg safe and atraumatic removal of all dressings. 
• Know how long a dressing can stay in place and indication(s) for dressing change. 
• Do not mix different primary and secondary types of dressings together, eg hydrogel and hydrofibre. 
• Select a dressing that is the correct size for the wound. A dressing that is too big or too small can be detrimental to the wound. 
• Remove old packing from the wound, apply any new packing loosely leaving tail(s) at the entrance and record the number of pieces of packing inserted within the wound care plan. 
• Use barrier skin preparations as appropriate for any damaged peri-wound skin or if needed as preventative measure. 
• For chronic or infected wounds refer to  
  • Algorithm for Assessment and Management of Chronic Wounds 
  • Scottish Ropper Ladder for Infected Wounds 

• If in doubt seek advice from appropriate healthcare professional, ie tissue viability nurse, dermatology nurse, podiatrist. 

© Healthcare Improvement Scotland 2021 

Published February 2021 

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