Clinical Guidelines (Nursing)

Wound care

  • Note: This guideline is currently under review.  


    The skin is the largest organ of the body, making up 16% of body weight. It has several vital functions, which include; immune function, temperature regulation, sensation and vitamin production. Skin is a dynamic organ in a constant state of change; cells of the outer layers continuously shed and are replaced by inner cells moving to the surface. These guidelines have been developed by a range of clinicians who treat children with skin disorders, breakdowns and wounds; they reflect current research and evidence based expert opinion.


      These guidelines are intended for use as a resource for wound management and should be available to all members of the healthcare team involved in the assessment, treatment and ongoing management of wounds throughout the Royal Children's Hospital. The guidelines are not a substitute for professional judgement but should support clinical decision making in relation to the assessment and management of wounds, in line with individual professional competence.

      Definition of Terms

      Acute Wound:is the result of tissue damaged by trauma. This may be deliberate, as in surgical wounds of procedures, or be due to accidents caused by blunt force, projectiles, heat, electricity, chemicals or friction. An acute wound is by definition expected to progress through the phases of normal healing, resulting in the closure of the wound.  

      A Chronic Woundfails to progress or respond to treatment over the normal expected healing time frame (4 weeks) and becomes "stuck" in the inflammatory phase. Wound chronicity is attributed to the presence of intrinsic and extrinsic factors including medications, poor nutrition, co-morbidities or inappropriate dressing selection

      Epidermis: Is the outer layer of the skin.

      • comprised of epithelial cells
      • avascular
      • 0.04mm thick
      • regenerated every 2-4weeks, subject to an individual's age and friction forces applied to the skin
      • receives nutrients from the dermis below
      • comprised of 4 to 5 layers depending on the body location

      Dermis: Is the middle layer of the skin and is approximately 0.5mm thick subject to anatomical site

      • made up of two layers
      • is very vascular
      • contains nerves, connective tissue, collagen, elastin and specialized cells such as fibroblasts and mast cells
      • responsible for inflammatory reactions which occur in response to trauma and infection
      • receptors for heat, cold, pain, pressure, itch and tickle

      Hypodermis: Is the inner most layer of the skin and is referred to as the subcutaneous layer

      • supports the dermis and epidermis
      • varies in thickness and depth
      • comprised of adipose tissue, connective tissue and blood vessels
      • the function is to store lipids, protect underlying organs, provide insulation and regulate temperature

      Skin Appendages: Includes Sweat glands, hair, nails and sebaceous glands which are all considered epidermal appendages.

      Figure 1 – Layers of the Skin

      2013 Wound care


      All patients with wounds will have their wounds appropriately assessed by nursing staff within 24hours of recognition with timely referrals to stomal therapy where appropriate.

      Documentation of wound assessment and management should be completed under the ‘Flowsheet’ activity, utilising the ‘LDA tab’ (Lines, Drains, Airway and Wound tab). Click on the ‘Add New LDA’ button to search for the correct wound type e.g. Burn, Surgical Incision, Flap/Digit Reimplant. 

      See Clinical Guideline (Nursing): Nursing Assessment for more detailed assessment information.


      Considerations for assessment

      Wound Bed
      • Granulating: healthy red tissue which is deposited during the repair process, presents as pinkish/red coloured moist tissue and comprises of newly formed collagen, elastin and capillary networks. The tissue is well vascularised and bleeds easily
      • Epithelializing: process by which the wound surface is covered by new epithelium, this begins when the wound has filled with granulation tissue. The tissue is pink, almost white, and only occurs on top of healthy granulation tissue
      • Sloughy: the presence of devitalized yellowish tissue. Is formed by an accumulation of dead cells. Must not be confused with pus
      • Necrotic: wound containing dead tissue. It may appear hard dry and black. Dead connective tissue may appear grey. The presence of dead tissue in a wound prevents healing
      • Hypergranulating; granulation tissue grows above the wound margin. This occurs when the proliferative phase of healing is prolonged usually as a result of bacterial imbalance or irritant forces
      Wound Measurement
      • 'Assessment and evaluation of the healing rate and treatment modalities are important components of wound care. All wounds require a two-dimensional assessment of the wound opening and a three- dimensional assessment of any cavity or tracking' (Carville, K. 2007)
      • Two-dimensional measures- use a paper tape to measure the length and width in millimetres. The circumference of the wound is traced if the wound edges are not even - often required for chronic wounds. (You may also consider photography)
      • Three -dimensional measures- the wound depth is measured using a dampened cotton tip applicator
      Wound Edges
      • Healthy wound edges present as advancing pink epithelium growing over mature granulated tissue.
        • Colour - pink edges indicate growth of new tissue; dusky edges indicate hypoxia; and erythema indicates physiological inflammatory response or cellulitis
        • Raised - wound edges (where the wound margin is elevated above the surrounding tissue) may indicate pressure, trauma or malignant changes
        • Rolled -wound edges (rolled down towards the wound bed) may indicate wound stagnation or wound chronicity
        • Contraction -    wound edges are coming together, signs of healing
        • Sensation - increased pain or the absence of sensation should be noted 
      • Is produced by all acute and chronic wounds (to a greater or lesser extent) as part of the natural healing process. It plays an essential part in the healing process in that it:
        • Contains nutrients, energy and growth factors for metabolising cells
        • Contains high quantities of white blood cells
        • Cleanses the wound
        • Maintains a moist environment
        • Promotes epithelialisation
      • It is important to asses and document the type, amount and odour of exudate to identify any changes.
      • Too much exudate leads to maceration and degradation of skin while too little can result in the wound bed drying out. It may become more viscous and odorous in infected wounds.
      • The exudate may be:
       Type  Colour Consistency   Significance
       Serous  Clear, straw coloured Thin, watery   Normal. An increase may be indicative of infection
       Haemoserous  Clear, pink Thin, watery   Normal
       Sanguinous  Red Thin, watery   Trauma to blood vessels


       Yellow, grey, green


       Infection. Contains pyogenic organisms and other inflammatory cells


      • Wound infection may be defined as the presence of bacteria or other organisms, which lead to a host reaction. A host reaction can present with one or a combination of the following local and systemic clinical indicators:
      • Local indicators
        • Redness (erythema or cellulitis) around the wound
        • Increased amounts of exudate
        • Change in exudates colour
        • Malodour
        • Localised pain
        • Localised heat
        • Delayed or abnormal healing
        • Wound breakdown
      • Systemic indicators
        • Increased systemic temperature
        • General malaise
        • Increased leucocyte count
        • Lymphangitis
      • If any of the above clinical indicators are present medical review should be instigated and an Microscopy & Culture Wound Swab (MCS) should be considered 
      Surrounding Skin
      • Surrounding tissue may present as
        • Healthy
        • Macerated
        • Dry/flaky
        • Eczematous
        • Black/blue discoloration
        • Fragile
        • Oedema
        • Erythema
        • Induration (hardening)
        • Cellulitis
      • The surrounding skin should be examined carefully as part of the process of assessment and appropriate action taken
      • The pain associated with chronic wounds can be underestimated. It is important that pain scores are captured accurately and regularly to ensure
        • patients have a more active role in dealing with their pain
        • effective pain relief can be provided
        • documented evidence of pain patterns are captured
      • Numerous pain assessment tools are used throughout the RCH:
        • Wong Baker faces - used in most inpatient areas
        • FLACC Scale - either used in isolation or in conjunction with Wong Baker faces
        • Neonatal Pain Assessment  tool
        • Comfort B - used only in PICU
      • Pain scores should be clearly documented in the ViCTOR charts
      • Accurate assessment of pain is essential with regard to choice of the most appropriate dressing. Assessment of pain before, during and after the dressing change may provide vital information for further wound management
      • (Exceptions: patients with peripheral neuropathy who may have reduced sensation.)

      Factors Delaying Wound Healing

      Holistic assessment of the patient is an important part of the wound care process. A number of local and systemic factors can delay or impair wound healing. These may include:

      • Malnutrition- inadequate supply of protein, carbohydrates, fatty acids, and trace elements essential for all phases of wound healing
      • Reduced Blood supply - Cardiovascular disorders and Ischaemia
      • Medication - Non-steroidal anti inflammatory drugs and Corticosteroids.
      • Chemotherapy - suppresses the immune system and inflammatory response
      • Radiotherapy - increases production of free radical which damage cells
      • Psychological stress and lack of sleep- increase risk of infection and delayed healing
      • Obesity - decreases tissue perfusion
      • Infection -prolong inflammatory phase, use vital nutrients, impair epithelialisation and release toxins
      • Reduced wound temperature - prolonged dressing changes or use of cold cleansing products.
      • Underlying Disease - Diabetes Mellitis and Autoimmune disorders
      • Maceration - excess wound exudates or contact with bodily fluids reduces wound tensile strength
      • Inappropriate wound management
      • Patient compliance
      • Unrelieved pressure
      • Immobility
      • Substance abuse including alcohol and cigarette smoke

      Types of Wounds throughout RCH 

      Acute Surgical Wounds 

      A clean cut with a sharp instrument which cuts or punctures the skin deliberately during a surgical procedure. Acute surgical wounds normally proceed through an orderly and timely reparative process resulting in sustained restoration of anatomic and functional integrity. If an acute wound fails to heal within six weeks, it can become a chronic wound.

      Trauma Wounds

      A stressful event caused by either a mechanical or a chemical injury resulting in tissue damage. Depending on its level, trauma can have serious short-term and long-term consequences.


      Injuries to tissues caused by heat, friction, electricity, radiation, or chemicals. Burns may be caused by even a brief encounter with heat greater than 120°F (49°C). The source of this heat may be the sun , hot liquids, steam, fire, electricity, friction (causing rug burns and rope burns), and chemicals (causing a caustic burn upon contact).

      Chronic Wounds

      Fail to heal in an orderly and timely manner. The chronic wound environment is different to the acute wound environment. The clinical signs of chronic wounds may include:

      • Non viable wound tissue (slough and/or necrosis)
      • Lack of healthy granulation tissue (wound tissue may bepale, greyish and avascular)
      • No reduction in wound size over time
      • Recurrent wound breakdown
      Pressure Injuries 

      A localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear and/or friction, or a combination of these factors.

      Infected Wounds

      Invasion of wound tissue by and multiplication of pathogenic microorganisms, which may produce subsequent tissue injury and progress to overt disease through a variety of cellular or toxic mechanisms

      Level of bacterial impairment  Bacterial activity  Clinical signs
      Contaminiation Bacteria are on the wound surface. No division is occurring 

      No impairment to healing
      No obvious clinical signs of infection

      Colonisation Bacteria are dividing No impairment to healing
      No obvious clinical signs of infection
      Topical infection
      (Critical colonisation)
      Bacteria are dividing and have invaded the wound surface
      There may be an increasing variety of bacteria present
      Biofilm may be present
      Impairment to healing
      Clinical signs of infection may not be obvious or are subtle; dull wound tissue, absence of vibrant granulation tissue, slough, hypergranulation, rolled or raised wound edges
      Local infection Bacteria and / or their products have invaded the local tissue Impairment to healing
      Usually obvious signs of infection localised to the wound environment; wound breakdown, increase in size, erythema, increased pain, purulent or discoloured exudate, malodour and increased temperature at wound site
      Regional / Spreading infection / Cellulitis Bacteria and / or their products have invaded the surrounding tissue Impairment to healing
      Usually obvious signs of infection. May have systemic signs; spreading erythema (more than 2cm from wound edge), induration of regional tissue, fever, oedema of regional tissue, malaise and/or general feeling of unwellness
      Sepsis Bacteria and / or their products have entered the blood stream and may have spread to distant sites or organs Impairment to healing
      Usually obvoius systemic clinical signs; patient acutely unwell, damage to organs may occur, high fever, lymphangitis and regional lymphadenopathy, organ compromise or failure and possibly circulatory shock (including hypotension, tachypnoea, tachcardia) 



      Phases of Wound Healing to consider

      • Phase 1 - INFLAMMATORY PHASE (0-3 Days) the body's normal response to injury. This phase activates vasodilatation leading to increased blood flow causing HEAT, REDNESS, PAIN, SWELLING, LOSS OF FUNCTION (e.g. arm swells and cannot bend). Wound ooze may be present and this is also a normal body response.
      • Phase 2 - PROLIFERATIVE PHASE (3-24 Days) the time when the wound is healing. The body makes new blood vessels, which cover the surface of the wound. This phase includes reconstruction and epithelialisation. The wound will become smaller as it heals.
      • Phase 3 - MATURATION PHASE (24-365 Days) the final phase of healing, when scar tissue is formed. The wound at this stage is still at risk and should be protected where possible.

      Mechanisms of wound healing to consider

      • Primary Intention; most clean surgical wounds and recent traumatic injuries are managed by primary closure. The edges of the wounds are approximated with steri strips, glue, sutures and/or staples. Minimal loss of tissue and scarring results.
      • Delayed Primary Intention; is defined as the surgical closure of a wound 3 -5 days after the thorough cleansing or debridement of the wound bed. Used for 1. Traumatic wounds, 2. Contaminated surgical wounds.
      • Secondary intention; occurs slowly by granulation, contraction and re-epithelialisation and results in scar formation. Commonly used for 1. Pressure Injuries 2. Leg ulcers 3. Dehisced wounds
      • Skin Graft; removal of partial or full thickness segment of epidermis and dermis from its blood supply and transplanting it to another site to speed up healing and reduce the risk of infection.
      • Flap; is a surgical relocation of skin and underlying structures to repair a wound

      Acute Management


      It is an expectation that all aspects of care, including assessment, treatment and management plans, implementation and evaluation are documented clearly and comprehensively.

      All wounds should be assessed regularly and outcomes of the assessment docuemented. Documentation of wound assessment and management should be completed under the ‘flowsheet’ activity, utilising the ‘LDA tab’ (Lines, Drains, Airway and Wound tab). Click on the ‘Add New LDA’ button to search for the correct wound type e.g. Burn, Surgical Incision, Flap/Digit Reimplant. The ‘LDA’ tab can be used to monitor and record progress of the wound through its stages of healing. Wound care and dressing changes can also be ordered/preplanned utilising the ‘Orders’ activity. 

      Wound cleansing

      Requires the application of fluid to clean the wound and optimise the healing environment.

      The goal of wound cleansing is to:

      • Remove visible debris and devitalised tissue
      • Remove dressing residue
      • Remove excessive or dry crusting exudates


      • Use Aseptic Technique procedure
      • Wound cleansing should not be undertaken to remove 'normal' exudate
      • Cleansing should be performed in a way that minimises trauma to the wound
      • Wounds are best cleansed with sterile isotonic saline or water
      • The less we disturb a wound during dressing changes the lower the interference to healing
      • Fluids should be warmed to 37°C to support cellular activity
      • Skin and wound cleansers should have a neutral pH and be non-toxic
      • Avoid alkaline soap on intact skin as the skin pH is altered, resistance to bacteria decreases
      • Avoid delipidising agents as alcohol or acetone as tissue is degraded
      • Antisepticsare not routinely recommended for cleansing and should only be used sparingly for infected wounds


      • Irrigation is the preferred method for cleansing open wounds. This may be carried out utilising a syringe in order to produce gentle pressure - in order to loosen debris. Gauze swabs and cotton wool should be used with caution as can cause mechanical damage to new tissue and the shedding of fibres from gauze swabs/cotton wool delays healing.  
      Choiceof dressing

      Awound will require different management and treatment at various stages of healing. No dressing is suitable for all wounds; therefore frequent assessment of the wound is required. Considerations when choosing dressing products -

      • Maintain a moist environment at the wound/dressing interface
      • Be able to control (remove) excess exudates. A moist wound environment is good, a wet environment is not beneficial
      • Not stick to the wound, shed fibres or cause trauma to the wound or surrounding tissue   on removal
      • Protect the wound from the outside environment - bacterial barrier
      • Good adhesion to skin
      • Sterile
      • Aid debridement if there is necrotic or sloughy tissue in the wound (caution with ischaemic lesions)
      • Keep the wound close to normal body temperature
      • Conformable to body parts and doesn't interfere with body function
      • Be cost-effective
      • Diabetes - choose dressings which allow frequent inspection
      • Non-flammable and non-toxic
       Dry wound  Minimal exudate  Moderate exudate  Heavy exudate
       Non adherent island dressing Hydrogel   Calcium alginate  Hydrofibre
       Hydrocolloid  Hydrocolloid  Hydrofibre Foam 
       Films semi permeable Silicone absorbent   Foams  Absorbent dressing
           Negative Pressure  Negative pressure wound therapy
           Hydrocolloid: paste/powder  Ostomy bags

      Wound Dressings - Quick Reference Guide

      Refer to the Dressing Choices Table for a more comprehensive guide to assist you in your decision making

      Dressings can be catagorized into four types:

      1. Primary dressing: is one that comes directly in contact with the wound bed
      2. Secondary dressing:is used to cover a primary dressing when the primary dressing does not protect the wound from contamination
      3. Occlusive dressing: covers a wound from the outside environment and keep nearly all wound vapors at the wound site
      4. Semi-occlusive dressing: allows some oxygen and moisture vapour to evaporate
      Management recommendations for specific wound types - throughout RCH

      Ongoing management

      Management of complications and troubleshooting

      Inappropriate management of wounds can lead to delayed healing, deterioration of wounds and wound breakdown. Wounds should be carefully reassessed with every dressing change to ensure the most appropriate products are used. If unsure refer to a more experienced member of your team or refer to the stomal therapist. Stomal therapy referrals can be made by paging the Stomal therapy team on 5338; Stomal therapists are available during business hours Monday to Friday.

      Discharge planning and community-based management

      Provide parents/carers with appropriate discharge information. Please click here for the fact sheet on wound care.

      Parents and carers should be given a plan for the ongoing management of the wound at home with the appropriate dressing products prescribed. Dressings can be obtained from the Equipment Distribution Centre : EDC Home or a preferred pharmacy. 

      If required, a patient can be referred to the Nurse Led Outpatient Clinic which is available to provide nursing services to patients post admission or as ongoing outpatients and can include wound care as requested by medical or nursing staff. Patients are firstly reviewed in clinic times and if additional dressings are required this is coordinated with nursing staff. Please complete a referral form for suitable patients, Nurse led Outpatient Clinic Referral Form.

      Referrals to RCH @ Home should be considered when the wound requires ongoing assessment and management. RCH @ Home can source outside providers for patients who live in rural settings.  To make a referral complete the RCH HIP Services Referral and contact the intake liaison officer on extension 5674.

      For those patients requiring a one off check or review, follow up with their regular General Practitioner (GP) should be encouraged.

      For complex wounds follow up appointments with Stomal Therapy should also be organized for one week following discharge. Stomal Therapy should already be involved with these patients.

      Special Considerations

      For patients with impaired nutritional status a dietitian referral should be considered.

      Companion Documents



      • Australian Wound Management Association Inc. (August 2011). Bacterial impact on wound healing: From contamination to infection. Position Paper, Version 2.
      • Ashton J, Morton N, Beswick S, Barker V, Blackburn F, Wright C, Turner L, Morton K, Jennings A. BoltonNHS - Primary Care Trust. (March 2008) "Wound care Guidelines"
      • Butler. C. T. (2006) Paediatric Skin care: Guidelines for Assessment, prevention and Treatment. Paediatric Nursing, 32(5), 443-450.
      • Carville K, Keaton J, Rayner R, Prentice JL & Santamaria N. 'Wounds West education: taking the evidence on wounds to the clinician". (August 2009) Wound Practice and Research. Volume 17 Number 3 Pages 114 - 120
      • Cooper, C. L., & Nolt, J. D. (2007). Development of an evidence-based paediatric fall prevention program. Journal of Nursing Care Quality, 22(2), 107-112
      • Dunk AM & Taylor J."A survey of clinicians' perceptions of, and product choices for, the infected wound" (February 2009) Wound practice and Research. Volume 17 Number 1. Page 5-11
      • Derbyshire A."Innovative solutions to daily challenges". (September 2010) British Journal of Community Nursing, Volume 15, Issue. 9 Pages S38 - S45
      • Dumville JC, Walter CJ, Sharp CA, Page T."Dressings for the prevention  of surgical site infection" The Cochrane Library Issue 7 (2011)
      • Enoch S & Harding K. (2003) Wound bed preparation: the science behind the removal of barriers to healing. WOUNDS 2003; 15, 213-229.
      • Ken J Farion, Kelly F Russell, Martin Hamond, Lisa Hartling, Terry P Klassen, Tamara Durec, Ben Vandermeer"Tissue adhesives for traumatic lacerations in children and adults" (January 2009) Cochrane wounds Group
      • Marja N Storm-Versloot, Cronelis G Vos, Dirk T Ubbink, Hester Vermeulen.(2010)  "Topical silver for preventing wound infection". The Cochrane Wounds Group. Issue 3
      • Moore K. (2003) Wound physiology: from healing to chronicity. J Wound Care (Suppl):2-7.
      • Owens, p.L., Zodet, M.W., Berdahl, T., Dougherty, D., McCormick, M. C., & Simpson, L. A (2008) Annual report on health for children and youth in the United states: focus on injury-related emergency department utilisation and expenditures. Ambulatory Paediatrics, 8(4), 219-240.
      • Templeton S. (2005) Management of chronic wounds: the role of silver-containing dressings. Primary Intention. 13(4), 170-179.
      • Vancouver Island health Authority (2007) Wound and Skin Care clinical Guideline
      • Vermeulen H, Ubbink D, Goossens A, De Vos R, Legemate D, Westerbos S J."Dressings and topic agents for surgical wounds healing by secondary intention" (2009) The Cochrane Wounds Group

      Evidence Table

      Please remember to read the disclaimer 

      The development of this clinical guideline was coordinated by Kylie Moon, Nursing Services. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published April 2012, current as of July 2013.