In this section
A wound is a disruption to the integrity of the skin that leaves the body vulnerable to pain and infection. The skin is the body’s largest organ and is responsible for protection, sensation, thermoregulation, metabolism, excretion and cosmetic. Poorly managed wounds are one of the
leading causes of increased morbidity and extended hospital stays. Therefore, wound assessment and management is fundamental to providing nursing care to the paediatric population.
The guideline aims to provide information to assess and manage a wound in paediatric patients. Ongoing multidisciplinary assessment, clinical decision-making, intervention, and documentation must occur to facilitate optimal wound healing.
PHYSIOLOGY OF WOUND HEALING
Wound healing occurs in four stages, haemostasis, inflammation, proliferation and remodelling, and the appearance of the wound will change as the wound heals. The goal of wound management is to understand the different stages of wound healing and treat the wound accordingly.
Having the knowledge, skills and resources to assess a wound will result in positive outcomes, regardless of product accessibility.
TIME is a valuable acronym or clinical decision tool to provide systematic assessment and documentation of wounds. It stands for Tissue, Infection or Inflammation, Moisture balance and Edges of the wound or Epithelial advancement.
Tissue is usually described by colour.
Inflammation is an essential part of wound healing; however, infection causes tissue damage and impedes wound healing.
ODOUR can be a sign of infection. It can be described as:
If any of the above clinical indicators are present (including fever, pain, discharge or cellulitis) a medical review should be initiated and consider a Microscopy & Culture Wound Swab (MCS).
Moisture/ exudate is an essential part of the healing process. It is produced by all wounds to:
The overall goal of exudate is to effectively donate moisture and contain it within the wound bed. Excess exudate leads to maceration and degradation of skin, while too little moisture can result in the wound bed drying out.
Advancing of edges can be assessed by measuring the depth (cavity/sinus), length and width of the wound using a paper tape measure.
Assess the surrounding skin (peri wound) for the following:
Pain is an essential indicator of poor wound healing and should not be underestimated. Pain can occur from the disease process, surgery, trauma, infection or as a result of dressing changes and poor wound management practices.
Assessing pain before, during, and after the dressing change may provide vital information for further wound management and dressing selection. See RCH
Pain assessment and measurement guideline.
Accurate assessment of pain is essential when selecting dressings to prevent unnecessary pain, fear and anxiety associated with dressing changes. Prepare patients for dressing changes, using pharmacological and non-pharmacological techniques as per the RCH
Procedure Management Guideline.
Factors affecting wound healing can be extrinsic or intrinsic. It is essential for optimal healing to address these factors.
Effective wound management requires a collaborative approach between the nursing team and treating medical team. Referrals to the Stomal Therapy, Plastic Surgery, Specialist Clinics or Allied Health teams (via an EMR referral order) may also be necessary for appropriate management and dressing selection, to optimise wound
Wound healing may be by:
Frequency of dressing changes:
Things to consider prior to procedure:
1. Inform and consent patient
2. Perform hand hygiene
3. Clean surfaces to ensure you have a clean safe work surface
4. Perform hand hygiene
5. Open and prepare equipment, peel open sterile equipment and drop onto aseptic field if used (dressing pack, appropriate cleansing solution, appropriate dressings, stainless steel scissors, tweezers or suture cutters if required)
6. Perform hand hygiene, use gloves where appropriate
7. Remove dressings, discard, and perform hand hygiene
8. Clean and assess the wound (wound and peri wound should be cleaned separately if washing the patient)
9. Perform procedure ensuring all key parts and sites are protected
10. Perform hand hygiene and change gloves if required
11. Apply new dressings
12. Apply fixation if required
13. Perform hand hygiene
14. Dispose of single-use equipment into waste bag and clean work surface
a. Single-use equipment: dispose after contact with the wound, body or bodily fluids (not into aseptic field)
b. Multiple-use equipment: requires cleaning, disinfection and or sterilisation after contact with the wound, body or bodily fluids
c. Stainless steel scissors that do not come into contact with the wound, body or bodily fluids can be re-used for the sole purpose of cutting that patient’s unused dressings. Scissors should be cleaned with an alcohol or disinfectant wipe before and after use.
Ensure cleansing solutions are at body temperature.
RCH Procedure Skin and surgical antisepsis
Standard or surgical aseptic technique is used as per the RCH Procedure Aseptic
Select personal protective equipment (PPE) where appropriate. Outlined in the Procedures:
Standard Precautions and
Transmission based precautions
Debridement is the removal of dressing residue, visible contaminants, non-viable tissue, slough or debris. Debridement can be enzymatic (using cleansing solutions), autolytic (using dressings) or surgical.
Determining when debridement is needed takes practice. If you are not familiar with wound assessment/debridement confer with a senior/expert nurse.
For complex wounds any new need for debridement must be discussed with the treating medical team.
It is important to select a dressing that is suitable for the wound, goals of wound management, the patient and the environment.
Dressings that have direct contact with the wound and have the ability to change the wound (e.g. moisture donation/ retention, debridement and decreasing bacterial load)
-Broad spectrum antimicrobial agent to reduce/ treat infected wounds
-If the silver needs to be activated, it should be done with water (normal saline will deactivate the silver)
Can be left on for 7 days (Acticoat3™ is changed every 3 days). Should only be used for 2-3 weeks
-Moisture management for moderate- high exudate
-Absorbs fluid to form a gel (can be mistaken for slough)
-To fill irregular shaped wounds e.g. cavities
-Ideal for bleeding wounds due to haemostatic properties
Change every 1-7 days depending on exudate. Stop using once wound bed is dry
-For low- high exudate
-Used for granulating and epithelializing wounds as it provides protection
-Can be used in conjunction with other dressings to increase absorption and prevent maceration
-Not to be used with hydrogel
Change every 1-7 days depending on exudate
-Moisture management for moderate- high exudate
-To fill irregular shaped wounds e.g. cavities. Needs to be bigger than the wound as it will shrink in size
-Prevents peri wound maceration
Continue to use until there is low- nil exudate
-Protects the wound base and prevents trauma to the wound on removal
-Does not absorb exudate
Can be left on for up to 14 days (for orthopaedic wounds)
-Protective dressing for low- moderate exudate
-Can adhere to the wound bed and cause trauma on removal (consider the use of an atraumatic dressing/ impregnated gauze)
Stop using when exudate is too high or the wound has healed
-Moisture donation for low-moderate exudate
-Self-adhesive and water repellent
-Forms a gel when exudate present (white bubbles)
-Not for use in infected wounds
-Can be used as a primary or secondary dressing
Change every 3-7 days
-Iodine is only be used in acute superficial wounds as it can damage granulating tissue so should be used with caution
-Has antifungal and antibacterial properties
-Moisture donation for low- moderate exudate
-Used on dry/ necrotic wounds as it hydrates the wound bed and promotes autolytic debridement
Change every 3-7 days depending on exudate
-Protective dressing for nil-low exudate
-Allows for inspection through dressings
Mepilex Lite ™
-Protective dressing for low- heavy exudate
-Absorbs moisture and distributes pressure (good for pressure injuries)
-Atraumatic to the wound and surrounding skin
-Can be used on infected wounds
Silicone foam adhesive
Allevyn Gentle Border™
-Same as silicone foam but includes adhesive film
-For infected, contaminated or malodorous wounds as it promotes autolytic debridement
-For moderate-high exudate or hypergranulation tissue
-Used for moist necrotic wounds and draining infected wounds
For best results change frequently (more than once daily). Stop using when wound is granulating or epithelising
Dressings that cover/ compliment primary dressings and support the surrounding skin.
Absorbent/ Protective pad
-Provides protection for moderate exudate
-Can adhere to the wound bed and cause trauma on removal (consider the use of an atraumatic dressing)
-Permeable dressing but can be washed and dried
-Conforms to the body and controls oedema
-Can be used as a primary dressing or secondary dressing as well
-Provides wound support
Tubular Form™ (Tubigrip)
-Provides protection and compression
Elastic conforming gauze bandage (handiband)
-Provides extra padding, protection and securement of dressings
* Dressings not available on ward imprest/more extensive dressing supplies can be sourced in hours from
is an expectation that all aspects of wound care, including assessment,
treatment and management plans are documented clearly and comprehensively.
Documentation of wound assessment and management is completed in the EMR under the Flowsheet activity (utilising the LDA tab or Avatar activity), on the Rover device, hub, or planned for in the Orders tab. For more information follow the
Parkville EMR | Nursing – Documenting Wound Assessments (phs.org.au)
Clinical images are a valuable assessment tool that should be utilised to track the progress of wound management. See
Clinical Images- Photography Videography Audio Recordings policy for more information regarding collection of clinical images.
Wound management follow up should be arranged with families prior to discharge (e.g. Hospital in the Home, Specialist Clinics or GP follow up).
The evidence table for this guideline can be viewed here.
Please remember to read the disclaimer
The revision of this clinical guideline was coordinated by Mica Schneider, RN, Platypus. Approved by the Clinical Effectiveness Committee. Updated February 2023.