Bedside Decision Support
Rapid Dressing & Protocol Matcher
Suggest evidence-based dressing plans from wound-bed status, exudate volume, and infection risk.
Rapid Wound Bed Assessment & Management
Core tissue recognition, clinical goals, and contraindications
Wound-bed appearance examples (open-licence clinical photos)
Source: Wikimedia Commons; teaching identification only — not local cases.
Granulation Tissue
ProliferativeAppearance:Beefy red, glossy moist, cobblestone granular surface with rich capillary loops.
Clinical Objectives:
- Maintain an ideal moist healing environment
- Protect fragile new capillaries from shear and trauma
- Manage excess exudate while avoiding wound-bed desiccation
Primary Selection:
Low exudate: Hydrogel, Hydrocolloid sheet/paste.
High exudate: Calcium alginate, Hydrofibre, Foam.
High exudate: Calcium alginate, Hydrofibre, Foam.
Pitfall:Never scrub aggressively. Avoid dry gauze that strips capillaries on removal.
Overgranulation
HyperplasiaAppearance:Raised above surrounding skin, spongy, hyperaemic, bleeds easily on light touch.
Clinical Objectives:
- Suppress hyperplastic tissue down to skin-edge level
- Clear the barrier so epithelium can migrate level
- Check for foreign body / undissolved suture
First-Line Interventions:
- Hydrophilic foam with local pressure
- Mesalt (27% hypertonic saline)
- Daily Povidone Iodine 10% paint + dry gauze pressure
- Silver nitrate chemical cautery (requires medical order)
Contraindications:Strictly avoid occlusive film, hydrocolloid sheet, and moisture-donating hydrogel.
Sloughy Tissue
DevitalizedAppearance:Yellow, creamy, or grey-white stringy fibrin, leukocytes, and cellular debris.
Clinical Objectives:
- Clear slough (autolytic / mechanical / enzymatic)
- Eliminate the medium for bacterial colonization
- Protect periwound skin from moisture maceration
Primary Selection:
Autolytic: Hydrogel, Hydrocolloid sheet.
Mechanical/Chemical: Hypertonic saline (Mesalt).
Enzymatic: Collagenase ointment.
Mechanical/Chemical: Hypertonic saline (Mesalt).
Enzymatic: Collagenase ointment.
Practice Tip:For stubborn slough, soak with PHMB (Prontosan) for 10 minutes before dressing.
Necrotic (Eschar)
AvascularAppearance:Dry, thick, leathery, dark brown or black non-viable tissue.
Standard Body Sites:
- Cross-hatch eschar with a scalpel to aid hydration
- Use amorphous Hydrogel + secondary film/foam
- Prepare for Conservative Sharp Wound Debridement (CSWD)
CRITICAL heel/digit rule:
On the heel, toe, or finger,dry and intact eschar must be kept dry and intact Do not soften or debride unless infected!
Infected / Bioburden
BioburdenHallmarks:Erythema >2 cm, heat, induration, foul odor, purulent discharge, delayed healing, friable bleeding bed.
Clinical Protocol:
- Obtain a sample with the Levine Technique before starting antibiotics
- Choose broad-spectrum antimicrobial dressings (Silver, Cadexomer Iodine, Honey)
- Ensure adequate drainage; change daily
Contraindications:Do not use occlusive film or hydrocolloid wafer on actively infected wounds.
Epithelializing Wound
MaturationAppearance:Pale pink, translucent, fragile new epidermis advancing from the margins.
Clinical Objectives:
- Maintain a fine moisture balance; avoid maceration
- Prevent shear injury to migrating epithelium
- Use atraumatic dressing removal
Primary Selection:
Silicone contact layer, Hydrocolloid thin, Lipid-colloid contact sheet (Physiotulle/Urgotul).
Bedside Wound Cleansing Solutions Guide
Indications, toxicity profile, and application points
| Solution | Type / Mechanism | Best Indications | Limits & Toxicity | Bedside Tip |
|---|---|---|---|---|
| Normal Saline (0.9% NaCl) | Isotonic physiologic solution | Clean granulating beds, routine irrigation, post-sampling flush | No antimicrobial / disinfectant action | Safety baseline — non-cytotoxic to viable tissue. |
| Chlorhexidine 2% Aqueous | Broad-spectrum bisbiguanide disinfectant | General skin and superficial wound disinfection | Ineffective against acid-fast bacilli, fungi, viruses; inactivated by blood/pus | Lower tissue toxicity than older antiseptics. Use aqueous preparations on open wounds. |
| Cetrimide (0.015% Chloro + 0.15% Cetrimide) | Quaternary ammonium surfactant + detergent | Initial clean of heavily soiled / grit-contaminated traumatic wounds | Toxic to fibroblasts! Easily contaminated by Pseudomonas aeruginosa Contamination | Use only for initial dirt removal; never use on routine granulating wound beds. |
| Povidone Iodine 10% | Halogen releasing free iodine | Heavily contaminated wounds, pre-op prep, overgranulation paint | Cytotoxic to fibroblasts; systemic iodine absorption risk (acidosis, renal load) | Contraindications:Pregnancy, lactation, thyroid disease, large-area use. |
| PHMB + Surfactant (e.g. Prontosan) | Polyhexanide + betaine | Stubborn biofilm, thick slough, colonized chronic ulcers | Cost; rare allergy | Method:Soak gauze in place for 10 minutes then dress. |
| Hypochlorite-based (e.g. Granudacyn) | Hypochlorous acid (HOCl) + Sodium hypochlorite | Biofilm deep cavities, acutely infected wounds, malodorous ulcers | Cost; heavy organic exudate may partially inhibit | Rapid antimicrobial action against Gram+/Gram− with relatively little damage to healthy granulation. |
Wound Dressing Product Directory
Mechanism, wear time, advantages, contraindications, and product examples
Calcium Alginates
Moderate to Heavy Exudate
Algal polysaccharide; absorbs 17–20× own weight; Na/Ca exchange forms a soft hydrophilic gel.
Advantages:Haemostatic; less painful on removal; supports autolytic debridement.
Contraindications:Low-exudate wounds; dry hard eschar. Needs a secondary dressing.
Wear Time:12 hours to 3–4 days.
Examples: Algisite M, Kaltostat, Sorbalgon, Melgisorb, Suprasorb A
Hydrofibre / Gelling Fibre
Heavy Exudate
Pure sodium CMC; vertical fluid lock reduces periwound maceration.
Advantages:Removes as one piece with little residue; bacteria trapped in the gel matrix.
Notice:Contracts slightly when hydrated; pack loosely.
Wear Time:Infected: daily; non-infected: up to 7 days.
Examples: Aquacel Extra, Durafiber, Exufibre, CMC Ribbon
Hydrophilic Foams
Low to Moderate Exudate
Hydrophilic polyurethane foam with breathable backing; manages moderate exudate, warms, and cushions bony prominences.
Advantages:Non-adherent to fragile beds; usable under compression; cushions tubing.
Contraindications:Dry wounds or hard black eschar (except pure cushioning).
Wear Time:Clean wounds 3 to 5 days.
Examples: Allevyn, Mepilex, Biatain, Tielle, Lyofoam
Hydrocolloids
Low–Moderate / Autolytic
Adhesive wafer with gelatin, pectin, sodium CMC; swells into a moist gel on contact with exudate to promote autolytic debridement.
Method of Use:Need ≥ 2 cm intact skin beyond wound edge for adhesion.
STRICT CONTRAINDICATION:Do not use on infected wounds!
Wear Time:3 to 7 days (watch for skin tears on removal).
Examples: DuoDERM CGF, Hydrocoll, Comfeel Plus
Hydrogels
Dry to Low Exudate
Polymer matrix ~90% water; donates moisture to hard eschar and rehydrates necrotic slough.
Advantages:Soothing cooling; analgesia; autolytic debridement; extravasation relief.
Contraindications:Heavily draining deep cavities; actively infected pockets.
Wear Time:12 to 48 hours.
Examples: Intrasite Gel, DuoDERM Gel, Hydrosorb, Kerralite Cool
Hypertonic Saline (Mesalt)
Slough & Hypergranulation
Non-woven impregnated with 27% NaCl; osmotic gradient draws oedema, bacteria, and debris.
Advantages:Clears thick slough; osmotic suppression of hypergranulation.
Notice:May sting on application; avoid healthy granulating beds; do not use on dry eschar.
Wear Time:12 to 24 hours.
Examples: Mesalt
Cadexomer / Povidone Iodine
Infected & Slough
Slow release of free iodine (0.9–1.0%) on contact with exudate. Cadexomer beads absorb slough with broad-spectrum kill.
Advantages:Deodorises; clears infected sloughy ulcer beds.
Contraindications:Pregnancy, lactation, children, thyroid disease.
Wear Time:12 to 48 hours.
Examples: Iodosorb Paste/Sheet/Powder, Inadine
Medical Honey
Infected & Odor
Standardised medical honey; high osmolarity and acidic pH (3.2–4.5) suppress pathogens and promote autolysis.
Advantages:Controls malodour; barrier against resistant strains; absorbs exudate.
Notice:Honey allergy; transient stinging; do not use in unopened deep body cavities.
Wear Time:1 to 7 days.
Examples: Medihoney (gel, tulle, alginate), Activon Tube
Silver-Containing (Ag)
Antimicrobial
Releases silver ions (Ag⁺) or nanocrystalline silver; disrupts bacterial membranes, DNA replication, and respiratory enzymes.
Indications:Acute/chronic infected wounds; critical colonization; deep burns; graft sites.
Rule of Practice:Reassess at 14 days; stop once infection controlled.
Wear Time:3 to 7 days.
Examples: Aquacel Ag, Acticoat, Biatain Ag, Urgotul SSD
Superabsorbent Polyacrylate (SAP)
Rinsing & AbsorptionHydrophilic superabsorbent pad pre-activated with Ringer's; continuous interactive rinse and exudate lock.
Advantages:Can continue up to 72 hours softening thick slough; microbes locked in the pad.
Wear Time:Up to 72 hours.
Examples: HydroClean, HydroClean Plus
Odour-Absorbing (Activated Charcoal)
Odour ManagementActivated carbon fabric micropores adsorb volatile odor molecules and electrostatically trap bacteria.
Best Indications:Malodorous fungating wounds, necrotic pressure ulcers, small faecal fistulae.
Critical Rule:Do not cut through the outer seal of the dressing.
Wear Time:Daily to 48 hours.
Examples: Actisorb Plus, CarboFlex, Carbonet
Low-Adherent & Tulle Gras
Contact Layer
Perforated polyester/plastic film or paraffin-impregnated open-weave gauze preventing secondary pad adherence.
Best Indications:Sutured incisions, graft donor/recipient sites, superficial abrasions.
Warning:Paraffin gauze left >24–48 h dries and can strip new epithelium on removal.
Wear Time:Open wounds 12–24 hours; clean sutured wounds 7–10 days.
Examples: Jelonet, Physiotulle, Adaptic, Primapore, Cosmopor
Bedside vascular assessment
Ankle-Brachial Index (ABI) Calculator
Patient supine 15–20 minutes before assessment. Doppler probe ~45°.
Take the higher of DP and PT arterial signals.
Vessel calcification / ABI > 1.3
Toe-Brachial Pressure Index (TBPI)
Hallux PPG + mini cuff. Especially important when ankle vessels are calcified (diabetes/renal disease).
Semmes-Weinstein Monofilament (SWME) Bedside Rules
- Use Standard 5.07 monofilament (delivers 10 g force).
- Press vertically until the filament bows; hold 1–2 seconds.
- Patient eyes closed; say “yes” when touch is felt.
- Do not test on callus, ulcer edge, scar, or necrotic eschar!
Lower-Extremity Ulcer Compression Decision Pathway
Select gradient pressure from Doppler signals and vascular indices
ABI 0.8 – 1.3
Venous Leg Ulcer
Arterial perfusion preserved. Oedema creates tissue hypertension and a cellular barrier that impedes healing.
Triphasic / Biphasic signals:
Safe to use when Full Gradient Compression (40 mmHg at ankle).
Safe to use when Full Gradient Compression (40 mmHg at ankle).
Monophasic / Muffled Sounds:
Start with reduced compression (17–23 mmHg); titrate toward 40 mmHg if tolerated.
Start with reduced compression (17–23 mmHg); titrate toward 40 mmHg if tolerated.
Maintenance:After healing, wear Class 2 or Class 3 compression stockings.
ABI 0.5 – 0.8
Mixed Arterial / Venous Ulcer
Venous hypertension coexists with significant peripheral arterial disease.
DO NOT APPLY FULL 40 mmHg!
Action:Consult vascular surgery. If approved, use Reduced Light Compression (17–23 mmHg) and monitor perfusion frequently.
Teach patients: remove bandage immediately if severe calf or toe rest pain develops.
ABI < 0.5 or severe LEAD
Severe Arterial Insufficiency
Severe limb-threatening ischaemia. Ulcers unlikely to heal without surgical revascularisation.
Compression absolutely contraindicated!
Compression can trigger acute arterial occlusion, gangrene, and limb loss.
Immediate Action:Urgent vascular surgery referral. Keep dry and protected.
Sentinel safety protocol
Wound Cavity Packing Safety
Interactive Packing Reconciliation Verifier:
Pieces documented as inserted last time:
Pieces removed today:
Nursing procedure boundaries
Conservative Sharp Debridement (CSWD)
Absolute Red Flags / Contraindications:
- Necrotic tissue tightly adherent with unclear interface to viable margins
- Patients on anticoagulation (warfarin, NOACs) or with bleeding disorders
- Uninfected dry eschar on heel, toes, or fingers
- Located onface, hands, or overlying the Achilles tendon wounds
- Near arterial branches, bypass grafts, or dialysis fistulae
- Fungating/malignant wounds; neonates and paediatric patients
Procedure Stopping Triggers:
- Patient reports sharp or excessive pain
- Exposed shiny white tendon, fascia, or periosteum
- Pulsatile or active arterial bleeding
Gold standard (~91% sensitivity)
Levine > Z-technique
Wound Swab Procedure (Levine Technique)
Collect before antibiotics. Do not sample superficial pus or dead slough.
1
Cleanse Bed:Irrigate thoroughly with 0.9% Normal Saline to remove superficial colonisers and debris.
2
Blot Dry:Blot dry with sterile gauze.
3
Moisten Swab:Moisten sterile swab tip with 0.9% Saline (improves microbial recovery).
4
Target 1 cm² Viable Granulation:Apply moderate pressure on clean viable bed to express interstitial fluid; rotate swab over 1 cm².
5
Transport:Place in transport medium, label correctly, send immediately to microbiology.
Advanced therapies
Continuous Diffusion of Oxygen (CDO) and NPWT
Continuous Diffusion of Oxygen (CDO):
- Delivers 98% humidified pure oxygen continuously at 3–13 mL/hour to the tissue.
- Crucial Early Expectation:In the first 14 days the wound may appear temporarily larger, exudate may increase (stimulates autolysis).
- STRICT RULE:neverPetroleum/oily ointments on the wound bed — they block oxygen diffusion.
- Ideal course ≥ 25 days.
Negative Pressure Wound Therapy (NPWT):
- Untreated osteomyelitis, exposed vessels/organs, or dry eschar are contraindications.
- Do not interrupt therapy >2 hours — bacterial build-up and foam adherence risk.
- Turn off negative pressure and thoroughly soak foam before removal.