{Agency Name}

Wound Care Policy

Date:
Approved by:
Policy:
To provide wound care treatments/services (using a multidisciplinary approach) based on
evidence-based standards of care under the direction of a physician.

Procedure:
Initial Assessment

1. A qualified agency Registered Nurse or Registered Physical Therapist will assess

wound(s) as part of the comprehensive initial assessment and will document all clinical
findings as per agency policy. Patients will be accepted for service based on the
Admission Policy.
2. Patients are also assessed for risk factors for further skin breakdown and pressure ulcer
development using a validated skin risk assessment tool (e.g., Braden, Norton)
3. The admitting clinician will document each wound status including, location and
etiology, measurement of length, width and depth, undermining and tunneling, if
present, description of the wound bed, drainage, signs and symptoms of infection,
healing and peri wound skin condition.
4. Each wound will be numbered and documentation associated with each numbered
wound will be completed on each visit.
5. Optional: Each wound will be photographed and digitally sent to the assigned regional
Wound Care Specialist for approval of the wound image and assessment of the wound
and ordered treatment. Agency needs to ensure proper HIPAA compliance and digital
encryption to send electronically.
6. The clinician, in conjunction with the patient and caregiver, will develop an appropriate
plan of care based on the patient’s needs and the assessment findings. Each patient will
be evaluated and treated using an individualized care plan based on the patient’s
unique medical condition.
7. The plan of care will be approved by the ordering physician.
8. Patients and caregivers are expected to participate in the plan of care, including
providing ordered wound care.
9. The clinician will provide wound care instruction and self-management education to the
patient /caregiver at each visit.
 10. Referrals for Interdisciplinary team members (OT, PT, MSW, Wound Care Specialist,
Dietician, HCA, and Diabetes Specialist) are made as appropriate to address risk factors,
maximize function, and promote healing.
11. Appropriate adaptive equipment and pressure redistribution support surfaces will be
ordered through an appropriate DME vendor.

Continued/Ongoing Treatment

1. Nurse/therapist will provide wound care per physician orders and continue to
implement and evaluate the plan of care based on the effectiveness of treatment
regimen, response to treatment, effectiveness of interdisciplinary services, need for
assessment by Wound Care Specialist, patient/caregiver participation and identification
of obstacles/risk factors interfering with wound healing. The nurse/therapist will notify
the physician for any change in the patient condition or lack of progress.
2. At each visit the patient’s skin will be assessed. At each dressing change the wound will
be assessed and documentation will include a description of the wound bed, drainage,
signs and symptoms of infection, healing and peri wound skin condition. Include a full
set of vital signs including temperature.
3. At least every week, the wound assessment and documentation will include
measurement of length, width, depth and undermining and tunneling if present.
4. Optional: Wound digital images are used as an adjunct to electronic/written
documentation.
5. Skin Risk Assessment Tool will be completed every 60 days and with a change in
condition. Prevention interventions will be initiated as indicated by the tool or based on
risk factors assessed by the clinician.
6. If patient is not responding to established treatment regimen, the nurse/therapist shall
evaluate for:
a. Need for treatment change
b. Referral to Wound Care Specialist for wound assessment
c. Referral for consultation by physician or wound clinic
d. Re-assess need for interdisciplinary services and/or appropriate DME
e. Referral for nutritional consult
7. Optional: For complex, non-healing wounds, a Wound Care Specialist will assess and
evaluate wound treatment and response to care. A Wound Care Specialist should be
consulted for the following:
a. Stage 3 or 4 Pressure Ulcers
b. Complex wounds and/or complex care
c. Wounds that are not progressing after 2-3 weeks
d. Non-healing chronic wounds
 e. Daily or more frequent wound care
f. Problematic ostomies
g. Complex skin concerns
h. Multiple co morbidities and/or factors affecting healing
8. Optional: The Wound Care Specialist or designee is responsible for tracking active
complex wounds and evaluating treatment regimens, plans of care, patient outcomes,
and cost effectiveness of the treatment plans. The Wound Care Specialist/designee is
responsible for coordinating the Multidisciplinary Wound Team in each office.

Patient/Caregiver Education (Recommended)

1. As part of the agency Patient Responsibilities Policy, patients and/or caregivers are
expected to participate in the wound care plan of care. Clinical staff will identify the
caregiver who will assist with the wound care.
2. The admitting clinician will assess the patient or caregiver willingness and ability to
perform the ordered wound care. If appropriate, the patient and caregiver will be
instructed in wound care technique during the first 1-2 visits. Teaching is done based on
the patient/caregiver level of understanding and includes a demonstration of the wound
care procedure using the teach-back method. The teaching and patient/caregiver
response must be documented in the clinical record and include evaluation of the
patient/caregiver’s ability.
3. Additional education topics may include signs and symptoms of infection, infection
control measures including proper storage of supplies and disposal of soiled materials,
when to call agency and/or physician, pressure relief measures, nutritional and fluid
requirements, incontinence management, and other care as appropriate.
Documentation of the education provided will include patient/caregiver ability to teach
back topics covered.

Wound Care and Treatments—Agency considerations

1. Wound care treatments are provided within an individualized plan of care under the
direction of a physician.
2. Wound care treatments will be based on the principles of moist wound healing and
recommendations from the Wound, Ostomy and Continence Nurses Society (WOCN)
and the National Pressure Ulcer Advisory Panel (NPUAP).
3. Optional: A formulary of advanced wound care supplies is available, and it is expected,
unless otherwise specified by the ordering physician, that wound care treatments are
implemented using the chosen formulary. All physician-ordered wound care items or
 supplies not found on the formulary require approval by the Wound Care Specialist or
RN designee.
4. When ordering wound care supplies, consider ordering the generic category vs specific
brand name (e.g, foam, alginate, silver products)
5. Wet to dry dressings are not an accepted standard of care. When they are ordered, the
clinician should contact the physician for alternative orders and consult the Wound Care
Specialist (if available) if the physician is unwilling to change the wound care orders.
6. The use of advanced wound care products reduces the need for daily treatments. At
times, the wound condition and amount of drainage may necessitate daily dressing
changes and in that case the patient is expected to participate in the care or identify a
willing and able caregiver that can provide the care.
7. All wound care, unless otherwise ordered, is done using clean technique following
standard precautions.
8. Bottles of solutions should be dated when opened and discarded after 7 days.
9. For handwashing and glove use, refer to Infection Control Policy.

The Multidisciplinary Wound Care Team--OPTIONAL

1. Services of a multidisciplinary team are available to each patient. The Wound Care team
is responsible for identifying problems, coordinating care, and promoting development
of the team and the program.
2. The Specialty Program Manager is responsible for the daily operations of the Wound
Program through planning, development, implementation and oversight. The Specialty
Program Manager is responsible for planning implementing staff education.
3. Certified Wound, Ostomy, Continence Nurse (CWOCN), Certified Wound Care Nurses
(CWCN) are responsible for oversight of wound care rendered to all wound care
patients, including the patient assessments, evaluation treatment regimens, plans of
care, care outcomes, and cost effective of the treatment plan of care.
4. Wound Care Nurses provide case management, assessment and skilled interventions to
patients requiring the care of a specially trained wound care nurse and assist with the
above.
5. Physical and Occupational Therapists provide assessment and treatment of wounds to
patients requiring the care of a specially trained Physical Therapist.
6. Registered Dietitians/Nutritionists provide diet instruction and assessment to assist
adequate nutrition/hydration balance.
7. Medical Social Workers provide assessment and treatment of psychological, social, and
financial factors impacting the progression of the plan of care
8. Home Health Aides assist with personal care needs, and assists in maintaining a safe and
therapeutic home environment.
Staff Education and Competency Testing
1. Newly hired RNs, LPNs, Physical, Occupational and Speech therapists will attend classes
on skin and wound care. Topics will include assessment, determining wound etiology,
documentation, product selection and use, wound care techniques and OASIS
assessments (LPNs and therapy assistants are excused from OASIS training).

2. All nursing staff will complete competency assessments for basic wound care, Negative
Pressure Wound Therapy and multilayer compression wraps. These will be completed
during an additional wound in-service training. In addition to orientation and staff
development in-services, a field competency visit is required for Negative Pressure
Wound Therapy.

3. Therapy staff will complete competency assessments for basic wound care and suture
and staple removal.

4. Competency field visits will be conducted with those staff that require additional
instruction for other skills.

5. Optional: Annually, mandatory “Wound Care Stations” will be held for all clinicians.
Topics will vary and will be determined by the Wound Care Teams, Wound Care
Specialists and/or Program Manager based on patient outcome reporting or feedback
from Clinical Supervisors and Regional Directors.

6. Additional education will be provided on an as needed basis either agency-wide or

office/team specific.

Program Evaluation (Optional)

1. The Wound Care Program will be evaluated annually to review compliance with agency
policies and standards of care.

2. Publicly reported Patient Outcomes (Home Health Compare) will be monitored to

measure the adequacy and effectiveness of the program.

3. Audits of clinical record documentation will be conducted to identify staff education

needs, patient care trends and to also evaluate the adequacy and effectiveness of the
program. Annually a review will be done to assess the financial viability of the program.
References
National Pressure Ulcer Advisory Panel
Wound Ostomy Continence Nurses Society Guidance on Oasis-C Integumentary Items OASIS-C
Guidance Document – Content Validated - December, 2014
VNAA Policy and Procedure Manual for specific wound procedures

Wound Care Policy/CAHCH/tpw_11_2016