How to Care for an Open Wound

This procedure describes how to care for an open wound using a structured, seven-phase approach: assess, cleanse, protect, fill, cover, secure, and evaluate. It is intended to guide clinicians through consistent, evidence-based wound care from initial assessment through ongoing monitoring, helping to reduce complications and support optimal healing.

Purpose & scope

Wound assessment is the foundational step in effective wound management. The purpose of this procedure is to identify and address all issues that may impact or delay healing, and to use that information to guide the most effective treatment plan in line with established wound care guidelines.

The source material does not specify a particular patient population or care setting (e.g., ward, ICU, or outpatient clinic). When adapting this procedure locally, document the intended patient population and care setting explicitly.

Patient assessment

Begin wound care by inspecting and evaluating the wound based on several key characteristics. A thorough assessment forms the basis for every subsequent phase of care.

Record the wound location on a body diagram for documentation purposes.

Measure and document wound dimensions for ongoing tracking.

Classify exudate using standard color and consistency references.

Differentiate tissue types using visual guides.

Document the periwound condition for ongoing monitoring.

Check and record additional inflammatory signs to guide treatment planning.

Notify the healthcare provider if infection is suspected, and use all gathered findings — location, size, exudate, tissue type, periwound condition, and signs of infection or inflammation — to develop the treatment plan.

Care protocol

Once assessment is complete, proceed through the following phase-based interventions in order.

Cleanse the wound

Protect the periwound

Fill the wound

Filling prevents pockets of abscess from forming and is especially important for wounds with depth, such as tunneling wounds, undermined wounds, and stage three or four pressure injuries. Select the filler based on the assessment, the wound's contours, and clinical judgment.

Available fillers include gauze, foams, fibers, alginates, and gels; add an antimicrobial agent to the filler for infected wounds.

Fill all open spaces so the material conforms to the wound's shape and depth, using clinical discretion to avoid overpacking or underpacking.

Cover the wound

Secure the dressing

Choose from gauze, conforming stretch bandages, tape, transparent film, or composite dressing based on provider policy and procedures.

Pain management

The assessment phase requires asking and recording the patient's level of pain as part of the wound evaluation. The source material does not provide a multimodal pain management plan, medication table, pain score targets, or escalation pathway; this section should be completed locally with the drug, dose, route, frequency, target pain score, and escalation contacts used at your facility.

Mobility milestones

No mobility milestones or progressive activity timeline are included in the source material. This section should outline facility-specific mobility goals (such as bed exercises, chair transfers, and ambulation) with an associated day-by-day timeline.

Complication monitoring

Evaluate the wound regularly to determine whether it is healing, regressing, or showing no change, and use clinical judgment to decide whether the current approach is effective or whether another intervention is needed.

At each evaluation, check for:

• New signs of infection, such as changes in wound color or odor
• Whether both the protective and secondary dressings are staying securely in place
• Whether drainage control, if in use, is functioning properly

Record findings regarding healing, regression, or lack of change, and take appropriate action, such as adjusting the wound care plan, based on the evaluation. No specific escalation contacts are provided in the source material; document your facility's escalation pathway here.

Discharge criteria

The source material does not define measurable discharge criteria. This section should list specific, measurable benchmarks — such as wound status, absence of infection, and the patient's ability to manage self-care — that must be met before discharge.

Patient education

Review the seven steps of effective wound management with the patient and family as appropriate: assess, cleanse, protect, fill, cover, secure, and evaluate.

What's next

For more detailed information and additional resources on wound care, consult cardinalhealth.com/skinandwound. By following the seven steps — assess, cleanse, protect, fill, cover, secure, and evaluate — you support comprehensive, effective wound management, promoting optimal healing and patient safety.