Wound & Ulcer Management

Assessment · Dressings · Ulcer Protocols

RED FLAGS:

ABPI < 0.5 → Emergency vascular referral — NO compressionWagner Grade 3+ DFU → Hospital admission + IV antibiotics

ABPI < 0.5 → Emergency vascular referral — NO compressionWagner Grade 3+ DFU → Hospital admission + IV antibioticsPressure Ulcer Stage IV / bone exposed → Urgent surgical reviewWet gangrene or rapidly spreading infection → 999 / Emergency

Wound Assessment

TIMES framework, classification, ABPI

NICE · IWGDF · BAD GuidelinesUpdated 2024

TIMES Wound Bed Preparation Framework

International Wound Care Guidelines

A systematic approach to wound assessment and management planning — assess each component at every dressing change.

Slough (yellow/white)

Devitalised fibrinous tissue. Must be debrided to progress healing.

Debride — autolytic (hydrogel), surgical, or enzymatic

Eschar (black/brown)

Hard dry necrotic tissue. Prevents wound assessment and healing.

Sharp/surgical debridement usually needed (unless ischaemic — refer)

Granulation (red/pink)

Healthy vascularised connective tissue. Indicates active healing.

Protect — non-adherent dressings. Avoid trauma.

Epithelialisation (pink/white edges)

New skin forming from wound edges. Final healing phase.

Maintain moist environment. Film or silicone dressing.

Hypergranulation

Overgrown granulation proud of wound surface.

Topical steroid (short course) or silver nitrate cautery

Wound Type Classification

Click any wound type for detailed clinical features and immediate management.

Venous Leg Ulcer

Routine

Gaiter area (medial malleolus)

Irregular, shallow edges
Moderate-heavy exudate
Fibrinous slough base

Arterial Ulcer

Urgent

Toes, heel, pressure points, lateral malleolus

Punched-out, well-defined edges
Pale/necrotic base
Minimal exudate

Diabetic Foot Ulcer

Urgent

Plantar surface, pressure points, toes

Punched-out, circular
Callus surrounding
Often painless (neuropathy)

Pressure Ulcer

See Soon

Sacrum, heels, occiput, trochanters, ischium

Staged I–IV or unstageable
Related to pressure/shear/friction
Often in immobile patients

Malignant/Fungating Wound

Urgent

Breast, head/neck, trunk — related to underlying tumour

Proliferating, irregular
Foul odour
Friable/bleeding base

ABPI (Ankle Brachial Pressure Index) Reference

ABPI must be measured before applying compression to any leg ulcer. Performed with a handheld Doppler probe.

ABPI Range	Interpretation	Compression Decision
> 1.3	Calcified vessels (DM/elderly)	Interpret with caution — Toe pressure / TcPO₂ needed
0.9 – 1.3	Normal	Full multi-layer compression bandaging safe
0.8 – 0.9	Mild PAD	Modified (reduced) compression — specialist advised
0.6 – 0.79	Moderate PAD	Reduced compression only with vascular review
0.5 – 0.59	Significant PAD	NO compression — urgent vascular referral
< 0.5	Severe PAD / critical ischaemia	NO compression — EMERGENCY vascular referral

Wound Documentation Checklist

Document all parameters at every assessment to track healing trajectory and ensure medico-legal compliance.

Wound location (anatomical — exact site)

Dimensions: length × width × depth (cm)

Wound bed tissue type (TIMES — T)

Exudate: amount (none/low/moderate/heavy) and type (serous/sanguinous/purulent)

Periwound skin: maceration, erythema, warmth, oedema

Odour: absent/faint/moderate/strong

Signs of infection (NERDS / STONEES criteria)

Pain score (0–10 NRS) — at rest and at dressing change

Photograph with ruler/scale included

Dressing applied and next review date

ABPI result (leg ulcers)

Wound duration (weeks/months) and healing trajectory