Summary: This page details our protocol for dressing wounds.
Who’s it for: Any member of the Nursing team, provided they have completed the appropriate training.
Wound care requires a F2F appointment with a member of the Nursing team (double appointment if translator required). The appointment can be broken down into the following parts:
1️⃣ Assessment
You must adhere to our Infection Prevention & Control policies and use the Aseptic Non-Touch Technique (ANTT) at all times throughout a wound dressing appointment.
- Open the clinical template ‘Wound Care Penrose Health’ on EMIS.
- Complete pg. 1 (’Examinations and Observations’), and the ‘Wound Assessment’ and ‘Examination of Wound’ sections of pg. 2 (’Wound Care’).
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2️⃣ Preparation for Dressing
- If the wound is suitable for dressing, select a suitable type and size of dressing using the appropriate formulary below.
- Lewisham: Primary Care Wound Care Formulary
- Lambeth & Southwark: ⬇️
- Lewisham practices: please click here and sign in
- Lambeth & Southwark practices: order under prescription
- Check that the dressing packs are intact and in date.
- Explain the care plan (e.g., what dressings to use, how frequently they should be replaced) to the patient, ensuring that they are happy with this.
- Make sure the patient is comfortable, with the wound site supported.
- If the patient requires ulcer dressing, go straight to step four. If not, continue to step three.
Preferred Dressings List GSTT for Lambeth and Soutwark.pdf688.1KB
To order dressings, at:
Please note that if the patient has a hospital discharge letter, it may include a requested care plan.
3️⃣ Dressing
To ensure correct disposal of clinical waste during dressing, follow our Waste management policy.
- Clean all required equipment (e.g., sterile scissors, probe) as per Cleaning equipment & environment.
- Offer the patient pain medication, if deemed necessary.
- Wash and dry your hands, then apply non-sterile gloves and an apron.
- Remove and dispose of the patients old dressing(s).
- Dispose of soiled gloves, then wash your hands again.
- Open the new dressing, sterile scissors and probe (if required) onto a sterile surface. Put a new pair of non-sterile gloves on.
- Clean the wound and surrounding area using tap water and sterile gauze swabs. Saline solution can be used instead of tap water, if necessary.
- Apply sterile gloves.
- Apply dressings to the wound, using sterile scissors to cut to size (if required).
- Dispose of your gloves and apron, and wash hands.
- Complete the ‘Dressings’, ‘Wound Healing’ and ‘Medical Photography’ sections of the clinical template.
If you notice any signs of infection, or that the patient has uncontrolled pain, escalate to Lead Nurse or a GP.
4️⃣ Dressing - Leg or Foot Ulceration Only
- Complete pg. 3 (’Ulcers’) of the clinical template.
- Review the ulcer for red flags and escalate to a duty doctor if necessary.
- Dress the ulcer as per step three.
- If ABPI test has been completed and the result is 0.8 - 1.3, offer compression bandaging, as below:
- Leg ulcer: offer mild graduated compression (if patient has NO red flags)
- Foot ulcer: implement offloading or pressure redistribution strategies
- If full compression / reduced compression is not possible, you may be able to use compression stockings (provided there is no oozing / discharging from the wound).
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If there is no doctor on site → refer the patient to Community Tissue Viability Nursing Team (Southwark & Lambeth), District Nurse (Lewisham), Community Foot Health (Podiatry), Foot Health Services (UHL), or South East Vascular Network (SEVN) as appropriate.
If the patient has a foot ulcer and is diabetic → refer to Multi-disciplinary Foot (MDFT) Clinics.
If you are not trained in compression bandaging, please book the patient an appointment with a Practice Nurse or refer to Community Tissue Viability Nursing Team (Southwark & Lambeth) or foot health services (linked above).
5️⃣ Further Advice
- Assess whether shared care with the patient (and/or their carer) is appropriate by completing the document below. This document also includes wound self-care information, and should be given to the patient once completed.
- Ensure that the patient has enough dressings, and arrange a follow-up appointment if necessary.
Shared Care for Wounds.pdf280.2KB