Wound Management Procedure
Canberra Hospital and Health Services
Clinical Procedure
Wound Management
|Contents |
Contents 1
Purpose 2
Scope 2
Section 1 – Key Principles for Wound Management 2
Section 1.1 Basic Dressing Technique 6
Section 1.2 Wound Probing 8
Section 1.3 Wound Debridement 10
Section 1.4 Wound Swabbing 12
Section 1.5 Wound suture and staple removal 14
Section 1.6 Wound and sinus packing 18
Section 1.7 Wound drainage tube shortening and removal 19
Section 2 – Managing Specific Wound Types 22
Section 2.1 Skin Tears 22
Section 2.2 Management of Burns 25
Section 2.3 Management of lower leg ulceration 28
Section 2.4 Managing Skin Grafts and Donor Sites 35
Section 2.5 Postoperative managing of Skin Flaps 37
Section 2.6 Managing Malignant Wounds 41
Implementation 43
Evaluation 43
Related Policies, Procedures, Guidelines and Legislation 44
References 44
Search Terms 46
Consultation 46
Attachments 48
|Purpose |
The purpose of this document is to provide a governance framework for professional practice and clinical decision-making in the provision of wound management services, which is based on the best available evidence.
|Scope |
This document pertains to all patients who require wound management provided by the Canberra Hospital and Health Services.
This document applies to:
• Medical Officers
• Nurses and Midwives who are working within their scope of practice (Refer to Nursing and Midwifery Continuing Competence Policy)
• Allied Health Clinicians who are working within their scope of practice
• Students under direct supervision
|Section 1 – Key Principles for Wound Management |
1. There is a collaborative practice and interprofessional care approach to promote optimal healing of the individual
2. Acknowledges the central role of the individual and their carer in wound management and relevant health care decisions
3. An ongoing process of clinical decision-making facilitates the optimal healing of the individual with a wound. This process will determine the risks associated with the wound aetiology and healing responses
4. Documentation in the patient’s clinical record must facilitate communication and continuity of care between interprofessional teams e.g. dieticians and fulfil legal requirements
5. The safety and wound healing potential of the individual is ensured by clinical practice that respects and complies with legislation, codes of practice, and policies
6. The clinician maximises opportunities for advancing self-knowledge and skills in wound care sharing this knowledge with patients and carers through the process of education
7. That evidence based wound prevention and management advances optimal outcomes for the individual and the interprofessional teams and is based on contemporary research and consensus recommendations.
8. Wound healing is a dynamic process, and the clinicians must anticipate that wound management practices will change, as new scientific evidence becomes available
9. Ensure patients have adequate pain relief prior to dressing changes.
(The Standards for Wound Management Australian Wound Management Association Inc
2nd edition, March 2010)
Procedure
The individual with a wound will receive a comprehensive assessment that reflects the intrinsic and extrinsic factors specific to each individual and which have the potential to impact on wound healing or potential wounding.
A wound assessment must be performed and the results documented in the patient’s clinical record. Information may include:
1. Type of wound and aetiology
2. Location of the wound
3. Dimensions of the wound
4. Clinical appearance of the wound
5. Presence of infection, pain, odour or foreign bodies
6. State of surrounding skin and alterations in sensation
7. Physiological implications of wounding to the individual
8. Psychological implications of wounding to the individual and significant others
9. The use of validation tools in practice
10. The use of diagnostic investigations to ascertain and monitor wound healing potential
11. Wound photographs and consent see Diagnostic Digital Photography Images and/or Recordings Policy, SOP
12. In the Community Care Program (CCP) a photo is taken every two weeks or when there is deterioration in the wound.
13. In the CCP a paper ruler is positioned next to the wound, and identified with the patient’s initials, UR no, date of birth and date of photograph. These photographs are to be printed on the appropriate template and added to the patients file, then the photo deleted from the camera.
14. Wound measurements and tracing is attended at the initial assessment, and at regular intervals to access the process of healing.
Ongoing Assessment of Wound Healing Process
Ongoing assessment will be performed and documented and provide evidence of wound healing or deterioration in wound healing.
Individualised Care Plan
An individualised care plan will be:
1. Documented in accordance with the individual’s preference and assessment outcomes
2. Reflective of ongoing assessments
3. Used to guide optimal management
4. Used to evaluate the effectiveness of treatment
5. Maintain communication with patient regarding healing outcomes.
Wound Management
Wound Management is practiced according to the best available evidence for optimising outcomes for the individual, their wound and their healing environment.
A clinician comprehends the importance of and is able to:
• Determine when an aseptic non touch technique - standard or surgical technique is required if the individual, their wound and their healing environment is compromised
Optimum Healing Environment
Maintain an optimal wound moisture balance
Promote a moist wound environment unless the clinical goal is to maintain eschar in a dry and non infected condition.
Wound healing is facilitated in the presence of moisture therefore moist wound healing principles will be maintained unless not clinically indicated. A clinical indication for maintaining dry eschar exists when there is insufficient blood flow to an affected body part to support infection control and wound healing.
Maintaining a constant wound temperature consistent with optimal healing
It has been demonstrated that wound healing is impaired when the wound temperature decreases one degree Celsius, therefore the clinician will:
• Avoid exposing the wound to cooling temperatures or appliances
• Avoid leaving wounds exposed for lengthy periods
• Use wound cleansing solutions at body temperature
• Provide advice on interventions, appropriate for maintaining core body and skin temperature, such as the wearing of warm clothes and the maintenance of a stable and comfortable environmental temperature.
It has been demonstrated that an increase of one degree Celsius in skin temperature can compromise skin integrity in individuals at risk of pressure ulceration. There for clinicians will:
• Avoid overheating with clothing, bed linen or heating devices
• Avoid or limit or limit contact with plastic bed protection covers and plastic lined garments
• Ensure adequate hydration
• Provide advice on interventions appropriate for maintaining core body and skin temperature such as removal of excess garments or bed linen and maintenance of a stable and comfortable environment temperature.
Maintain a neutral or slightly acidic pH consistent with optimal healing
The skin has an acid mantle that ranges between a pH of 4.0 - 6.8. Wound healing is promoted when the skin and wound pH is maintained at a slightly acidic pH.
The clinician will:
• Avoid the use of alkaline soaps and cleansers
• Avoid leaving the wounds exposed for lengthy periods
• Avoid desiccation of wound bed as this increased alkalinity.
Prevent and manage infection
The clinician will observe infection control principles and reduce the potential risk of wound infection by:
• Performing the 5 moments of Hand Hygiene as required
• Using non-sterile or sterile gloves as deemed relevant for practice when there is a risk of contamination to the individual or clinician
• Assessing for the clinical signs and symptoms of clinical infection
• Performing qualitative or quantitative diagnostic investigation when clinically indicated to determine a definitive diagnosis of clinical infection
• Appropriately managing clinical infection.
Protect the wound environment
The clinician will endeavour to protect the fragile wound environment by:
• Avoiding aggressive wound cleansing unless the goal of care is mechanical debridement
• Avoiding the use of devices that desiccate or traumatise the wound bed or surrounding skin
• Avoid known or suspected toxic agents or allergens
• Protecting the wound and peri-wound area from trauma and maceration
• Removing foreign bodies from the wound
• Avoid packing a sinus where the depth of the sinus tracking cannot be determined without further investigation
• Ensuring that any packing or drainage tube inserted into a sinus must be in one continuous piece and remains visible and secure at the wound surface
• Avoid packing the wound too tightly, so that capillary blood supply is compromised
• Use pressure relieving devices to prevent further damage to the wound.
Maintain the integrity of wound management products, pharmaceuticals and devices
Maintain the integrity of wound management products and devices by:
• Appropriate and secure storage of dressing products
• Changing dressing or appliances as frequently as required to effectively remove excessive exudate or infected material
• Using appropriate dressings or appliances to contain anticipated amounts of exudate
• Use appropriate dressings to ensure patient comfort and compliance, while maintaining optimal healing environment.
Minimise the actual and potential impact of pain
• Adequately identify causative factors of pain
• Ascertain type of pain and its characteristics
• Implement strategies to prevent, minimise and manage pain
Use products and devices in accordance with licensing acts and/or regulatory bodies and manufacturing guidelines
All wound management products; devices and pharmaceuticals used in Australia should have Therapeutic Goods Administration endorsement unless they are used as a component of a research protocol with appropriate ethical approval.
The clinician will use wound management dressings, pharmaceutical and devices in accordance with the manufacturers’ instruction or research protocols
Section 1.1 Basic Dressing Technique
Procedure
To describe the procedure for undertaking a basic wound dressing that promotes:
• The utilisation of appropriate dressing material, optimal wound moisture balance, protection and wound temperature to ensure an optimal healing environment
• Provision of an environment that is conducive to patient comfort and healing when undertaking a basic wound dressing.
Equipment Acute and Ambulatory Care setting
• Alcohol based hand rub (ABHR)
• Dressing trolley
• Detergent impregnated wipes (to clean trolley)
• Personal protective equipment (PPE) includes, safety goggles or face shield and gown
• Clean gloves
• Sterile gloves (optional)
• General waste receptacle
• Clinical waste receptacle
• Basic dressing pack
• Normal saline packaged 30mls (at body temperature warmth) or other wound cleansing solution ie Prontasan.
• Additional gauze swab (optional)
• Dressing equipment as per patient’s care plan, (Note: there may be a need for change of the type of dressing based on the clinical assessment of the wound)
• Underpad for collection of excess saline e.g. gauze or absorbent pads
• Wound grid and tracing pen (optional) or camera (refer to digital photography policy).
Equipment Community setting
• Identify suitable clean surface in the home setting.
• Detergent impregnated wipes (to clean suitable surface)
• All equipment as above
Procedure
1. Check patient’s clinical record for any medical/nursing orders
2. Attend hand hygiene before touching the patient by either hand washing or using ABHR
3. Ensure privacy
4. Explain the process and purpose of the dressing change
5. Obtain verbal consent
6. Confirm allergies to dressings or tapes
7. Ensure adequate analgesic cover prior to dressing change
8. Ensure the patient is placed in a comfortable position
9. Attend hand hygiene by either hand washing or using ABHR
10. Clean trolley or suitable surface with detergent impregnated wipes and wipe dry
11. Set up equipment on trolley by the side of the patient
12. Discard packaging in general waste receptacle
13. Don PPE prior to opening sterile equipment
14. Open the basic pack and position equipment using the setting up forceps
15. Attend hand hygiene by either hand washing or using ABHR,
16. Don clean gloves
17. Expose the wound site
18. Remove the soiled dressing with setting-up forceps
19. Discard the dressing and forceps and gloves into the clinical waste receptacle
20. Attend hand hygiene by either hand washing or using ABHR
21. Open additional sterile equipment after reviewing the wound; add solution into the appropriate areas of dressing pack
22. Trace the wound and with "Wound Grid", if appropriate. (NB: This “wound grid" is not sterile.) Alternatively use camera to photograph the wound ensuring patient has consented prior to the photo being taken and confidentiality is maintained. Digital photographs require downloading to medical records, with patient’s UR number and date and time
23. Ensure that the process is timely so as to avoid exposing the wound to cooling temperatures
24. Attend hand hygiene by either hand washing or using ABHR
25. Don glove (clean or sterile)
26. Use wound cleansing solutions at body temperature irrigate with normal saline solution, to remove debris and contaminates
27. Clean the wound surface, swabbing from the non-discharged area to the discharging area (clean to dirty in one direction) and discard swab (into clinical waste receptacle). Or using gentle irrigation method (allowing a controlled pressure of saline using a syringe or saline container) by using warmed normal saline.
| |
|NOTE: |
|Do not use cotton wool swabs. Use gauze swabs only for cleaning of the wounds. |
28. Observe the wound for:
• Colour
• Depth
• Exudate, (describe the amount, colour and character from the wound)
• Granulation tissue, epitheliating, slough, necrotic, hypergranulation
• Peri wound skin
29. Assess the wound for clinical signs and symptoms of infection. If signs of infection cover the wound and notify the Medical Officer for review
30. Apply new dressing and secure with adhesive tape or bandages
31. Discard equipment and gloves into clinical waste receptacle
32. Clean trolley or surface with detergent impregnated wipes
33. Attend hand hygiene by either hand washing or using ABHR
34. Ensure patient is comfortable with new dressing change and understands when the next dressing change will be attended
35. Change dressing or appliances as frequently as required to effectively remove excessive exudate or infected material
36. Document in patient’s clinical record and wound care chart:
• a description of the wound
• type of dressing applied
• any change of dressing
• the reason for the change
• if using VAC® therapy consider type of sponge, cycle, pressure, dressing change interval and initial cycle
• signs of wound infection and actions taken (where noted)
Section 1.2 Wound Probing
• Examine and determine the depth and direction of a wound, sinus or cavity
• Promote optimal management strategies and healing outcomes for a patient with a wound bed involving a sinus
• Provide information on depth to assist in the decision making of product choice
Equipment Acute and Ambulatory Care Setting
• Alcohol based hand rub (ABHR)
• Sterile single use wound probe
• Sterile gloves
• Disposal measuring device, e.g. paper ruler
• Sharps bin
• Clinical waste receptacle
• General waste receptacle
• Basic dressing pack
• Normal saline warmed to body temperature
• Appropriate dressing
• Adhesive tape or bandages
• Clean gloves x2
• Personal protective equipment (PPE) including safety glasses, goggles or shield
• Clean dressing trolley (clean with detergent impregnated wipes).
Equipment Community setting
• Identify suitable clean surface in the home setting.
• Detergent impregnated wipes (to clean suitable surface)
• All equipment as above
|NOTE: |
|Single use only equipment will be used as per the manufacture’s recommendation, and dispose appropriately. Identify suitable clean |
|surface in the home setting. |
Procedure
• Ensure the following principles in Wound Management are followed.
• Assessment and evaluation of the healing rate and treatment plans are important components of wound care. By using the technique of wound probing in conjunction with wound tracing a two dimensional measurement of the wound can be created and recorded.
|ALERT: |
|Clinicians who perform wound probing should be familiar with the underlying anatomical structures that are in proximity to the wound in |
|order to avoid injury |
|Never use force when introducing a probe into a wound. |
|Do not use cotton tipped swabs or applicators as they may shed cotton fibres into the wound |
1. Attend hand hygiene before touching the patient by either hand washing or using ABHR
2. Explain procedure and obtain verbal consent
3. Ensure privacy
4. Position the patient to ensure comfort during the procedure
5. Ensure the patient has adequate analgesia for dressing change
6. Ensure the process is timely as to avoid lengthy exposure thus cooling the temperature of the wound
7. Attend hand hygiene by either hand washing or using ABHR
8. Prepare and set up equipment on clean dressing trolley or suitable surface
9. Discard packaging in general waste receptacle
10. Attend hand hygiene by either hand washing or using ABHR
11. Don goggles and gloves
12. Expose the wound site by removing the dressing
13. Remove gloves
14. Discard dressing, forceps and gloves in clinical waste receptacle
15. Attend hand hygiene by either hand washing or using ABHR
16. Don clean gloves
17. Clean wound with normal saline warmed to body temperature (warm N/Saline by immersing in bowl of warm water)
18. Introduce probe through opening of wound; gently guide probe along track of the wound or sinus
19. Note any tracking or shelving, including the direction of insertion
20. Place finger at skin level against the probe to indicate depth, do not move finger
21. Remove the probe and measure depth by placing probe next to measuring device (alternative probe have measuring scales )
22. Discard probe in sharps bin
23. Observe the wound for:
• Colour
• Depth
• Exudate (be descriptive)
• Granulation tissue, epithelialising, slough, necrotic, hypergranulation
• Peri wound skin
• Undermining or sinus
24. Apply new dressing and secure with adhesive tape or bandages
25. Discard equipment into clinical waste receptacle
26. Use appropriate dressing to ensure patient comfort and compliance, while maintaining optimal healing environment
27. Ensure patient is comfortable with new dressing change
28. Remove gloves and discard into clinical waste receptacle
29. Attend hand hygiene by either hand washing or using ABHR
30. Remove glasses or goggles and use ABHR
31. Document in patient clinical record and wound care chart, a description of the wound and any change in type of dressing and reason for change
32. Report any concerns to the Medical Officer
33. Communicate change of dressing product to community nurses if applicable
34. Change dressing or appliance as frequently as required
Section 1.3 Wound Debridement
Wounds are debrided to remove devitalised tissue from the wound bed to optimise wound healing. The presence of devitalised tissue slows the healing process and increases the risk of infection.
Methods of Debridement
1. Autolytic Debridement:
Autolysis uses the body’s own enzymes and moisture to re-hydrate, soften and finally liquefy hard eschar and slough. Autolytic debridement is selective; only necrotic tissue is liquefied. It is also virtually painless for the patient. Autolytic debridement can be achieved with the use of occlusive or semi-occlusive dressings that maintain wound fluid in contact with the necrotic tissue.
Advantages:
• Very selective with no damage to surrounding tissue
• A safe process using the body’s own defence mechanisms to clean the wound of necrosis
• Effective, versatile and easy to perform
• Little or no pain to patient
Disadvantages
• Not as rapid as surgical/sharp debridement
• Wound must be monitored closely for signs of infection
• May promote anaerobic growth if an occlusive hydrocolloid is used
2. Conservative Sharp Wound Debridement (CSWD)
Clinicians who are familiar with the anatomical structures can debride loose, sloughy or necrotic tissue from the wound bed. If tissue is adhered to the wound bed, do not debride as this may cause damage to adjacent tissues and structures. Refer to Medical officer/Specialist, Nurse Practitioner Wound Management, CNC Wound Management or Podiatrist.
• Clinicians performing CSWD must have a good knowledge of the anatomy and physiology of the area being debrided. Sloughy tissue may be similar in appearance to tendon or adipose (fatty) tissue and other structures. If in doubt do not debride, consult with Medical Officer/Specialist, Nurse Practitioner Wound Management, CNC Wound Management or Podiatrist.
• Aseptic non touch technique and sterile surgical equipment is to be used at all times, and disposed of appropriately. Adequate lighting, positioning of the patient and analgesic prior to the procedure is essential.
Advantages: Fast, can be extremely effective
Disadvantages: May be painful for patient, danger of damage to healthy tissue
Do not debride:
• Ischaemic ulcers that are covered with hardened eschar such as dry gangrene. There may be insufficient blood supply to support infection control and wound healing.
• Diabetic and neuropathic foot ulcers. Patients with diabetic and neuropathic foot ulcers should be referred to an appropriate podiatrist. Podiatry services are available for eligible clients at the High Risk Foot Clinic or through the Community Care Podiatry Service
• Patients with impaired blood clotting or who are taking anticoagulant medication.
Procedure for Conservative Sharp Wound Debridement
Equipment Acute and Ambulatory Care setting
• Alcohol based hand rub (ABHR)
• Sterile single debriding instruments (sterile scissors, forceps, or sterile scalpel blade and handle)
• Sterile gloves
• Disposable measuring device, e.g. paper ruler
• Sharps bin
• Clinical waste receptacle
• General waste receptacle
• Basic dressing pack
• Normal saline warmed to body temperature
• Appropriate dressing
• Adhesive tape or bandages
• Clean gloves x2
• Personal protective equipment (PPE) including safety glasses, goggles or shield
• Clean dressing trolley (clean with detergent impregnated wipes).
• Tracing sheet or probe for measuring wound
• Camera – take a photo before and after debridement
Equipment Community setting
• Identify suitable clean surface in the home setting.
• Detergent impregnated wipes (to clean suitable surface)
• All equipment as above
Procedure
Use an aseptic non touch technique when performing CSWD
Be aware of underlying and adjacent anatomical structures
1. Identify and assess area of loose sloughy or necrotic tissue
2. Gently cut away loose tissue, be conservative
3. Flush wound with tepid sterile saline to remove any loose debris
3. Mechanical Debridement
There are various forms of mechanical debridement
• Syringing out the wound with normal saline under pressure performs some degree of debridement of loose tissue.
• Showering may also provide some degree of debridement.
• The technique of allowing a dressing to proceed from moist to wet, then manually removing the dressing causes a form of non-selective debridement. Healthy or healing tissue can be debrided along with slough. This method can be time consuming and painful for the patient. This method is not recommended.
• Hydrotherapy is also a type of mechanical debridement. Its benefits vs. risks are an issue. Hydrotherapy can cause tissue maceration. Also water borne pathogens may cause contamination or infection. Disinfectant additives may be cytotoxic.
Section 1.4 Wound Swabbing
To obtain a wound specimen for clinical analysis when a clinical wound infection is suspected.
Equipment Acute and Ambulatory Care setting
• Alcohol based hand rub (ABHR)
• Basic dressing pack
• Normal Saline, 30mls warmed to body temperature
• Appropriate swab container and medium
• Underpad eg. Absorbent pad
• Gauze swab
• Personal protective equipment (PPE) including, safety goggles, glasses or shield and clean gloves
• Clinical waste receptacle
• General waste receptacle.
Equipment Community setting
1. Attend hand hygiene before touching the patient by either hand washing or using ABHR
2. Explain procedure and obtain patient consent
3. Ensure privacy
4. Attend hand hygiene by either hand washing or using ABHR
5. Position the patient to ensure that the patient will be comfortable during the procedure
6. Ensure that the process is timely as to avoid lengthy exposed thus cooling the temperature of the wound
7. Attend hand hygiene by either hand washing or using alcohol ABHR
8. Prepare and set up equipment on a cleaned dressing trolley
9. Discard packaging in general waste receptacle
10. Attend hand hygiene by either hand washing or using ABHR
11. Don clean gloves and goggles
12. Expose the wound site, by removing the dressing
13. Discard
14. Sampling should take place after wound cleansing and if appropriate debridement
15. Irrigate the wound with normal saline solution at body temperature to remove wound debris and/or contaminates
|ALERT: |
|If the wound is dry, moisten the swab with normal saline. If the wound is moist, a dry swab should be used. |
| |
|Remove excessive debris and all dressing residue without unduly disturbing the wound surface using gentle stream of warmed normal saline.|
|Wait for 1-2 minutes before taking the swab. |
16. Remove swab-stick from sterile container
17. Moisten wound swab with normal saline, or transport medium (not dry swab)
18. To swab the suspected infection site, use the Levine technique. The swab is rotated over a 1 cm square area with sufficient pressure to express fluid from within the wound tissue. This technique is believed to be more reflective of tissue bioburden than swabs of exudate or swabs taken within a broad Z-stroke. The Levine technique is the best technique for wound swabbing, provided the wound is cleansed first and the area sampled is over viable tissue, not necrotic tissue or eschar
19. Place swab specimen in container and labelled. Details required:
• Patient’s name
• UR number
• Date
• Time
• Anatomical site
• Full clinical details to ensure that the most appropriate staining, culture and antibiotic susceptibility analyses are performed and that the laboratory is able to provide clinically relevant advice
20. Arrange immediate delivery to pathology with completed request form
a. Apply the appropriate wound dressing. Note: dressing if antimicrobial eg silver impregnated dressing/ wound honey / iodine / chlorhexidine base
b. Discard in clinical waste receptacle
c. Attend hand hygiene
d. Document in the patients clinical record
e. Ensure that ongoing wound assessment and evaluation of the effectiveness of treatment are documented
Refer to the Infection Control documents for swabbing for MRSA and VRE patients, where "attention infection control" must be written on the pathology form
|ALERT: |
|Some wound dressings may not be appropriate to apply to an infected wound. |
Section 1.5 Wound suture and staple removal
• To remove sutures or staples with minimal trauma to the patient.
• Medical officer prescribes the removal of sutures and or staples.
Note:
In the Canberra Hospital Orthopaedic Fracture Clinic there is a standing order supported by the Clinical Director to allow RNs to remove sutures from two week post-operative review patients prior to their review by the Registrar, if wounds:
• are clean and dry,
• have no signs of infection, and
• have no evidence of dehiscence.
The technique used for removing sutures will depend on the:
• Type of sutures used either interrupted, continuous
• Style of insertion.
Alternative sutures and staples are removed first. If the wound union is satisfactory the remainder of the sutures and staples are then removed as prescribed unless otherwise ordered. Rationale: The method of alternative suture or staple removal may prevent wound dehiscence.
Surgical wounds usually heal by primary intention, this is where there is a minimal tissue loss and the edges of the wound are held in close apposition by sutures or staples, resulting in minimal scarring. The edges of the wound are held together by using sutures, staples and glues to effect primary closure.
Ensure prior to removal of sutures or staples appropriate length of healing time has taken place. The length of time a sutured wound will take to heal depends not only on the general health of the individual but also on the anatomical site of the incision.
|ALERT: |
|If the wound is unsatisfactory notify the medical officer prior to removal of any sutures or staples. If wound edges separate when suture|
|or staples are removed do not continue to remove sutures or staples. Notify the medical officer. |
Equipment Acute and Ambulatory Care setting
• Dressing trolley
• Detergent impregnated wipes to clean trolley
• Personal protective equipment (PPE) including, safety glasses, goggles or shield and clean gloves
• Sterile gloves
• General waste receptacle
• Clinical waste receptacle
• Paper bag for the disposal of used/soled materials
• Dressing equipment as per care plan, (NB: Dressing type will require review once sutures or staples are removed and document in clinical record
• Normal saline packaged 30mls, warmed to body temperature
• Basic dressing pack
• Appropriate under pad of collection of excess saline e.g. gauze or absorbent pads
• Sterile suture removal set, as appropriate. This maybe metal forceps and sterile stitch cutter or sterile staple remover.
• Check patients clinical record for any medical orders
Equipment Community setting
• Identify suitable clean surface in the home setting.
• Detergent impregnated wipes (to clean suitable surface)
• All equipment as above
Procedure
1. Attend hand hygiene before touching the patient by either hand washing or using ABHR
2. Ensure Privacy
3. Explain the process and purpose of the dressing change
4. Obtain verbal consent
5. Confirm allergies to dressings or tapes
6. Ensure adequate analgesic cover prior to dressing change
7. Ensure the patient is placed in a comfortable position
8. Attend hand hygiene by either hand washing or using ABHR
9. Clean trolley with detergent impregnated wipes and wipe dry
10. Set up equipment on trolley at the patient’s bedside
11. Don PPE prior to opening sterile equipment
12. Open the basic pack and position equipment using the setting up forceps
13. Discard packaging in general waste receptacle
14. Attend hand hygiene by either hand washing or using ABHR,
15. Don clean gloves
16. Expose the wound site
17. Remove the soiled dressing with setting-up forceps
18. Discard the dressing and forceps and gloves into the clinical waste receptacle
19. Attend hand hygiene by either hand washing or using ABHR
20. Open additional sterile equipment after reviewing the wound
21. Add solution into the appropriate areas of dressing pack (tray)
22. Use wound cleansing solutions at body temperature, irrigate with saline solution, to remove debris and contaminates
23. Attend hand hygiene by either hand washing or using ABHR
24. Don PPE
25. Clean the wound surface by:
26. Swabbing (in one direction only, clean to dirty) with normal saline soaked gauze, or irrigating with normal saline
27. Observe the wound for: unity of skin edges and peri wound appearance
28. Remove sutures or staples
Sutures
1. Lift the knot using forceps
2. Using a stitch cutter, cut between the knot and the skin, on one side as close to the skin as possible
3. Remove the suture by pulling the unexposed material through the wound
Staples
1. Using staple remover, slide the flat edge of the staple remover under the staple
2. Close staple remover in scissor like motion, using steady and firm pressure (the sides of the staple will move in an upward direction
3. Ensure the staple remover is fully closed and remains secure on the staple
4. Using a rocking movement gently free the staple from one side of the incision line then the other
5. Apply steri strips if required
6. Leave wound undressed or otherwise use appropriate dressings to ensure patient comfort and compliance
7. Discard equipment and gloves into clinical waste receptacle
8. Clean trolley with detergent impregnated wipes
9. Attend hand hygiene by either hand washing or using ABHR
10. Ensure patient is comfortable with the dressing change and understands management of their scar
11. Change dressing or appliances as frequently as required to effectively remove excessive exudate or infected material
12. Document in patient’s clinical record and wound care chart: a description of the wound, type of dressing applied, any change of dressing and the reason for the change
13. Signs of wound infection and actions taken (where noted)
14. Where applicable notify the community nurses of a change of dressing products / wound management plan to maintain continuity of care.
Section 1.6 Wound and sinus packing
To provide guidelines that outline the packing of a wound this is performed to:
• Promote healing by secondary intention in those wounds, which are described as a cavity of sinus
• Absorb exudate
• Prevent abscess formation
• Prevent premature closure of the wound surface
• Control odour if present
• Protect the surrounding skin
• Protect wound from pathogens and further trauma.
Equipment Acute and Ambulatory Care setting
• Alcohol based hand rub (ABHR)
• Basic dressing pack
• Sterile scissors
• Normal saline warmed to body temperature
• Appropriate secondary dressing for exudates management
• Packing materials (e.g. x-ray lined packing gauze, VAC® GranuFoam™ , VAC®WhiteFoam™), VAC® SilverFoam™)
• Adhesive tape or bandage to secure dressing
• Personal protective equipment (PPE) including safety goggles or shield and clean gloves
• Sterile gloves
• Sterile probe
• General waste receptacle
• Clinical waste receptacle
Equipment Community setting
• Identify suitable clean surface in the home setting.
• Detergent impregnated wipes (to clean suitable surface)
• All equipment as above
Procedure
1. Attend hand hygiene before touching the patient by either hand washing or using ABHR
2. Explain procedure to the patient and the purpose of packing a wound/sinus
3. Ensure privacy
4. Position patient to ensure comfort during the procedure
5. Ensure the patient has adequate analgesia cover for dressing change if required or requested
6. Ensure that the process is timely as to avoid lengthy exposure thus cooling the temperature
7. Open the basic dressing pack and position sterile equipment.
8. Attend hand hygiene by either hand washing or using ABHR
9. Don PPE
10. Expose the wound site by removing the dressing and packing material
11. Discard the dressing, forceps and gloves in the clinical waste receptacle
12. Attend hand hygiene by either hand washing or using ABHR
13. Don sterile gloves
14. Clean wound with warm normal saline
15. Assess the wound for clinical signs and symptoms of infection. Notify the medical officer if appropriate
16. Repack wound with appropriate packing material, the amount of packing material should be recorded. A sterile disposable probe or forceps may need to be used to assist in inserting the packing material into the wound
17. Leave a small wick of packing material exposed to facilitate easy removal. Cut the remaining packing material with sterile scissors
18. Apply appropriate secondary dressing and secure with tape or bandage
19. Discard equipment
20. Attend hand hygiene by either hand washing or using ABHR
21. Ensure client is comfortable with dressing and understands management regime
22. Change secondary dressing as frequently as required to effectively remove excessive exudate or infected material
23. Document in patient’s clinical record and wound care chart, assessment, dressing regime, amount and number of packing used and any change of dressing regime.
|ALERT: |
|Wound sinus should be loosely packed to prevent damage to granulating cells and retard healing. |
Section 1.7 Wound drainage tube shortening and removal
• To provide guidelines for the shortening and removal of drainage tubes
• This document pertains to adult or paediatric patient’s that require shortening or removal of drainage tubes at the Canberra Hospital and Health Services
Wound drainage systems are used to remove collections of fluid from around surgical incisions or wound in order to reduce:
• Tension placed on the wound by accumulated fluid that prevents healing
• Medium for growth of microorganisms to prevent infection
Shortening a drainage tube is performed to:
• Facilitate tissue granulation
• Remove excess drainage
• To remove the drain without trauma
Equipment Acute and Ambulatory Care setting
• Alcohol based hand rub (ABHR)
• Dressing trolley
• Detergent impregnated wipes (to clean trolley)
• Personal protective equipment (PPE) including safety glasses, goggles or shield and clean gloves and gown
• Basic dressing pack
• Sterile scissors
• Sterile metal forceps
• Sterile safety pin (if shortening the drain)
• Sterile Dressing towel
• Combine dressing and gauze swabs
• Sterile gloves
• Stitch cutter (if drain is sutured in)
• Solution normal saline x 30mls body temperature warmth
• Adhesive tape
• Clinical waste receptacle
• General waste receptacle
• Appropriate dressing to manage exudate, or redress the drain site.
Equipment Community setting
• Identify suitable clean surface in the home setting.
• Detergent impregnated wipes (to clean suitable surface)
• All equipment as above
Procedure
1. Check the medical officer's orders regarding removal of the drainage tube or the amount of tube to be shortened
2. Attend hand hygiene before touching the patient by either hand washing or using ABHR
3. Explain procedure and obtain patient consent
4. Ask the patient if they have any allergies to dressings or adhesive tapes
5. Ensure privacy
6. Ensure the patient has adequate analgesic cover prior to dressing change if required or requested
7. Attend hand hygiene by either hand washing or using ABHR
8. Clean dressing trolley with detergent impregnated wipes and wipe surface dry with disposable paper towel
9. Gather required equipment
10. Attend hand hygiene by either hand washing or using ABHR
11. Ensure that the patient is positioned in a comfortable position for the procedure
12. Position patient with wound drain area exposed
13. Place under-pad in position in proximity to the drain site
14. Attend hand hygiene by either hand washing or using ABHR
15. Don gown prior to opening sterile equipment
16. Don clean gloves and safety glasses
17. Set up equipment at the patient's bedside
18. Open the basic pack and position equipment using the setting up forceps
19. Open and add additional sterile equipment
20. Discard packaging into general waste receptacle
21. Pour solution into appropriate area of dressing pack
22. Remove the soiled dressing with setting-up forceps.
23. Discard the dressing and forceps and gloves into the clinical waste receptacle
24. Perform procedural hand washing
25. Don sterile gloves
26. Clean the drain site and wound, when swabbing discharging wounds, swab from the non-discharging area to the discharging area and discard swab in clinical waste receptacle
27. Swab gently and in one direction only (clean to dirty)
28. Observe the wound and at completion of procedure document in notes findings such as union of wound, signs of infection, exudate, inflammation and healing including:
a. The colour and depth of the wound
b. The amount, characteristics of wound exudate
c. Condition of surrounding skin (peri wound)
d. The amount of drainage tube shortened or the removal of the drainage tube
e. The condition of the tube (eg if removed not that tip is intact)
|ALERT: |
|Do not use cottonwool swabs. Use gauze swabs only for the cleansing of the wound and Report any concerns to the medical officer |
To Shorten a Drainage Tube
Follow steps 1-28 of above procedure
29. Remove suture holding drain insitu, with stitch cutter if present
30. Withdraw drainage tube gently, using a rotating movement to the prescribed length
31. Secure drainage tube with a sterile safety pin by inserting the pin in the drainage tube flush to the skin and at right angles to the wound
32. Cut the drainage tube 4cm above the level of the safety pin. (The pin will prevent the drain tube from slipping back into the wound; however will not stop the drain from falling or being pulled out)
33. Place drain dressing around the drainage tube under the safety pin
34. Apply dressing secondary dressing
35. Secure with adhesive tape if necessary
36. A wound drainage bag may be applied if drainage is excessive
37. Discard equipment and gloves into the clinical waste receptacle
38. Attend hand hygiene by either hand washing or using ABHR
39. Ensure patient is comfortable with new dressing change and understands when the next dressing change will be
40. Document in the patient’s clinical record and nursing care plan that the drain tube has been shortened.
To Remove a Drainage Tube
Follow steps 1-28 of above procedure
29. Remove suture, with stitch cutter if present
30. Withdraw drainage tube gently using a rotating movement
31. Swab wound, if required
32. Apply exudate absorbing dressing, secure with adhesive tape if necessary
33. A wound drainage bag may be applied if drainage is excessive
34. Discard equipment and gloves into the clinical waste receptacle
35. Attend hand hygiene by either hand washing or using ABHR
36. Ensure patient is comfortable with new dressing change and understands when the next dressing change will be
37. Document in the patient’s clinical record and nursing care plan that the drain tube has been removed.
38. Record and monitor exudate drainage in the clinical record.
|ALERT: |
|When a drainage tube, which has been inserted by a surgeon in the Operating Room is removed at Canberra Hospital, a second nurse who may |
|be a registered nurse or an enrolled nurse must witness the removal of the drainage tube. Both nurses must sign the Registered Nurse |
|Operating Theatre Report. |
Back to Table of Contents
|Section 2 – Managing Specific Wound Types |
Section 2.1 Skin Tears
To promote evidence base practice to the classification and management and prevention of a specific wound aetiology defined as skin tear.
Skin tear is defined as “a traumatic wound occurring principally on the extremities of the older adult, as a result of friction alone or shearing and friction forces.
Both shearing and friction forces separate the epidermis from the dermis (partial thickness wound) or which then separates both the epidermis and the dermis from underling structures (full thickness wound).
Validated tool to describe the extent of skin trauma is known as the Payne and Martin Classification System, 1993.
Skin tears require classification as part of the assessment of the wound.
Classification of skin tears is described in three categories as below;
Category I (skin tear without tissue loss)
• Skin flap can be approximated so that no more than one millimetre of dermis is exposed.
Category II (skin tear with partial tissue loss)
• Scant tissue loss. Partial thickness in which 25% of less of the epidermal flap is lost and at least 75% or more of the dermis is covered by the flap.
• Moderated to large tissue loss. Partial thickness wound in which more than 25% of the epidermal flap is lost and more than 25% of the dermis exposed.
Category III (skin tear with complete tissue loss)
• Epidermal flap is absent
Equipment Acute and Ambulatory Care setting
• Alcohol based hand rub (ABHR)
• Dressing trolley
• Detergent impregnated wipes (to clean trolley)
• Safety glasses or goggles
• Clean gown and gloves
• Sterile gloves
• Clinical waste receptacle
• General waster receptacle
• Basic dressing pack
• Sterile scissors
• Normal saline warmed to body temperature
• Appropriate primary and secondary dressing (Refer to Appendix 1)
• Underpad for collection of excess saline eg gauze or absorbent pads
• Dressing equipment as per patient’s care plan, (Note: there may be a need for change of the type of dressing based on the clinical assessment of the wound)
• Gauze swab moistened with saline to cover the wound prior to redressing
• Wound grid and tracing pen, disposable ruler (if appropriate) or camera.
Equipment Community setting
• Identify suitable clean surface in the home setting.
• Detergent impregnated wipes (to clean suitable surface)
• All equipment as above
Procedure
1. Attend hand hygiene before touching the patient by either hand washing or using ABHR
2. Check medical orders in patients clinical record
3. Obtain the patients consent
4. Ensure Privacy
5. Explain to the patient the process and purpose of the dressing change
6. Ask the patient if they have any allergies to dressings or tapes
7. Ensure the patient has adequate analgesic cover prior to dressing change if required or requested
8. Ensure that the patient is positioned in a comfortable position for the procedure
9. Attend hand hygiene by either hand washing or using ABHR
10. Clean trolley with detergent impregnated wipes and wipe dry
11. Set up equipment on trolley at the patient’s bedside
12. Don safety glasses and gown prior to opening sterile equipment
13. Open the basic pack and position equipment using the setting up forceps
14. Discard packaging in general waste receptacle
15. Attend hand hygiene by either hand washing or using ABHR
16. Don clean gloves
17. Expose the wound site
18. Remove the soiled dressing with setting-up forceps
19. Discard the dressing and forceps and gloves into the clinical waste receptacle
20. Attend hand hygiene by either hand washing or using ABHR
21. Open additional sterile equipment after reviewing the wound; add solution into the appropriate areas of dressing pack
22. Trace the wound and with "Wound Grid", if appropriate. (NB: This “wound grid" is not sterile.) Alternatively measure with a disposable ruler or use camera to photograph the wound ensuring patient has consented prior to the photo being taken and confidentiality is maintained. Digital photographs require downloading to medical records, with patient’s UR number, date and time
23. Attend hand hygiene by either hand washing or using ABHR
24. Don sterile gloves
25. Use wound cleansing solutions at body temperature irrigate with normal saline solution to remove debris and contaminates
26. Clean the wound surface, floating the skin across the wound to approximate the skin edges using the body temperature saline solution. Roll skin flap into place to obtain optimum skin coverage.
27. Protect the peri wound skin with skin prep.
|ALERT: Use gauze swabs only for cleaning of the wounds. |
28. Swab gently in one direction only
29. Classify skin tear into category using (Payne and Martin Classification System)
30. Observe the wound for: colour, depth, exudate, (describe the amount, colour and character from the wound), granulation tissue, epitheliating, slough, necrotic, hypergranulation and peri wound skin
31. Assess the wound for clinical signs and symptoms of infection. If signs of infection notify the Medical Officer
32. Apply new dressing (appendix A), silicone interfaced.
33. Document on dressing removal date and arrow to indicate “arrow head to face intact skin “
34. Remove dressing from arrow head to reduce further trauma to skin tear, use saline to assist with removal if required
35. Discard equipment and gloves into clinical waste receptacle
36. Remove goggles
37. Attend hand Hygiene by either hand washing or using ABHR
38. Clean trolley with detergent impregnated wipes
39. Ensure patient is comfortable with new dressing change and understands when the next dressing change will be attended
40. Change dressing or appliances as frequently as required to effectively remove excessive exudate or infected material
41. Document in patient’s clinical record and wound assessment and management chart: a description of the wound and location, type of dressing applied and any change of dressing and the reason for the change
42. Notify the community nurses of a change of dressing products to maintain continuity of management
43. Preventative management strategies, tubular bandage for protection of the limbs eg forearms and shin areas
ALERT: Most skin tears occur during routine handling of patients
Preventative strategies should:
1. Identify patients at risk
2. Implement strategies that prevent falls and other trauma
3. Gently handing of the patient and the use of transfer and repositioning devices that reduce friction and shear
4. Cover vulnerable skin surfaces with clothing and skin protection devices
5. Avoid adhesive dressing on fragile skin consider lightweight roller or tubular bandages
6. Optimise nutrition and hydration status
7. Avoid the use of drying of pH altering soaps and pharmaceuticals use emollients
8. Moisturise the skin regularly
9. Discuss with the patient, family and carers information and education on prevention of skin tears.
Referral to multidisciplinary teams should be considered eg Occupational Therapist for further preventive strategies and management, Physiotherapist, Dieticians for nutritional supplements and/or social worker. Eg protected bed rails, wheelchair plate covers.
• The patient’s wound is dressed with minimal discomfort and no adverse effects
• Wound healing is enhanced through appropriate dressing selection.
|Alert |
|Patients who have an allergy to silicone products use products which provide moist interface, protect the fragile skin environment and |
|absorb exudates. eg, tulle grass and non adherent foam. |
Section 2.2 Management of Burns
To describe the procedure and provide guidance to clinical staff responsible for the management of burns dressings
This document pertains to all patients who require management of burns dressings at the Canberra Hospital and health services, excluding the Emergency Department (ED).
Equipment Acute and Ambulatory Care setting
• Alcohol based hand rub (ABHR)
• Dressing trolley
• Detergent impregnated wipes (to clean trolley)
• Personal protective equipment (PPE) including safety glasses, goggles or shield, gown and clean gloves
• Sterile gloves
• Clinical waste receptacle
• General waster receptacle
• Basic dressing pack
• Sterile drapes (green)Sterile scissors
• Normal saline warmed to body temperature
• Appropriate primary and secondary dressing (Refer to Attachment 1)
• Adhesive tapes or bandages to secure dressing (minimise adhesive tapes where possible)
• Underpad for collection of excess saline e.g. gauze or absorbent pads
• Dressing equipment as per patient’s care plan, (Note: there may be a need for change of the type of dressing based on the clinical assessment of the wound)
• Gauze swab moistened with saline to cover the wound prior to redressing
• Wound grid and tracing pen, disposable ruler or camera
Equipment Community setting
• Identify suitable clean surface in the home setting.
• Detergent impregnated wipes (to clean suitable surface)
• All equipment as above
Procedure
Ensure the principles of Wound Management principles are maintained.
1. Attend hand hygiene before touching the patient by either hand washing or using ABHR
2. Check medical orders in patients clinical record
3. Obtain the verbal consent
4. Ensure Privacy
5. Explain to the patient the process and purpose of the dressing change
6. Ask the patient if they have any allergies to dressings or tapes
7. Ensure the patient has adequate analgesic cover prior to dressing change if required or requested
8. Ensure that the patient is positioned in a comfortable position for the procedure
9. Attend hand hygiene by either hand washing or using ABHR
10. Clean trolley with detergent impregnated wipes and wipe dry
11. Set up equipment on trolley at the patient’s bedside
12. Don PPE prior to opening sterile equipment
13. Open the basic pack and position equipment using the setting up forceps
14. Discard packaging in general waste receptacle
15. Attend hand hygiene by either hand washing or using ABHR
16. Don clean gloves
17. Expose the wound site
18. Remove the soiled dressing with setting-up forceps
19. Discard the dressing and forceps and gloves into the clinical waste receptacle
20. Attend hand hygiene by either hand washing or using ABHR
21. Open additional sterile equipment after reviewing the wound; add solution into the appropriate areas of dressing pack
22. Trace the wound and with "Wound Grid", if appropriate. (NB: This “wound grid" is not sterile.) Alternatively use camera to photograph the wound ensuring patient has consented prior to the photo being taken and confidentiality is maintained. Digital photographs require downloading to medical records, with patient’s UR number, date and time
23. Attend hand hygiene by either hand washing or using ABHR
24. Don sterile gloves
25. Use wound cleansing solutions at body temperature irrigate with normal saline solution to remove debris and contaminates
26. Clean the wound surface, swabbing from the non-discharged area to the discharging area (clean to dirty) and discard swab (into clinical waste receptacle) or using gentle irrigation method (allowing a controlled pressure of saline using a syringe) by using warmed normal saline to achieve cleansing.
|ALERT: Use gauze swabs only for cleaning of the wounds. |
27. Swab gently in one direction only
28. Observe the wound for: colour (red, yellow, green, black, pink), depth, exudate (describe the amount, colour and character from the wound), granulation tissue, epitheliating, slough, necrotic, hypergranulation and the peri wound Assess the wound for clinical signs and symptoms of infection. If signs of infection notify the Medical Officer
29. Apply new dressing and secure with adhesive tape or bandages
30. Discard equipment and gloves into clinical waste receptacle
31. Remove goggles
32. Attend hand Hygiene by either hand washing or using ABHR
33. Clean trolley with detergent impregnated wipes
34. Ensure patient is comfortable with new dressing change and understands when the next dressing change will be attended
35. Change dressing or appliances as frequently as required to effectively remove excessive exudate or infected material
36. Document in patient’s clinical record and wound care chart: description of the wound, type of dressing applied, any change of dressing and the reason for the change
37. if using VAC® therapy consider type and number of sponge, cycle, pressure, dressing change interval and initial cycle
38. Notify the community nurses of a change of dressing products to maintain continuity of management if appropriate.
|ALERT: Silver Impregnated Products |
|Silver impregnated products need to be removed prior to: |
|Radiation treatment |
|Medical Resonance Imaging (MRI) |
39. Referral to multidisciplinary teams should be considered eg Occupational Therapist for scar management, Physiotherapist, Dieticians for nutritional supplements and/or social worker.
Section 2.3 Management of lower leg ulceration
Causes of Leg Ulcers
• Vascular disorders
• Lymphatic disorders
• Autoimmune disorders
• Haematological disorders
• Metabolic disorders
• Tumours
• Infections
• Trauma
• Allergic responses
Treatment of the leg ulcer involves
• Removing or treating the cause
• Promoting circulation and improving venous return
• Promoting healing
• Promoting preventative care
Management of leg ulcers
The management of a leg ulcer is influenced by the patient’s co-morbidities; therefore a holistic assessment is required for any patient who presents with a leg ulcer, in addition to a comprehensive wound assessment. This information is to be documented on the wound assessment form
A holistic assessment includes
• Clinical history
• Clinical examination
• Palpation of pedal and leg pulses
• Hand held Doppler ultrasound
Vascular assessment
The aim of a vascular assessment is to distinguish arterial aetiologies from venous and other aetiologies and assess the extent of venous insufficiency.
Investigations that can assist in the diagnosis of ulcer aetiology
|Blood pressure (BP) |Measures the pressure of the blood on the vessel walls using a sphygmomanometer. It provides an |
| |indication of the possible presence of a range of cardiovascular diseases. The systolic BP is used in |
| |the calculation of ABPI. |
|Ankle brachial pressure index (ABPI) |A non invasive vascular test using Doppler ultrasound that identifies large vessel peripheral arterial |
| |disease in the leg. It is used to determine adequate arterial blood flow in the leg before use of |
| |compression therapy. Systolic BP is measured at the brachial artery and also at the ankle level. Using |
| |these measurements ABPI is calculated as the highest systolic blood pressure from the foot arteries |
| |(either dorsalis pedis or posterior tibial artery) divided by the highest brachial systolic pressure, |
| |which is the best estimate of central systolic blood pressure.41 An ABPI of 0.8 to 1.1 is usually |
| |considered indicative of good arterial flow in the absence of other clinical indicators for arterial |
| |disease. An ABPI of less than 0.8 and a clinical picture of arterial disease should be considered as |
| |arterial insufficiency. An ABPI above 1.2 is suggestive of possible arterial calcification. |
| |ABPI = highest systolic foot pressure |
| |Highest systolic brachial blood pressure |
|Duplex ultrasound |A non invasive test that combines ultrasound with Doppler ultrasonography in which the blood flow |
| |through arteries and veins can be investigated to reveal obstructions. |
|Photoplethysmography (PPG) |A non invasive test that measures venous refill time by using a small light probe that is placed on the |
| |surface of the skin just above the ankle. The test requires the patient to perform calf muscle pump |
| |exercises for brief periods followed by rest.43 The PPG probe measures the reduction in skin blood |
| |content following exercise. This determines the efficiency of the musculovenous pump and the presence of|
| |abnormal venous reflux. Patients with problems with the superficial or deep veins usually have poor |
| |emptying of the skin and abnormally rapid refilling usually less than 25 seconds |
|Pulse oximetry |A non invasive test that measures the red and infrared light absorption of oxygenated and deoxygenated |
| |haemoglobin in a digit. Oxygenated haemoglobin absorbs more infrared light and allows more red light to |
| |pass through a digit. Deoxygenated haemoglobin absorbs more red light and allows more infrared light to |
| |pass through the digit. There is insufficient evidence to recommend this investigation as the primary |
| |diagnostic tool. |
|Toe brachial pressure index (TBPI) |A non invasive test which measures arterial perfusion in the toes and feet. A toe cuff is applied to the|
| |hallux (or second toe if amputated) and the pressure is divided by the highest brachial systolic |
| |pressure, which is the best estimate of central systolic blood pressure. The TBPI is used to measure |
| |arterial perfusion in the feet and toes of patients with incompressible arteries due to calcification as|
| |may occur in patients with diabetes and renal disease. |
|Transcutaneous oxygen (TCPO2) |Measures the amount of oxygen reaching the skin through blood circulation. There is insufficient |
| |evidence to recommend this investigation as the primary diagnostic test. |
(Reproduced with permission of the Australian Wound Management Association. All rights reserved)
Ankle/Brachial Pressure Index
Registered Nurses and Allied Health must be assessed as competent in this procedure prior to attending an ABPI.
Equipment
• Hand held Doppler
• Ultrasound gel
• Tissues
• Sphygmomanometer cuff
• Doppler ABPI guide
• Hand wipes
Procedure
1. Explain procedure to the patient and obtain consent
2. Perform hand hygiene
3. Place the patient in the supine position, allay anxiety and encourage relaxation for at least 15 minutes to stabilise blood pressure
4. Obtain the brachial systolic pressure as follows
a. Place sphygmomanometer cuff around the arm
b. Palpate the brachial pulse
c. Hold Doppler probe between forefinger and thumb at 45-degree angle (pointed towards the heart) and place over brachial pulse until blood flow is maximally heard
d. Inflate the cuff until the ‘Doppler’ sound disappears; slowly deflate the cuff until the sound returns
5. Repeat this process on the other arm
6. The higher of these 2 readings is acknowledged as the brachial systolic pressure
7. Obtain the ankle systolic pressure as follows
a. Place the sphygmomanometer cuff around the leg just above the ankle. If the wound is at this site, cover it with plastic wrap or a sterile dressing
b. Locate the dorsalis pedis pulse on the same side
c. Apply gel over pulse
d. Hold Doppler probe between forefinger and thumb at 45-degree angle and place over dorsalis pedis pulse until blood flow is maximally heard
e. Inflate cuff until Doppler sound disappears; slowly deflate cuff until sound returns
8. Repeat this process for the posterior tibial pulse
9. Wipe the gel from the pulse sites
10. Acknowledge the higher of these 2 readings as the ankle systolic pressure for that particular leg
11. Calculate the patient’s ABPI by using the Doppler ABPI guide. If no guide is available, then calculate it manually as follows:
Ankle-Brachial Pressure Index (ABPI) = ankle systolic pressure
brachial systolic pressure
12. Repeat the procedure on the other leg
13. Document findings on wound clinical pathway and on leg ulcer assessment form
14. Clinical observation must be used in addition to the ABPI prior to the commencement of compression therapy
15. Consult with the patient’s Medical Practitioner regarding the results of the ABPI and a diagnosis of venous/arterial ulceration
If a patient’s ABPI is unable to be determined, eg. due to pain or difficulty obtaining an accurate reading, their Medical Practitioner must be notified. The patient may be referred on for further investigations such as a Duplex Arterial Ultrasound.
Compression Therapy
• Registered Nurses who have been assessed as competent in obtaining an ABPI recording can instigate compression bandaging if the ABPI reading falls between 0.8 and 1.2mmHg and a comprehensive holistic assessment has been performed.
• Registered Nurses and Enrolled Nurses must be assessed as competent in applying compression bandaging prior to attending this procedure
• When ABPI is < 0.8 or > 1.2, consult with the patient’s GP or Medical Specialist prior to applying compression bandaging and obtain a written order:
The medical order must specify
– Type of compression therapy for e.g. high stretch or short stretch, two layer or four layer bandage or stockings
– Amount of pressure to be applied
– Which limb to apply compression therapy
– Where possible use two layer bandages and change weekly
– Notify the GP if a leg ulcer shows no signs of healing after three months or if there is a cause for concern prior to this
– A non healing leg ulcer should be referred to the Nurse Practitioner Wound Clinic. (See Wound Management Service Referrals in the Community Care Program SOP)
– Please note if the Nurse Practitioner is away e.g., on leave, the GP should be notified and assess the patient and refer onto appropriate Medical Specialist or health facility
Do not apply compression bandaging to a patient if the ABPI is less than 0.8 or above 1.2 without a medical order from their GP/Medical Specialist/Nurse Practitioner Wound Management/CNC.
• ABPI < 0.8: liaise with patient’s Medical Practitioner regarding the possibility of further investigations to accurately determine the aetiology
• ABPI < 0.5 liaise with patient’s Medical Practitioner - advise the patient to seek an urgent referral to a vascular surgeon
• ABPI > 1.2 may indicate uncompressible arteries; therefore seek advice from the medical practitioner or Nurse Practitioner Wound Management prior to commencing compression therapy
Venous Leg Ulcers
• Generally located lower 1/3 of leg – anterior to medial malleolus
• Patient may have a history of deep venous thrombosis, valvular incompetence, obesity or a deficit in calf muscle pump function
Management of venous leg ulcers
1. Assess and document leg ulcer on wound assessment form
2. Photograph leg ulcer every two weeks or if there is a deterioration in the ulcer
3. Cleanse wound and leg at dressing change
4. Encourage patient to shower leg and ulcer prior to dressing change – ensuring there is no contamination of the ulcer
5. Apply moisturiser to the leg
6. Apply appropriate dressing according to the wound assessment and treatment orders
7. Ensure patient has been assessed for peripheral arterial disease and that it is safe to apply compression therapy
8. Apply compression therapy as per treatment orders and as per the manufacturer’s recommendation
9. Apply an elastic retention tube to assist the bandage to stay in place if required.
10. The compression bandage may be left intact for up to 7 days.
11. More frequent changes may be necessary if there is excessive exudate or if clinical signs of infection are present.
12. The bandage may need to be loosened if there is discomfort or tingling/numbness in foot/toes
13. Refer patient to dietitian if ulcer present for > three months or wound healing delayed
14. Ensure patient has adequate pain control
15. Advise patient to
a. walk regularly or perform calf/foot exercises
b. elevate feet above level of heart when sitting
c. inspect skin integrity daily, and moisturise skin
d. stop smoking
e. lose weight if obese
f. follow a nutritional diet
16. Venous leg ulcers usually recur unless preventative measures are maintained. Patients should continue wearing compression hosiery as prescribed and purchase new stockings at least every six months
Advise the patient to remove the bandage if they experience an increase in pain or discomfort, notice discolouration, coolness or pain in their foot/toes.
Manual Handling Risk - Technique for applying graduated compression bandage
|Manual Handling (MH) risks are associated with dressing and bandaging of patients’ lower limbs. |
|At the initial patient assessment a Community Manual Handling Risk Assessment Tool is to be completed and the care plan is adjusted |
|accordingly. |
|In order to minimise the risks to the clinician the following should be considered: |
|Working at waist height, avoid stretching/twisting/turning |
|Treating the patient in the Ambulatory Care Clinic (where adjustable bed/equipment is available) |
|Using equipment/aids such as leg lifter, stool and height adjustable hospital bed |
|Two staff members attending to dressing/bandaging (especially for obese and bariatric patients) |
|Reducing the frequency of dressing and bandaging, using two layer and four layer bandaging and try to leave intact for seven days |
|When more frequent changes are ordered by the treating doctor, the case manager can contact the doctor and discuss alternatives. |
Examples of available compression systems
|Also referred to as |Description and function |
|Two, three and four layer bandaging |A compression system with more than one layer or aspect. Most bandaging systems include at least a |
| |padding layer and bandages so are classified as multi-component systems. |
| |Can also refer to a system that consists of several layers which use a combination of elastic and |
| |inelastic bandages (ie. four layer bandage system). This system is also available as kits. |
|Short stretch bandages |Bandages with minimal or no elastomers. Low extensibility and high stiffness (high SSI). Low resting |
| |pressure and high working pressure. |
| |Compression bandaging system that has only one layer or aspect to the system. Most bandage systems |
| |currently used in practice include a padding layer and so are not described as single component systems. |
|Tubular stockings, compression |Available in a range of compression levels. International consensus on compression scales is lacking and |
|stockings, |different scales are used around the world. Two scales and/or classifications of compression hosiery |
|multi-layer hosiery systems |commonly used by Australian and New Zealand manufacturers include: |
| |Scale one:120 |
| |extra light (5mm Hg) |
| |light (15 mm Hg) |
| |mild (18—24 mm Hg) |
| |moderate (20—40 mmHg) |
| |strong (40—60 mmHg) |
| |very strong (>60 mmHg) |
| |Scale two: |
| |Class I |
| |Class II |
| |Class III |
| |Class IV |
|Unna’s boot |Although there are several systems referred to as Unna’s boot it is commonly a gauze bandage impregnated |
| |with zinc paste under a cohesive inelastic bandage. |
|Pump compression |Pressure is applied via a boot inflated by a machine either continuously, intermittently or in sequential|
| |cycles. |
(Reproduced with permission of the Australian Wound Management Association. All rights reserved)
Arterial Leg Ulcers
Arterial leg ulcers occur due to peripheral arterial disease and are frequently located between toes and at tip of toes, over phalangeal and metatarsal heads, on side or sole of foot.
Management of Arterial Ulcers
1. Assess and document leg ulcer on wound assessment form
2. CCP
3. Photograph leg ulcer every two weeks or if there is a deterioration in the ulcer
4. Cleanse wound and leg at dressing change
5. Encourage patient to shower leg and ulcer prior to dressing change – ensuring there is no contamination of the ulcer
6. Apply moisturiser to the leg and foot
7. Apply appropriate dressing according to the wound assessment and treatment orders
8. No compression bandaging of limb as this will reduce the blood supply
9. If the ABPI is < 0.8, advise the patient to seek an urgent referral to a vascular surgeon
10. Liaise with patient’s Medical Practitioner regarding a referral to a vascular surgeon
11. Refer patient to a Podiatrist
12. Refer patient to a Dietitian
13. Refer patient to a Occupational Therapist if pressure injury prevention strategies are indicated
14. Ensure patient has adequate pain control
15. Advise the patient to
16. exercise as tolerated
17. inspect skin integrity daily, and moisturise skin
18. avoid tight clothing/shoes
19. avoid trauma to the skin (including adhesive tapes and thermal extremes)
20. stop smoking
21. ensure that legs are in a neutral or dependant position whilst sitting or lying
22. lose weight if obese
23. follow a nutritional diet
Do not debride ischaemic ulcers that are covered with hardened eschar, such as dry gangrene. There may be insufficient blood supply to support infection control and wound healing.
For arterial ulcers – Do not apply compression bandaging of limb as this will further reduce the blood supply to the lower leg.
Mixed Arterial/Venous leg Ulcers
• Ulcers are considered to be mixed when more than one factor is operative, eg. Venous leg ulcers associated with diabetes, peripheral arterial disease, or rheumatoid arthritis
• Compression therapy may be contra-indicated in these patients due to poor peripheral arterial circulation
• If light compression is prescribed by the Medical Practitioner or Specialist, the circulation of the patient’s leg/feet must be monitored at each visit to prevent and detect any early signs of ischaemia
• Advise the patient to remove the bandage if they experience an increase in pain or discomfort, notice discolouration, coolness or pain in their foot/toes
• Consultation should be sought with a vascular surgeon
Possible indicators for specialist referral include:
(Reproduced with permission of the Australian Wound Management Association. All rights reserved)
• Diagnostic uncertainty
• Atypical ulceration distribution
• Suspicion of malignancy
• For treatment of underlying conditions including diabetes, rheumatoid arthritis and vasculitis
• Peripheral arterial disease indicated by an ABPI less than 0.8
• ABPI above 1.2
• Contact dermatitis
• Ulcers that have not healed within 3 months
• Recurring ulceration
• Healed ulcers with a view to venous surgery
• Antibiotic resistant infected ulcers
• Ulcers causing uncontrolled pain
Section 2.4 Managing Skin Grafts and Donor Sites
Skin grafting, also known as skin transplants or auto-grafts, is a surgical procedure in which a piece of skin is transplanted from one location of the body to another area of a patient’s body to cover a wound that involves a defect in skin and/or subcutaneous tissue. Skin grafting is used to replace skin lost by injury. The area where the skin is removed from is called the donor site.
Skin grafts are used to speed up the healing and reduce the risk of infection. Care of a skin graft depends on the type of graft.
There are two types of skin grafting procedures: split-thickness and full-thickness. Split-thickness skin grafts (STSG) include the upper layer (epidermis) and most of the lower layer (dermis) of the skin. A full-thickness skin graft (FTSG) transfers all layers of the donated skin to the wound. A FTSG offers more durable coverage and more sensation than a STSG.
A split-thickness skin graft can be meshed or non-meshed prior to placement. The process of meshing allows fluid from within the wound to escape through the fenestrations, thus decreasing the risk of graft failure due to the pressure of trapped wound fluids. Meshing the skin also increases the amount of area that can be covered as the skin can be expanded up to nine times.
A full-thickness skin graft is harvested by excision. A FTSG is closed primarily with skin closure devices and the incision can be cared for with a topical ointment. This wound should heal with a fine line scar. A FTSG is taken from areas that most closely match the area where they are to be transplanted. For example, a defect on the face can be covered by skin from behind the ear.
Postoperative Care
Split skin graft (or split thickness graft)
The donor and grafts sites must be protected and the pain controlled. The graft site is elevated and never left in a dependent position. While the skin graft is adhering to the wound bed, the graft must be protected from fluid collection, tension and movement.
Collection of wound fluid, blood and serum beneath the skin graft can separate it from the wound bed. This collection of fluid prevents revascularization, therefore inhibiting nutrient and oxygen from interfacing with wound bed and grafted tissue. Fluid collections can be evacuated by piercing the graft with a 25g needle, then using a sterile applicator to wick out the fluid. A Medical Officer’s order is required prior to removing any collection of fluid.
Revascularization begins within 36 hrs. The surgeon will usually remove the surgical dressing 3 to 5 days after surgery. At this time the graft should appear pink as capillary buds are formed and circulation is maintained. If no blood supply is present, the grafted area will appear white. If infection is present, the graft will have a red or inflamed appearance with graft loss.
When the graft is harvested it can be applied to the bed immediately or it can be stored to be applied later, this is called ‘delayed grafting’. The skin can be preserved for up to 2 weeks, by storing the donor skin on normal saline soaked gauze in a sterile container in the fridge.
Donor Sites
Following harvesting of the donor site, primary dressings are placed on the wound and pressure bandaging applied, because the donor site is a superficial wound that is likely to bleed. The pressure bandages remain intact for usually in excess of 24-48 hours. Primary dressings should remain intact until the dressings can be removed without trauma, usually in 10-14 days.
If leakage occurs, and clinical assessment does not indicate infection, the primary dressing should be reinforced. If leakage persists, the primary dressing should be removed and the site assessed for signs of infection. Redress the site with the primary dressing as per Medical Officer’s orders.
If the donor site has healed, leave exposed and teach patient/carer to apply a non perfumed, water based cream (Aqueous cream) 3 times per day. The donor site area once healed may be hypersensitive to touch, advise patient/carer that touching the area will help with de-sensitising. Advise the patient to avoid UV exposure to the donor site and apply sun screen when outdoors.
Full Thickness Grafts (Wolfe Graft)
These grafts are sutured to immobilise the graft. Follow Medical Officer’s orders regarding removal of sutures and dressing instructions.
Depending on the size of the graft, the donor site may be closed by primary intention or covered with a split skin graft.
Dressing procedure
Skin grafts and donor sites are considered acute wounds and an aseptic non touch technique is used when attending to dressings.
Section 2.5 Postoperative managing of Skin Flaps
Skin flaps
A flap is a surgical relocation of tissue from one part of the body to another part. Flaps contain skin and subcutaneous tissue but can also contain underlying fascia, muscle or bone.
This relocation will create a secondary defect that will require grafting or primary closure
Indication for flaps:
• Reconstructive surgery following major surgery such as tumour resection (e.g mastectomy)
• Extensive trauma or surgical management of a chronic wound (e.g pressure injury)
• Areas of prior infection
• Replants of a traumatically severed or complete amputation of body part most commonly fingers.
The most common types of flaps are:
• Free- flap: relocation of skin and subcutaneous tissue with an anastomosis of its blood vessels to the receiving area’s blood vessels.
• Pedicle- flap: transfer of skin and subcutaneous tissue but blood supply is maintained until a new blood supply is established. The pedicle is then freed.
• Rotational- flap: local pedicle flap whose width is increased by having the edge distal to the defect form a curved line; the flap is then rotated and a counter incision is made at the base of the curved line, which increases the mobility of the flap.
• DIEP (Deep Inferior Epigastric Perforator) Flap: based on the deep inferior epigastric vessels, an artery and vein at the bottom of the rectus abdominis muscle. These vessels provide the primary blood supply to the skin and fat of the lower abdomen. The lower abdominal skin and fat is removed without having to harvest any of the rectus abdominis muscle. Blood supply is provided through the perforator vessels that are teased out form the rectus muscle, using a muscle incision.
Post-operative management of skin flap (not including DIEP flap)
Equipment:
• Alcohol based hand rub (ABHR)
• PPE including clean gloves
• Doppler
• Lubricant
• Tissue
• General waste receptacle
Procedure:
1. Explain procedure to the patient and obtain consent
2. Perform hand hygiene
3. Ensure privacy
4. Position the patient to ensure comfort during the procedure
5. Don PPE (as indicated)
6. Expose flap site
7. Perform and document flap observations as per Limb Observation Chart-Skin Flap form. Refer to The Canberra Hospital – Limb Observation Chart – Skin Flap and ACT Health – Neurovascular Observations Chart which can be found on the Clinical Forms Register
8. Ensure no pressure is applied anywhere near the flap
9. Attend capillary refill, flap temperature, colour, peripheral temperature, urine output, blood pressure, doppler thrill and drain output
10. To check for doppler sounds, locate the area where it is marked by the Surgeon
NOTE:
Frequency of flap observations is dependent on the Plastic VMO orders. Daily review, documentation of the treatment, and ongoing management plan for flap is required by the treating team. If any change in condition, the treatment must be reviewed more frequently as required. The Plastic VMO may order a 1:1 special nurse, skilled in microvascular observations, if the flap requires closer and more frequent observations
11. Wipe excess lubricant from doppler site
12. Cover flap if necessary
13. Remove PPE
14. Perform hand hygiene
15. Record observations attended.
16. Any changes from previous observations should be reported to the Plastics registrar on duty
17. Keep patient warm and comfortable
18. Cleanse doppler with neutral detergent wipes
19. Perform hand hygiene
20. Skin flaps will be sutured, check Surgeons orders regarding removal of sutures.
ALERT:
Contact the treating Plastic Registrar when:
• Flap becomes congested, blue or white
• Capillary return is sluggish, brisk (36.5° C |100mmHG or depending on Surgeon’s accepted |Drop in blood pressure inform Plastic |
| |value |Registrar |
Post operative management of a DIEP flap
ALERT:
A DIEP flap will always require a 1:1 special nurse, skilled in post microvascular observations, for a minimum of 48hrs post op. The 1:1 special nurse can only be ceased by the Plastic VMO.
Frequency of observations
• 15 minutely for first 6 hours
• 30 minutely for the next 12 hours
• Review by consultant to determine ongoing frequency
Equipment:
• Alcohol based hand rub (ABHR)
• Clean gloves
• Doppler
• Lubricant
• Tissue
• Bair hugger
• Alternating air mattress (reactive)
• General waste receptacle
Procedure:
1. Increased Patient Care/ Supervision Request Form must be completed by the ward CNC or the Team Leader on the shift. Refer to ACT Health Increased Patient Care / Supervision Request Form which can be found on the Clinical Forms Register. Requirement of the special can be changed according to frequency of observations (e.g hourly flap observations)
2. Staff to organise alternating air mattress, calf compressors, and bair hugger from Central Equipment Stores, prior to the patient coming to the ward. Alternating air mattress can be requested to be sent to Recovery so that patient can be transferred directly to this post surgery (Patients will require to be resting in bed for 48 hours or as directed by the Plastic surgeon)
On admission to the ward:
3. Special Nurse together with the ward Nurse In-charge will receive handover from Recovery nurse, making sure flap hand over and observation is performed in front of the receiving nurse and documented. If doppler is required, ensure exact location where to use doppler and doppler sounds have been handed over.
4. Post operative observations to be attended as per protocol. Refer to ACT Health Post Operative Handover and Observations – Adult patients (first 24 hours) which can be found on the policy register
5. Monitor Observations as per Limb Observation Chart – Skin Flap. Refer to Post operative management of skin flap for management of skin flap observations
6. Frequency can change depending on Plastic Surgical team instructions.
7. Flap observations are to be handed over at the bedside. The outgoing nurse to handover the flap observations along with the location of the flap and also the Doppler sound to be handed to the incoming nurse.
8. To check for doppler sounds, locate the area where it is marked by the Surgeon
9. Connect the bair hugger and maintain desired temperature of patient (as directed by surgeon)
10. Monitor urine output every hour and Intravenous fluid therapy can be titrated according to the output but only if advised by the Plastic Registrar
11. Check, monitor, and date the drains. Change the drain bag and record the output every 24 hours. Document the drain output on the Fluid Balance Chart. (Monitor and ensure the drain patency as these patients are at high risk of seroma)
12. Ensure patient has adequate analgesia
13. Do not apply pressure on the flap
14. Monitor donor site for bleeding or ooze
15. Monitor Haemoglobin level
Other types of microvascular surgery:
Replantation: the restoration of any body part to its original site. This also requires repairing of blood vessels, nerves and tendons. It is commonly used in post traumatic injury such as finger amputation. Bone is often shortened to allow extra length of vessels for tension free anastomosis. K wires are used to join the bone, usually retained for 4-6 weeks until the bone unites.
Management:
• Refer to Flap post-operative observations
• If replantation deteriorates, may require leech therapy ordered by the Plastic VMO. Refer to Medicinal Leech Therapy Clinical Procedure for management.
Section 2.6 Managing Malignant Wounds
Malignant wounds develop by direct extension from a tumour to the skin, as a secondary tumour, or as a result of lymph nodes that are involved with disease.
These lesions mainly occur with cancers of the breast, kidney, head and neck, lung, ovary, colon, penis and bladder. They may also occur with lymphoma, leukaemia and melanoma.
Initially they will appear as a firm, flesh coloured nodule and may eventually turn red or blue. These lesions quickly develop a necrotic core because of poor oxygenation and metabolite toxicity. The skin will eventually break down.
Chemotherapy or radiation therapy is sometimes used to reduce the size of the mass, limit the bleeding, or control the pain.
Vigorous cleaning should be avoided as this will predispose the wound to bleeding.
Sharp debridement is contraindicated because of the persistent nature of the necrosis and the friability of the underlying tumour.
Following discussion with the patient, the primary goals are:
• Reducing odour
• Managing exudate
• Promoting comfort
• Preventing bleeding
• Preventing Infection
• Maintaining aesthetics
Malodour
Malodour is a frequent problem in fungating wounds, and is caused by bacterial activity in the devitalised tissue. Odour may be controlled by the topical application of Metronidazole or Manuka honey. Carbon based dressings may also be used for odour control however in case of excessive exudate the charcoal will be inactivated by the moisture. Dressings may need to be changed daily, depending on the odour and the amount of exudate.
Environmental factors such as good ventilation and room deodorants may assist with odour control.
Exudate management
Excessive exudate may occur due to the increased permeability of blood vessels within the tumour and the secretion of vascular permeability factor by tumour cells. Suitable dressing products for a highly exudating malignant wound include: alginate, hydrofibre, foams, or non-adherent contact dressings with an absorbent secondary dressing. Drainage bags may be required to collect high volume exudate.
Pain
Pain may be caused by the tumour itself, or by adherence of the dressing to the wound. Ensure the patient has adequate pain relief, particularly prior to dressing change. Choose an appropriate dressing product that will not cause pain upon removal such as: non-adherent dressing, impregnated gauze, calcium alginate, hydrocolloids, hydrogels, and foams. Cleansing the wound by irrigation or showering will be less painful for the patient than a swabbing technique.
Bleeding
Malignant wounds frequently bleed due to erosion of blood vessels. The risk of bleeding can be minimised by using non-adherent dressings and avoiding trauma to the wound. Bleeding may be controlled by the application of alginate dressings or stomahesive powder. Refer the patient to their Medical Practitioner if continual heavy bleeding occurs, as cautery or ligation may be necessary. Where possible, secure the dressings with a tubular dressing (mesh) to prevent any additional skin damage from repetitive tape removal.
Aesthetics
Malignant wounds can affect a patient’s self esteem. Appropriate wound management techniques can have a positive effect on self-esteem. Promote quality of life by using dressings that minimise disfigurement, such as skin coloured dressings. Referral to Palliative Care Service may be required for a multi-disciplinary approach to patient care.
Infection
Malignant wounds are susceptible to infection because of devitalised or decayed state of the tissue. Topical antiseptic dressings such as cadoexemer iodine, honey, silver, polyhexamethyl biguanide can assist in the control of infection. Systemic antibiotics may need to be prescribed.
Back to Table of Contents
|Implementation |
These procedures will be implemented and communicated through all educational wound care days facilitated through the Staff Development Program in the Staff Development Unit and Practice Development Program in the Community Care Program (CCP). Clinical Development Nurses and Allied Health Educators will be alerted to these procedures in the clinical areas.
Back to Table of Contents
|Evaluation |
Outcome Measures
• Adults and children with a wound will be assessed and managed safely
• Wound management is practiced according to the best available evidence for optimising healing acute or chronic wounds
• Clinicians adhere to the general principles of care and management of patients with a wound and to the procedures outlined in this document
• Wound management plans are developed in consultant with patient and carers
• Increase aseptic non touch technique for wound dressing technique compliance
Method
• Compliance with assessment and management of a wound will be conducted through the annual clinical record documentation audits, audit angels, and feedback is reported at team/unit meetings
• Ongoing assessments are performed and documented on the wound assessment chart to provide evidence of wound healing or deterioration in wound healing which may influence the management plan and product choice.
• Riskman clinical incident reports are monitored and any issues relating to wound management are assessed by the relevant nursing and allied health managers and discussed with relevant clinicians
• Riskman clinical incidents reports are monitored by the Tissue Viability Unit at Canberra Hospital and the Nurse Practitioner – Wound Management and CNC in the CCP and discussed with the relevant clinicians and managers
• Consumer engagement - liaise with relevant managers regarding patient feedback
Back to Table of Contents
|Related Policies, Procedures, Guidelines and Legislation |
• ACT Health Infection Prevention and Control Policy
• ACT Health Waste Management Policy
• Canberra Hospital & Health Services Personal Protective Equipment SOP
• ACT Health Nursing and Midwifery Continuing Competence Policy and SOP
• Non-Diagnostic Digital Photography Images and/or Recordings Policy, SOP and Consent
• Canberra Hospital & Health Services Aseptic Non Touch Technique -SOP
• Hand Hygiene SOP
Back to Table of Contents
|References |
Australian Wound Management Association Inc, (2009) AWMA Position Document: Bacterial impact on wound healing: From contamination to infection. AWMA.
Australian Wound Management Association Inc ,(2001)the Australian and New Zealand Clinical Practice Guideline for Prevention and Management Venous Leg Ulcers. Cambridge Media Osborne Park, WA.
Australian Wound Management Association Inc, (2010) Standards for Wound Management
Bale S; Jones, V. (2006), Wound Care Nursing – A patient –centred approach 2nd Edition
Carville, K. (2005), Wound Care Manual 5th Edition, Silver Chain Nursing Association WA
European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel Pressure Ulcer Prevention and Treatment Clinical Practice Guidelines (2009) accessed 1/8/14
Dealey, Carol. (2013), The care of wounds: a guide for nurses, Wiley-Blackwell, UK
Flanagan, M, (2013) Wound Healing and Skin Integrity, Principles and Practice, Wiley & Sons.
National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.
New South Wales Severe Burn Injury Service: accessed 10 August 2014
Principles of best practice; Wound Infection in clinical practice. (2008), An international consensus. London: MEP Ltd.
Sargent, R. L. (2006), Management of blisters in the partial-thickness burn: an integrative research review. Journal of Burn Care & Rehabilitation. Vol 1. 66-81.
Wound Healing and Management Node Group, 2012. Evidence summary: Wound infection - iodophors and biofilms, The Joanna Briggs Institute/Curtin University.
Wound Healing and Management Node Group, 2012. Evidence summary: Wound infection -silver products and biofilms, The Joanna Briggs Institute/Curtin University.
Wound Healing and Management Node Group, 2012. Evidence summary: Wound Management Dressing - Alginate, The Joanna Briggs Institute/Curtin University.
Wound Healing and Management Node Group, 2013. Evidence summary: Wound Management: Debridement - wet to dry moistened gauze The Joanna Briggs Institute/Curtin University.
Wound Healing and Management Node Group, 2014. Recommended Practice: Ankle Brachial Pressure Index: Using a hand held Doppler. The Joanna Briggs Institute/Curtin University.
Wound Healing and Management Node Group, 2013. Evidence summary: Wound Management: Autolytic, The Joanna Briggs Institute/Curtin University.
World Union of Wound Healing Societies (2008). Principles of Best Practice, Diagnositics and Wounds. A consensus Document London MEP Ltd.
Back to Table of Contents
|Search Terms |
• Wound
• Wound Management
• Acute wounds
• Chronic wounds
• Painful wounds
• Wound Infection
• Wound debridement
• Compression bandaging
• Burns
• Skin tears
• Leg ulcers
• Malignant wounds
• Wound drains
• Wound swab
• Packing a sinus
• Removal of sutures/staples
Back to Table of Contents
|Consultation |
|Name/position/Division of |Feedback Received |Feedback |Comment |
|person(s) consulted |Yes/No |incorporated | |
| | |Yes/No | |
|NP Wound Management Rehabilitation|Yes |Yes | |
|Aged and Community Care (RACC) | | | |
|Community Care Program | | | |
|CNC Tissue Viability Unit Canberra|Yes |Yes | |
|Hospital | | | |
|CNC Wound Management (RACC) |Yes |Yes | |
|Community Care Program | | | |
|CDN 11B Canberra Hospital |Yes |Yes | |
|CNC (RACC) Community Care Program |Yes |Yes | |
|Nurse Manager Tuggeranong Health |Yes |Yes | |
|Centre Nursing Team (RACC) | | | |
|Community Care Program | | | |
|Nurse Manager Phillip Health |Yes |Yes | |
|Centre Nursing Team (RACC) | | | |
|Community Care Program | | | |
|Nurse Manager City Health Centre |Yes |Yes | |
|Nursing Team (RACC) Community Care| | | |
|Program | | | |
|RN Level 2 Belconnen Nursing Team |Yes |Yes | |
|(RACC) Community Care Program | | | |
|Allied Health Manager (RACC) |Yes |Yes | |
|Community Care Program | | | |
|Office of the Chief Allied Health |Yes |Yes | |
|Officer | | | |
|Health Care Improvement Unit |Yes |Yes | |
|Calvary Hospital |Yes |Yes | |
Back to Table of Contents
|Attachments |
Attachment 1 Dressings of choice for burns
Attachment 2 Burn Assessment Tool
Disclaimer: This document has been developed by ACT Health, specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
|Date Amended |Section Amended |Approved By |
|26 September 2017 |Section 1.5 |CHHS PC |
|11 October 2017 |Section 2.5 Postoperative managing of Skin |CHHS PC |
| |Flaps added | |
Attachment 1 Dressings of choice for burns
Non infected wounds
|Generic Dressing |Company name |Notes |
|Silicone interface with /or without|Mepilex® |Superficial to mid dermal burns |
|foam |Mepitel® |Do not use if infected |
| | |Change 2-4 days dependant on exudate |
| | |Mepitel requires secondary dressing |
|Hydrogel sheets |AquaClear® |Superficial to mid dermal burns |
| | |Initial treatment in cooling |
| | |Minimal exudate |
| | |Do not use if infected |
| | |Change 1-2 days dependant on exudate |
|Hydrocolloid |DuoDerm® or |Devitalised tissue sloughy wound |
| |Comfeel® |Low to moderate exudate |
| | |Do not use if infected |
| | |Change 2- 5 days dependant on exudate |
Infected wounds
|Generic Dressing |Company name |Notes |
|Vaseline gauze with chlorhexidine |Bactigras |Apply directly to wound bed in 2-3 layers |
|impregnated | |Avoid if patient has a chlorhexine sensitivity or allergy|
| | |Soak off if adhered to wound bed |
| | |Change 1-3 days |
|Silcone interface with Foam and | |Apply directly to wound bed |
|silver |Mepilex® AG |Change 1-7 days dependant on exudate |
| | |Temporary skin staining |
|Silver sheets- nanocrystalline Ag |Acticoat 3 day / or Acticoat |Moisten dressing with H2O apply to wound bed |
|coated mesh with inner rayon layer |Flex 3 |Avoid if patient has an allergy to silver |
| |Acticoat 7 day / or |Keep 7 day moistened |
| |Acticoat Flex 7 |Change secondary dressing as required |
| | |Temporary skin staining |
Attachment 2 Burn Assessment Tool
Severity of the burns injury is determined by assessment of surface area and depth of the burn.
Surface area of the burn is determined by the “Rule of Nines” and depth of the burn into 5 classifications:
• Epidermal
• Superficial Dermal
• Mid-Dermal
• Deep Dermal
• Full Thickness
Table 1 Burn Assessment by depth
|Depth |Colour |Blisters |Capillary Refill |Healing |Scarring |
|Superficial |Red/ Pale pink |Small |Brisk 1-2 sec |Within 14 days |None slight colour |
|Dermal | | | | |mismatch |
|Mid-Dermal |Dark pink |Present |Sluggish > 2 sec |2-3 weeks grafting |Yes ( if healing >3 |
| | | | |may be required |weeks) |
|Deep Dermal |Blotchy Red/ White |+/- |Sluggish > 2 sec / |Grafting required |Yes |
| | | |absent | | |
|Full Thickness |White/Brown/Black (charred)/ |No |absent |Grafting required |Yes |
| |Deep Red | | | | |
[pic]
“Rule of Nines” by %
Burns patient who require admission to the Plastic Surgical Ward area often have epidermal, superficial dermal or mid- dermal injuries.
Blisters
Dependent on the mechanism blisters are often lance or aspirated. Lift a section of the skin to view wound bed and ascertain capillary refill.
Blisters that are de-roofed to allow appropriate treatment of the underlying tissue. Use appropriate dressings.
Capillary refill
Lift small area of skin, apply pressure and observe for capillary refill, replace the skin as a biological dressing if there is acceptable refill time
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