AGPN acknowledges the financial support of the Australian Government Department of Health and Ageing

Wound Management in General Practice

Provision of Clinical Care 2.3April 2009

Learning objectives

Outline the principles of wound management in the general practice setting

Identify factors relating to delayed wound healing

Outline strategies to manage:

• skin tears

• burns and blisters

• lower leg ulceration

• diabetic foot ulceration

Specify various dressings and techniques for their application

Be cognizant of wound management MBS.

Principles of Wound Management

define aetiology

control factors influencing healing

select appropriate dressing or device

plan for maintenance.

Wounds seen in General Practice

trauma: abrasions and cuts

superficial partial thickness burns

venous leg ulcers

arterial leg ulcers

foot wounds often associated with neuropathy and neuro-ischaemia

skin cancers.

Generally do not see: pressure injuries or dehisced surgical wounds

Factors Influencing Healing

poor nutrition

Infection/inflammation

ongoing trauma

incorrect cleansing and dressing

underlying disease processes.

Other Factors Related to Delayed Wound Healing

age

debris and foreign bodies in the wound

smoking

wound tissue too dry or too wet

pain

psychological issues.

Decision Making Tools

Tissue colour

Wound depth

Exudate level

Periwound skin condition

Predicted weartime

Skill of carer

Availability/cost of product

Select the most appropriate dressing according to:

T.I.M.E

Source: http://www.ewma.org

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Dry necrosis

A 75 yr old male who is a smoker and has type 2 diabetes, presents with the following:

What would you do?

A.moisten to encourage autolytic debridement

B.moisten to facilitate sharp debridement

C.refer for surgical debridement

D.none of the above.

World of Wounds

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World of Wounds 16

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Matching Colour and Product

Black………………….. if aiming to heal: cleansing dressing

Green…………………. antimicrobial dressing

Wet yellow…………. antimicrobial dressing

Dry yellow…………. rehydrating dressing

Red……………………… protect

Hypergranulation. antimicrobial dressing

Pink……………………. protect.

This is not a prescription but a guide to where to start

Ideal Dressing

provide mechanical protection

protect against secondary infection

non adherent and easily removed without trauma

leave no foreign particles in the wound

remove excess exudates

cost effective

offer effective pain relief.

Generic Names

impregnated mesh dressings

low adherent lightly absorbent pads

super absorber pads

protective film wipes

film sheets

foam and foam like absorbent dressings

hydrocolloid wafers and paste

hydrogel sheets and amorphous gels with or without additives.

calcium alginates

hydrofibre

hypertonic salt

cadexomer iodine

silver

medicated honey

zinc bandages

Generic Names

Purchasing Products

most practices have agreements with distributors

the fee for dressings is either born by the practice or passed on to the patient

if asking the patient to purchase their own dressings perhaps look at distributors that will offer products at reasonable prices

Rebate schemes

Department of Veterans Affairs (DVA) patients will be able to secure most dressings as long as the general practitioner writes the required item on a script

11996 is the Medicare item number to be used for the nurse performing wound care

AWMA is seeking to have products listed on PBS

Case Studies

skin tear

burn

venous ulcer

arterial ulcer

foot wound.

Star skin tear classification system

STAR Tool

utilise the STAR tool to classify skin tear severity

the STAR tool can be downloaded from the Silver Chain website at:

http://www.silverchain.org.au/Research/Research-Projects/

STAR-Project/

Skin Tear: 1a

Skin Tear: 1b

Skin Tear: 2a

Skin Tear: 2b

Skin Tear: 3

Key Points for Skin Tears

develop your own set of protocols for managing skin tears

write these up and add to your wound resource folder

companies do have protocols for you to follow

Burns: First Contact

Assessment

site

depth

surface area involved

age of patient

other influencing factors

What is reasonable to care for in general practice?

small superficial partial burns not involving face, feet, hands, perineum, genitalia on the very young or the elderly

further guidelines and very good advice may be found on the NSW DoH Website for Severe Burn Injury or ringing Concord Burns Unit

Superficial Burn Characteristics

epidermis only

erythema (vasodilatation)

tenderness (nerve irritability)

oedema.

Superficial Partial Burn Characteristics

epidermis and outer dermis

blisters (fluid shift)

shedding of skin

painful exposed (nerve endings to kinins)

bleeds when pricked with needle

hair present (hard to pull out)

full sensation

blanches on pressure.

Burn Surface Area Wallace’s rule of nines

Lund and Browder chart

closed palmar hand of victim

= 1% of body surface area.

Anatomical Site Considerations

hands

feet

face

perineum

genitalia

joints

circumferential burns

Other Considerations

extremes of age: very young or very old will need special care

co-morbidities

medications.

What to do about blisters?

controversial: removal causes pain

tense blisters can interfere with dermal circulation, restrict movement

beware of blisters with “red rings”

blisters can hide deep burns

popped blisters may need to be debrided.

Key Points for Burns

have standard policies and procedures

know where nearest specialist burns centre is and how long it takes by road or air

liaise with burn centre for care in interim

closely monitor patient for signs of impending infection and sepsis.

Example of a Burn Protocol

superficial partial thickness burns of less than 10%

body surface area, not involving feet, face, hands,

genitalia, over joints, the very young and the

elderly, can be nursed in the practice

deeper partial thickness burns of less than 5% body

surface area will be treated in the practice BUT if

no response within one week should be referred on

Useful Websites

http://www.ameriburn.org

http://www.anzba.org.au

http://www.worldburn.org

http://www.journalofburns.com

http://www.burnsurgery.org

http://www.skinhealing.com

http://www.worldwidewounds.com

Lower Leg Ulceration

Statistics

venous 70%

arterial 10%

mixed 10%

skin cancers 2%

others 8%

Venous Ulcer Characteristics

firm ‘brawny’ oedema

inverted “champagne” bottle leg

irregular shape

medial or lateral aspect lower third of leg

wet, shallow, minimal necrotic tissue

atrophie blanche

venous eczema, staining, lipodermatosclerosis

palpable pulses, minimal pain, relieved when elevated.

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Arterial Ulcer Characteristics usually located between ankles and toes or high

up on leg or posterior leg

deep, punched out regular shape, often dry

thin, shiny, non hair bearing skin

thickened toenails

diminished or absent foot pulses

elevation pallor, dependant rubor

necrotic tissue, infection

pain, especially at night or when elevated.

World of Wounds

Venous Ulcer Management

ensure adequate dressing to assist in managing wound exudate

if thinking some bacteria present use an anti microbial, cover with absorbent pad apply light crepe bandage toes to knee

then cover the bandage with different length layers of straight elasticated tubular bandage or shaped tubular bandage

3 layers of straight elasticated bandage

Arterial Ulcer Management

have the patient reviewed by a vascular surgeon

use Iodosorb powder if the wound is wet or if the area is dry then paint it with Betadine

if the surgeon can not revascularise, then the wound is ‘maintenance’ or ‘palliative’ and the aim is to keep it infection free and stable

Foot Wounds

The high risk foot:

diabetes

neurovascular disease

neuropathic diseases

congenital or other foot abnormalities

Monofilament Testing Semmes-Weinstein monofilament is often used to assess

protective sensation in the feet of patients with diabetes

nylon filament mounted on a holder

10 gram force

assess 10 sites over the foot, randomly so the

patient cannot anticipate the next site

http:/ndep.nih.gov/resources/feet/index.htm

Areas at risk of damage

Using the monofilament

Diabetic Foot Examination D deformity

I infection

A atrophic nails

B breakdown of skin

E oedema

T temperature

I ischaemia

C callosities

S skin colour

Diabetic Foot Examination

Deformity charcot’s, pes cavus, claw toe, hammer toe

Infection crepitus, fluctuation, deep tenderness

Atrophic nails fungal infections and sub ungal ulcers

Breakdown of skin

ulcers, fissures, blisters

Ischaemia pulses may be weak or absent

Callosities plantar surface, metatarsal heads

Skin colour red = charcot’spale = ischaemiapink, with pain and absent pulses = ischaemia

Dressings for Diabetic Foot UlcerationsAntimicrobial Iodosorb

Hypertonic salt: Mesalt, Curasalt Silver products: Acticoat, Aquacel Ag,

Atrauman Ag, Contreet, even silver lined socks and

hosiery

Absorbent Exudry, Mesorb, Zetuvit, Dry-Max Allevyn, Biatain, Lyofoam Extra Aquacel Algisite M, Kaltostat, Calcicare, Sorbalgon

Padding or cushioning

Podiatry felt Silipos Dermal pad

Debriding Iodosorb Mesalt TenderWet Hydrocolloid paste.

Key Points for Diabetic Foot Ulcerations

remember diabetics may have micro or macro vascular disease or both

always be suspicious of infection

do not use occlusive dressings on foot wounds

HBO is often helpful in diabetic vascular wounds and osteomyelitis

Assistance is available via the SSWAHS High Risk Foot Service

Conclusions

wounds in general practice are varied

it is ideal to have treatment cards for most common types of wounds seen

product range needs to be kept to a minimum but cover all generic types of wounds and an antimicrobial

always establish the underlying diagnosis of the wound and reassess if failing to follow normal healing pathways

Resources http://www.woundpedia.com

http://www.worldwidewounds.com

http://www.globalwoundacademy.com

http://www.ewma.org

http://www.wuwhs.org

Useful book: Wound Care Manual by Keralyn Carville

http://www.silverchain.org.au/html/WoundCareForm.htm

Clinical Friends of World of Wounds Visit the website and enrol an expression of

interest

Can provide clinical advice via email for $10 per consult

Website: http://www.worldofwounds.com/Home/

Wound Management Competency Standards for General Practice Nurses Wound management competency standards for general practice

nurses have been developed as part of the Nursing in General Practice Program at General Practice NSW and funded by the Australian Government Department of Health and Ageing

Cpetency standards should be used as a framework to assess competence and should be read in conjunction with:

— the Australian Nursing and Midwifery Council competency standards

— the Competency Standards for Nurses in General Practice — the Australian Wound Management Association standards

Standards may be accessed on the APNA website: http://www.apna.asn.au/displaycommon.cfm?an=1&subarticlenbr=294