Wound Management Procedure · Web viewEncourage patient to shower leg and ulcer prior to dressing change – ensuring there is no contamination of the ulcer Apply moisturiser to the

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Canberra Hospital and Health ServicesClinical ProcedureWound ManagementContents

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

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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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 Inc2nd edition, March 2010)



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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 wound3. Dimensions of the wound4. Clinical appearance of the wound5. Presence of infection, pain, odour or foreign bodies6. State of surrounding skin and alterations in sensation7. Physiological implications of wounding to the individual8. Psychological implications of wounding to the individual and significant others9. The use of validation tools in practice10. The use of diagnostic investigations to ascertain and monitor wound healing potential11. Wound photographs and consent see Diagnostic Digital Photography Images and/or

Recordings Policy, SOP12. 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 ProcessOngoing assessment will be performed and documented and provide evidence of wound healing or deterioration in wound healing.

Individualised Care PlanAn individualised care plan will be:1. Documented in accordance with the individual’s preference and assessment outcomes2. Reflective of ongoing assessments3. Used to guide optimal management4. Used to evaluate the effectiveness of treatment5. 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:Doc Number Version Issued Review Date Area Responsible PageCHHS14/042 1.0 Nov 2014 Nov 2018 RACC 3 of 51


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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 EnvironmentMaintain an optimal wound moisture balancePromote 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 healingIt 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



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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 environmentThe 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 devicesMaintain 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



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Use products and devices in accordance with licensing acts and/or regulatory bodies and manufacturing guidelinesAll 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 TechniqueProcedureTo 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

Procedure1. Check patient’s clinical record for any medical/nursing orders2. Attend hand hygiene before touching the patient by either hand washing or using ABHR3. Ensure privacy4. Explain the process and purpose of the dressing change5. Obtain verbal consentDoc Number Version Issued Review Date Area Responsible PageCHHS14/042 1.0 Nov 2014 Nov 2018 RACC 6 of 51


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6. Confirm allergies to dressings or tapes7. Ensure adequate analgesic cover prior to dressing change8. Ensure the patient is placed in a comfortable position9. Attend hand hygiene by either hand washing or using ABHR10. Clean trolley or suitable surface with detergent impregnated wipes and wipe dry11. Set up equipment on trolley by the side of the patient 12. Discard packaging in general waste receptacle13. Don PPE prior to opening sterile equipment14. Open the basic pack and position equipment using the setting up forceps15. Attend hand hygiene by either hand washing or using ABHR, 16. Don clean gloves17. Expose the wound site18. Remove the soiled dressing with setting-up forceps19. Discard the dressing and forceps and gloves into the clinical waste receptacle20. Attend hand hygiene by either hand washing or using ABHR21. Open additional sterile equipment after reviewing the wound; add solution into the

appropriate areas of dressing pack22. 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 ABHR25. Don glove (clean or sterile)26. Use wound cleansing solutions at body temperature irrigate with normal saline solution,

to remove debris and contaminates27. 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



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30. Apply new dressing and secure with adhesive tape or bandages31. Discard equipment and gloves into clinical waste receptacle32. Clean trolley or surface with detergent impregnated wipes 33. Attend hand hygiene by either hand washing or using ABHR34. Ensure patient is comfortable with new dressing change and understands when the next

dressing change will be attended35. Change dressing or appliances as frequently as required to effectively remove excessive

exudate or infected material36. 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).



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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 consent3. Ensure privacy4. Position the patient to ensure comfort during the procedure5. Ensure the patient has adequate analgesia for dressing change6. Ensure the process is timely as to avoid lengthy exposure thus cooling the

temperature of the wound7. Attend hand hygiene by either hand washing or using ABHR 8. Prepare and set up equipment on clean dressing trolley or suitable surface9. Discard packaging in general waste receptacle10. Attend hand hygiene by either hand washing or using ABHR 11. Don goggles and gloves12. Expose the wound site by removing the dressing13. Remove gloves14. Discard dressing, forceps and gloves in clinical waste receptacle 15. Attend hand hygiene by either hand washing or using ABHR 16. Don clean gloves17. 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



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19. Note any tracking or shelving, including the direction of insertion20. Place finger at skin level against the probe to indicate depth, do not move

finger21. Remove the probe and measure depth by placing probe next to measuring

device (alternative probe have measuring scales )22. Discard probe in sharps bin23. 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 bandages25. Discard equipment into clinical waste receptacle26. Use appropriate dressing to ensure patient comfort and compliance, while

maintaining optimal healing environment27. Ensure patient is comfortable with new dressing change28. Remove gloves and discard into clinical waste receptacle29. Attend hand hygiene by either hand washing or using ABHR30. 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 change32. Report any concerns to the Medical Officer33. Communicate change of dressing product to community nurses if applicable34. Change dressing or appliance as frequently as required

Section 1.3 Wound DebridementWounds 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 Debridement1. 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



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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 DebridementEquipment 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



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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


ProcedureUse an aseptic non touch technique when performing CSWD Be aware of underlying and adjacent anatomical structures1. Identify and assess area of loose sloughy or necrotic tissue2. Gently cut away loose tissue, be conservative3. Flush wound with tepid sterile saline to remove any loose debris

3. Mechanical DebridementThere 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 SwabbingTo 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



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Personal protective equipment (PPE) including, safety goggles, glasses or shield and clean gloves

Clinical waste receptacle General waste receptacle.

Equipment Community setting1. Attend hand hygiene before touching the patient by either hand washing or using ABHR 2. Explain procedure and obtain patient consent3. Ensure privacy4. Attend hand hygiene by either hand washing or using ABHR5. Position the patient to ensure that the patient will be comfortable during the procedure6. 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 ABHR8. Prepare and set up equipment on a cleaned dressing trolley9. Discard packaging in general waste receptacle10. Attend hand hygiene by either hand washing or using ABHR11. Don clean gloves and goggles12. Expose the wound site, by removing the dressing13. Discard 14. Sampling should take place after wound cleansing and if appropriate debridement15. 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 container17. 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



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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 forma. Apply the appropriate wound dressing. Note: dressing if antimicrobial eg silver

impregnated dressing/ wound honey / iodine / chlorhexidine baseb. Discard in clinical waste receptaclec. Attend hand hygiened. Document in the patients clinical recorde. 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.



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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.



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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


Procedure1. Attend hand hygiene before touching the patient by either hand washing or using ABHR2. Ensure Privacy3. Explain the process and purpose of the dressing change4. Obtain verbal consent5. Confirm allergies to dressings or tapes6. Ensure adequate analgesic cover prior to dressing change7. Ensure the patient is placed in a comfortable position8. Attend hand hygiene by either hand washing or using ABHR9. Clean trolley with detergent impregnated wipes and wipe dry10. Set up equipment on trolley at the patient’s bedside11. Don PPE prior to opening sterile equipment12. Open the basic pack and position equipment using the setting up forceps13. Discard packaging in general waste receptacle14. Attend hand hygiene by either hand washing or using ABHR, 15. Don clean gloves16. Expose the wound siteDoc Number Version Issued Review Date Area Responsible PageCHHS14/042 1.0 Nov 2014 Nov 2018 RACC 16 of 51


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17. Remove the soiled dressing with setting-up forceps18. Discard the dressing and forceps and gloves into the clinical waste receptacle19. Attend hand hygiene by either hand washing or using ABHR20. Open additional sterile equipment after reviewing the wound21. 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 contaminates23. Attend hand hygiene by either hand washing or using ABHR24. Don PPE25. Clean the wound surface by:26. Swabbing (in one direction only, clean to dirty) with normal saline soaked gauze, or

irrigating with normal saline27. Observe the wound for: unity of skin edges and peri wound appearance 28. Remove sutures or staples

Sutures1. Lift the knot using forceps2. Using a stitch cutter, cut between the knot and the skin, on one side as close to the skin

as possible3. Remove the suture by pulling the unexposed material through the wound

Staples1. 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 direction3. Ensure the staple remover is fully closed and remains secure on the staple4. Using a rocking movement gently free the staple from one side of the incision line then

the other5. Apply steri strips if required 6. Leave wound undressed or otherwise use appropriate dressings to ensure patient

comfort and compliance7. Discard equipment and gloves into clinical waste receptacle8. 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 scar11. Change dressing or appliances as frequently as required to effectively remove excessive

exudate or infected material12. 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 change13. 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 packingTo provide guidelines that outline the packing of a wound this is performed to:Doc Number Version Issued Review Date Area Responsible PageCHHS14/042 1.0 Nov 2014 Nov 2018 RACC 17 of 51


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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


Procedure1. Attend hand hygiene before touching the patient by either hand washing or using ABHR2. Explain procedure to the patient and the purpose of packing a wound/sinus3. Ensure privacy4. Position patient to ensure comfort during the procedure5. Ensure the patient has adequate analgesia cover for dressing change if required or

requested6. Ensure that the process is timely as to avoid lengthy exposure thus cooling the

temperature7. Open the basic dressing pack and position sterile equipment.8. Attend hand hygiene by either hand washing or using ABHR9. Don PPE10. Expose the wound site by removing the dressing and packing material11. Discard the dressing, forceps and gloves in the clinical waste receptacle12. Attend hand hygiene by either hand washing or using ABHR13. Don sterile gloves14. Clean wound with warm normal salineDoc Number Version Issued Review Date Area Responsible PageCHHS14/042 1.0 Nov 2014 Nov 2018 RACC 18 of 51


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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 bandage19. Discard equipment20. Attend hand hygiene by either hand washing or using ABHR21. Ensure client is comfortable with dressing and understands management regime22. Change secondary dressing as frequently as required to effectively remove excessive

exudate or infected material23. 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 Doc Number Version Issued Review Date Area Responsible PageCHHS14/042 1.0 Nov 2014 Nov 2018 RACC 19 of 51


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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.


Procedure1. 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 consent4. Ask the patient if they have any allergies to dressings or adhesive tapes5. Ensure privacy6. 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 ABHR8. Clean dressing trolley with detergent impregnated wipes and wipe surface dry with

disposable paper towel9. Gather required equipment10. Attend hand hygiene by either hand washing or using ABHR11. Ensure that the patient is positioned in a comfortable position for the procedure 12. Position patient with wound drain area exposed13. Place under-pad in position in proximity to the drain site14. Attend hand hygiene by either hand washing or using ABHR 15. Don gown prior to opening sterile equipment16. 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 forceps19. Open and add additional sterile equipment20. Discard packaging into general waste receptacle21. 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 receptacle24. 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



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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 tubee. 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 TubeFollow steps 1-28 of above procedure29. Remove suture holding drain insitu, with stitch cutter if present 30. Withdraw drainage tube gently, using a rotating movement to the prescribed length31. 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 dressing35. Secure with adhesive tape if necessary 36. A wound drainage bag may be applied if drainage is excessive37. Discard equipment and gloves into the clinical waste receptacle38. Attend hand hygiene by either hand washing or using ABHR39. 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 TubeFollow steps 1-28 of above procedure29. Remove suture, with stitch cutter if present30. Withdraw drainage tube gently using a rotating movement31. Swab wound, if required 32. Apply exudate absorbing dressing, secure with adhesive tape if necessary33. A wound drainage bag may be applied if drainage is excessive 34. Discard equipment and gloves into the clinical waste receptacle35. 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

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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 TearsTo 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



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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.


Procedure1. Attend hand hygiene before touching the patient by either hand washing or using ABHR2. Check medical orders in patients clinical record3. Obtain the patients consent4. Ensure Privacy5. Explain to the patient the process and purpose of the dressing change6. Ask the patient if they have any allergies to dressings or tapes7. Ensure the patient has adequate analgesic cover prior to dressing change if required or

requested8. Ensure that the patient is positioned in a comfortable position for the procedure9. Attend hand hygiene by either hand washing or using ABHR10. Clean trolley with detergent impregnated wipes and wipe dry11. Set up equipment on trolley at the patient’s bedside12. Don safety glasses and gown prior to opening sterile equipment13. Open the basic pack and position equipment using the setting up forceps14. Discard packaging in general waste receptacle15. Attend hand hygiene by either hand washing or using ABHR16. Don clean gloves17. Expose the wound site18. Remove the soiled dressing with setting-up forceps19. Discard the dressing and forceps and gloves into the clinical waste receptacle20. Attend hand hygiene by either hand washing or using ABHRDoc Number Version Issued Review Date Area Responsible PageCHHS14/042 1.0 Nov 2014 Nov 2018 RACC 23 of 51


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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 ABHR24. Don sterile gloves25. Use wound cleansing solutions at body temperature irrigate with normal saline solution

to remove debris and contaminates26. 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 only29. 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 required35. Discard equipment and gloves into clinical waste receptacle36. Remove goggles37. Attend hand Hygiene by either hand washing or using ABHR38. Clean trolley with detergent impregnated wipes 39. Ensure patient is comfortable with new dressing change and understands when the next


exudate or infected material41. 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



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ALERT: Most skin tears occur during routine handling of patients

Preventative strategies should:1. Identify patients at risk2. Implement strategies that prevent falls and other trauma3. Gently handing of the patient and the use of transfer and repositioning devices that

reduce friction and shear4. Cover vulnerable skin surfaces with clothing and skin protection devices5. Avoid adhesive dressing on fragile skin consider lightweight roller or tubular bandages6. Optimise nutrition and hydration status7. Avoid the use of drying of pH altering soaps and pharmaceuticals use emollients8. Moisturise the skin regularly9. 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.

AlertPatients 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 BurnsTo 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



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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


ProcedureEnsure the principles of Wound Management principles are maintained.1. Attend hand hygiene before touching the patient by either hand washing or using ABHR2. Check medical orders in patients clinical record3. Obtain the verbal consent4. Ensure Privacy5. Explain to the patient the process and purpose of the dressing change6. Ask the patient if they have any allergies to dressings or tapes7. Ensure the patient has adequate analgesic cover prior to dressing change if required or

requested8. Ensure that the patient is positioned in a comfortable position for the procedure9. Attend hand hygiene by either hand washing or using ABHR10. Clean trolley with detergent impregnated wipes and wipe dry11. Set up equipment on trolley at the patient’s bedside12. Don PPE prior to opening sterile equipment13. Open the basic pack and position equipment using the setting up forceps14. Discard packaging in general waste receptacle15. Attend hand hygiene by either hand washing or using ABHR16. Don clean gloves17. Expose the wound site18. Remove the soiled dressing with setting-up forceps19. Discard the dressing and forceps and gloves into the clinical waste receptacle20. Attend hand hygiene by either hand washing or using ABHR21. Open additional sterile equipment after reviewing the wound; add solution into the

appropriate areas of dressing pack22. 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

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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 only28. 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 bandages30. Discard equipment and gloves into clinical waste receptacle31. Remove goggles32. Attend hand Hygiene by either hand washing or using ABHR33. Clean trolley with detergent impregnated wipes 34. Ensure patient is comfortable with new dressing change and understands when the next


exudate or infected material36. 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 change37. if using VAC® therapy consider type and number of sponge, cycle, pressure, dressing

change interval and initial cycle38. Notify the community nurses of a change of dressing products to maintain continuity of

management if appropriate.

ALERT: Silver Impregnated ProductsSilver 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.



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Section 2.3 Management of lower leg ulcerationCauses 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 ulcersThe 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 assessmentThe aim of a vascular assessment is to distinguish arterial aetiologies from venous and other aetiologies and assess the extent of venous insufficiency.



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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



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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 IndexRegistered 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

Procedure1. Explain procedure to the patient and obtain consent2. Perform hand hygiene3. Place the patient in the supine position, allay anxiety and encourage relaxation for at

least 15 minutes to stabilise blood pressure4. Obtain the brachial systolic pressure as follows

a. Place sphygmomanometer cuff around the armb. Palpate the brachial pulsec. 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 heardd. Inflate the cuff until the ‘Doppler’ sound disappears; slowly deflate the cuff until the

sound returns5. Repeat this process on the other arm6. The higher of these 2 readings is acknowledged as the brachial systolic pressure7. 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 sidec. Apply gel over pulsed. 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 sites10. Acknowledge the higher of these 2 readings as the ankle systolic pressure for that

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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 pressure12. Repeat the procedure on the other leg13. Document findings on wound clinical pathway and on leg ulcer assessment form14. Clinical observation must be used in addition to the ABPI prior to the commencement of

compression therapy15. 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



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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 ulcers1. Assess and document leg ulcer on wound assessment form2. Photograph leg ulcer every two weeks or if there is a deterioration in the ulcer 3. Cleanse wound and leg at dressing change4. Encourage patient to shower leg and ulcer prior to dressing change – ensuring there is

no contamination of the ulcer5. Apply moisturiser to the leg6. Apply appropriate dressing according to the wound assessment and treatment orders7. Ensure patient has been assessed for peripheral arterial disease and that it is safe to

apply compression therapy8. Apply compression therapy as per treatment orders and as per the manufacturer’s

recommendation9. 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 delayed14. Ensure patient has adequate pain control15. Advise patient to

a. walk regularly or perform calf/foot exercisesb. elevate feet above level of heart when sitting c. inspect skin integrity daily, and moisturise skind. stop smokinge. lose weight if obesef. 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



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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 daysWhen 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 functionTwo, 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 stockings, multi-layer hosiery systems

Available in a range of compression levels. International consensus on compression scales is lacking and different scales are used around the world. Two scales and/or classifications of compression hosiery 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



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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 Ulcers1. Assess and document leg ulcer on wound assessment form2. CCP 3. Photograph leg ulcer every two weeks or if there is a deterioration in the ulcer 4. Cleanse wound and leg at dressing change5. Encourage patient to shower leg and ulcer prior to dressing change – ensuring there is

no contamination of the ulcer6. Apply moisturiser to the leg and foot7. Apply appropriate dressing according to the wound assessment and treatment orders8. No compression bandaging of limb as this will reduce the blood supply9. If the ABPI is < 0.8, advise the patient to seek an urgent referral to a vascular surgeon10. Liaise with patient’s Medical Practitioner regarding a referral to a vascular surgeon11. Refer patient to a Podiatrist 12. Refer patient to a Dietitian13. Refer patient to a Occupational Therapist if pressure injury prevention strategies are

indicated 14. Ensure patient has adequate pain control15. Advise the patient to16. exercise as tolerated17. inspect skin integrity daily, and moisturise skin18. avoid tight clothing/shoes19. avoid trauma to the skin (including adhesive tapes and thermal extremes)20. stop smoking21. ensure that legs are in a neutral or dependant position whilst sitting or lying22. lose weight if obese23. 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.



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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 SitesSkin 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



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(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 CareSplit 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 SitesFollowing 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



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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 procedureSkin 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 flapsA 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



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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 consent2. Perform hand hygiene3. Ensure privacy4. Position the patient to ensure comfort during the procedure5. Don PPE (as indicated)6. Expose flap site7. 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 flap9. 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



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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 site12. Cover flap if necessary13. Remove PPE14. Perform hand hygiene15. Record observations attended.16. Any changes from previous observations should be reported to the Plastics registrar on

duty17. Keep patient warm and comfortable18. Cleanse doppler with neutral detergent wipes 19. Perform hand hygiene20. 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 (<1 second) or absent There is a reduction in temperature at the flap site There are signs of infection

Normal AbnormalCapillary refill 2-3 seconds Sluggish ≥3 seconds

(ischaemic)Brisk ≤ 1 second (congested)

Flap temperature (use back of hand or finger to assess)

Warm Cool, Cold

Colour (note: can vary based on the donor, please consider to compare the colour of the flap with the donor)

Pink Purple/Blue-possible clots (venous occlusion)White – no blood supply (arterial occlusion)- inform Plastic Registrar

Peripheral Temperature >36.5° C <36.5°C – vasospasmKeep patient warm, use bair hugger

Doppler Biphasic Monophasic – call Plastic Registrar for review

Urine Output 0.5-1 ml/kg/hr – or Drop in urine output inform



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Normal Abnormaldepending on Surgeon’s

preferencePlastic Registrar

Systolic Blood Pressure >100mmHG or depending on Surgeon’s accepted value

Drop in blood pressure inform Plastic 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.



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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 Surgeon9. 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 Registrar11. 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 analgesia13. Do not apply pressure on the flap14. Monitor donor site for bleeding or ooze15. 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 WoundsMalignant 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.



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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

MalodourMalodour 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 managementExcessive 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.

BleedingMalignant 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 Doc Number Version Issued Review Date Area Responsible PageCHHS14/042 1.0 Nov 2014 Nov 2018 RACC 42 of 51


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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.


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.


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.



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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


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


References

Australian Wound Management Association Inc, (2009) AWMA Position Document: Bacterial impact on wound healing: From contamination to infection. AWMA. http://www.awma.com.au/awma/index.php

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 http://www.awma.com.au

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 http://ewma.org/english/publications.html

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.



http://www.awma.com.au/

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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 http://www.health.nse.gov.au/gmct/burninjury

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.




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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


Consultation

Name/position/Division of person(s) consulted

Feedback Received Yes/No

Feedback incorporatedYes/No

Comment

NP Wound Management Rehabilitation Aged and Community Care (RACC) Community Care Program

Yes Yes

CNC Tissue Viability Unit Canberra Hospital

Yes Yes

CNC Wound Management (RACC) Community Care Program

Yes Yes

CDN 11B Canberra Hospital

Yes Yes

CNC (RACC) Community Care Program

Yes Yes



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Nurse Manager Tuggeranong Health Centre Nursing Team (RACC) Community Care Program

Yes Yes

Nurse Manager Phillip Health Centre Nursing Team (RACC) Community Care Program

Yes Yes

Nurse Manager City Health Centre Nursing Team (RACC) Community Care Program

Yes Yes

RN Level 2 Belconnen Nursing Team (RACC) Community Care Program

Yes Yes

Allied Health Manager (RACC) Community Care Program

Yes Yes

Office of the Chief Allied Health Officer

Yes Yes

Health Care Improvement Unit

Yes Yes

Calvary Hospital Yes Yes


Attachments



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Attachment 1 Dressings of choice for burnsAttachment 2 Burn Assessment Tool

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> 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 By26 September 2017 Section 1.5 CHHS PC11 October 2017 Section 2.5 Postoperative

managing of Skin Flaps added

CHHS PC



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Attachment 1 Dressings of choice for burns

Non infected woundsGeneric Dressing Company name Notes

Silicone interface with /or without foam

Mepilex® Mepitel®

Superficial to mid dermal burnsDo not use if infectedChange 2-4 days dependant on exudateMepitel requires secondary dressing

Hydrogel sheets AquaClear® Superficial to mid dermal burnsInitial treatment in cooling Minimal exudate Do not use if infected Change 1-2 days dependant on exudate

Hydrocolloid DuoDerm® or Comfeel®

Devitalised tissue sloughy woundLow to moderate exudateDo not use if infectedChange 2- 5 days dependant on exudate

Infected woundsGeneric Dressing Company name Notes

Vaseline gauze with chlorhexidine impregnated

Bactigras Apply directly to wound bed in 2-3 layersAvoid if patient has a chlorhexine sensitivity or allergySoak off if adhered to wound bedChange 1-3 days

Silcone interface with Foam and silver Mepilex® AG

Apply directly to wound bedChange 1-7 days dependant on exudateTemporary skin staining

Silver sheets- nanocrystalline Ag coated mesh with inner rayon layer

Acticoat 3 day / or Acticoat Flex 3Acticoat 7 day / or Acticoat Flex 7

Moisten dressing with H2O apply to wound bedAvoid if patient has an allergy to silverKeep 7 day moistenedChange secondary dressing as requiredTemporary skin staining



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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 depthDepth Colour Blisters Capillary

RefillHealing Scarring

Epidermal Red No Brisk 1-2 sec Within 7 days

None

SuperficialDermal

Red/ Pale pink Small Brisk 1-2 sec Within 14 days

None slight colour

mismatchMid-Dermal Dark pink Present Sluggish > 2

sec2-3 weeks

grafting may be required

Yes ( if healing >3

weeks)Deep Dermal Blotchy Red/ White +/- Sluggish > 2

sec / absentGrafting required

Yes

Full Thickness

White/Brown/Black (charred)/ Deep Red

No absent Grafting required

Yes

“Rule of Nines” by %



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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 refillLift small area of skin, apply pressure and observe for capillary refill, replace the skin as a biological dressing if there is acceptable refill time



Documents

Wound Management Procedure · Web viewEncourage patient to shower leg and ulcer prior to dressing change – ensuring there is no contamination of the ulcer Apply moisturiser to the