Transcript Document

AGPN acknowledges the financial support of the Australian Government Department of Health and Ageing
Wound Management
in General Practice
Provision of Clinical Care 2.3
April 2009
Learning objectives

Outline the principles of wound management in the general practice
setting

Identify factors relating to delayed wound healing

Outline strategies to manage:
•
skin tears
•
burns and blisters
•
lower leg ulceration
•
diabetic foot ulceration

Specify various dressings and techniques for their application

Be cognizant of wound management MBS.
Principles of Wound Management

define aetiology

control factors influencing healing

select appropriate dressing or device

plan for maintenance.
Wounds seen in General Practice
 trauma: abrasions and cuts
 arterial leg ulcers
 superficial partial thickness
burns
 foot wounds often associated with
neuropathy and neuro-ischaemia
 venous leg ulcers
 skin cancers.
Generally do not see: pressure injuries or dehisced surgical wounds
Factors Influencing Healing

poor nutrition

Infection/inflammation

ongoing trauma

incorrect cleansing and dressing

underlying disease processes.
Other Factors Related to Delayed
Wound Healing
 age
 debris and foreign bodies in the wound
 smoking
 wound tissue too dry or too wet
 pain
 psychological issues.
Decision Making Tools
Select the most appropriate dressing according to:
 Tissue colour
 Wound depth
 Exudate level
 Periwound skin condition
 Predicted weartime
 Skill of carer
 Availability/cost of product
T.I.M.E
Source: http://www.ewma.org
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Dry necrosis
 A 75 yr old male who is a smoker and
has type 2 diabetes, presents with the
following:
What would you do?
A. moisten to encourage autolytic
debridement
B. moisten to facilitate sharp
debridement
C. refer for surgical debridement
D. none of the above.
World of Wounds
World of Wounds
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World of Wounds
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Matching Colour and Product
 Black…………………..
if aiming to heal: cleansing dressing
 Green………………….
antimicrobial dressing
 Wet yellow…………. antimicrobial dressing
 Dry yellow………….
rehydrating dressing
 Red………………………
protect
 Hypergranulation. antimicrobial dressing
 Pink…………………….
protect.
This is not a prescription but a guide to where to start
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Ideal Dressing
 provide mechanical protection
 protect against secondary infection
 non adherent and easily removed without trauma
 leave no foreign particles in the wound
 remove excess exudates
 cost effective
 offer effective pain relief.
Generic Names
 impregnated mesh dressings
 low adherent lightly absorbent pads
 super absorber pads
 protective film wipes
 film sheets
 foam and foam like absorbent dressings
 hydrocolloid wafers and paste
 hydrogel sheets and amorphous gels with or without additives.
Generic Names
 calcium alginates
 hydrofibre
 hypertonic salt
 cadexomer iodine
 silver
 medicated honey
 zinc bandages
Purchasing Products
 most practices have agreements with distributors
 the fee for dressings is either born by the practice or passed on to
the patient
 if asking the patient to purchase their own dressings perhaps look
at distributors that will offer products at reasonable prices
Rebate schemes
 Department of Veterans Affairs (DVA) patients will be able to secure
most dressings as long as the general practitioner writes the required
item on a script
 11996 is the Medicare item number to be used for the nurse
performing wound care
 AWMA is seeking to have products listed on PBS
Case Studies
 skin tear
 burn
 venous ulcer
 arterial ulcer
 foot wound.
Star skin tear classification system
STAR Tool
 utilise the STAR tool to classify skin tear severity
 the STAR tool can be downloaded from the Silver Chain website at:
http://www.silverchain.org.au/Research/Research-Projects/STAR-Project/
Skin Tear: 1a
Skin Tear: 1b
Skin Tear: 2a
Skin Tear: 2b
Skin Tear: 3
Key Points for Skin Tears
 develop your own set of protocols for managing skin tears
 write these up and add to your wound resource folder
 companies do have protocols for you to follow
Burns: First Contact
Assessment
 site
 depth
 surface area involved
 age of patient
 other influencing factors
What is reasonable to care for in
general practice?
 small superficial partial burns not involving face, feet, hands,
perineum, genitalia on the very young or the elderly
 further guidelines and very good advice may be found on the NSW
DoH Website for Severe Burn Injury or ringing Concord Burns Unit
Superficial Burn Characteristics
 epidermis only
 erythema (vasodilatation)
 tenderness (nerve irritability)
 oedema.
Superficial Partial Burn Characteristics
 epidermis and outer dermis
 blisters (fluid shift)
 shedding of skin
 painful exposed (nerve endings to kinins)
 bleeds when pricked with needle
 hair present (hard to pull out)
 full sensation
 blanches on pressure.
Burn Surface Area
 Wallace’s rule of nines
 Lund and Browder chart
 closed palmar hand of victim
= 1% of body surface area.
Anatomical Site Considerations
 hands
 feet
 face
 perineum
 genitalia
 joints
 circumferential burns
Other Considerations
 extremes of age: very young or very old will need special care
 co-morbidities
 medications.
What to do about blisters?

controversial: removal causes pain

tense blisters can interfere with
dermal circulation, restrict movement

beware of blisters with “red rings”

blisters can hide deep burns

popped blisters may need to be
debrided.
Key Points for Burns
 have standard policies and procedures
 know where nearest specialist burns centre is and how long it takes
by road or air
 liaise with burn centre for care in interim
 closely monitor patient for signs of impending infection and sepsis.
Example of a Burn Protocol
 superficial partial thickness burns of less than 10% body surface
area, not involving feet, face, hands, genitalia, over joints, the
very young and the elderly, can be nursed in the practice
 deeper partial thickness burns of less than 5% body surface area
will be treated in the practice BUT if no response within one week
should be referred on
Useful Websites
 http://www.ameriburn.org
 http://www.anzba.org.au
 http://www.worldburn.org
 http://www.journalofburns.com
 http://www.burnsurgery.org
 http://www.skinhealing.com
 http://www.worldwidewounds.com
Lower Leg Ulceration
Statistics
 venous
70%
 arterial
10%
 mixed
10%
 skin cancers
2%
 others
8%
Venous Ulcer Characteristics
 firm ‘brawny’ oedema
 inverted “champagne” bottle leg
 irregular shape
 medial or lateral aspect lower third of leg
 wet, shallow, minimal necrotic tissue
 atrophie blanche
 venous eczema, staining, lipodermatosclerosis
 palpable pulses, minimal pain, relieved when elevated.
World of Wounds
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Arterial Ulcer Characteristics
 usually located between ankles and toes or high up on leg or
posterior leg
 deep, punched out regular shape, often dry
 thin, shiny, non hair bearing skin
 thickened toenails
 diminished or absent foot pulses
 elevation pallor, dependant rubor
 necrotic tissue, infection
 pain, especially at night or when elevated.
World of Wounds
Venous Ulcer Management
 ensure adequate dressing to assist in managing wound exudate
 if thinking some bacteria present use an anti microbial, cover with
absorbent pad apply light crepe bandage toes to knee
 then cover the bandage with different length layers of straight
elasticated tubular bandage or shaped tubular bandage
3 layers of straight elasticated bandage
Arterial Ulcer Management
 have the patient reviewed by a vascular surgeon
 use Iodosorb powder if the wound is wet or if the area is dry
then paint it with Betadine
 if the surgeon can not revascularise, then the wound is ‘maintenance’
or ‘palliative’ and the aim is to keep it infection free and stable
Foot Wounds
The high risk foot:
 diabetes
 neurovascular disease
 neuropathic diseases
 congenital or other foot abnormalities
Monofilament Testing
 Semmes-Weinstein monofilament is often used to assess protective
sensation in the feet of patients with diabetes
 nylon filament mounted on a holder
 10 gram force
 assess 10 sites over the foot, randomly so the
patient cannot anticipate the next site
http:/ndep.nih.gov/resources/feet/index.htm
Using the monofilament
Areas at risk of damage
Diabetic Foot Examination
D
deformity
I
infection
A
atrophic nails
B
breakdown of skin
E
oedema
T
temperature
I
ischaemia
C
callosities
S
skin colour
Diabetic Foot Examination
Deformity
charcot’s, pes cavus, claw toe, hammer toe
Infection
crepitus, fluctuation, deep tenderness
Atrophic nails
fungal infections and sub ungal ulcers
Breakdown of skin
ulcers, fissures, blisters
Ischaemia
pulses may be weak or absent
Callosities
plantar surface, metatarsal heads
Skin colour
red = charcot’s
pale = ischaemia
pink, with pain and absent pulses = ischaemia
Dressings for Diabetic Foot Ulcerations
Antimicrobial




Iodosorb
Hypertonic salt: Mesalt, Curasalt
Silver products: Acticoat, Aquacel Ag, Atrauman Ag,
Contreet, even silver lined socks and hosiery
Absorbent




Exudry, Mesorb, Zetuvit, Dry-Max
Allevyn, Biatain, Lyofoam Extra
Aquacel
Algisite M, Kaltostat, Calcicare, Sorbalgon
Padding or
cushioning
 Podiatry felt
 Silipos
 Dermal pad
Debriding




Iodosorb
Mesalt
TenderWet
Hydrocolloid paste.
Key Points for Diabetic Foot Ulcerations
 remember diabetics may have micro or macro vascular disease or both
 always be suspicious of infection
 do not use occlusive dressings on foot wounds
 HBO is often helpful in diabetic vascular wounds and osteomyelitis
Assistance is available via the SSWAHS High Risk Foot Service
Conclusions
 wounds in general practice are varied
 it is ideal to have treatment cards for most common types of
wounds seen
 product range needs to be kept to a minimum but cover all generic
types of wounds and an antimicrobial
 always establish the underlying diagnosis of the wound and reassess
if failing to follow normal healing pathways
Resources
 http://www.woundpedia.com
 http://www.worldwidewounds.com
 http://www.globalwoundacademy.com
 http://www.ewma.org
 http://www.wuwhs.org
Useful book: Wound Care Manual by Keralyn Carville
http://www.silverchain.org.au/html/WoundCareForm.htm
Clinical Friends of World of Wounds
 Visit the website and enrol an expression of interest
 Can provide clinical advice via email for $10 per consult
Website: http://www.worldofwounds.com/Home/
Wound Management Competency
Standards for General Practice Nurses

Wound management competency standards for general practice nurses have
been developed as part of the Nursing in General Practice Program at General
Practice NSW and funded by the Australian Government Department of Health
and Ageing

Cpetency standards should be used as a framework to assess competence and
should be read in conjunction with:
— the Australian Nursing and Midwifery Council competency standards
— the Competency Standards for Nurses in General Practice
— the Australian Wound Management Association standards

Standards may be accessed on the APNA website:
http://www.apna.asn.au/displaycommon.cfm?an=1&subarticlenbr=294