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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Health Service
Rehabilitation Aged and Community Care
Speciality Area
Community setting – patients of all ages
Setting
The Nurse Practitioner – Wound Management works within a collaborative
multidisciplinary team consisting of nurses, doctors and allied health
professionals to deliver health services to people with a chronic or complex
wound, where healing is delayed or an expert opinion and assessment is
required. The service/consultancy is available to the ACT community in the
following settings:

Ambulatory Care Clinics in the Community Health Centres

Specialised Nurse Practitioner Wound Clinics

Services to patients in the home setting

Outpatient clinics Canberra Hospital

Transitional care program

Aged care facilities

Appropriate referrals to the Nurse Practitioner from other sources will
also be accepted
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012
Nurse Practitioner Role
The Nurse Practitioner – Wound Management provides a comprehensive
assessment of the patient and implements a management plan, including the
appropriate treatment, ordering of diagnostic investigations, prescribing of
medications, referral to specialists, educating and supporting patients and
carers, discharge planning and evaluating outcomes to ensure the best
possible outcomes for patients with a chronic or complex wound.
Other aspects of the Nurse Practitioner role involve educating and supporting
staff, conducting research and ensuring best available evidence in wound
care. The Nurse Practitioner is able to work in the community and network
closely with ACT hospitals and other appropriate health professionals,
providing specialised treatment to minimise episodes of admission and/or
facilitate early discharge from hospital.
In the case of a medical emergency the Nurse Practitioner’s role is that of basic
life support and to facilitate appropriate and immediate transfer to acute care
services.
Client/Patient Population
Patients with a chronic or complex wound can be of any age and may require
management of one or more co morbidities.
Date of approval
Review date
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012
Contents
Overview
Health service –specialty area and setting
Nurse Practitioner - Wound Management role
Patient population
Local Service Area Clinical Practice Guideline
Advisory Committee Members
1-3
4
Introduction
Assessment
Physical examination
5-6
Conditions for Referral
Emergency Department
Urgent
Conditions for referral to another health professional
7
Management
8 - 11
Treatment options and conditions for Nurse Practitioner treatment
Diagnostic investigations
Health promotion/illness prevention
Non pharmacological approaches
Medication intervention
Follow up management
Medication Formulary
12 - 14
Plans
Dissemination of Clinical Practice Guidelines
Implementation of Clinical practice guidelines
Review of Clinical Practice Guidelines
15
References
16 - 17
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012
Local Service Area Clinical Practice Guideline Advisory Committee Members
Name
Position
Professional
Qualifications
Organization
Signature
Date
Nurse
Practitioner
Wound
Management
Senior
Registered
Nurse
Royal Perth
Hospital
21 Sept
2012
ACT Health
Directorate –
Rehabilitation,
Aged and
Community
Care
ACT Health
Directorate –
Rehabilitation,
Aged and
Community
Care
Canberra
Hospital
30 Jan
2013
Donna Angel
Nurse
Practitioner
Maxine
Scicluna
Director of
Community
Care
Marina
Boogaerts
Clinical
Nurse
Consultant
Research
and Quality
Senior Nurse
Clinician
Ann Marie
Dunk
Clinical
Nurse
Consultant
Tissue
Viability
Unit
Medical
Officer
Clinical Nurse
Consultant
Research
Vascular
Surgeon
ACT Health
Directorate –
Director of the
Wound Clinic
20 Dec
2012
Ben Gilbert
Pharmacist
B. Pharm
MPS
University of
Canberra
17 Dec
2012
Ngaire
Whitehead
Consumer
Health Care
Consumers
ACT
Association
13 Nov
2012
Professor
David
Hardman
10 Oct
2012
15 Oct
2012
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012
Introduction
These Clinical Practice Guidelines outline the extended scope of clinical
practice within the ACT for the Nurse Practitioner – Wound Management.
These guidelines enable the Nurse Practitioner to work safely and
appropriately in the delivery of nursing practice to patients who are referred
for consultation. The Nurse Practitioner works within the community and
outpatient setting. The Nurse Practitioner provides holistic nursing care to
patients of any age with an acute or chronic wound. These guidelines include
the management and treatment of referred patients with vascular leg ulcers,
complex wounds, including pressure injuries, burns, surgical wounds/ fistulas
and the high-risk foot, including neuropathy and diabetic foot ulcers.
Autonomous practice in collaboration with appropriate specialist health
professionals will occur with all conditions covered in these guidelines.
This document reflects what is currently regarded as safe clinical practice.
However, as in any clinical situation there will be factors, which cannot be
covered by a single set of guidelines. In these situations the Nurse Practitioner
will exercise the judicious application of clinical judgement specific for each
individual presentation.
Assessment
This would include, but not be limited to

Comprehensive patient history

Family history

Presenting signs and symptoms

Wound history
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012

Previous diagnostic investigations

Allergy history, including nature and significance of the allergy

Pharmacological history, including complementary and over the
counter medicines

Prompt medications such as puffers, creams, eye drops

Pain assessment

Activities of daily living/functional history

Mobility/gait assessment

Social, occupational and cultural history

Other specialist referrals and services in place
Physical examination
This would include, but not be limited to

General health assessment

Assessment of wound bed, location, tissue loss and surrounding skin,
noting characteristic features

Assess clinical presentation
-
raised unusual purpura, vasculitic nodules
-
suspicion of neoplastic disease
-
senescent tissue
-
hypergranulation tissue
-
non healing despite optimum treatment
-
presence of infection
-
presence of contamination/dead material e.g. devitalised tissue

Examine and assess amount/type of wound exudate

Assessment – duration of wound and history of previous wounds
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012

Assessment of allergies including adverse reactions to wound products
and creams

Pressure injury risk assessment using the Waterlow Risk Assessment
Tool

Presence of other wounds

Signs of topical wound infection

Signs of systemic infection e.g. cellulitis, lymphangitis,
lymphadenopathy

Signs of osteomylitis

Examination of femoral, popliteal and pedal pulses

Assessment of peripheral neuropathy

Assessment of wound bed/tissue for possible neoplastic disease
Conditions for Urgent Referral to Emergency Department
This would include but not be limited to
Immediate transfer for
Medical emergency e.g. cardiac arrest, respiratory arrest, myocardial
infarction, suspected pulmonary embolism, deep venous thrombosis or
sepsis.
Conditions for referral to another health professional – compromising
exacerbation or new presentation of

Urgent conditions – ischaemia limb/s or serious infection

Diabetic ulcers and neuropathy/Charcot’s

Tissue loss – exposed bone, tendon or muscle

Surgical intervention required

Ankle brachia index < 0.7mmHg or ankle systolic <80mmHg
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012

Suspected neoplastic pathology

Venous disease/hypertension – varicose veins

Burns according to severity - body percentage, partial, full thickness
burns, location, age

Wound infection

Wound fistulaes – intracavity contents exposed – (dehiscence)

Recommendation to GP for a referral to an accredited pharmacist for a
Home Medicines Review (e.g. to address medication management
issues, review new/existing medications relevant to both wound care
and general health conditions).
Management
Treatment options and conditions for Nurse Practitioner treatment
This would include but not be limited to

Lower leg ulceration

High risk foot – Charcot

Pressure injuries

Surgical wounds

Skin grafts/flaps - donor site

Traumatic wounds

Minor burns

Wound fistulas/stomas

Cancerous/fungating wounds
Diagnostic Investigations
Investigations for consideration by Nurse Practitioner
This would include but not be limited to
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012

Ankle brachial index/Doppler signal characteristics

Full blood examination, full blood count , electrolytes, liver function
test, erythrocyte sedimentation rate, C-reactive protein, total protein,
albumin, lipids, thyroid function

Blood glucose levels

HBA1C

Urinalysis

Wound swab/s - microbiology, culture and sensitivity

Wound punch biopsy - attended in OPD at CH
-
histological examination to confirm wound aetiology
-
microbiological examination to identify organisms and
sensitivities

Medical imaging – plain x- ray, bone scan, venous/arterial duplex scan
Health promotion/illness prevention

Hygiene

Dietary education

Weight management

Smoking cessation

Daily foot/leg inspection

Foot wear - orthotics

Bandaging technique

Exercise regimes

Pressure injury prevention – access to appropriate equipment

Support groups

Life style modifications

Advanced care directives
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012

Pain Management

Prevention of recurrence and assessment of potential hazards

Disease process and health maintenance

Management of the non-healing wound

Psychosocial support

Provision of consumer health promotion literature

Promotion of Quality Use of Medicines
Non-pharmacological approaches

Appropriate use of dressings and compression bandages

Appropriate use of drainage appliance and devices including negative
pressure systems and dynamic bed systems

Wound debridement/curette

Offload pressure – appropriate foot wear/contact casting

Skin care and moisturisers
Medication Intervention – see Medication Formulary

Analgesia - pain management

Antimicrobial - treatment of wound infection

Local anaesthetic – wound debridement

Corticosteroids - topical - treatment of skin conditions/irritations

Antibiotics – oral and topical - treatment of wound infection and
cellulitis without systemic complication

Antifungal topical creams - treatment of fungal infection

Provision of Consumer Medicine Information (CMI)

Explanation of CMI
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012

Referral to community pharmacist for further management of
medicines and ancillary treatments
Follow up management

Review appropriately in a timely manner according to clinical
condition

Review treatment plan in accordance with assessment and diagnostic
results

Evaluate therapeutic response

Drug therapy assessment

Monitor test results – order as appropriate

Management of abnormal results within scope of practice

Monitor wound progress

Maintenance of healed wound

Pressure injury prevention

Specialist referral for treatment that is outside the scope of Nurse
Practitioner practice

Reinforcement of health promotion/illness prevention message

Continuity of care and communication/collaboration with the
GP/Specialists and/or other health professionals

Co-ordinate case conference specific to complex wound management
as appropriate
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012
Medication Formulary
Analgesia
1. Paracetamol (eg. Panadol)
2. Paracetamol with codeine S3 (eg. Panadeine Extra)
3. Paracetamol with codeine S4 (eg. Panadeine Forte)
Antibiotics
1. Amoxycillin (eg. Amoxil)
2. Amoxycillin & Clavulanate (e.g Augmentin Forte)
3. Cephalexin (eg. Keflex, Ibilex)
4. Dicloxacillin (eg. Diclocil)
5. Ciprofloxacin (eg. Ciproxin)
6. Clindamycin (eg. Dalacin)
7. Doxycycline (eg. Vibramycin, Doxylin)
8. Metronidazole (eg. Flagyl)
Topical antimicrobial
1. Flamazine - Silver Sulfadiazine (SSD)
2. Metronidazole gel (eg. Rozex)
3. Mupirocin (eg. Bactroban)
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012
Topical corticosteroid & antimicrobial
1. Neomycin/Triamcinolone/Nystatin/Gramicidin (e.g. Kenacomb)
Antifungal
1. Nystatin (eg. Nilstat, Mycostatin)
2. Clotrimazole (eg. Canesten)
3. Terbinafine (eg. Lamisil)
4. Imidazole (eg. Bifonazole)
Topical corticosteroids
1. Betamethasone dipropionate (eg. Diprosone, Betnovate)
2. Betamethasone valerate (eg. Celestone)
3. Methyprednisolone aceponate (eg. Advantan)
4. Mometasone furoate (eg. Elocon)
5. Triamcinolone acetonide (eg. Aristocort, Kenocort A)
Local Anaesthetic
1. Lignocaine (eg. Xylocaine)
2. Lignocaine & Prilocaine (eg. EMLA)
3. Lignocaine with adrenaline) (eg. Xylocaine & Adrenaline)
4. Bupivacaine (eg. Marcain)
Hypergranulation
1. Topical silver nitrate
Trace Elements, Minerals and Vitamin Supplements
1. Zinc (eg. Zincaps)
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012
2. Iron (eg. Ferro-Gradumet)
3. Vitamin C (eg. Ascorbic Acid)
4. Multivitamin & Minerals (eg. Centrum)
5. Alginade
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012
Plan for the dissemination, implementation, review and evaluation of the
Clinical Practice Guidelines
1. Copy held at Rehabilitation, Aged and Community Care
2. Copy held in office of the Chief Nurse, ACT Health directorate
3. Copy held at ACT Division of General Practice
4. Copy lodged with Australian Nurse Practitioner Association
5. Implementation will be immediate
6. Formal review and evaluation of the Clinical Practice Guidelines is
scheduled for August 2015
7. Interim updates to the ACT Clinical Practice Guidelines are required
annually (or earlier if there is a change in population or practice) to
ensure that they remain at the level of best practice.
8. Notify Chief Pharmacist
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012
References
Australian Capital Territory Health Directorate (2011). Wound Care Manual.
Community Care, ACT Health Directorate, ACT
Australian Capital Territory Nursing and Midwifery office (2008). Nurse
Practitioner in the Australian Capital Territory – The Framework, ACT
Australian Wound Management Association and the New Zealand Wound
Care Society 2011. Australian and New Zealand Clinical Practice Guideline for
Prevention and Management of Venous Leg Ulcers. Cambridge Publishing, Perth
Australian Wound Management Association (2012). Standards for Wound
Management (2nd Ed) Cambridge Publishing, Perth WA
Australian Wound Management Association (2012). Pan Pacific Clinical
Practice Guideline for the Prevention and Management of Pressure Injuries
Cambridge Publishing, Perth WA
Carville, K. (2012). Wound Care Manual (6th Ed) Silver Chain Nursing
Association, Perth, WA
Cullum, N; Nelson, EA; Fletcher, AW & Sheldon, TA. (2005). Compression for
venous leg ulcers, A Cochrane Review. The Cochrane Library
MacLellan, L; Gardner, G & Gardner, A (2002). Designing the future in wound
care: the role of the nurse practitioner. Primary Intention 10(3) p. 97-106.
Cambridge Publishing, Perth WA
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012
Marley, J. (2009). (Ed). Therapeutic Guidelines: Dermatology. Version 3.
Therapeutic Guidelines Limited. North Melbourne
Medicines, Poisons and Therapeutic Goods Act 2008
http://www.legislation.act.gov.au/a/2008-26/default.asp
Medicines, Poisons and Therapeutic Goods Regulation 2008
http://www.legislation.act.gov.au/sl/2008-42/default.asp
National Institute of Clinical Studies. (2005). Applying compression therapy to
treat chronic venous leg ulcers. Evidence gaps report Vol 2
Nelson, EA, Bell-Syer & Cullum, NA. (2006). Compression for preventing
recurrence of venous ulcers – The Cochrane Database of Systematic Reviews
Pagana, M. & Pagna, C. (2006). Mosby's Manual of Diagnostic and Laboratory
Tests. (3rd ed). Mosby, USA
Palfreyman, SJ; Nelson, EA; Lochiel, R; Michaels, JA. (2006). Dressings for
healing venous leg ulcers. Cochrane Database of Systematic Reviews.
3:CD001103
Rossi, S. (Ed). (2013). Australian Medicines Handbook. Pharmaceutical Society of
Australia. SA
Therapeutic Guidelines (Antibiotic) Version 14 (2010)
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Nurse Practitioner Wound Management
Clinical Practice Guidelines
Rehabilitation, Aged and Community Care
December 2012