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Nurse Practitioner
CLINICAL PROTOCOL
Open Wounds
INTRODUCTION: The skin is the largest organ of the human body. It is comprised of 3
layers;
1. Epidermis: is comprised of epithelial cells and regenerates every 2-4 weeks.
2. Dermis: contains nerves, connective tissue, collagen, elastin and specialist cells.
3. Hypodermis (or subcutaneous): comprises adipose and connective tissue and blood
vessels.
An intact layer of skin provides protection from dehydration, colonization by bacteria and
trauma by mechanical, chemical or thermal means.
Wound healing is affected by many variables including: co-morbidities, age, medications,
malnutrition and smoking.
CLINICAL PRACTICE GUIDELINE
Nurse
Practitioner
Medical
Practitioner
+/Nurse
Practitioner
Scope
All open trauma/wound injuries.
Pts. not considered suitable for management
by NP include;
• Co-existing medical condition requiring
hospital admission.
• Extensive wound trauma requiring
operative procedures.
• Wound requires suturing or insertion
of drains etc.
• Uncontrolled haemorrhage.
• Lacerations to face, hand, over a joint.
•
Underlying
medical
pathology
/
complex patient
• Neurovascular compromise
• Multiple injuries
• Altered conscious state including
effects of drugs/ETOH
• Hx consistent with collapse.
• Pts. identified as above.
Initial Assessment and Interventions
Presenting
• Relevant past medical Hx and
History
medication history
• Known allergies
• Immunisation status (esp. ADT)
• Cause of wound (if known)
• Duration of wound
• Any treatment received
Outcomes
Identify patients suitable for
NP clinical protocol. Refer
unsuitable pts. to current GP.
Identify patients not suitable
for NP CP and redirect to usual
GP care +/- ED
Outcomes
Identify patients not suitable
for NP CP and redirect to usual
GP care +/- ED
Nurse Practitioner
CLINICAL PROTOCOL
Open Wounds
Physical
examination
•
•
•
•
1.
2.
3.
4.
5.
6.
7.
8.
Pain
assessment
Tetanus
vaccination
status
Pathology
Primary survey – ABC
Mechanism of trauma, any other
injuries sustained
Vital signs (T, P, R, BP)
Wound assessment:
Type (laceration, abrasion, contusion,
puncture or incision).
Aetiology of wound. Intentional/non
intentional.
Severity: penetrating or superficial.
Clean, contaminated, infected?
Depth: epidermis, dermis,
subcutaneous tissue, muscle, fascia,
bone.
Characteristics: granular tissue,
epithelisation, slough, necrosis.
Exudate: sanguiness, purulent,
haemoserous, serous.
Neurovascular assessment: colour,
warmth, movement, sensation,
capillary refill, peripheral pulses,
nerves or tendons.
level of pain using appropriate pain
Asses
scale.
• Vaccination for tetanus prone wounds
if required.
• If tetanus immunoglobulin required –
refer current GP.
Investigations
Wound swab for MCS if clinical evidence of
infection.
Not required if:
• No Hx of injury
• No bony tenderness
• No suspicion of bone, joint/tendon
involvement.
Consider imaging if:
• ? foreign body in situ
• Joint involvement
• ? fracture
• ?osteomyelitis
Patient Education / Follow-up
Follow up
Verbal instruction to patient:
appointment
• Review appointment may be indicated
Identify patients not suitable
for NP CP → exit CP and refer
to current GP.
Determine need for and type of
analgesia required.
Identifies current immunisation
status and update provided if
required.
Outcomes
Detect underlying pathology
and identify degree of systemic
infection present.
Imaging
Detect foreign body and
determine bone, joint and/or
tendon involvement. Exit NP CP
and refer to current GP.
Outcomes
Ensure patient understands
problem, treatment and follow
Nurse Practitioner
CLINICAL PROTOCOL
Open Wounds
by pathology results; NP to contact
patient to schedule follow-up
appointment.
Patient
Education
Medication
instructions
Referrals
Certificates
Letter
Verbal instruction and patient information
handout re
• When to seek further advice (wound
swelling or inflammation, continued
pain, drainage of pus, increasing
fever).
• Verbal/written instructions from NP/GP
Referrals may be required for specific patient
problems or as required to:
• Physiotherapy
• Drug and alcohol counsellor
• Other problems outside of NP scope of
practice
• Absence from work certificates
• Certificate of attendance
• Copy of notes to GP / Specialist or
acute care facility
Interpretation of results and management decisions
up.
Referral to GP will be
determined on result of
laboratory tests.
Refer to current GP if no
response to Rx within 48 hrs.
Patient understanding of the
problem, treatment and
measures which may reduce
the risk of ongoing infection.
Ensure patient understands
problem, treatment and follow
up
Patients with problems outside
the NPs scope of practice are
referred to appropriate health
care providers.
Ensure appropriate
documentation completed
Ensure continuity of care and
referral to health care team
GP Æ hospital admission
Outcome
All medications will be stored, labelled and dispensed in accordance with hospital policy and relevant legislation
Positive wound
culture
Abnormal
imaging results
Wound care
Evidence of wound colonisation, no clinical
signs of systemic infection – cover with an
antimicrobial dressing as per the facility
protocol.
Identify causative organisms
and formulate treatment plan.
Evidence of spreading infection – consider
use of cellulitis NP protocol, or referral to
current GP dependent upon severity.
Osteomyelitis, joint/tendon involvement, #
or foreign body in situ – refer to current GP.
Clean Wound: no evidence of contamination
noted, healthy viable tissue present, wound
edges display good apposition.
Contaminated wound: Presence of
debris/contaminants noted, wound edges or
wound bed display devitalised tissue.
Nerve/tendon damage: refer to current GP
Transfer to cellulitis CP or refer
to current GP if required.
Exit NP CP and refer to current
GP for further management.
Care provided by NP CP
Identify Pts. not suitable for NP
care (e.g. extensive
contaminants or devitalisation)
and refer to GP.
Nurse Practitioner
CLINICAL PROTOCOL
Open Wounds
Joint involvement: refer current GP.
Wounds considered suitable for NP care
• Cleanse with appropriate solution.
• Approximate wound edges using
technique considered most suitable
for the Pt.
1. Steri Strips: simple LAC, minimal
tension of the skin, Pt. able to
keep area dry for 48 hours.
2. Tissue Adhesive: simple LAC
<3cm long with good apposition.
Pt. able to comply with after care.
3. Suture/staple: refer to current GP.
4. Dresssings: Wounds to heal by
primary intention. Select most
appropriate dressing dependent
on need for; wound protection and
immobilisation, absorption of
exudate, compression to control
blood loss, prevention of infection.
Goals of Treatment
• Relief of symptoms
•
Eradication / prevention of infection
•
Prevention of recurrence
•
Prevention of complications
Identify Pts. not suitable for NP
CP and refer to current GP for
ongoing management.
Nurse Practitioner
CLINICAL PROTOCOL
Open Wounds
Drug Formulary
FORMULARY
PARACETAMOL
IBUPROFEN
Drug (generic name): paracetamol
Drug: Ibuprofen
Poisons schedule: unscheduled
Therapeutic class: NSAID
Therapeutic class: 4(b) simple analgesics and antipyretics,
Dose range: 200-400mg
non-opioid analgesic.
Route: oral
Dosage range: 500mg-1g
Frequency of administration: 3-4 times per day.
Route: oral/rectal
Duration of order: as required, max 2400mg daily.
Frequency of administration: 4- 6 hourly
Actions: Inhibits synthesis of prostaglandins by inhibiting Cox 1
Duration of order: as required max 4g daily
and COX 2.
Actions: inhibition of prostaglandin synthesis
Indications for use: mild to moderate pain when anti -
Indications for use: mild-moderate pain, migraine, headache,
inflammatory properties may be useful.
fever, muscular pain
Adverse reactions: nausea, dyspepsia, GI ulceration/bleeding.
Contraindications for use: nil –caution for resident with liver
disease.
Adverse drug reactions: (rare) rash, drug fever, mucosal
lesions, neutro/pancyto/thrombocytopenia
NOTE: if pain is uncontrolled with paracetamol, consider
changing to panadeine / panadeine forte (in lieu of
paracetamol).
Nurse Practitioner
CLINICAL PROTOCOL
Open Wounds
ADT BOOSTER
Time since
Type of
last
wound
ADT
Tetanus
immunoglobulin
vaccination
Hx of 3 or more doses of tetanus vaccine
< 5 years
All wounds
No
No
5-10 years
Clean
No
No
Yes
No
Yes
No
minor
wounds
All other
wounds
>10 years
All wounds
Uncertain vaccination Hx or <3 doses of tetanus
vaccine
Clean
Yes
No
Yes
Yes
minor
wounds
All other
wounds
NB: tetanus toxoid is only available in combination with other
antigens.
Therapeutic Guidelines, 2011
Unexpected
representation
Evaluative strategies
Review Patient Notes. Full audit clinical
events.
Nurse Practitioner
CLINICAL PROTOCOL
Open Wounds
NP Clinical
Practice
NP Clinical Practice/Medical Report Audit
Key Terms
CP – Clinical Protocol
NP – Nurse Practitioner
GP – General Practitioner
S4 – Schedule of the drug administration
act
References
1. Australian Medicines handbook (internet). 2011, Nov. Accessed 2011 Dec 1 at
http://www.amh.net.au
2. Carville K. Wound care manual. 5th ed. Osborne Park, WA: Silver Chain Foundation;
2005.
3. etg complete (internet). Melbourne: Therapeutic Guidelines Limited; 2011 Nov.
Accessed 2011 Dec 1 at http://etg.tg.com.au/ref/ref
4. Silver Chain Nurse Practitioner guidelines. Injury – acute open wounds.
Authorship, Endorsement and acknowledgement
This CP was originally written by:
Reviewed and authorised by:
Carol Jones
Dr. Frank Reedman Jones
Nurse Practitioner
MBBCh, DCH, DRCOG, FRACGP, FACRRM
Murray Medical Centre Mandurah
Murray Medical Centre: Primary Care
Physician
We acknowledge the authorship and
input of :
Dr. Eileen Bristol
MBChB,MRCGP,DRCOG,FRACGP
Murray Medical Centre: Primary Care
Physician
Carol Jones
RN, RM, PGradDipNursePractitioner, NP
Nurse Practitioner
Date Written: November 2011
Review Date: November 2013