Download Injury Open Wound

Nurse Practitioner
CLINICAL PRACTICE GUIDELINE
Open Injury
Nurse
Practitioner
Medical
Practitioner
+/Nurse
Practitioner
Primary Survey
History
Focussed
Clinical
Assessment
Neurovascular
Assessment
•
•
•
•
Scope
All open wound injuries
Wound requiring specialist suture technique
Uncontrolled haemorrhage
Compensable status – MVIT/WC (all assessment and
documentation must be completed by a GP)
Initial Assessment and Interventions
• Airway
• Breathing
• Circulation
• MIST: Mechanism: Injuries sustained; Signs – vitals
Treatment given/pre hospital management/time
• Range of movement/ability to weight bear
• Deformity
• Past medical history/medications
• Allergies/immunisations/tetanus status
• Last food/fluids
Assess size and location of wound
Classify by: • Severity – Superficial/Penetrating
• Degree of Contamination – clean/contaminated/infected
• Tidy/untidy – straight edges vs. jagged edges
• Depth – epidermis/dermis/subcutaneous/muscle
fascia/bone
• Cause – intentional/unintentional
NB: Clenched fist/animal or human bite – preference is wound
healing by secondary intention
• Description – cut/laceration/abrasion/contusion/
incision/puncture
• Consider referral for:
o Facial wounds
o Wounds overlying a joint
o Wounds in young children
o Injuries involving tendons
o Nerve damage
o Contaminated wounds
o Untidy wounds
(see acute referrals)
After anesthetising wound:
• Thoroughly explore wound for any underlying structures
i.e. tendon injury
If bony tenderness or suspicion of foreign body see appropriate
CPG
• Colour
• Warmth
• Movement
Outcomes
Identify patients suitable for
NP CPG
Identify patients not suitable
for NP CPG and redirect to
GP +/- NP in team
Outcomes
Abnormal primary survey
identified Æexit CPG
Identify patients not suitable
for NP CPG Æ exit CPG
Determine method of closure
and additional management
required
D/W GP re need for referral
for specialist
consult/management (as
appropriate).
Identify patients not suitable
for NP CPG → exit CPG
Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this
Clinical Practice Guideline.
1
Nurse Practitioner
CLINICAL PRACTICE GUIDELINE
Open Injury
•
•
•
•
Pain
Assessment
Analgesia /
First Aid
Management
Imaging
Pathology
Diagnosis
•
Sensation – complete sensory loss
– partial sensory loss/hypoesthesia
Capillary refill
Peripheral pulse
Nerves/tendons (a thorough understanding of colour,
anatomy and function of the injured limb is essential for
proper management)
Pain score
•
First Aid
o
Rest
o
Ice/immobilisation
o
Compression
o
Elevation
• Administration of analgesia (see medications)
• Consider early application of Local Anaesthetic after
thorough assessment and documentation of
neurovascular function
Working diagnosis and Investigations
• No imaging required where there is no suspicion of
bony injury or foreign body
• X-ray required if:
o Pain and localised tenderness suggestive of bony
injury
o Suspicion of foreign body
• Ultrasound in addition to X-ray may be required if non
radio opaque foreign body is suspected
Not routinely indicated but consider:
• Wound swab if moderate or severe infection, especially
where there is:
• Cellulitis
• Signs and symptoms of systemic infection
• Delayed presentation
• Insert cannula if required
• If surgical repair required, pre operative investigations
may include FBP, U&E, Group & Hold, and INR as
discussed with admitting medical officer / specialist
•
•
•
•
Clean wound – appears clean, no evidence of
contamination, healthy tissue present, good opposition
of wound edges evident
Tidy/untidy – straight edges vs. jagged edges – see
acute referral
Contaminated wound – see acute referral
Nerve damage – see acute referral
Determine need for and type
of analgesia
Reduction/relief of pain.
Minimise or prevention of
complications
Outcomes
Detect foreign body or
determine joint involvement
Ongoing assessment of need
for intravenous access
Referral to acute care facility
identifies need for preoperative investigations –
performed as requested
Patient identified as suitable
for NP CPG and discharged
safely
Correct diagnosis made and
patient management carried
out and/or referred to acute
Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this
Clinical Practice Guideline.
2
Nurse Practitioner
CLINICAL PRACTICE GUIDELINE
Open Injury
•
•
Tendon damage – see acute referral
Other – Need for antibiotics and or tetanus immunoprophylaxis will depend on patient MIST, wound
examination findings and whether delayed presentation
as per therapeutics guidelines.
Interpretation of results (diagnostic features) & Management decisions
Wound irrigation: A 30ml syringe attached to 19g cannula
Cleaning of
without the stylet should be used to vigorously irrigate with 0.9%
Wounds
NaCl
• Wound cleansing
• Chlorhexidine solution soaked gauze used to topically
clean wound
• Contaminated wounds – 1% Povidine Iodine applied
for 3 – 5 minutes then washed off
Management
a. Tissue Adhesive
• Simple wounds <3cm in length – ensure good wound
edge approximation
• Consider for wounds in children
b. Steri-strip
• May be adequate in simple wounds in areas with little
skin tension i.e. not over joints – requires patient
compliance, keep dry for 72hrs, minimal movement etc.
c. Suture
• Select appropriate suture material – absorbable/nonabsorbable
• Wound usually requires infiltration with local anaesthetic
which allows for thorough wound examination/cleaning
d. Dressing
Dressing will be required for closure of wounds. Select
appropriate dressing according to need. Consider: • Absorption of blood/ exudate
• Wound immobilisation/pain relief
• Application of pressure
• Occlusion from dirt, bacteria and inquisitive fingers
• Aesthetic covering
Associated Care Consider:
• ECG for patients > 65yrs who require surgical
intervention
Consider need for acute referral for:
Acute Referral
• Facial wounds requiring Plastics/Surgical specialty
review
• Wounds overlying a joint requiring Surgical/Orthopaedic
specialty review
• Wounds in young children
• Tendon damage – evidence of peripheral tendon
damage after focussed clinical examination and direct
visualisation of wound may require specialty unit review
(dependant on injury sustained and location)
care facility / specialist consult
for management +/admission (see acute
referral)
Outcomes
Selection of appropriate
closure material will ensure
good wound healing and
cosmesis
Correct diagnosis made –
D/W GP to identify +/- need
for referral to acute care
facility or specialist consult
for management +/admission
Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this
Clinical Practice Guideline.
3
Nurse Practitioner
CLINICAL PRACTICE GUIDELINE
Open Injury
•
Contaminated wounds – evidence of contamination and
presence of debris in wound, devitalisation of wound
edges
o Extent of contamination of the wound will
determine whether referral to Plastics unit is
required as the wound may require surgical
debridement in an operating theatre if
extensive.
• Jagged edges – may require debridement or specialist
suture technique
Patient discharge education
• Verbal/written instructions from NP
• Written patient education information
When to return
Follow up
appointment
•
Verbal/written instructions from NP
Medication
instructions
•
Verbal/written instructions from NP/GP
POP care (where
appropriate)
•
•
Verbal/written instructions from NP
Written patient education
Safety
Assessment
i.e. crutches
•
•
Refer patient for crutches as appropriate
Patients > 60 yrs of age consider referrals
Other Referrals
Certificates
Letter
Consider referrals for specific patient problems as required:
• Social Work
• Physiotherapy
• SW Community Drug Service Team
• Aboriginal Liaison Officer
• SW 24 / SW Mental Health Service
• Interpreter
• Silver Chain
• Hospital @ Home
• Absence from work certificates
• Certificate of attendance
•
Copy of notes to specialist or acute care facility
Outcomes
Ensure patient understands
problem, treatment, follow up
and is safe for discharge
home
Ensure patient understands
problem, treatment, follow up,
and is safe for discharge
home
Ensure patient understands
problem, treatment, follow up,
and is safe for discharge
home
Ensure patient understands
problem, treatment, follow up,
and is safe for discharge
home
Ensure patient understands
problem, treatment, follow up,
and is safe for discharge
home
Ensure patient understands
problem, treatment, follow up,
and is safe for discharge
home
Ensure appropriate
documentation completed
Refer to GP for relevant WC
and MVIT documentation
Ensure continuity of care and
referral to health care team
GP to complete BDH Patient
Admission Pack
Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this
Clinical Practice Guideline.
4
Nurse Practitioner
CLINICAL PRACTICE GUIDELINE
Open Injury
Medications
Outcomes
All medications will be stored, labelled and dispensed in accordance with hospital policy and relevant legislation
MILD PAIN
S2 – S4
Simple analgesia
MODERATE PAIN
S2 – S4
On initial assessment of mild pain:
ADULTS:
• Paracetamol: 500mg – 1g 4-6 hourly PO/PR, not to
exceed 4g in 24hr
OR
• Paracetamol 500mg/Codeine 8mg per tablet: 1 or 2
tablets PO 4 – 6 hourly, not to exceed 8 tablets in
24hrs.
CHILDREN
• Paracetamol: 15mg/kg/dose 4 hourly PO/PR up to 4
times/day. Not to exceed 4 doses in 24hrs
OR
• Painstop Day: 0.6 – 0.8ml/kg PO 4 – 6 hourly. Not to
exceed 4 doses in 24hrs.
OR
• Painstop Night: 6 – 8 hourly PO: Max 3 doses in 24hrs
Age: 2yrs: 4-5ml; 3-4yrs: 6-7ml; 5-6yrs: 7-8ml; 7-8yrs:
9-10ml
Total daily maximum of paracetamol 60mg/kg/24hrs for the first
48hrs, thereafter 60mg/kg/24hrs.
CAUTION: PAINSTOP NIGHT
When dosing at maximum level of paracetamol: dose will deliver
a larger than recommended promethazine dose and may give a
higher than necessary codeine dose leading to an increase in
sedation.
Patients given analgesia
appropriate to allergies,
current medications and past
medical history
On initial assessment of moderate pain or failure to relieve mild
pain:
ADULTS:
• Paracetamol 500mg/Codeine 30mg per tablet: 1 or 2
tablets PO 4 – 6 hourly, not to exceed 8 tablets in 24hrs
AND/OR
• Naproxen: 500mg PO initially then 250mg 6 – 8 hourly
OR
• Ibuprofen:400mg PO 3 – 4 times daily
CHILDREN
• Ibuprofen: 10mg/kg PO 3 – 4 times daily to maximum
of 600mg in 24hrs
Failure to control moderate
pain Æ Discuss further
management with GP
Analgesia requirements are
determined by ongoing
assessment of pain and the
provision of adequate
analgesia
Patients with excessive pain
or pain unrelieved by
analgesia Æ review by GP
If NSAIDS contraindicated:
• Tramadol (adults and children>12yrs)
o Oral: 50-100mg QID, maximum 400mg over
Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this
Clinical Practice Guideline.
5
Nurse Practitioner
CLINICAL PRACTICE GUIDELINE
Open Injury
SEVERE –
reassess
Narcotic
Analgesia S8
Anti-emetic S4
PRN
Local Analgesia
(LA) S4
Antibiotics S4
24hrs
OR
o IM: 50-100mg QID, maximum 600mg over
24hrs
Special Note:
TRAMADOL:
• Contraindicated in epilepsy and SSRI use.
• Caution must be used in the elderly – maximum dose
300mg daily
NOTE: Currently NP’s require medical prescription for S8
medications
ADULTS (only)
• Morphine: IM: 5 – 10mg single dose
CHILDREN
• Morphine: IM: 0.2mg/kg single dose
Consider need for:
• Metoclopramide hydrochloride: PO/IM/IV
o Adult > 60kg: 10mg 3 times per day
o 30-59kg: 5mg 3 times per day
o 20-29kg: 2.5mg 3 times per day
o 15-19kg: 2mg 2-3 times per day
o 10-14kg: 1mg 2-3 times per day
o <10kg: 0.1mg/kg (maximum 1mg) twice
daily
Total daily dose should not normally exceed 0.5mg/kg,
especially in children and young adults.
• Procholperazine:
ADULT
• Oral - Initially 20mg, then 10mg 2 hours later; if still
needed, 5-10mg 3 times daily
• IM/IV – 12.5mg 8 hourly as needed
• Rectal – 25mg followed by oral medication (if possible)
6 hours later
CHILDREN > 2YRS
• Oral – 250micrograms/kg 2-3 times daily
• Lignocaine 1% (plain)
• Lignocaine 1% with adrenaline 1:100,000
*Administration via infiltration techniques:
Lignocaine (plain): MAX dose 3mg/kg
Lignocaine (with adrenaline): MAX 7mg/kg
*Consider need for digital nerve block
**Preparations containing ADRENALINE are not to be used on digits, nose,
Initial assessment of severe
pain – discuss further
management with GP
ears, penis or contaminated wounds.
- The use and appropriateness of antibiotic therapy in the treatment of
potentially infected/infected wounds depends on the cause, condition, and likely
microbial organisms to be treated.
- Refer to the Antibiotic Therapeutic Guidelines for appropriate antibiotic drug
administration.
CLEAN WOUNDS
Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this
Clinical Practice Guideline.
6
Nurse Practitioner
CLINICAL PRACTICE GUIDELINE
Open Injury
LOW RISK: Not Routinely used for clean wounds not involving
tendons or joints that can be adequately debrided and irrigate
and are seen within 8 hours
HIGH RISK/ESTABLISHED INFECTION including delayed
presentation or difficult debridement
• Di/flucloxacillin: 500mg (child: 12.5mg/kg up to
500mg) PO 6 hourly for 5 days
PLUS
• Metronidazole: 400mg (child:10mg/kg up to
400mg) PO 12 hourly for 5 days
Alternatively use:
• Amoxycillin + clavulanate: 875 + 125mg (child: 22.5 +
3.2mg/kg up to 875 + 125mg) PO 12 hourly for 5 days
*Patients with penicillin hypersensitivity:
• Cephalexin: 500mg (child: 12.5mg/kg up to
500mg)
6 hourly for 5 days
PLUS
• Metronidazole: 400mg (child: 10mg/kg up to 400mg)
PO 12 hourly 5 days
CONTAMINATED WOUNDS
• Di/flucloxacillin: 2g (child: 50mg/kg up to 2g) IV 6
hourly
PLUS
• Gentamicin: 4-6mg/kg (child: <10yrs 7.5mg/kg; > 10
years: 6mg/kg) IV daily (adjust dose for renal function)
PLUS
• Metronidazole: 500mg (child: 12.5mg/kg up to 500mg)
IV 12 hourly
*Patients with penicillin hypersensitivity:
• Metronidazole: 500mg (child: 12.5mg/kg up to 500mg)
IV 12 hourly
PLUS
• Cephazolin:2g (child: 50mg/kg up to 2g) IV 8 hourly
OR
• Cephalothin: 2g (child: 50mg/kg up to 2g) IV 6 hourly
NOTE: Duration of treatment should be at least 5 days.
Correct diagnosis made –
D/W GP to identify +/- need
for referral to acute care
facility or specialist consult for
management +/- admission
CLENCHED FIST/ANIMAL and HUMAN BITES
HIGH RISK:
o Delayed presentation
o Puncture/difficult debridement
o Wounds on hands/feet/face
o Involving underlying structures eg joints/tendons
• Amoxycillin + Clavulanate: 875 + 125mg (child: 22.5
+ 3.2mg/kg up to 875 + 125mg) PO 12 hourly for 5 days
PLUS
Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this
Clinical Practice Guideline.
7
Nurse Practitioner
CLINICAL PRACTICE GUIDELINE
Open Injury
•
Procaine penicillin: 1.5g (child 50mg/kg up to 1.5g) IM
single dose (if commencement of above delayed)
followed by above.
ESTABLISHMENT INFECTION &/OR SEVERE
PRENETRATING INJURY
• Metronidazole: 400mg (child: 10mg/kg up to 400mg)
PO 12 hourly (consider initial IV dose)
PLUS
• Cefotaxime: 1g (child 25mg/kg up to 1g) IV 8 hourly
OR
• Ceftriaxone: 1g (child: 25mg/kg up to 1g) IV daily
Alternatively use:
• Ticarcillin + Clavulanate (Timentin): 3 + 1.0g (child:
50+ 1.7mg/kg up to 3+ 1.0g) IV 6 hourly
*Patients with penicillin hypersensitivity:
• Metronidazole:400mg (child: 10mg/kg up to 400mg)
PO 12 hourly
PLUS EITHER
• Doxycycline: 200mg (child >8yrs 5mg/kg up to 200mg)
PO for 1st dose, then 100mg (child 2.5mg.kg up to
100mg) PO daily
OR
• Trimethoprim + sulfamethoxazole: 160 + 800 mg
(child 4 + 20mg/kg up to 160 + 800 mg) PO 12 hourly
OR
• Ciprofloxacin: (authority prescription) 500mg
(child:10mg/kg up to 500mg) PO 12 hourly days
Correct diagnosis made and
D/W GP to identify +/- need
for referral to acute care
facility or specialist consult
for management +/admission
NOTE: A low threshold should exist for discussing these patients with a
Specialist Consultant/Infectious Disease for appropriate therapy and
management regimes
Vaccine/
Immunisation
S4
*Consider tetanus immuno-prophylaxis in tetanus prone
wounds
Refer to Australian Immunisation Handbook 9th Edition – section on
Immunisation for tetanus prone wounds – for dosage regimen
(dependent upon previous immunisation status and type of exposure)
Unexpected
representation
NP Clinical
Practice
Evaluative strategies
Review Patient Notes
NP Clinical Practice/Medical Report Audit
NP – Nurse Practitioner
GP – General Practitioner
S1 – S4; S8 – Schedule of the drug
administration act
Key Terms
CPG – Clinical Practice Guideline
WC – Worker’s Compensation
MVIT – Motor Vehicle Insurance Trust
Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this
Clinical Practice Guideline.
8
Nurse Practitioner
CLINICAL PRACTICE GUIDELINE
Open Injury
References and existing CPG’s
Naturaliste Medical Group Nurse Practitioner Clinical Practice Guideline: Open Injury
Authorship and Endorsement
This guideline was written by:
Lisa Scholes - Nurse Practitioner
Broadwater Medical Practice & Dunsborough Medical Practice
Signature: _________________
Reviewed and authorised by:
Dr Andrew Lill - General Practitioner
Broadwater Medical Practice & Dunsborough Medical Practice
Signature: _________________
Dr Mostyn Hamdorf -General Practitioner
Broadwater Medical Practice & Dunsborough Medical Practice
GP Down South: Chair
Signature: _________________
Dr Scott McGregor - General Practitioner
Broadwater Medical Practice & Dunsborough Medical Practice
Signature: _________________
Jarred Smith - Pharmacist
West Busselton Pharmacy
Signature: _________________
Date written: June 2010
Review Date: June 2011
Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this
Clinical Practice Guideline.
9