Download Wound Management Clinical Protocols

Nurse Practitioner Wound Management Clinical Protocols
Clinical Protocol 1: Wound Diagnostics and Treatment
Clinical Protocol 2: Minor Surgical Procedures
Clinical Protocol 3: Lower Leg Ulcers
Overview of Practice
The prevalence of wounds in the community and within the hospital setting
demonstrates the need for wound care services and the role of the Nurse
Practitioner (NP) in Wound management.
Any client with a wound has a right to expect a high standard of care in line with
best practice standards, regardless of the aetiology of their wound, where the
care is delivered or by whom. When a client with a wound is managed
inappropriately, they can suffer from failure to heal which results in the wound
being present for longer than necessary and an increased risk of complications.
Posnett and Franks (2008) stated that a high proportion of chronic wounds
remain unhealed for long periods and for almost certainly longer than
necessary. Ineffective management such as this can result not only in
prolonged client suffering but also increased cost to healthcare organisations
through ongoing resource use and increased length of stay.
Non-healing chronic wounds affect client’s lives emotionally, mentally,
physically and socially. They can be pivotal in preventing full recovery,
increasing hospital stay and increasing the need for ongoing treatments
(Splisbury et al 2007).
Optimal wound care is care that addresses every need of the patient in order to
maximise their quality of life while they have that wound. This involves
addressing concurrent issues that may impact on their health such as undernutrition, illness, infection, the environment in which care is carried out and the
expertise available to provide the care.
Mofffat et al (2008) suggested that this involves a complex interplay with the
patient, their wound, the knowledge and skills of the healthcare professional
and availability of recourses all being important in planning and progression.
Although the provision of wound care should be relatively straight forward it is
often not so. According to Queen et al (2004) over the last 20 or 30 years
wound care has changed dramatically with significant developments in scientific
research and clinical knowledge.
The Nurse Practitioner Wound Management (NPWM) role has been established
in Victoria (Warnamboo), New South Wales (Hunter Valley), Royal Perth
Hospital and Sir Charles Gairdner Hospital Western Australia.
Carville and Lewin (1998) reported a wound prevalence of 1699 patients with
wounds across Silver Chain Services in Western Australia in 1996. Of the
nursing visits 44% were devoted to wound care. Leg ulcers (including diabetic
foot ulcers) were the primary group treated comprising 81.5%.
Data from a Nurse Practitioner feasibility study at the Canberra Hospital
(MacLellan, Gardner & Gardner, 2002) demonstrated the common wound
aetiologies to be chronic leg ulcers, infected leg ulcers, cellulitis, pressure
ulcers, diabetic foot ulcers, multi-trauma wounds, and fungating tumours. These
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 2 of 39
patterns are similar to the wound referrals currently reviewed by the Clinical
Nurse Consultant Vascular/Chronic wounds at Fremantle Hospital and Health
Service.
The patient presenting with an Acute or Chronic wound requires a
comprehensive assessment that will include the wound history, client history,
and physical examination performed by the NPWC. There may be the
requirement of a number of diagnostic investigations to complete a
comprehensive assessment to determine an accurate diagnosis and initiate
appropriate treatment.
Management of care may require working in collaboration with other health care
providers, prescription of medications, management of pain and topical
management of skin and wound conditions.
Client outcomes include wound healing or wound maintenance depending on
the aetiology and the patient’s Co-morbidity factors. Wound specific outcomes
may include odour control, treatment of infection, debridement and pain
management.
Client education plays an important part in the role of the Nurse Practitioner,
including promoting health and developing a partnership in care. Follow up
care and discharge will be dependent on the individual patient and their
management plan.
The protocols that follow are inter-related and outline key processes and actions
for the Nurse practitioner treating patients with Acute/Chronic Wounds. These
protocols have been developed by working in parallel with those currently in use
at Royal Perth Hospital and Sir Charles Gairdner Hospital therefore I would like
to acknowledge their work.
The information provided in these Clinical Protocols is intended for information
purposes only. Clinical Protocols are designed to improve the quality of health
care and decrease the use of unnecessary or harmful interventions. These
Clinical Protocols have been developed to be used within South Metropolitan
Health Service, and they provide advice regarding the care and management of
clients presenting with Wounds.
While every reasonable effort has been made to ensure accuracy of these
clinical protocols, no guarantee can be given that the information is free from
error or omission. The recommendations do not indicate an exclusive course of
action or serve as a definitive mode of client care. Variations, which take into
account individual circumstances, clinical judgement and client choice may also
be appropriate. Users are strongly recommended to confirm by way of
independent sources that the information contained within the Clinical Protocols
is correct.
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 3 of 39
CLINICAL PROTOCOL 1
WOUND DIAGNOSTICS AND TREATMENT
Introduction
The following protocol (see Table 1) outlines the sequence of events in the
assessment, investigation, diagnosis and management of a patient with a
wound either Acute or Chronic, and forms the basis for the protocols which
follow. This is further outlined in a flow chart (see Figure 1).
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 4 of 39
PROCESS
ACTION
GUIDANCE
History
A complete history is taken
• Medical, surgical, allergy history
• Current medications (prescribed and over
the counter (OTC)
• Previous diagnostic investigations, surgery
• Social and occupational history (including
•
•
•
•
Examination
Physical examination of the
wound and associated area
Generalised assessment as
necessary
home support/carer)
Physical mobility
Activities of daily living
Nutritional status
Smoking history
•
•
•
•
Clinical features of the wound and skin
Presence of other wounds/lesions
Peripheral perfusion
Peripheral neurological examination (e.g.
Semmes Weinstein 10g monofilament,
tendon reflexes, vibration)
• Footwear (diabetes, lower limb/foot
wounds)
• Physical and joint mobility
Explore differential diagnosis
Investigations
Establish appropriate
investigations required to
assist in an accurate
diagnosis, or be able to
provide a baseline of health
status
Pathology (possible investigations)
Haematology
• FBP,ESR,CRP,INR,
Biochemistry
U & Es
LFT, (Total Protein, Albumin), Pre-albumin,
Glucose, HbA1C
Lipids
Thyroid Function
•
•
•
•
•
Immunology
• RH Factor
• Auto Antibody Screen
Microbiology and Histology
• Wound fluid/swabs-microscopy, culture
and sensitivity (MC&S)
• Wound/tissue biopsy-MCS and
Histopathology
• Skin Scraping, Immunofluorescence
Biopsy
May be required if wound has been nonhealing, despite optimal treatment, for greater
than 4-6 weeks, duration greater than 6
months, previous SCC/BCC and/or is
assessed as atypical
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 5 of 39
PROCESS
ACTION
GUIDANCE
Investigations
(cont)
Radiology/Medical Imaging
• Ankle Brachial Pressure Index (ABPI)
• Toe Pressures
• Photo plethysmography (PPG)
• Duplex Scan (Arterial/Venous)
• X-Ray
• Angiogram: MRA/CTA/DSA (Consultant
decision)
• Bone Scan/MRI (Consultant decision)
Arterial Duplex: To
determine presence and/or
severity of Arterial Disease
or Graft/Bypass patency in
lower limb
Venous Duplex: To
determine disease or
impairment of superficial,
deep or perforating veins
and their valves.
Diagnosis
Make provisional Diagnosis
Management
Urgent Referrals:
• Life/limb threatening
infection
• Abnormal test results that
require medical
intervention
• Treatment required
outside the NP scope of
practice
• Acute DVT
• New patients with an ABI
<0.7 or ankle systolic <
80mmHg
• Patient that requires
surgical intervention
ABPI- Performed on all patients with a leg
ulcer. If the ABPI does not complement the
clinical assessment or is inconclusive then
further diagnostic investigations may be
required
Arterial/Venous Duplex Scan – Noninvasive investigation recommended for initial
diagnosis
X-Ray – An X-Ray may be required if there is
a suspicion of osteomyelitis, sinus, significant
undermining or foreign body.
Bone Scan/MRI - If there is a suspicion of
Osteomyelitis, then a bone scan or MRI may
be ordered following consultation with an
Infectious Diseases Physician or Vascular
Surgeon
On clinical picture, available assessment data
and results of investigations
Referrals
If the wound fails to heal despite optimal
therapy following best practice, then
consultation with other health care
practitioners and further investigations may
be required.
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 6 of 39
PROCESS
ACTION
GUIDANCE
Management
(cont)
• Ulcers on the planter
aspect of the foot to have
immediate Podiatry
referral
• Significant deterioration
in wound since last
review
• Patient systemically
unwell
Nurse Practitioner:
Non-Pharmacological
treatment
Non-Pharmacological treatment
• Appropriate dressing and/or compression
therapy based on diagnosis and patient
lifestyle
• Cleaning and debridement of wound
Patient Education For Self
Care
Client/Carer Education for self care
• Hygiene (Cleansing self care and
waterproofing i.e. leg bags as required
• Diet (importance of essential vitamins and
minerals as required)
• Lifestyle changes (smoking cessation,
optimal weight ,blood pressure and lipids,
structured exercise regime)
• Bandaging/stocking/dressing techniques
• Pain management (Adjunct therapy)
• Medications
• Disease and health maintenance
• Indications to seek medical assistance
(To include relevant consumer handouts)
Pharmacological treatment
– Based on diagnostic
investigations, clinical
assessment and
Therapeutic Guidelines
Management
Partnerships
Appropriate referrals to
assist in overall
management
Pharmacological Treatment
• Analgesics
• Topical antimicrobials/antifungals
• Local anaesthetic
• Topical corticosteroids
• Oral antibiotics
• Moisturisers/barrier ointments, skin
cleansers
Other Health Professional as required:
Medical:
• Vascular Surgeon/Registrar
• Plastic Surgeon
• Infectious Disease Physician
• Dermatologist
• Endocrinologist
• Pain Management Service
• Palliative Care
• Geriatrician/Rehabilitation Physician
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 7 of 39
• General Practitioner
PROCESS
ACTION
GUIDANCE
Allied Health:
• Dietician
• Podiatrist/Orthotist
• Diabetic Educator
• Physiotherapist
• Occupational Therapist
• Hospital in The Home (HITH)
/Rehabilitation in The Home (RITH)
• Pharmacist
• Social Worker
Management
Partnerships
(cont)
Community Care Providers:
• Silver Chain Nursing
• HITH/RITH
• GP Practice Nurses
• Other home care providers
Ongoing
Management
Follow-Up
Review as appropriate:
• Monitor progress
• Test results
• Maintenance of wound
• Review of treatment plan in accordance
with investigative results
Separation
Discharge from service
As Appropriate:
• Wound healing achieved
• Referral to community services for longterm management
• Referral for specialist care
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 8 of 39
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 9 of 39
CLINICAL PROTOCOL 2
MINOR SURGICAL PROCEDURES
Introduction
There are occasions when wound biopsies or sharp debridement procedures
are required to manage the wound, both procedures can be classified as minor
surgical procedures. The flow chart demonstrates the protocol (see figure 2).
Biopsy
Skin biopsy is a biopsy technique in which a segment of skin is removed and
sent to the pathologist to render a microscopic diagnosis.
The common punch size used to diagnose most inflammatory skin conditions is
the 3.5 or 4mm punch. Ideally, the punch biopsy includes the full thickness skin
and subcutaneous fat in the diagnosis of skin disease.
Curettage biopsy can be done on the surface of tumours or on small epidermal
lesions with minimal to no topical anaesthetic using a round curette blade.
Diagnosis of basal cell carcinoma can be made with some limitation, as
morphology of the tumour is often disrupted. The pathologist needs to be aware
of the type of anaesthetic used, as topical anaesthetic can cause infarct in the
epidermal cells.
Debridement
Wound healing is delayed by the presence of devitalised tissue (National
Institute for Clinical Excellence 2001).
An ulcer or open wound can not be thoroughly assessed until all devitalised
tissue is removed. Dead or foreign material in a wound adds to the risk of
infection and sepsis and inhibits wound healing (Leaper 2002).
Debridement is the removal of necrotic or foreign material from and around a
wound to optimise wound healing. There are many different methods that can
be used to debride a wound. They can broadly classified as surgical/sharp,
mechanical, biological, chemical, enzymatic and autolytic.
Conservative sharp debridement (CSWD) is a procedure used to debride nonviable tissue from a wound down to non-bleeding tissue using sharp
instruments (e.g. scalpel, scissors). Sharp debridement may be necessary in
either acute wounds (e.g. skin tears) or chronic wounds (e.g. pressure ulcers).
Consideration to perform the procedure requires consideration of both local and
systemic factors.
Debridement may also be undertaken in preparation for skin grafting,
application of skin substitutes, or topical negative pressure therapy (e.g. VACVacuum Assisted Closure).
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 10 of 39
The outline of assessment process, investigations and management are outlined in Table 2
Table 2 Assessment and Management: Minor Surgical Procedures
PROCESS
ACTION
GUIDANCE
History
A complete history is taken
• Medical, surgical, allergy history/
•
•
•
•
•
•
Examination
Physical examination of the
wound and associated
are/limb
More generalised
assessment as necessary
co-morbidities
Wound history
Current medications (prescribed and OTC)
Previous diagnostic investigations
Social and occupational history including
carer or home support
Physical mobility
Activities of daily living
Findings from assessment of complex,
infected wounds, leg ulcers and diabetic foot
ulcers
Abnormal clinical presentation:
• Raised/unusual clinical features
• Suspicion of neoplastic disease
• Senescent tissue
• Hypergrannulation tissue
• Non healing wound despite optimal
treatment
Presence of:
• Infection not responding to antibiotic
treatment
• Contaminated/non-viable material
• Foreign bodies
Investigations
Biopsy of wound for
histology and/or
microbiology
Histology
• To confirm wound aetiology
Microbiology
• To identify organisms and sensitivities
Diagnosis
Make provisional diagnosis
On clinical picture, available assessment data
and results of investigations
Management
Urgent referrals:
• Life/Limb threatening
infection
• Abnormal test results that
require medical
intervention
• Treatment required
outside NP scope of
practice
• Significant deterioration
in wound since last
review
Notify medical practitioners of investigations
ordered and referrals organised
If the wound fails to heal despite optimal
therapy then consultation with other health
care practitioners and further investigations
may be required at that time
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 11 of 39
PROCESS
ACTION
GUIDANCE
Management
(cont)
Nurse Practitioner:
Non-Pharmacological
treatment
• Appropriate dressings/bandaging based on
Non-Pharmacological treatment
diagnosis and patient lifestyle preferences
• Cleansing and debridement of wound
Client education for self care Client/Carer education for self care
• Hygiene (cleansing self and wound
waterproofing as required)
• Diet (the importance of essential vitamins
and minerals as required)
• Signs and symptoms of complications
• Bandaging/dressing techniques
• Exercise regimes
• Lifestyle factors/changes
• Disease process and health maintenance
• Prevention of recurrence
• Pain management
• Medications
(Include relevant consumer literature in the
form of leaflets/booklets)
Pharmacological treatment
– Based on diagnostic
investigations, clinical
assessment, and
Therapeutic Guidelines
Pharmacological treatment
• Analgesics
• Topical antimicrobials/antifungals
• Local anaesthetics
• Topical corticosteroids
• Oral antibiotics
Conservative sharp surgical
Debridement
Conservative Sharp Surgical Debridement
To remove:
• Contaminated material
• Foreign bodies
• Non viable tissue
To prepare the wound environment for:
• Topical Negative Pressure Therapy (VAC)
• Skin Grafts
• Substitutes to accelerate the healing
process
Management
Partnership
Appropriate referrals to
assist in overall
management
Other Health Professionals as required:
• General Practitioner
• Plastic Surgeon
• Dermatologist
• Infectious Diseases Physician
• Vascular Surgeon
Consultation with the medical practitioner if
required for further treatment and
investigations
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 12 of 39
PROCESS
ACTION
GUIDANCE
Allied Health:
• Dietician
• Podiatrist
• Diabetes Educator
• Occupational Therapist
• Pharmacist
Management
Partnership
(cont)
Community Care Providers:
• Silver Chain Nursing
• Other home care providers
Ongoing Care
Follow-Up
Review as appropriate:
• Test results
• Monitor progress
• Maintenance of wound
• Review treatment plan in accordance in
investigative results
Separation
Discharge from service
As appropriate:
• Wound healing achieved
• Referral to community services for long
term management
• Referral for specialist care
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 13 of 39
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 14 of 39
CLINICAL PROTOCOL 3
LOWER LEG ULCERS
Introduction
This protocol has been designed to guide and facilitate the NPWM in
diagnosing and providing appropriate care for clients with leg ulcers. Lower leg
ulcers are a common and expensive problem for the healthcare system
(Bergqvist, and Lindagen 1996).
The prevalence of leg ulcers increases markedly with age particularly the older
group (Baker et al 1991) It is estimated that 2–3 percent of people over the age
of 65 suffer from open or healed venous ulceration (Bradbury et al 2001).
The cost to treat these chronic wounds is estimated at A$3 billion per annum
representing a significant burden on the health care dollar. Venous ulcers are
notorious for recurring despite best practice/interventions, with recurrence rates
as high as 69% (Walker et al 2002).
Leg ulceration is not a diagnosis, it is the underlying aetiology that defines the
ulcer and its associated management decisions. It is crucial that a client is
assessed before treatment decisions are made, and that ongoing assessment
takes place, as disease processes such as venous insufficiency can be
progressive, or other diseases such as arterial disease may progress or
become apparent (Vowden & Vowden 1996). Risk factors for ulceration and
delayed wound healing need to be identified at assessment (Morrison & Moffatt
2004).
Venous Ulcers
The socioeconomic impact of chronic venous insufficiency is enormous, as
venous leg ulcers are more prevalent in the elderly, this financial burden will
escalate as the population ages. In addition to the clinical and cost-of-care
implications, disability from venous leg ulcers results in significant amount of
lost working days and has a major impact on quality of life (Laing, W 1992).
Chronic venous insufficiency is a significant health problem affecting an
estimated 13% of the adult population (Bradbury et al 2001). Approximately
20% of chronic venous insufficiency clients have concomitant arterial
insufficiency.
Venous ulcers are the most serious consequence of chronic venous
insufficiency (Laing,1992). Chronic leg ulcers can result in disfigurement,
disability and a lifelong need for medical treatment (Weingarten, 2001).
These ulcers develop due to ambulatory hypertension, which arises as a result
of ineffective venous return from the lower legs. This increases the pressure in
the superficial venous system on exercise, which affects the exchange of
nutrients in the capillary bed. Fluid is not reabsorbed effectively into the venous
system from the interstitial spaces, resulting in oedema.
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 15 of 39
This means that the tissues are undernourished and waste metabolites in the
interstitial spaces. Red cells and protein also leak into the tissues resulting in
haemosiderin deposits and tissue fibrosis.
Staining of the skin results, varicose eczema may form and skin integrity may
be compromised by infections such as cellulitis. This can ultimately lead to
ulceration (Morrison & Moffat 2004). The aim of treatment is to reduce venous
reflux, ambulatory venous hypertension and oedema.
Arterial Ulcers
Arterial ulcers result from insufficient perfusion of the skin and subcutaneous
tissues in the lower limb leading to ischaemia and tissue necrosis (Holloway,
2001) This may be due to partial arterial obstruction or arterial occlusion.
Atherothrombosis and arteriosclerosis are common processes that can lead to
arterial insufficiency.
Blood flow through the arteries is impaired due to atherosclerotic plaque lining
the arterial wall. This reduces the lumen of the vessel and subsequently affects
the oxygen and nutrients to the lower leg. Poorly perfused tissue is at risk of
sudden and dramatic ulceration following injury.
The lack of adequate oxygen supply means that the wound can be very slow to
heal, or may not heal at all (Herbert, 1997). Additional risks include thrombus
formation in areas of atheroma, which occlude the vessel completely.
Surgical intervention may help restore circulation. If the disease is extensive
and not reconstructable, then the management of the arterial ulcer centres on
symptom management particularly pain and wound management (Herbert
1997).
Mixed Aetiology Ulcers
Clients with these ulcers have venous disease and a significant level of arterial
disease, but their blood supply is not yet compromised to cause critical
ischaemia. The key clinical factor in mixed aetiology ulceration is that, without
intervention arterial disease is progressive, and eventually the arterial problem
will take precedence over the venous problem in treatment decisions.
Population
Clients presenting with leg ulcers will be received into the leg ulcer clinic for
assessment via a referral from General Practitioners, Consultants/Registrars
within the hospital setting, Emergency Department, in-patients and out-patients
at Fremantle Hospital and Health Service. Referrals will also be accepted from
within Western Australia if suitable for the Ulcer Clinic.
Presentation Rates
The Leg Ulcer Clinic at Fremantle Hospital and Health Service has in excess of
1750 presentations of active leg ulcers per year, and offers a chronic wound
management out-patient clinic. The service also provides a prophylactic
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 16 of 39
programme in the management of healed clients, with the prescription of
compression hosiery be it custom made or off the shelf, and yearly
assessments.
Direct referrals will be possible with the designation of a Nurse Practitioner in
Wound Management.
Expected Outcomes of the Protocol
Leg ulcer outcomes will be aligned with aetiology, predicted healing rates, and
recurrence rates.
The increased scope of the Nurse Practitioner will increase the effectiveness
and efficiency of the care offered to clients with lower leg ulcers.
The Lower Leg Ulcer Protocols will:
• improve client outcomes – including improved wound healing, quality of life,
and prevention of leg ulcer recurrence
• reduce health costs through improved wound healing rates
• reduce variation in clinical practice
• improve client satisfaction
• enhance continuity of care with other health care providers
• improve community awareness of professional wound services available.
Venous leg ulceration and chronic venous insufficiency represents a significant
health problem and the key to successful management lies in the use of
compression therapy.
Compression is a potent therapy, used correctly it can promote healing and
change a client’s quality of life. Used incorrectly it can result in delayed healing,
pain, trauma or even the loss of a limb.
According to Barwell et al (2004) anticipated healing rates of venous leg ulcers
are expected to be around 12-24 weeks, 68-83% of the time. Those with ulcers
of longer duration will be expected to have longer time to healing (Vowden et al
1997).
Of those who heal recurrence will be dependent on client participation in care
and management of Co-morbidity factors.
For those clients with arterial ulcers and evidence of arterial disease, the focus
of outcomes may be to relieve pain, improve mobility and independence, wound
care and improve quality of life if possible.
Assessment
Assessment of the individual client will follow as per Protocol 1., “Wound
Diagnostics and Management”. The following information outlines in more detail
the specific process for the NPWM in managing clients with lower leg ulcers
(see Table 3) using evidence grading. A flow chart outlining the Lower Leg
Clinical Protocol is shown in figure 3 and the guidelines for compression
bandages are represented in Figure 4. An explanation of compression
bandaging components is outlined in Appendix 1.
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 17 of 39
Table 3 Assessment and management of Lower Leg Ulcers
PROCESS
ACTION
History
• A complete history is taken: medical, surgical,
•
•
•
•
•
•
LEVEL OF EVIDENCE
GUIDANCE
allergy history
Wound history
Current medications (prescribed and OTC)
Previous diagnostic investigations
Social and occupational history including
carer/or home support
Physical mobility
Activities of daily living
Assess history of Ulcers
• duration of current ulcer
• mechanism of injury
• previous methods of treatment
Assess for Venous Insufficiency:
• Family history of venous disease
• Client history of DVT/PE
• Lower limb fractures or other major leg injury
• Previous vein surgery or sclerotherapy
• Prior history of ulceration – with or without
compression therapy
C
C
B
Assess for Arterial Insufficiency:
• History of intermittent claudication or rest pain A
• Previous graft surgery/interventions
• Hypertension
• Heart disease
• Diabetes
• Ischaemic stroke/TIA
• Smoking (or stopped < 5 years)
In the presence of mixed disease (arterial +
venous, client may present with both
B
Assess for diabetes, rheumatoid arthritis and
systemic vasculitis (specialist
assessment/referral should be considered)
Assess for correctable factors that may
C
delay healing, including smoking, anaemia, and
evidence poor nutrition
Assess for pain and formulate plans that
involve exercise (including ankle exercises) and
leg elevation for venous ulcers and adequate
analgesia irrespective of aetiology
C
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 18 of 39
Physical examination of the wound and
associated area/limb
Conduct lower limb examination of both legs
(e.g. the presence of varicose veins LSV/SSV in
venous disease)
Examine for signs of arterial insufficiency:
Lower skin temperature, palpation of peripheral
pulses (weak absent), unilateral signs may be
present where there is acute deterioration
Examination
Assess for malignancy – can be a cause or
may be a sequel of leg ulceration
B
A
B
Signs suggestive of malignancy are: irregular
nodular appearance of the surface of the ulcer,
raised or rolled edge, raised granulation tissue
above the ulcer base, failure to respond to
treatment, rapid increase in ulcer size and
abnormal pigmentation
Assess the wound and surrounding tissue:
• The surface area should be measured at
regular intervals or photographed to monitor
progress
C
Venous Ulcers are generally shallow, moist and
appear on the gaiter area of the leg
B
• Eczema, haemosiderin pigmentation, ankle
oedema and ankle flare are often present
• Varicose veins, atrophe banche and
lipodermatosclerosis may also be present
Arterial Ulcers have a punched out
appearance, a poorly perfused base and are
C
pale, dry and may have necrotic tissue in the
base
• Surrounding skin is shiny and taut, dependant
rubor is present
C
Lower Limb Pulses – palpable pulses alone
are insufficient to rule out arterial disease
More generalised assessment as necessary
• Clinical features of the wound and skin
• Presence of other wounds/lesions
• Peripheral perfusion
• Neurological examination (e.g. using Semmes
Weinstein 10g monofilament)
• Signs and symptoms of infection
• Footwear (diabetes, lower limb/foot wounds)
• Physical and joint mobility)
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 19 of 39
PROCESS
ACTION
LEVEL OF EVIDENCE GUIDANCE
Explore differential diagnosis
Investigations Ankle Brachial Pressure Index (ABPI) to be
performed on all in-patient and out-patient leg
ulcer clients. If the ABPI does not complement
the clinical assessment or is inconclusive then
further diagnostic investigations may be
required.
Measurement of ABPI by handheld Doppler
• ABPI - Normal 0.9-1.2
• A ratio of <0.8 indicates the presence of
peripheral arterial disease (PAD)
• Further investigations should be considered
prior to initiating compression therapy if a
patient has an ABPI > 0.8 in the presence of
signs and symptoms of PAD, rheumatoid
arthritis, systemic vasculitis or diabetes
mellitus
• Doppler determination of ABPI should not be
used in isolation from clinical assessment
• Repeat measurements of ABPI when an ulcer
deteriorates, is not fully healed by 3/12; or
when a client presents with recurrence.
• Toe Doppler Pressures/index and arterial
Photophlethysmography (PPG) are adjunct
tests to ascertain arterial insufficiency
particularly where diabetes, incompressible
vessels or calcification are present.
• Venous PPG will provide information on
venous refilling time as an assessment of
venous insufficiency (<25 seconds)
A
B
A
C
A
B
Determine which investigations may be
required to assist in a diagnosis or provide a
baseline of nutrition and health
Pathology
Haematology
• FBP
Biochemistry
• U&E
• LFT, total protein, albumin
• Glucose, HbA1C
• Lipid profile
• Thyroid function
• CRP
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 20 of 39
PROCESS
ACTION
LEVEL OF EVIDENCE GUIDANCE
Investigations Immunology
(cont)
• Rheumatoid Factor
• ANF
Microbiology and Histology
• Wound fluid/swabs – microscopy, culture and
sensitivity (MC&S)
• Wound/ tissue biopsy – MCS and
histopathology
• Skin scraping, Immunofluorescence
Note: Routine bacteriological swabs are
unnecessary unless there is evidence of
clinical infection
B
Biopsy
This may be required if the wound has been
non-healing for 4-6 weeks with optimal
treatment, is assessed as atypical, or has been
present greater than 6 months.
Radiology/Medical Imaging
• Duplex Scan (Arterial/Venous)
• X-Ray
Arterial/Venous Duplex Scans
Non-invasive investigation is recommended for
initial diagnosis
Arterial Duplex Scan:
To determine presence and/or severity of
arterial disease in the lower limb.
On clinical picture,
available assessment
data and results of
investigations
Venous Duplex Scan:
To determine disease or impairment of
superficial, deep, and perforating veins and
valves.
X-Ray
If there is suspicion of osteomyelitis, sinus,
significant undermining or foreign body, then an
X-ray may be ordered.
Diagnosis
Make provisional diagnosis
On clinical picture,
available assessment
data and results of
investigations
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 21 of 39
PROCESS
ACTION
LEVEL OF EVIDENCE GUIDANCE
Management
Urgent Referrals:
• Life/limb threatening infections
• Abnormal test results that require medical
intervention
• Treatment required outside the NP scope of
practice
• DVT
• New patients with a ABPI <0.7 or ankle
systolic <80mmHg
• Client that requires surgical intervention
• Ulcers on the plantar aspect of the
foot/toes/heels subject to pressure from
weight-bearing or footwear to have immediate
podiatry referral
• Significant deterioration in wound since last
review
Referrals
If the wound fails to heal
despite optimal therapy
then consultation with
other health care
practitioners and further
investigations may be
required
Nurse Practitioner:
Non-Pharmacological Treatment:
• Compression bandaging should be applied
•
•
•
•
when venous insufficiency is present, and
should be based on the ABPI and
interpretation of clinical signs and additional
data (Figure 2), NB. Compression stockings
may be patients choice and be accepted
practice
Compression bandaging (inelastic &
elastic™) has been demonstrated effective in
the healing of venous leg ulcers
Reduced compression may be effective in
selected patients with mixed disease (venous
+ arterial) where the ABPI is 0.6-0.8 however
these clients should be monitored closely for
signs of reduced circulation/ischaemia in a
specialised clinic
Dressing technique should be clean and
aimed at preventing cross-infection – strict
asepsis is not necessary
Ulcers can be cleaned with either portable
water or sterile saline.
A
B
C
C
C
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 22 of 39
PROCESS
ACTION
LEVEL OF EVIDENCE GUIDANCE
Management
(cont)
• Wound debridement may be undertaken
C
where necrotic/non viable tissue is present.
There is no evidence to favour one method of
debridement, whether mechanical, surgical,
biosurgical, autolytic, chemical or enzymatic
and choice would be based on patient
assessment (Also see minor procedures
protocol)
Client/Carer education for self care
• Hygiene (cleansing self and waterproofing as
required)
• Diet (the importance of essential vitamins and
minerals as required, in particular Vitamin C
and Zinc)
• Signs and symptoms of complications
• Bandaging/dressing technique
• Exercise regimes
A
Exercise programmes can improve calf muscle
function, walking distances and pain for clients
with intermittent claudication
• Lifestyle changes
• Disease process and health maintenance
• Prevention of recurrence
• Pain management
• Medications
(Includes relevant consumer handouts)
Pharmacological treatment
Based on diagnostic investigations, clinical
assessment, and Therapeutic Guidelines
• Analgesics
• Oral antibiotics
• Topical antimicrobials
• Topical anti-fungal
• Topical corticosteroids
• Local anaesthetic
Moisturisers
Barrier ointments, creams, wipes
Skin cleansers
Note: Clients can become sensitised at any
time. Products which commonly cause
sensitivity such as those containing lanolin, cetyl
alcohol or topical antibiotics are best avoided.
B
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 23 of 39
PROCESS
ACTION
LEVEL OF EVIDENCE GUIDANCE
Management
(cont)
Associated Clinical Practice Guidelines:
• Wound management and diagnostics
• Minor surgical procedures
Management
Partnerships
Appropriate referrals to, or liaison with other
health professionals to assist in overall
management
Medical:
• Vascular surgeon
• Plastic surgeon
• Infectious diseases physician
• Endocrinologist
• Pain management
• General practitioner
• Dermatologist
Note: Clients with dermatitis which do not
resolve following the removal of common
sensitisers and treatment with moderate topical
steroids should be considered for referral to a
Dermatologist
C
Venous surgery followed by graduated
compression hosiery is an option for
consideration in clients with superficial venous
insufficiency
B
Allied Health:
• Dietician
• Podiatry
• Diabetes Educator
• Occupational Therapist
• Physiotherapist
• Pharmacist
Community care providers:
• Silver Chain Nursing
• Hospital in the Home
• Residential care agencies
• Other home care providers
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 24 of 39
PROCESS
ACTION
LEVEL OF EVIDENCE GUIDANCE
Ongoing
Management
Review as appropriate **
• Test results
• Monitor progress
• Maintenance of the wound
• Prophylactic review (e.g. 6/12 review for
clients with healed venous ulcersprescription for graduated compression
stockings
** Patient reviews will be determined according
to:
• Whether the client is new to the service
• Whether compression therapy is initiated
• Access to transport and their location
• Availability of appointments
• Partnership of care in place
• Client and wound factors
Clients commencing compression therapy for
the first time - review is usually 2-3 weeks. Ongoing review will be 4-6 weeks or earlier if
required.
Those clients will healed venous ulcers will have
their stockings renewed six monthly and have
an annual review and ABPI recorded.
As with all client related visits all relevant
findings will be documented in the client’s
integrated medical records and leg ulcer data
base.
Review treatment plan in accordance with
response to treatment and investigative
results.
Separation
Discharge from service
As appropriate:
• Wound healing achieved
• Referral to community services for long term
management
• Referral for specialist care
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 25 of 39
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 26 of 39
28
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 27 of 39
COMPRESSION BANDAGING SYSTEMS
Multi-layer
Layers – usually 3-4 layers and may include either elastic or inelastic compression
bandages, cohesive/adhesive bandages, crepe bandages and/or padding layers.
Zinc bandages - elastic and rigid varieties. Wound & skin contact layer.
Underpadding - cotton or synthetic padding to protect the skin/bony prominences
from bandage trauma and may have additional absorbent capacity.
Used as base layer under most compression bandage systems
- Wraps - e.g. Kerlix, Velband
- Tubular knitted padding - e.g. Tubular Plus
Compression bandages
- elastic with various degrees of elasticity
- inelastic
Cohesive elastic wraps e.g. Coban, CoPlus or elastic tubular support e.g. Tubigrip
Elastic
May be used across range of mobile and immobile patients but
particularly indicated for immobile patients or those with reduced
ankle mobility/fixed ankle deformity where calf muscle
contraction is limited.
Provide sustained compression with minor variations during
walking.
Single layer – e.g. Setopress
Inelastic
Suitable for actively mobile clients where the bandage
reinforces or supports the action of the calf muscle pump.
They provide high pressure on moving and low resting
pressures. May be more effective in patients with extensive
deep vein reflux (Marston & Vowden, 2003).
Number of layers according to ABPI, full compression usually 2 layers – sub-bandage
pressures will vary according to a number of factors including wear-time and oedema e.g.
Comprilan
Multilayer systems: - e.g. Profore system, Proguide
Multilayer – light (reduced) compression (15-25 mm Hg versus High compression 35-45
mm Hg, @ ankle) e.g. Profore Light, Lastodur Light
Note: The degree of compression in governed by La Place’s law
where sub-bandage pressure is demonstrated thus:
P is proportional to :
NxT
CxW
P
N
T
C
W
= pressure exerted by bandage
= number of layers
= bandage tension (elasticity)
= circumference of limb
= bandage width
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 29 of 39
Evidence Base
The clinical protocol for management of lower leg ulcers is based on the
systemic identification and synthesis of the best available scientific evidence
and review of clinical guidelines. Existing clinical; practice guidelines utilised
and reviewed included:
•
Compression for venous leg ulcers (Review), The Cochrane Collaboration
(Cullum, Nelson, Fletcher, &Sheldon, 2001)
•
The care of patients with chronic leg ulcers. The Scottish Intercollegiate
Guidelines Network (SIGN, 1998).
•
Guidelines for the treatment of arterial insufficiency ulcers (Hopf, Ueno,
Aslam, at al., 2006)
•
Nursing best practice guidelines: Assessment and management of venous
ulcers, Registered Nurses association of Ontario (RNAO, 2004)
•
Guideline for the management of wounds in patients with lower-extremity
arterial disease, Wound Ostomy and Continence Nurses Society (WOCN,
2002)
•
Guidelines for the assessment and management of leg ulcers, Irish Clinical
Resource Efficiency Support Team (CREST, 1998).
The above guidelines have utilised different systems for classifying and they
have been broadly categorised as follows:
Statement of Evidence
Level 1a
Evidence obtained from meta-analysis of randomised
controlled trials
Level 1b
Evidence obtained from at least one randomised
controlled trial
Level 11a
Evidence obtained from well designed controlled study
without randomisation
Level 11b
Evidence obtained from at least one other type of welldesigned quasi-experimental study
Level 111
Evidence obtained from well-designed non-experimental
descriptive studies, such as comparative studies,
correlation studies and case studies
Level 1v
Evidence obtained from expert committee reports or
opinions and/or clinical experiences or respected
authorities
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 30 of 39
Grades of Recommendations
Grade A
Requires at least one randomised controlled trial as part of a
body of literature of overall good quality and consistency
addressing the specific recommendation
(Evidence levels 1a,1b)
Grade B
Requires the availability of well conducted clinical studies but
no randomised trials on the topic of recommendation.
(Evidence levels 11a,11b,111)
Grade C
Requires evidence obtained from expert committee report or
opinions and/or clinical experiences of respected authorities.
Indicates the absence of directly applicable clinical studies of
good quality.
(Evidence level 1v)
The initiation and type of bandage therapy is based on the International Leg
Ulcer Advisory Boards recommendations (Stacey, Falanga, Marston, et al 2002)
and the European Wound Management Association position document
“Understanding Compression Therapy” (Caine, 2003).
Review
These clinical protocols will become effective once approval and designation
have been agreed and will be reviewed every 2 years or earlier if significant
research becomes available to change practice or there are new developments
in the drug formulary listings.
Further protocols will be developed in relation to chronic wounds and diabetic
foot ulcers.
Implementation Plan
Implementation of the NPWM Protocols will occur at the appointment of the
Nurse Practitioner Wound Management at Fremantle Hospital and Health
Service.
The time frame will be approximately two months to allow for the introduction of
the role of the NP into the organisation.
Evaluation Plan
Submitted protocols will be reviewed annually and evaluated using the Clinical
Governance Framework. Reporting will be provided to the key line manager of
the designated NP (Nursing Director Surgical Services at Fremantle Hospital
and Health Service), and the Director General of Health as outlined by the
Office of Chief Nursing Officer (Department of Health Western Australia, 2003).
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 31 of 39
Professional Development and Management
The NP will set realistic objectives and a professional development plan in
collaboration with their Nursing Director Surgical Services.
Educational requirements to professional colleagues will be ongoing.
The NP will be involved in research pertinent to their clinical field.
Participation in Hospital and Health Sector activities undertaken in role related
guidelines, policies and standards will be identified.
Clinical Risk
The NP in Wound Management will have input into relevant practice guidelines,
relevant research and ensure that standards following evidence based best
practice are undertaken, working closely with Wound West and other clinical
experts.
Potential risks, including clinical incidents and adverse effects will be identified,
managed and reported as part of the annual NP review and reporting process to
the Department of Health. There will be ongoing liaison with the FHHS Clinical
Governance Unit.
Consumer Value
Consumer satisfaction/complaints will be ascertained via satisfaction and
complaints surveys of key customer groups. Auditing of practice may be
benchmarked against best practice/guidelines that are available to ensure
consumer satisfaction and expectations are met.
Consumer input into protocols or patient education material will also be
considered.
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 32 of 39
Drug Formulary
Wound Management
Classification
Drug
Dosage
Analgesic
Paracetamol
Analgesic
Paracetamol+/-Codeine
500mg/8mg 4-6 hourly
Antibiotic
Amoxycillin Clavulanate
500/125-875/125mg 12 hourly
Antibiotic
Cephalexin
250-500mg 6 hourly
Antibiotic
Flucloxacillin
250-500mg 6 hourly
Antibiotic
**Ciprofloxacin
250-500mg twice daily
Antibiotic
**Clindamycin
Antibiotic
Metronidazole
200-400mg 8-12 hourly
Topical Antibiotic
Metronidazole
0.5% twice daily
Topical Antibiotic
Silver Sulphadiazine
Chlorhexidine digluconate
1%, 0.2% 1-2 x/day
Topical Antifungal
Clotrimazole
1% 3 x/day
Topical Antifungal
Terbinafine
1% 1-2 x/day
Topical Antifungal
Nystatin
100,000units/g 2-3 x/day
Topical Antiseptic,
Anti-infective
**Mupirocin
2% 3 x/day
Topical Corticosteroid
Hydrocortisone
0.5-1% 1-2 x/day
Topical Corticosteroid
Hydrocortisone acetate
0.5-1% 1-2 x/day
Topical Corticosteroid
Triamcinolone Acetonide
0.02% 1-2 x/day
Topical Corticosteroid
Betamethasone valerate
0.02-0.05% 1-2 x/day
Topical Corticosteroid
Betamethasone dipropionate
0.05% 1-2 x/day
Topical Anaesthetic
Lignocaine
0.05-1% Pre-procedure
Local Anaesthetic
Lignocaine with Adrenaline
0.05-1% Pre-Procedure
Local Anaesthetic
Lignocaine with Prilocaine
0.05-1% Pre-Procedure
500mg 4-6 hourly
150-450mg 8 hourly
** IDD APPROVAL
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 33 of 39
Classification
Indications
Considerations
Analgesics
Mild pain:
• Paracetamol 500mg 4-6 hourly,
maximum daily dose 4000mg
For more severe pain, review
causative factors and refer to
appropriate specialist (e.g.
Pain Service, Vascular
Surgeon)
Mild to moderate pain:
• Paracetamol with codeine
500mg/8mg 1-2 tablets 4 to 6 hourly
maximum dose 4000mg paracetamol
OR
• Tramadol 50mg to 100mg 4 to 8
hourly maximum daily dose 400mg
(300mg maximum dose for elderly)
(Therapeutic Guidelines: Analgesics, 2002)
Antibiotics
(topical)
Localised skin infections, critical
colonisation of wounds (e.g. leg
ulcers and pressure ulcers) and
minor burn prophylaxis
• Silver sulfadiazine (SSD) 1% +
chlorhexidine 0.2% cream topically,
once or twice daily
(contraindicated if sulpha or
chlorhexidine allergy)
Impetigo, infected small skin lesions
(mild or localised infections) and
elimination of Staph. aureus carriage
• Mupirocin 2% topical, following skin
cleansing 3 times per day for up to
10 days.
Alternatives to consider
include silver, povidoneiodine and cardexomer iodine
dressing products
Approval is required from a
Clinical Microbiologist or ID
Physician for Mupirocin use
Cancerous malodorous wounds
• Metronidazole gel 0.75% topically
• Silver sulfadiazine (SSD) 1% +
chlorhexidine 0.2% cream topically,
once or twice a day
(Sibbals, Orsted, Shultz et al., 2003.
Therapeutic Guidelines: Antibiotic 2006;
Therapeutic Guidelines: Dermatology, 2002)
Antibiotics
Skin and soft tissue infection
The routine use of antibiotics
is not advocated in chronic
wounds
Empirical antibiotics to be commenced
whilst waiting for sensitivities
Antibiotic to be commenced
only when there is clinical
evidence of infection (e.g.
localised erythema, localised
pain. Localised heat. Cellulitis
and oedema)
(systemic)
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 34 of 39
Classification
Indications
Considerations
For mild to moderate infection with
surrounding cellulitis, use:
• Flucloxacillin 250- 500mg orally 6hourly for at least 5 days
If no clinical improvement
within one week (next visit) or
worsening of symptoms, for
medical review
For clients hypersensitive to
penicillin (excluding immediate
hypersensitivity) use:
• Cephalexin 500mg 6-hourly for at
least 5 days
Diarrhoea is a common adverse effect
and the client should be told to seek
medical attention should this persist
Alternatively, if Gram-Negative
organisms are suspected or known
to be involved, use:
• Amoxycillin+Clavulanate 875+125mg
orally, 12 hourly for 5 days
Gram-negative organisms often
colonise ulcers, therefore for less
severe infections, antibiotics against
gram positive organisms should be
used initially. If the infection is not
responding then broadening to include
gram-negative cover can be
considered.
For more severe infections,
particularly where systemic
symptoms are present, and
for intravenous antibiotics,
medical review will be
required
Antibiotic susceptibilities of
gram negative organisms
should be reviewed and
advice obtained from a
Clinical Microbiologist or ID
Physician for organisms
resistant to amoxicillin +
clavulanate
(Therapeutic Guidelines: Antibiotic 2006)
Diabetic foot infections:
For mild to moderate infection with
no evidence of osteomyelitis or
septic arthritis, use:
• Amoxycillin+clavulanate 875+125mg
orally, 12 hourly for at least five days
OR
• Cephalexin 500mg orally, 6 hourly,
for at least five days
For severe limb-or life
threatening infection
(systemic toxicity/ septic
shock, bacteraemia, marked
necrosis or gangrene,
ulceration to deep tissues,
severe cellulitis, presence of
osteomyelitis) medical review
is required
Plus
• Metronidazole 400mg orally, 12
hourly for at least five days
Inform patients that nausea, diarrhoea
and metallic taste is an adverse effect
whilst taking metronidazole. To seek
medical attention for persistent nausea
and diarrhoea
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 35 of 39
Classification
Indications
For clients with penicillin
hypersensitivity, use:
• Ciprofloxacin 500mg orally, 12 hourly
for at least five days
To seek medical attention if the client
develops a rash, nausea, vomiting,
diarrhoea, abdominal pain, and/or
dyspepsia
Considerations
Approval is required from a
clinical Microbiologist or ID
Physician for ciprofloxacin
and Clindamycin use
Plus
• Clindamycin 300mg to 450mg orally,
t.d.s for at least five days
Patients must be informed of the
adverse effects of diarrhoea with a risk
of pseudomembranous colitis, whilst
taking clindamycin. Clients must be told
to report these side effects and seek
medical attention
(Therapeutic Guidelines: Antibiotic, 2006)
Topical
Antifungal
Tinea
(Body,limbs,face and interdigital)
• Terbinafine 1% topically, daily for 7
days
Or an imidazole:
Diagnosis of fungal infections
can be confirmed via
microscopy and culture of
skin scrapings, subungual
debris, nails or plucked hair
• Clotrimazole 1% topically, 2 to 3
times daily for 2 to 4 weeks,
continued for 14 days after
symptoms resolve.
Cutaneous candidiasis
• Clotrimazole 1% topically, 2 to 3
times daily for 2 to 4 weeks,
continued 14 days after symptoms
resolve.
If necessary for inflammation, add
• Hydrocortisone cream 1% topically, 2
to 3 times daily
(Therapeutic Guidelines: Dermatology, 2004)
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 36 of 39
Classification
Indications
Considerations
Topical
Stasis/contact dermatitis
Corticosteroids
Mild
• Hydrocortisone cream 1% topically, 2
to 3 times daily
Uncomplicated stasis
dermatitis is common in
chronic leg ulcers. Stasis
dermatitis is frequently
complicated by allergic
contact dermatitis, which
Or
usually resolves with the
• Hydrocortisone acetate 1% cream or removal of the sensitising
ointment 30g. Apply once or twice a
agents (frequently
day.
encountered in many
dressing products) and
Moderate
treatment with a
• Betamethasone valerate 0.02%-0.5% mild/moderate topical
cream or ointment topically, once or
corticosteroid
twice a day.
If poor response, refer to a
Dermatologist
Severe
Betamethasone dipropionate cream or
ointment 0.05%, topically once or twice
daily (use sparingly, and for as short a
period of time as possible, due to
potency and potential adverse effects
(Therapeutic Guidelines: Dermatology, 2004)
Local
anaesthetic
Biopsy
• Lignocaine (7mg/kg) with Adrenaline
(5 micrograms/mL).
Lignocaine/Adrenaline 1:100 000,
5mL
• Lignocaine 1%, 5mL
Local Wound Debridement (pre
procedure) where appropriate
• Lignocaine with Prilocaine 0.05%-1%
topically
Rossi (Ed), 2005; Therapeutic Guidelines:
Dermatology, 2004.
Lignocaine with adrenaline
should not be used on an
extremity such as a digit,
especially in the presence of
PAD, to avoid potential
necrosis.
For infiltration 1-2 mL is
sufficient to provide
anaesthesia and will not
distort histology
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 37 of 39
References
1.
Baker, S., Stacey, M., Jopp-McKay A., Hoskins, S., Thompson, P. (1991)
Epidemiology of Chronic ulcers. British Journal of Surgery (78), 864-867.
2.
Bennett, G., Moody, M. (1995). Wound care for health professionals.
London: Chapman Hall.
3.
Bradbury, A., Ruckley, CV. (2001). Clinical assessment of patients with
venous disease, In: Gloviczki, P., Yao, JST., eds. Handbook of Venous
Disorders. 2nd Edition. New York, NY: Oxford University Press Inc; 71-82
4.
Calne, S. (Ed). (2003). EWMA Position Document: Understanding
compression therapy. London: Medical Education partnership.
5.
Carville, K. (2005). Wound care manual. (5TH edition). Perth: Silver Chain
Foundation.
6.
Carville, K., Lewin, G. (1998). Caring in the community: A wound
prevalence survey. Primary intention, 6(2), 54-62.
7.
Cullum, N., Nelson, E., Fletcher, A., Sheldon, T. (2001). Compression for
venous leg ulcers (Review). The Cochrane Database for systemic reviews
(2)
8.
Herbert, LM. (1997) Caring for the Vascular Patient. London: Churchill
Livingstone.
9.
Holloway, G. (2001). Arterial ulcers: assessment, classification and
management. In D. Kranser, G, Rodeheaver & R. Sibbald (Eds), Chronic
Wound care: A clinical source book for healthcare professionals (3rd ed.
Pp. 495-710.
10. Laing, W. (1992). Chronic Venous diseases of the leg. London, UK: Office
of Health Economics: United Kingdom. 1-44
11. Leaper, D. (2002). Sharp technique for wound debridement. World Wide
Wounds
12. MacLellan, L., Gardner, G., Gardner, A. (2002). Designing the future in
wound care: The role of the Nurse Practitioner. Primary Intention, 10(3),
97-112.
13. Moffatt, C., Vowden, P. (2008), Hard to heal wounds: a holistic approach.
In: EWMA position document: Hard to Heal Wounds. MEP Ltd, London.
14. Morrison, MJ., Moffatt, C. (2004). Leg ulcers. In: Morrison, MJ at al (eds)
Chronic Wound Care. London
15. National Institute of Clinical Excellence (2001). Guidance on the use of
debriding agents and specialist wound care clinics for difficult to heal
surgical wounds. Technology Appraisal Guidelines 24.Nice. London
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 38 of 39
16. Office of the Chief Nursing Officer, Department of Health Western
Australia (Ed.). (2003) Business case and clinical protocol templates.
Perth: Department of Health Western Australia
17. Posnett, J., Franks, PJ. (2008). The burden of chronic wounds in the UK.
Nursing Times 104 (3): 44-5
18. Queen, D., Orsted, H., Sanada, H., Sussman, G. (2004). A dressing
history. International Wound Journal 1(1): 59-77.
19. Registered Nurses Association of Ontario (RNAO) (2004) Assessment and
Management of Venous Leg Ulcers. Ontario: RNAO.
20. Rossi, S. (2005) Ed. Australian Medicines Handbook. Adelaide:
Pharmaceutical Society of Australia
21. Scottish Intercollegiate Guidelines Network (1998). The care of patients
with chronic leg ulcers. A national clinical guideline. SIGN Publication
number 26. Edinburgh: Royal College of Physicians.
22. Splisbury, K., Nelson, A., Cullum, N., Iglesias, C., Nixon, J., Mason, S.
(2007) Pressure ulcers and their treatment and effects on quality of life:
hospital and patient perspectives. Journal of Advanced Nursing 57 (5):
494-504
23. Stacey,M., Falanga, V., Marston, W., Moffat, C., Phillips, T., Sibbald., R, et
al (2002). The use of Compression therapy in the treatment of venous leg
ulcers: a recommended management pathway. European Wound
Management Association Journal, 2(1), 1-7
24. Therapeutic Guidelines Ltd (2006). Analgesics: Version 4. North
Melbourne: Therapeutic Guidelines Limited
25. Therapeutic Guidelines Ltd (2006) Antibiotics: Version 13. North
Melbourne: Therapeutic Guidelines Limited
26. Therapeutic Guidelines Ltd (2004) Dermatology: Version 2. North
Melbourne. Therapeutic Guidelines Limited.
27. Vowden, KR., Vowden P. (1996). Arterial disease: reversible and
irreversible risk factors. Journal of Wound Care; 5: 2, 89-90
28. Walker, N., Rodgers, A., Birchall, N., Norton, R., MacMahon, S. (2002)
Leg ulcers in New Zealand: Age at onset, recurrence and provision of care
in an urban population. Journal of the New Zealand Medical Association,
115(1156).
29. Weingarten, MS. (2001). State-of-the-art treatment of chronic venous
disease. Clinical Infectious Diseases. 32: 949-954
30. Wound Ostomy Continence Nurses Society (2002). Guidelines for the
management of wounds in patients with lower-extremity arterial disease.
Glenview: Wound Ostomy and Continence Nurses Society.
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 39 of 39
Authorship and endorsement
This Clinical Protocol was written by:
Lorraine Linacre, RN BSc (Hons) Dip He (Health
Studies) PGDip (NP)
Acknowledgment:
• M. Jacobson, Nursing Director Surgical
Services, Fremantle Hospital and Health
Service
• P. Morey, Sir Charles Gairdner Hospital,
Perth Western Australia
• D. Angel, Royal Perth Hospital, Perth
Western Australia
• L.MacLellan, G. Gardner, A. Gardner,
Canberra Hospital
• T. Swanson, J. Smart and S. Morrison,
South West HealthCare, Warrambool,
Victoria
• M. Asimus, Hunter New England Health
(The Maitland Hospital), New South Wales
Date written: December 2011
Reviewed for FSH: December 2014
This Clinical Protocol has been reviewed and is
endorsed by
Dr Richard Bond
Head of Service
Vascular Surgery
Fiona Stanley Hospital
Dr Richard Price
Head of Service
Radiology
Fiona Stanley Hospital
Chair, DTC
Fiona Stanley Hospital
Ms Taylor Carter
Director, Nursing & Midwifery
Fiona Stanley Hospital
Dr Paul Mark
Executive Director Clinical Services
Fiona Stanley Hospital
Next Review date: January 2016
Nurse Practitioner Wound Management
Date Revised:
First Issue
Revision Due: January 2016
Page 40 of 39