Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Nurse Practitioner Clinical Protocols for Wound Management Services

Prepared by: Pam Morey, RN BN STN, MN(NP) MRCNA

March 2007 Sir Charles Gairdner Hospital North Metropolitan Health Service

Acknowledgement: L. MacLellan, G. Gardner, A. Gardner, Canberra Hospital T. Swanson, J.Smart, S.Morrison, South West Healthcare, Warnambool, Victoria M. Asimus, Hunter New England Health (the Maitland Hospital), New South Wales D. Angel, Royal Perth Hospital, Perth Western Australia Issued: Review: 2007 2009

Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Wound Diagnostics and Treatment

Clinical Protocol 1.

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 and forms the basis for the protocols which follow. This is further outlined in a flow chart (see Figure 1). Table 1. Assessment and Management of the Patient with a Wound PROCESS
HISTORY

ACTION
A complete history is taken

GUIDANCE
Medical, surgical, allergy history Wound history Current medications (prescribed and over the counter [OTC]) Previous diagnostic investigations Social and Occupational history including carer or home support Physical mobility Activities of daily living

EXAMINATION

Physical examination of the wound and associated area/limb More generalised assessment as necessary

Clinical features of the wound and skin Presence of other wounds/lesions Peripheral perfusion Peripheral neurological examination (eg using Semmes Weinstein 10g monofilament, tendon reflexes, vibration) Signs and symptoms of infection Footwear (diabetes, lower limb wounds)

Physical and joint mobility Explore differential diagnosis

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

PROCESS
INVESTIGATIONS

ACTION
Determine which investigations may be required to assist in a diagnosis or provide a baseline of nutrition and health

GUIDANCE
Pathology Haematology FBP, ESR, CRP, INR Biochemistry U & Es LFT, (Total Protein, Albumin), Pre-albumin Glucose, HbA1C Lipids Thyroid function Microbiology and Histology Wound fluid/swabs microscopy, culture and sensitivity (MC&S) Wound/tissue biopsy MCS and histopathology Skin Scraping, Immunofluorescence Biopsy This may be required if the wound has been non-healing, despite optimal treatment, for greater than 4 weeks; or the duration is greater than 6 months; and/or is assessed as atypical. Radiology / Medical Imaging Ankle Brachial Pressure Index (ABPI) Toe Doppler Pressures/Index Duplex Scan (Arterial & Venous) Photoplethysmography (PPG) X-Ray MRI

Referral for: Arterial Duplex Scan: To determine presence and/or severity or arterial disease in the lower limb Venous Duplex Scan: To determine disease or impairment of superficial, deep, and perforating veins and valves.

ABPI performed on all outpatient leg ulcer patients. If the ABPI does not complement the clinical assessment or is inconclusive then further diagnostic investigation may be required. Arterial/Venous Duplex Scan Non-invasive investigation is recommended for initial diagnosis X-Ray If there is a suspicion of osteomyelitis, sinus, fistula, significant undermining or foreign body, then an x-ray may be ordered. 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.

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

PROCESS
DIAGNOSIS

ACTION
Make provisional diagnosis

GUIDANCE
On clinical picture, available assessment data and results of investigations. Referrals 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.

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 patient with a ABI <0.7 or ankle systolic <80 mmHg Patient that requires surgical intervention Ulcers on the plantar aspect of the foot to have immediate Podiatry referral Significant deterioration in wound since last review Nurse Practitioner: Non-pharmacological treatment

Non-pharmacological treatment Appropriate dressings and/or compression bandages based on diagnosis and patient lifestyle preferences Cleansing and debridement of wound Patient /Carer education for self care Hygiene (cleansing self and waterproofing as required) Diet (the importance of essential vitamins and minerals as required). Indications to seek medical help Bandaging/dressing techniques Exercise regimes Lifestyle changes Disease process and health maintenance Prevention of recurrence Pain management Medication (Includes relevant consumer handouts) Pharmacological treatment Analgesics Topical antimicrobials/antifungals Local anaesthetics Topical corticosteroids Oral antibiotics Moisturisers Barrier ointments, creams and wipes Skin cleansers Lower leg ulcer Minor surgical procedures (further protocols to follow)

Patient education for self care

Pharmacological treatment - Based on diagnostic investigations, clinical assessment, and Therapeutic Guidelines

Refer to other Clinical Practice Guidelines

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

PROCESS
MANAGEMENT PARTNERSHIPS

ACTION
Appropriate referrals to assist in overall management

GUIDANCE
Other Health Professionals as required: Medical: Vascular Surgeon Plastic Surgeon Infectious Diseases Physician Dermatologist Endocrinologist Pain Management Palliative Care General Practitioner Allied Health: Dietitian Podiatrist Diabetic Educator Occupational Therapist Physiotherapist Pharmacist Community care providers: Silver Chain Nursing Other home care providers (eg Stanhope)

ONGOING MANAGEMENT

Follow-up

Review as appropriate: Test results Monitor progress Maintenance of wound Review treatment plan in accordance with investigative results As appropriate: Wound healing achieved Referral to community services for long term management Referral for Specialist care.

SEPARATION

Discharge from service

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Figure 1.

Wound Diagnostics and Treatment: Flow Chart

Patient History Medical history/Co-morbidities Wound History Current medications Social and occupational history Activities of daily living

1.Assessment

Physical examination Clinical features of wound and skin Presence of other wounds/lesions Peripheral perfusion Neurological examination eg tendon reflexes and monofilament testing

!! Consider conditions for urgent referral e.g. Ischaemic limb/s Serious infection e.g. wet gangrene Diabetic foot infections

2. Diagnosis

Investigations as indicated Full blood examination Urea & Electrolytes Blood glucose levels and HBA1C, other haematology, biochemical tests Ankle Brachial Index/Doppler signal characteristics Toe Doppler index Duplex scan X-Ray Wound swab/s Wound biopsy

3a. Conditions for specialist referral Urgent conditions as indicated above Treatment outside of NP scope of practice e.g. ischaemia, severe infection

3b. Treatment options / Conditions for NP treatment All wound conditions outside urgent treatment Management as per specific protocols

Non-pharmalogical approaches Cleansing and debridement of wound Appropriate dressings/bandages Skin care and moisturisers Patient education for self care Hygiene Diet Exercise Dressing/bandaging regimes Disease process and health maintenance Medication

3c. Integrated management of comorbidities Includes diabetes, autoimmune disease, cardiac failure Endocrinologist Vascular surgeon Dermatolologist Infectious diseases physician Plastic surgeon Pain Management Palliative Care General Practitioner Diabetic Educator Dietitian Podiatrist/Orthotist Pharmacist Other health professionals as required 4. Follow-up Review as appropriate Test results Monitor progress Maintenance of healed wound

Pharmacological agents Antibiotics Antifungals Analgesics Topical agents (eg corticosteroids, antimicrobials)

Adapted from 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 ACT Government, reprinted with permission.

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Minor Surgical Procedures

Clinical Protocol 2.

Introduction To provide appropriate management of wounds, there are occasions where either wound biopsy or sharp debridement procedures are required. Both of these are minor surgical procedures. The flow chart demonstrates the protocol (see Figure 2)

Biopsy Skin and wound biopsy are used for diagnosis and may identify the presence (or absence) or various skin conditions or diseases. In addition, biopsy may be performed for semi-quantitative bacteriology where surface swabs are inadequate. Wounds considered for biopsy may include long-standing wounds, those that are atypical in location or appearance, or those that have not responded to treatment (Trent, Federman, & Kirsner, 2003). Biopsy may be considered for lesions suspicious of malignancy where there is increase in size; malodour and pain; have excess granulation tissue, bleeding, or drainage; are exophytic; or have an irregular base or margin. The procedure involves prior assessment of the wound or lesion; preparation of the patient including explanation of the procedure; cleansing of the area, and anaesthetisation with local anaesthetic. There are various methods of biopsy and in this instance the preferred options are incisional or punch biopsy. Particular wound conditions that may be identified include squamous cell carcinoma, basal cell carcinoma, vasculitis, and calciphylaxis.

Debridement Debridement is the removal of devitalised (non-viable) tissue, particulate matter and foreign material (Fowler & van Risjwijk, 1995). Conservative sharp wound debridement (CSWD) is a procedure used to debride non-viable tissue from a wound down to non-bleeding tissue using sharp instruments (eg scalpel, scissors and forceps). Debridement may be undertaken to remove contaminated, dead and damaged tissue that may inhibit healing or contribute to infection in the wound . It may also be undertaken to prepare a wound for skin grafting, application of skin substitutes, or topical negative pressure therapy (e.g. VAC Vacuum Assisted Closure). Sharp debridement may be necessary in either acute wounds (eg skin tear with non-viable tissue), or chronic wounds (eg pressure ulcers), and the decision about this type of procedure being undertaken requires consideration of both local and systemic factors. These include but are not limited to knowledge of underlying -6-

Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

anatomical structures, local tissue perfusion, the presence of impaired clotting or the use of anticoagulant medication, and the presence of malignancy (Carville, 2005).

The outline of assessment process, investigations and management are outlined in Table 2.

Table 2 Assessment and Management: Minor Surgical Procedures. PROCESS

HISTORY

ACTION
A complete history is taken

GUIDANCE
Medical, surgical, allergy history/comorbidities 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

EXAMINATION

Physical examination of the wound and associated area/limb More generalised assessment as necessary

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 Hypergranulation tissue Non healing despite optimal treatment

Presence of: Infection not responding to antibiotic treatment Contaminated/non-viable material Foreign bodies

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

PROCESS
INVESTIGATIONS

ACTION
Biopsy of wound for histology and/or microbiology Histology

GUIDANCE
To confirm wound aetiology Microbiology To identify organisms (semiquantitative) and sensitivities

DIAGNOSIS

Make provisional diagnosis

On clinical picture, available assessment data and results of investigations. 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. Non-pharmacological treatment Appropriate dressings/bandaging based on diagnosis and patient lifestyle preferences Cleansing and debridement of wound Patient / 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 changes Disease process and health maintenance Prevention of recurrence Pain management Medication (Includes relevant consumer handouts)

MANAGEMENT

Urgent Referrals: Life/limb threatening infection Abnormal test results that require medical intervention Treatment required outside the NP scope of practice Significant deterioration in wound since last review Nurse Practitioner: Non-pharmacological treatment

Patient education for self care

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 To remove: Contaminated material Foreign bodies

Conservative Sharp Surgical Debridement

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols Non-viable tissue To prepare the wound environment for: Topical Negative Pressure Therapy (VAC) Skin grafts Substitutes to accelerate the healing process

MANAGEMENT PARTNERSHIPS

Appropriate referrals to assist in overall management

Other Health Professionals as required: Medical: General Practitioner Plastic Surgeon Dermatologist Infectious Diseases Physician Consultation with the medical practitioner if required for further treatment and investigation. Allied Health: Dietitian Podiatrist Diabetic Educator Occupational Therapist Physiotherapist Pharmacist Community care providers: Silver Chain Nursing Other home care providers

ONGOING MANAGEMENT

Follow-up

Review as appropriate: Test results Monitor progress Maintenance of wound Review treatment plan in accordance with investigative results As appropriate: Wound healing achieved Referral to community services for long term management Referral for Specialist care.

SEPARATION

Discharge from service

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Figure 2.

Minor Surgical Procedures for Diagnosis and Treatment in Wound Care. Contraindications e.g. severe ischaemia (refer to specialist)
1. Findings from assessment of: Complex wounds Lower leg ulcers Infected wounds Diabetic foot wounds

1a. Abnormal clinical presentations e.g. Raised/unusual features e.g. irregular raised edges, purpura, vasculitic nodules Suspicion of neoplastic disease Senescent tissue Hypergranulation tissue Non healing despite optimal treatment

1b. Presence of infection not responding to antibiotic treatment

1c. Presence of: Contaminated dead material e.g. slough or necrotic tissue Foreign bodies e.g. sutures

Pharmacological agents Analgesics paracetamol, codeine, tramadol Local anaesthetics Lignocaine/Prilocaine, lignocaine hydrochloride

2a. Biopsy of wound Histological examination to confirm wound aetiology

2b. Biopsy of wound Microbiological examination to identify organisms and sensitivities treatment

2c. Sharp surgical debridement/curette to: Remove: - Contaminated material - Foreign bodies e.g. sutures - Non-viable tissue Prepare for grafting of skin or skin substitutes; Prepare for application of topical negative pressure therapy (VAC) Accelerate healing process

3a. Conditions for specialist referral Biopsy results indicates Neoplastic disease refer to Plastic surgeon/Dermatologist/Vascular surgeon as appropriate Biopsy findings inconclusive or suggestive of vasculitis or other dermatological conditions beyond the scope of practice of the NP refer to Dermatologist/Vascular surgeon as appropriate

3b. Conditions for specialist referral Biopsy results indicate Infection refer to Infectious Diseases physician

4. Follow up Review as appropriate Test results Monitor progress Maintenance of healed wound

Adapted from 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 ACT Government, reprinted with permission. 10 -

Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Lower Leg Ulcers (Vascular)

Clinical Protocol 3

Introduction This protocol has been designed to guide and facilitate the Nurse Practitioner (NP) in diagnosing and providing appropriate care of clients with leg ulcers.

Assessment A thorough assessment of the individual will follow as per the Protocol 1., Wound Diagnostics and Management. The following information outlines in more detail the specific process for the NP in managing patients with lower leg ulcers (see Table 3) using evidence gradings outlined on page 32-33. A flow chart outlining the Lower Leg Ulcer Clinical Protocol is shown in Figure 3, and the Guidelines for Compression Bandaging are represented in Figure 4. An explanation of compression bandaging components is outlined in Appendix 1.

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Table 3 Assessment and Management of Lower Leg Ulcers. PROCESS ACTION

LEVEL OF EVIDENCE GUIDANCE

C

HISTORY

A complete history is taken: medical, surgical, 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 and previous methods of treatment Assess for venous insufficiency: Family history of venous disease; Patient history of DVT; Lower leg fracture or other major leg injury; Previous vein surgery; Prior history of ulceration - with or without compression bandaging.

Assess for arterial insufficiency: History of intermittent claudication or rest pain Hypertension. Heart disease; Diabetes, Ischaemic stroke Smoking (or stopped < 5 years),

B In the presence of mixed disease (arterial + venous), patients may present with both. Assess for diabetes, rheumatoid arthritis and systemic vasculitis (Specialist assessment/referral should be considered). C Assess for correctable factors that may delay healing, including smoking, anaemia, and evidence of malnutrition or 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.

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

PROCESS
EXAMINATION

ACTION
Physical examination of the wound and associated area/limb Conduct lower limb examination of both legs Eg the presence varicose veins in venous disease Examine for signs of arterial insufficiency: Lower skin temperature, auscultation of femoral bruit and pulses (weak or absent). Unilateral signs may be present where there is acute deterioration. Assess for malignancy can be a cause and may be a sequel of leg ulceration. 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 of ulcers should be measured at regular intervals to monitor progress Venous ulcers are generally shallow, moist and appear on the gaiter area of the leg; eczema, haemosiderin pigmentation, ankle oedema and ankle flare are often present; varicose veins, atrophie blanche & lipodermatosclerosis may be present. Arterial ulcers have a punched out appearance, a poorly perfused base and are pale and dry; surrounding skin is shiny and taut; dependent rubor present. A B

EVIDENCE / GUIDANCE

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 (eg using Semmes Weinstein 10g monofilament) Signs and symptoms of infection Footwear (diabetes, lower limb wounds) Physical and joint mobility Explore differential diagnosis

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

PROCESS
INVESTIGATIONS

ACTION
ABPI performed on all outpatient leg ulcer patients. If the ABPI does not complement the clinical assessment or is inconclusive then further diagnostic investigation may be required. Measurement of ABPI by handheld Doppler

EVIDENCE / GUIDANCE

Ankle Brachial Pressure Index (ABPI). Normal 0.9

1.2. A ratio of < 0.8 indicates the presence of peripheral arterial disease (PAD). Further tests should be considered prior to initiating compression bandaging 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 measurement of ABPI when an ulcer deteriorates; is not fully healed by 3/12; or when patient presents with recurrence (of whichever leg) 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

B A

A B

Determine which investigations may be required to assist in a diagnosis or provide a baseline of nutrition and health Pathology Haematology FBP, CRP

Biochemistry U & Es LFT, Total Protein, Albumin, Glucose, HbA1C Lipids Thyroid function 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 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. B

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols Radiology / Medical Imaging Duplex Scan (Arterial & Venous) X-Ray Arterial/Venous Duplex Scan Non-invasive investigation is recommended for initial diagnosis Arterial Duplex Scan: To determine presence and/or severity or arterial disease in the lower limb Venous Duplex Scan: To determine disease or impairment of superficial, deep, and perforating veins and valves X-Ray If there is a 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

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

PROCESS
MANAGEMENT

ACTION
Urgent Referrals: Life/limb threatening infection Abnormal test results that require medical intervention Treatment required outside the NP scope of practice DVT New patient with a ABI <0.7 or ankle systolic <80 mmHg Patient that requires surgical intervention Ulcers on the plantar aspect of the foot or other areas of the foot subject to pressure from weight-bearing or footwear, to have immediate Podiatry referral Significant deterioration in wound since last review Nurse Practitioner: Non-pharmacological treatment Compression bandaging should be applied when venous insufficiency is present, and should be based on the ABI and interpretation of clinical signs and additional investigative data. (Figure 2.) Compression bandaging (elastic and inelastic) has been demonstrated to be effective in the healing of venous leg ulcers. Reduced compression may be effective in selected patients with mixed disease (venous + arterial components) where the ABI is 0.6 -0.8 however these patient should be closely monitored for signs of reduced circulation/ischaemia in a specialised clinic. Dressing techniques should be clean and aimed at preventing cross-infection strict asepsis is not necessary. Ulcers can be cleansed with either potable water or sterile saline. Ulcerated legs can be washed normally in potable water. Wound debridement may be undertaken where necrotic tissue is present. There is no evidence to favour any 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).

EVIDENCE / GUIDANCE
Referrals 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.

Patient / 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 techniques Exercise regimes Exercise programmes can improve calf muscle function, walking distances and pain for people with intermittent claudication Lifestyle changes Disease process and health maintenance

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols Prevention of recurrence Pain management Medication (Includes relevant consumer handouts)

Pharmacological treatment - Based on diagnostic investigations, clinical assessment, and Therapeutic Guidelines Pharmacological treatment Analgesics Oral antibiotics Topical antimicrobials Topical anti-fungals Topical corticosteroids Local anaesthetics Moisturisers Barrier ointments, creams and wipes Skin cleansers Note: Patients can be sensitised to treatments at any time. Products which commonly cause sensitivity such as those containing lanolin, cetyl alcohol or topical antibiotics, are best avoided. B

Associated Clinical Practice Guidelines: Wound management and diagnostics Minor surgical procedures Diabetic foot ulcer* Infected wound* Complex Wound* *undergoing formulation.

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols 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: Patients with dermatitis that does not resolve following removal of common sensitisers and treatment with a moderate topical steroid should be considered for referral to a Dermatologist. Venous surgery followed by graduated compression is an option for consideration in patients with superficial venous insufficiency. Allied Health: Dietitian Podiatrist Diabetic Educator Occupational Therapist Physiotherapist Pharmacist Community care providers: Silver Chain Nursing Homelink / Hospital in the Home Residential care agencies Other home care providers ONGOING MANAGEMENT Review as appropriate**: Test results Monitor progress Maintenance of wound Prophylactic review (eg 6/12 review for patient with healed venous ulcers prescription of graduated compression stockings) ** Patient reviews will be determined according to a number of factors. This will include whether or not the client is new to the service, whether compression therapy is initiated, their access to transport and availability for appointments; partnerships in care in place, and patient and wound factors. For a patient commencing compression therapy for the first time, review is usually within 1-2 weeks. Ongoing review may vary from 4 12 weeks. In the case of the patient with a healed venous ulcer who is wearing maintenance compression therapy, reviews are usually 6 monthly. As with all patient related visits, findings of the review and treatment plans will be documented in the patients integrated medical record. C

Review treatment plan in accordance with response to treatment and investigative results.

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols SEPARATION Discharge from service As appropriate: Wound healing achieved Referral to community services for long term management Referral for Specialist care.

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Figure 3.

Flow Chart - Lower Leg Ulcer Clinical Protocol

Patient History Medical history/Co-morbidities Wound History Current medications Social and occupational history Activities of daily living

1.Assessment

Physical examination General health assessment Clinical features of wound and skin Presence of other wounds/lesions Examination of peripheral pulses Signs of autoimmune disease eg Rh Arthritis, SLE Neurological examination Signs of presence of infection eg lymphangitis,, lymphadenopathy Exclude neoplastic disease 2. Diagnosis

!! Consider conditions for urgent referral e.g. Ischaemic limb/s Serious infection Diabetic foot infection

Differential diagnosis Venous Mixed Arterial Vasculitic, Neuropathic, Infective, Neoplastic, Other

Investigations as indicated ABPI/Doppler signal characteristics/Toe pressures Duplex scan Photoplethysmography (PPG) Full blood examination Blood glucose levels, HBA1C, other haematology, biochemical tests Wound swab Wound biopsy (see Minor surgical procedures protocol)

3a. Conditions for specialist referral Urgent conditions as indicated above Treatment outside of NP scope of practice e.g. cellulitis, surgical intervention required ABPI < 0.7

3b. Treatment options / Conditions for NP treatment All wounds outside urgent treatment

Non-pharmalogical approaches Appropriate dressings and graduated compression therapy Refer to Figure 2 Debridement (see Minor surgical procedures protocol)

3c. Integrated management of comorbidities Includes diabetes, autoimmune disease, cardiac failure Medical: General Practitioner Vascular surgeon Dermatologist Infectious diseases physician Plastic surgeon Pain Management Endocrinologist Allied Health: Dietitian Podiatrist/Orthotist Pharmacist Other health professionals as required 4. Follow-up Review as appropriate Test results Monitor progress Maintenance of healed wound

Pharmacological agents as indicated Analgesics Antibiotics Topical antimicrobials Local Anaesthetic Topical corticosteroids

Patient education for self care Hygiene Diet Foot inspection (diabetes) Dressings/Bandaging/Compression Exercise regimes

- 20 Adapted from 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 ACT Government, reprinted with permission.

Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Figure 3. NP Management Pathway for Lower Leg Ulcers:

Patient presents with lower leg ulcer

Assessment
o

Patient history Examination Investigations

Diagnosis

Other
- Disease specific treatment/referral - Local ulcer treatment* - Appropriate compression for oedema control based on ABPI

Venous ulcer ABPI >0.8:

Compression therapy
Multilayer (Elastic or inelastic) Reduced compression Graduated compression stockings Intermittent Pneumatic compression (IPC) Medical and surgical treatment as necessary (referral) Local ulcer treatment* -

Mixed arterial and venous ulcer (ABPI 0.5-0.8)

- Reduced compression therapy (15 25 mmHg) - Local ulcer treatment* - Refer to Vascular surgeon if ABPI < 0.7 or patient symptomatic (eg intermittent claudication)

Mixed arterial & venous ulcer

Severe arterial insufficiency ABPI <0.5 - Refer to Vascular
surgeon - Local ulcer treatment*

Arterial Ulcer
- Refer to Vascular surgeon - Local ulcer treatment*

- NO compression

- NO compression

Reasons for referral:

Allergy Unable to tolerate compression Uncontrolled pain No reduction in ulcer size after 4-6/52 - Cellulitis unresponsive to treatment - Frequent recurrence -

Treat concurrent issues: Active/mobile patient 1st line therapy: - Multilayer compression (elastic or inelastic) 2nd line therapy - Elastic stockings Immobile/fixed ankle patient 1st line therapy: - Multilayer compression (elastic) 2nd line therapy: - Multilayer compression (elastic + IPC
- Pain eg analgesics - Infection eg antibiotics (see Protocol 3) - Dermatitis/Eczema Consider cause (eg venous or contact) and treatment: o Corticosteroids o Zinc paste bandages o Avoid sensitisers

Ulcer fails to heal (no reduction in size in 6/52) - Refer to specialist - Re-evaluation including reassessment and diagnosis - Evaluation for surgical correction or skin grafting

Healed ulcer - Prevention of recurrence including below the knee compression stocking - Evaluation for surgical correction - Education - Review

* Local ulcer treatment (Dressing) based on:

- Assessment of wound and surrounding

skin

- Allergies / Skin sensitivities - Product availability

Education - Foot and skin care - Exercise - Nutrition - Cessation of smoking - Weight loss if obese - Disease aetiology - Dressings and bandage/compression regimes - Medications

Adapted from International Leg Ulcer Advisory Board cited in Stacey, M., Falanga, V., Marston, W., Moffat, C., Phillips, T., Sibbald, R.G., Vanscheldt, W., & Lindholm. C. (2002) - 21 The use of compression therapy in the treatment of venous leg ulcers: a recommended management pathway. EWMA Journal 2(1)

Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

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 - eg Webril, Sofban, Kerlix Tubular knitted padding eg Dynacast, Tubular Plus, Samme Frotte Compression bandages, - elastic with various degrees of elasticity - inelastic Cohesive elastic wraps eg Coban, CoPlus or elastic tubular support eg Tubigrip, Versagrip, Tensogrip Single layer eg Setopress, Surepress, Tensopress

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. 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).

Multilayer systems: - eg Profore system, Veno 4, Proguide

Multilayer light (reduced) compression (15-25 mm Hg versus High compression 35-45 mm Hg, @ ankle) eg Profore Light, Lastodur Light 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 eg Comprilan, Lastolan, Tensolan

Note: The degree of compression in governed by La Places law where sub-bandage pressure is demonstrated thus: P is proportional to : N x T CxW

P = pressure exerted by bandage N = number of layers T = bandage tension (elasticity) C = circumference of limb W= bandage width

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Drug Formulary Wound Management Classification

Analgesic Analgesic Analgesic Antibiotic Antibiotic Antibiotic Antibiotic Antibiotic Antibiotic Antibiotic Topical Antibiotic Topical Antibiotic Topical Antifungal Topical Antifungal Topical Antifungal Topical Antiseptic, Anti-infective Topical corticosteroid + antimicrobial Topical corticosteroid Topical corticosteroid Topical corticosteroid Topical corticosteroid Topical corticosteroid Topical Anaesthetic Local Anaesthetic Local Anaesthetic

Drug
Paracetomol Paracetamol/Codeine Tramadol Amoxycillin Clavulanate Cephalexin Dicloxacillin Flucloxacillin Ciprofloxacin Clindamycin Metronidazole Metronidazole Silver Sulphadiazine Chlorhexidine digluconate Clotrimazole Terbinafine Nystatin Mupirocin

Dosage
500-1000 mg 500mg/8-30 mg 50-100mg 500/125 875/125 mg 250 500 mg 250 500 mg 250 500 mg 250 500 mg 150 450 mg 200 400 mg 0.5% 1%, 0.2% 1% 1% 100,000units/g 2% 4-6 hourly 4-6 hourly 4-8 hourly 12 hourly 6 hourly 6 hourly 6 hourly twice daily 8 hourly 8-12 hourly twice daily 1-2 x /day 3 x /day 1-2 x /day 2-3 x /day 3 x /day

Triamcinilone/Neomycin/Nystatin 0.1%, 0.25%, 100,000U/g, 0.025% / Gramicidin 2-3 x /day Hydrocortisone Hydrocortisone acetate Triamcinolone Acetonide Betamethasone valerate Betamethasone dipropionate Lignocaine Lignocaine with Adrenaline Lignocaine with Prilocaine 0.5-1% 0.5-1% 0.02% 0.02-0.05% 0.05% 0.05-1% 0.05-1% 0.05-1% 1-2 x /day 1-2 x /day 1-2 x /day 1-2 x /day 1-2 x /day Pre-procedure Pre-procedure Pre-procedure

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Analgesics

Mild Pain: Paracetamol 1000mg 4-6 hourly maximum daily dose 4000mg

For more severe pain, review causative factors and refer to appropriate specialist (eg Pain Team, Vascular Surgeon).

Mild to moderate pain: Paracetamol with Codeine 500/830mg 1-2 tablets 4 to 6 hourly maximum daily dose 4000mg paracetamol OR Tramadol 50 mg to 100mg 4 to 8 hourly maximum daily dose 400mg daily (300mg maximum dose for elderly)

(Therapeutic Guidleines: Analgesics, 2002)

Antibiotics (topical)

Localised skin infections, critical colonisation of wounds (eg leg ulcers and pressure ulcers), and minor burn prophylaxis Silver sulfadiazine (SSD) 1% + chlorhexidine 0.2% cream topically, once or twice daily.

Alternatives to consider include silver, povidoneiodine, and cadexomer iodine dressing products.

(contraindicated if sulpha or chlorhexidine allergy) Impetigo, infected small skin lesions(mild or localised infections) and elimination of Staph.aureus carriage Mupirocin 2% topically, following skin cleansing 3 times per day for up to 10 days

Cancerous malodourous wounds Metronidazole gel 0.75% topically Silver sulfadiazine (SSD) 1% + chlorhexidine 0.2% cream topically, once or twice daily.

(Sibbals, Orsted, Schultz et al., 2003; Therapeutic Guidelines: Antibiotic, 2006; Therapeutic Guidelines: Dermatology, 2002)

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Antibiotics (systemic)

Skin and soft tissue infection3 Common infecting organisms may include: Staphylococcus aureus, MRSA, Streptococcus species, Pseudomonas aeruginosa, and anaerobes Empirical antibiotics to be commenced whilst waiting for sensitivities For mild to moderate infection with surrounding cellulitis, use: Di/flucloxacillin 500 mg orally 6-hourly for at least 5 days

The routine use of antibiotics is not advocated in chronic wounds. Antibiotics to be commenced only when there is clinical evidence of infection (e.g. localised erythema, localised pain, localised heat, cellulitis, and oedema). If no clinical improvement within one week (next visit) or worsening of symptoms, for medical review.

For patients hypersensitive to penicillin (excluding immediate hypersensitivity), use:

Cephalexin 500mg 6-hourly for at least 5 days For more severe infections, particularly Diarrhoea is a common adverse effect where systemic and the patient should be told to seek symptoms are present, medical attention should this occur. and for, intravenous antibiotics, medical review Alternatively, if Gram-negative will be required. organisms are suspected or known to be involved, use: Amoxycillin+clavulanate 875+125mg orally, 12 hourly for 5 days Antibiotic susceptibilities of gram negative organisms should be reviewed and advice obtained from a clinical Microbiologist or ID Physician for organisms resistant to amoxycilllin + clavulanate.

Gram-negative organisms often colonise ulcers. Therefore for less severe infections, antibiotics against gram positive organism should be used initially. If the infection is not responding then broadening to include gram-negative cover can then be considered.
(Therapeutic Guidelines: Antibiotic, 2006)

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Diabetic foot infections: For mild to moderate infection with no evidence of osteomyelitis or septic arthritis, use: Or Cephalexin 500mg orally, 6-hourly for at least five days Amoxycillin+clavulanate 875+125mg orally, 12-hourly for at least five days

For severe limb- or lifethreatening 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 an adverse effect whilst taking metronidazole. To seek medical attention for nausea and diarrhoea. For patients with penicillin hypersensitivity, use: Ciprofloxacin 500mg orally, 12 hourly for at least 5 days Approval is required from a Clinical Microbiologist or ID Physician for Ciprofloxacin use.

To seek medical attention if the patient develops a rash, nausea, vomiting, diarrhoea, abdominal pain, and/or dyspepsia. Plus Clindamycin 300 mg to 450 mg orally, t.d.s. for at least 5 days

Patients must be informed of the adverse effect of diarrhoea with a risk of pseudomembranous colitis, whilst taking clindamycin. Patients must be told to report these side effects and seek medical attention.
(Therapeutic Guidelines: Antibiotic, 2006)

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Topical Antifungal

Tinea (body, limbs, face and interdigital) Terbinafine 1% topically, daily for 7 days

Or an imidazole: Clotrimazole 1% topically, 2 to 3 times daily for 2 to 4 weeks, continued for 14 days after symptoms resolve.

Diagnosis of fungal infection can be confirmed via microscopy and culture of skin scrapings, subungal debris, nails or plucked hair.

Cutaneous candidiasis Clotrimazole 1% topically, 2 to 3 times daily for 2 to 4 weeks, continued for 14 days after symptoms resolve. Or Nystatin 100,000 units/g cream topically, 2 to 3 times per day. Continue treatment for 2 weeks after symptoms resolve.

If necessary for inflammation, add Hydrocortisone cream1% topically, 2 to 3 times daily If poor response, or topical treatment is impracticable, refer to Microbiologist or dermatologist for consideration of systemic treatment.
(Therapeutic Guidelines: Dermatology, 2004)

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Sir Charles Gairdner Hospital Nurse Practitioner Wound Management Clinical Protocols

Topical Corticosteroid

Stasis/contact dermatitis 2 Mild Hydrocortisone cream1% topically, 2 to 3 times daily Or Hydrocortisone acetate 1% cream or ointment 30g. Apply once or twice daily Moderate Betamethasone valerate 0.02% 0.05% cream or ointment topically, once or twice daily Or Triamcinolone acetonide 0.02% topically once or twice daily 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 local adverse effects).
(Therapeutic Guidelines: Dermatology, 2004)

Uncomplicated stasis dermatitis is common in chronic leg ulcers. Stasis dermatitis is frequently complicated by allergic contact dermatitis, which usually resolves with the removal of the sensitising agents (frequently encountered in many dressing products) and treatment with a mild/moderate topical corticosteroid. If poor response, refer to a dermatologist.

Topical corticosteroid + antimicrobial

Skin infections and small areas of overgranulation Triamcinolone 0.1% / Neomycin 0.25% / Nystatin 100,000U/g / Gramicidin 0.025% cream topically 2 to 3 times per day for up to one week.

Local anaesthetic

Biopsy Lignocaine (7mg/kg) with Adrenaline (5 micrograms/ml). Lignocaine%, adrenaline 1:100 000, 5mL. Lignocaine 1%, 5mL 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 the histology

Local wound debridement (pre procedure) where appropriate Lignocaine with Prilocaine 0.05-1% topically.

(Rossi [Ed], 2005; Therapeutic Guidelines: Dermatology, 2004).

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