1. AGPN acknowledges the financial support of the Australian Government Department of Health and Ageing

2. Wound Management in General Practice Provision of Clinical Care 2.3 April 2009

3. Learning objectives  Outline the principles of wound management in the general practice setting  Identify factors relating to delayed wound healing  Outline strategies to manage: skin tears burns and blisters lower leg ulceration diabetic foot ulceration  Specify various dressings and techniques for their application  Be cognizant of wound management MBS.

4. Principles of Wound Management  define aetiology  control factors influencing healing  select appropriate dressing or device  plan for maintenance.

5. Wounds seen in General Practice  trauma: abrasions and cuts  superficial partial thickness burns  venous leg ulcers  arterial leg ulcers  foot wounds often associated with neuropathy and neuro-ischaemia  skin cancers. Generally do not see: pressure injuries or dehisced surgical wounds

6. Factors Influencing Healing  poor nutrition  Infection/inflammation  ongoing trauma  incorrect cleansing and dressing  underlying disease processes.

7. Other Factors Related to Delayed Wound Healing  age  debris and foreign bodies in the wound  smoking  wound tissue too dry or too wet  pain  psychological issues.

8. Decision Making Tools  Tissue colour  Wound depth  Exudate level  Periwound skin condition  Predicted weartime  Skill of carer  Availability/cost of product Select the most appropriate dressing according to:

9. T.I.M.E Source: http://www.ewma.org

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12. Dry necrosis  A 75 yr old male who is a smoker and has type 2 diabetes, presents with the following: What would you do? A.moisten to encourage autolytic debridement B.moisten to facilitate sharp debridement C.refer for surgical debridement D.none of the above.

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17. 17 Matching Colour and Product  Black…………………..if aiming to heal: cleansing dressing  Green………………….antimicrobial dressing  Wet yellow………….antimicrobial dressing  Dry yellow………….rehydrating dressing  Red………………………protect  Hypergranulation.antimicrobial dressing  Pink…………………….protect. This is not a prescription but a guide to where to start

18. Ideal Dressing  provide mechanical protection  protect against secondary infection  non adherent and easily removed without trauma  leave no foreign particles in the wound  remove excess exudates  cost effective  offer effective pain relief.

19. Generic Names  impregnated mesh dressings  low adherent lightly absorbent pads  super absorber pads  protective film wipes  film sheets  foam and foam like absorbent dressings  hydrocolloid wafers and paste  hydrogel sheets and amorphous gels with or without additives.

20.  calcium alginates  hydrofibre  hypertonic salt  cadexomer iodine  silver  medicated honey  zinc bandages Generic Names

21. Purchasing Products  most practices have agreements with distributors  the fee for dressings is either born by the practice or passed on to the patient  if asking the patient to purchase their own dressings perhaps look at distributors that will offer products at reasonable prices

22. Rebate schemes  Department of Veterans Affairs (DVA) patients will be able to secure most dressings as long as the general practitioner writes the required item on a script  11996 is the Medicare item number to be used for the nurse performing wound care  AWMA is seeking to have products listed on PBS

23. Case Studies  skin tear  burn  venous ulcer  arterial ulcer  foot wound.

24. Star skin tear classification system

25. STAR Tool  utilise the STAR tool to classify skin tear severity  the STAR tool can be downloaded from the Silver Chain website at: http://www.silverchain.org.au/Research/Research-Projects/STAR-Project/

26. Skin Tear: 1a

27. Skin Tear: 1b

28. Skin Tear: 2a

29. Skin Tear: 2b

30. Skin Tear: 3

31. Key Points for Skin Tears  develop your own set of protocols for managing skin tears  write these up and add to your wound resource folder  companies do have protocols for you to follow

32. Burns: First Contact Assessment  site  depth  surface area involved  age of patient  other influencing factors

33. What is reasonable to care for in general practice?  small superficial partial burns not involving face, feet, hands, perineum, genitalia on the very young or the elderly  further guidelines and very good advice may be found on the NSW DoH Website for Severe Burn Injury or ringing Concord Burns Unit

34. Superficial Burn Characteristics  epidermis only  erythema (vasodilatation)  tenderness (nerve irritability)  oedema.

35. Superficial Partial Burn Characteristics  epidermis and outer dermis  blisters (fluid shift)  shedding of skin  painful exposed (nerve endings to kinins)  bleeds when pricked with needle  hair present (hard to pull out)  full sensation  blanches on pressure.

36. Burn Surface Area  Wallace’s rule of nines  Lund and Browder chart  closed palmar hand of victim = 1% of body surface area.

37. Anatomical Site Considerations  hands  feet  face  perineum  genitalia  joints  circumferential burns

38. Other Considerations  extremes of age: very young or very old will need special care  co-morbidities  medications.

39. What to do about blisters?  controversial: removal causes pain  tense blisters can interfere with dermal circulation, restrict movement  beware of blisters with “red rings”  blisters can hide deep burns  popped blisters may need to be debrided.

40. Key Points for Burns  have standard policies and procedures  know where nearest specialist burns centre is and how long it takes by road or air  liaise with burn centre for care in interim  closely monitor patient for signs of impending infection and sepsis.

41. Example of a Burn Protocol  superficial partial thickness burns of less than 10% body surface area, not involving feet, face, hands, genitalia, over joints, the very young and the elderly, can be nursed in the practice  deeper partial thickness burns of less than 5% body surface area will be treated in the practice BUT if no response within one week should be referred on

42. Useful Websites  http://www.ameriburn.org  http://www.anzba.org.au  http://www.worldburn.org  http://www.journalofburns.com  http://www.burnsurgery.org  http://www.skinhealing.com  http://www.worldwidewounds.com

43. Lower Leg Ulceration Statistics  venous70%  arterial10%  mixed10%  skin cancers 2%  others 8%

44. Venous Ulcer Characteristics  firm ‘brawny’ oedema  inverted “champagne” bottle leg  irregular shape  medial or lateral aspect lower third of leg  wet, shallow, minimal necrotic tissue  atrophie blanche  venous eczema, staining, lipodermatosclerosis  palpable pulses, minimal pain, relieved when elevated.

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46. Arterial Ulcer Characteristics  usually located between ankles and toes or high up on leg or posterior leg  deep, punched out regular shape, often dry  thin, shiny, non hair bearing skin  thickened toenails  diminished or absent foot pulses  elevation pallor, dependant rubor  necrotic tissue, infection  pain, especially at night or when elevated.

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48. Venous Ulcer Management  ensure adequate dressing to assist in managing wound exudate  if thinking some bacteria present use an anti microbial, cover with absorbent pad apply light crepe bandage toes to knee  then cover the bandage with different length layers of straight elasticated tubular bandage or shaped tubular bandage

49. 3 layers of straight elasticated bandage

50. Arterial Ulcer Management  have the patient reviewed by a vascular surgeon  use Iodosorb powder if the wound is wet or if the area is dry then paint it with Betadine  if the surgeon can not revascularise, then the wound is ‘maintenance’ or ‘palliative’ and the aim is to keep it infection free and stable

51. Foot Wounds The high risk foot:  diabetes  neurovascular disease  neuropathic diseases  congenital or other foot abnormalities

52. Monofilament Testing  Semmes-Weinstein monofilament is often used to assess protective sensation in the feet of patients with diabetes  nylon filament mounted on a holder  10 gram force  assess 10 sites over the foot, randomly so the patient cannot anticipate the next site http:/ndep.nih.gov/resources/feet/index.htm

53. Areas at risk of damage Using the monofilament

54. Diabetic Foot Examination D deformity I infection A atrophic nails B breakdown of skin E oedema T temperature I ischaemia C callosities S skin colour

55. Diabetic Foot Examination Deformitycharcot’s, pes cavus, claw toe, hammer toe Infectioncrepitus, fluctuation, deep tenderness Atrophic nailsfungal infections and sub ungal ulcers Breakdown of skinulcers, fissures, blisters Ischaemiapulses may be weak or absent Callositiesplantar surface, metatarsal heads Skin colourred = charcot’s pale = ischaemia pink, with pain and absent pulses = ischaemia

56. Dressings for Diabetic Foot Ulcerations Antimicrobial  Iodosorb  Hypertonic salt: Mesalt, Curasalt  Silver products: Acticoat, Aquacel Ag, Atrauman Ag,  Contreet, even silver lined socks and hosiery Absorbent  Exudry, Mesorb, Zetuvit, Dry-Max  Allevyn, Biatain, Lyofoam Extra  Aquacel  Algisite M, Kaltostat, Calcicare, Sorbalgon Padding or cushioning  Podiatry felt  Silipos  Dermal pad Debriding  Iodosorb  Mesalt  TenderWet  Hydrocolloid paste.

57. Key Points for Diabetic Foot Ulcerations  remember diabetics may have micro or macro vascular disease or both  always be suspicious of infection  do not use occlusive dressings on foot wounds  HBO is often helpful in diabetic vascular wounds and osteomyelitis Assistance is available via the SSWAHS High Risk Foot Service

58. Conclusions  wounds in general practice are varied  it is ideal to have treatment cards for most common types of wounds seen  product range needs to be kept to a minimum but cover all generic types of wounds and an antimicrobial  always establish the underlying diagnosis of the wound and reassess if failing to follow normal healing pathways

59. Resources  http://www.woundpedia.com  http://www.worldwidewounds.com  http://www.globalwoundacademy.com  http://www.ewma.org  http://www.wuwhs.org Useful book: Wound Care Manual by Keralyn Carville http://www.silverchain.org.au/html/WoundCareForm.htm

60. Clinical Friends of World of Wounds  Visit the website and enrol an expression of interest  Can provide clinical advice via email for $10 per consult Website: http://www.worldofwounds.com/Home/

61. Wound Management Competency Standards for General Practice Nurses  Wound management competency standards for general practice nurses have been developed as part of the Nursing in General Practice Program at General Practice NSW and funded by the Australian Government Department of Health and Ageing  Cpetency standards should be used as a framework to assess competence and should be read in conjunction with: —the Australian Nursing and Midwifery Council competency standards —the Competency Standards for Nurses in General Practice —the Australian Wound Management Association standards  Standards may be accessed on the APNA website: http://www.apna.asn.au/displaycommon.cfm?an=1&subarticlenbr=294