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

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

Principles of Wound Management
define aetiology
control factors influencing healing
select appropriate dressing or device
plan for maintenance.
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
Factors Influencing Healing

poor nutrition
Infection/inflammation
ongoing trauma
incorrect cleansing and dressing
underlying disease processes.
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.
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:
T.I.M.E
Source: http://www.ewma.org
10
11
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.

World of Wounds
World of Wounds 15
World of Wounds 16
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
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.
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.
calcium alginates
hydrofibre
hypertonic salt
cadexomer iodine
silver
medicated honey
zinc bandages
Generic Names
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
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

Case Studies
skin tear
burn
venous ulcer
arterial ulcer
foot wound.
Star skin tear classification system
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/


Skin Tear: 1a
Skin Tear: 1b
Skin Tear: 2a
Skin Tear: 2b
Skin Tear: 3
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
Burns: First Contact
Assessment
site
depth
surface area involved
age of patient
other influencing factors
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
Superficial Burn Characteristics
epidermis only
erythema (vasodilatation)
tenderness (nerve irritability)
oedema.
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.

Burn Surface Area
Wallaces rule of nines
Lund and Browder chart
closed palmar hand of victim
= 1% of body surface area.
Anatomical Site Considerations
hands
feet
face
perineum
genitalia
joints
circumferential burns
Other Considerations
extremes of age: very young or very old will need special care
co-morbidities
medications.
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.
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.
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
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

Lower Leg Ulceration
Statistics
venous 70%
arterial 10%
mixed 10%
skin cancers 2%
others 8%
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.
World of Wounds 45
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.
World of Wounds
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

3 layers of straight elasticated bandage
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

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


Areas at risk of damage
Using the monofilament
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








Diabetic Foot Examination
Deformity charcots, pes cavus, claw toe, hammer toe
Infection crepitus, fluctuation, deep tenderness
Atrophic nails fungal infections and sub ungal ulcers
Breakdown of skin ulcers, fissures, blisters
Ischaemia pulses may be weak or absent
Callosities plantar surface, metatarsal heads
Skin colour red = charcots
pale = ischaemia
pink, with pain and absent pulses = ischaemia
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.
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
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
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



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/


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