Wound Management Procedure

CHHS14/042
Canberra Hospital and Health Services

Clinical Procedure
Wound Management
Contents
Contents......................................................................................................................................1
Purpose.......................................................................................................................................2
Scope...........................................................................................................................................2
Section 1 – Key Principles for Wound Management..................................................................2
Section 1.1 Basic Dressing Technique.....................................................................................6
Section 1.2 Wound Probing....................................................................................................8
Section 1.3 Wound Debridement.........................................................................................10
Section 1.4 Wound Swabbing...............................................................................................12
Section 1.5 Wound suture and staple removal.....................................................................14
Section 1.6 Wound and sinus packing..................................................................................18
Section 1.7 Wound drainage tube shortening and removal.................................................19
Section 2 – Managing Specific Wound Types............................................................................22
Section 2.1 Skin Tears............................................................................................................22
Section 2.2 Management of Burns.......................................................................................25
Section 2.3 Management of lower leg ulceration.................................................................28
Section 2.4 Managing Skin Grafts and Donor Sites...............................................................35
Section 2.5 Postoperative managing of Skin Flaps...............................................................37
Section 2.6 Managing Malignant Wounds............................................................................41
Implementation........................................................................................................................43
Evaluation..................................................................................................................................43
Related Policies, Procedures, Guidelines and Legislation.........................................................44
References.................................................................................................................................44
Search Terms.............................................................................................................................46
Consultation..............................................................................................................................46
Attachments..............................................................................................................................48
Doc Number Version Issued Review Date Area Responsible Page

CHHS14/042 1.0 Nov 2014 Nov 2018 RACC 1 of 51
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
CHHS14/042
Purpose
The purpose of this document is to provide a governance framework for professional practice
and clinical decision-making in the provision of wound management services, which is based
on the best available evidence.
Scope
This document pertains to all patients who require wound management provided by the
Canberra Hospital and Health Services.
This document applies to:
 Medical Officers
 Nurses and Midwives who are working within their scope of practice (Refer to Nursing
and Midwifery Continuing Competence Policy)
 Allied Health Clinicians who are working within their scope of practice
 Students under direct supervision
Section 1 – Key Principles for Wound Management
1. There is a collaborative practice and interprofessional care approach to promote optimal

healing of the individual
2. Acknowledges the central role of the individual and their carer in wound management
and relevant health care decisions
3. An ongoing process of clinical decision-making facilitates the optimal healing of the
individual with a wound. This process will determine the risks associated with the wound
aetiology and healing responses
4. Documentation in the patient’s clinical record must facilitate communication and
continuity of care between interprofessional teams e.g. dieticians and fulfil legal
requirements
5. The safety and wound healing potential of the individual is ensured by clinical practice
that respects and complies with legislation, codes of practice, and policies
6. The clinician maximises opportunities for advancing self-knowledge and skills in wound
care sharing this knowledge with patients and carers through the process of education
7. That evidence based wound prevention and management advances optimal outcomes
for the individual and the interprofessional teams and is based on contemporary research
and consensus recommendations.
8. Wound healing is a dynamic process, and the clinicians must anticipate that wound
management practices will change, as new scientific evidence becomes available
9. Ensure patients have adequate pain relief prior to dressing changes.
(The Standards for Wound Management Australian Wound Management Association Inc

CHHS14/042
2nd edition, March 2010)
Procedure
The individual with a wound will receive a comprehensive assessment that reflects the
intrinsic and extrinsic factors specific to each individual and which have the potential to
impact on wound healing or potential wounding.
A wound assessment must be performed and the results documented in the patient’s clinical
record. Information may include:
1. Type of wound and aetiology
2. Location of the wound
3. Dimensions of the wound
4. Clinical appearance of the wound
5. Presence of infection, pain, odour or foreign bodies
6. State of surrounding skin and alterations in sensation
7. Physiological implications of wounding to the individual
8. Psychological implications of wounding to the individual and significant others
9. The use of validation tools in practice
10. The use of diagnostic investigations to ascertain and monitor wound healing potential
11. Wound photographs and consent see Diagnostic Digital Photography Images and/or
Recordings Policy, SOP
12. In the Community Care Program (CCP) a photo is taken every two weeks or when there is
deterioration in the wound.
13. In the CCP a paper ruler is positioned next to the wound, and identified with the patient’s
initials, UR no, date of birth and date of photograph. These photographs are to be printed
on the appropriate template and added to the patients file, then the photo deleted from
the camera.
14. Wound measurements and tracing is attended at the initial assessment, and at regular
intervals to access the process of healing.
Ongoing Assessment of Wound Healing Process

Ongoing assessment will be performed and documented and provide evidence of wound
healing or deterioration in wound healing.
Individualised Care Plan

An individualised care plan will be:
1. Documented in accordance with the individual’s preference and assessment outcomes
2. Reflective of ongoing assessments
3. Used to guide optimal management
4. Used to evaluate the effectiveness of treatment
5. Maintain communication with patient regarding healing outcomes.
Wound Management
Wound Management is practiced according to the best available evidence for optimising
outcomes for the individual, their wound and their healing environment.
CHHS14/042
A clinician comprehends the importance of and is able to:

 Determine when an aseptic non touch technique - standard or surgical technique is
required if the individual, their wound and their healing environment is compromised
Optimum Healing Environment

Maintain an optimal wound moisture balance
Promote a moist wound environment unless the clinical goal is to maintain eschar in a dry
and non infected condition.
Wound healing is facilitated in the presence of moisture therefore moist wound healing
principles will be maintained unless not clinically indicated. A clinical indication for
maintaining dry eschar exists when there is insufficient blood flow to an affected body part
to support infection control and wound healing.
Maintaining a constant wound temperature consistent with optimal healing

It has been demonstrated that wound healing is impaired when the wound temperature
decreases one degree Celsius, therefore the clinician will:
 Avoid exposing the wound to cooling temperatures or appliances
 Avoid leaving wounds exposed for lengthy periods
 Use wound cleansing solutions at body temperature
 Provide advice on interventions, appropriate for maintaining core body and skin
temperature, such as the wearing of warm clothes and the maintenance of a stable and
comfortable environmental temperature.
It has been demonstrated that an increase of one degree Celsius in skin temperature can
compromise skin integrity in individuals at risk of pressure ulceration. There for clinicians
will:
 Avoid overheating with clothing, bed linen or heating devices
 Avoid or limit or limit contact with plastic bed protection covers and plastic lined
garments
 Ensure adequate hydration
 Provide advice on interventions appropriate for maintaining core body and skin
temperature such as removal of excess garments or bed linen and maintenance of a
stable and comfortable environment temperature.
Maintain a neutral or slightly acidic pH consistent with optimal healing

The skin has an acid mantle that ranges between a pH of 4.0 - 6.8. Wound healing is
promoted when the skin and wound pH is maintained at a slightly acidic pH.
The clinician will:
 Avoid the use of alkaline soaps and cleansers
 Avoid leaving the wounds exposed for lengthy periods
 Avoid desiccation of wound bed as this increased alkalinity.

CHHS14/042
Prevent and manage infection

The clinician will observe infection control principles and reduce the potential risk of wound
infection by:
 Performing the 5 moments of Hand Hygiene as required
 Using non-sterile or sterile gloves as deemed relevant for practice when there is a risk of
contamination to the individual or clinician
 Assessing for the clinical signs and symptoms of clinical infection
 Performing qualitative or quantitative diagnostic investigation when clinically indicated
to determine a definitive diagnosis of clinical infection
 Appropriately managing clinical infection.
Protect the wound environment

The clinician will endeavour to protect the fragile wound environment by:
 Avoiding aggressive wound cleansing unless the goal of care is mechanical debridement
 Avoiding the use of devices that desiccate or traumatise the wound bed or surrounding
skin
 Avoid known or suspected toxic agents or allergens
 Protecting the wound and peri-wound area from trauma and maceration
 Removing foreign bodies from the wound
 Avoid packing a sinus where the depth of the sinus tracking cannot be determined
without further investigation
 Ensuring that any packing or drainage tube inserted into a sinus must be in one
continuous piece and remains visible and secure at the wound surface
 Avoid packing the wound too tightly, so that capillary blood supply is compromised
 Use pressure relieving devices to prevent further damage to the wound.
Maintain the integrity of wound management products, pharmaceuticals and devices

Maintain the integrity of wound management products and devices by:
 Appropriate and secure storage of dressing products
 Changing dressing or appliances as frequently as required to effectively remove
excessive exudate or infected material
 Using appropriate dressings or appliances to contain anticipated amounts of exudate
 Use appropriate dressings to ensure patient comfort and compliance, while maintaining
optimal healing environment.
Minimise the actual and potential impact of pain

 Adequately identify causative factors of pain
 Ascertain type of pain and its characteristics
 Implement strategies to prevent, minimise and manage pain

CHHS14/042
Use products and devices in accordance with licensing acts and/or regulatory bodies and
manufacturing guidelines
All wound management products; devices and pharmaceuticals used in Australia should have
Therapeutic Goods Administration endorsement unless they are used as a component of a
research protocol with appropriate ethical approval.
The clinician will use wound management dressings, pharmaceutical and devices in
accordance with the manufacturers’ instruction or research protocols
Section 1.1 Basic Dressing Technique

Procedure
To describe the procedure for undertaking a basic wound dressing that promotes:
 The utilisation of appropriate dressing material, optimal wound moisture balance,
protection and wound temperature to ensure an optimal healing environment
 Provision of an environment that is conducive to patient comfort and healing when
undertaking a basic wound dressing.
Equipment Acute and Ambulatory Care setting

 Alcohol based hand rub (ABHR)
 Dressing trolley
 Detergent impregnated wipes (to clean trolley)
 Personal protective equipment (PPE) includes, safety goggles or face shield and gown
 Clean gloves
 Sterile gloves (optional)
 General waste receptacle
 Clinical waste receptacle
 Basic dressing pack
 Normal saline packaged 30mls (at body temperature warmth) or other wound cleansing
solution ie Prontasan.
 Additional gauze swab (optional)
 Dressing equipment as per patient’s care plan, (Note: there may be a need for change of
the type of dressing based on the clinical assessment of the wound)
 Underpad for collection of excess saline e.g. gauze or absorbent pads
 Wound grid and tracing pen (optional) or camera (refer to digital photography policy).
Equipment Community setting

 Identify suitable clean surface in the home setting.
 Detergent impregnated wipes (to clean suitable surface)
 All equipment as above
Procedure
1. Check patient’s clinical record for any medical/nursing orders
2. Attend hand hygiene before touching the patient by either hand washing or using ABHR
3. Ensure privacy
4. Explain the process and purpose of the dressing change
CHHS14/042
5. Obtain verbal consent

6. Confirm allergies to dressings or tapes
7. Ensure adequate analgesic cover prior to dressing change
8. Ensure the patient is placed in a comfortable position
9. Attend hand hygiene by either hand washing or using ABHR
10. Clean trolley or suitable surface with detergent impregnated wipes and wipe dry
11. Set up equipment on trolley by the side of the patient
12. Discard packaging in general waste receptacle
13. Don PPE prior to opening sterile equipment
14. Open the basic pack and position equipment using the setting up forceps
15. Attend hand hygiene by either hand washing or using ABHR,
16. Don clean gloves
17. Expose the wound site
18. Remove the soiled dressing with setting-up forceps
19. Discard the dressing and forceps and gloves into the clinical waste receptacle
21. Open additional sterile equipment after reviewing the wound; add solution into the
appropriate areas of dressing pack
22. Trace the wound and with "Wound Grid", if appropriate. (NB: This “wound grid" is not
sterile.) Alternatively use camera to photograph the wound ensuring patient has
consented prior to the photo being taken and confidentiality is maintained. Digital
photographs require downloading to medical records, with patient’s UR number and
date and time
23. Ensure that the process is timely so as to avoid exposing the wound to cooling
temperatures
25. Don glove (clean or sterile)
26. Use wound cleansing solutions at body temperature irrigate with normal saline solution,
to remove debris and contaminates
27. Clean the wound surface, swabbing from the non-discharged area to the discharging
area (clean to dirty in one direction) and discard swab (into clinical waste receptacle). Or
using gentle irrigation method (allowing a controlled pressure of saline using a syringe or
saline container) by using warmed normal saline.
NOTE:
Do not use cotton wool swabs. Use gauze swabs only for cleaning of the wounds.
28. Observe the wound for:

 Colour
 Depth
 Exudate, (describe the amount, colour and character from the wound)
 Granulation tissue, epitheliating, slough, necrotic, hypergranulation
 Peri wound skin

CHHS14/042
29. Assess the wound for clinical signs and symptoms of infection. If signs of infection cover
the wound and notify the Medical Officer for review
30. Apply new dressing and secure with adhesive tape or bandages
31. Discard equipment and gloves into clinical waste receptacle
32. Clean trolley or surface with detergent impregnated wipes
34. Ensure patient is comfortable with new dressing change and understands when the next
dressing change will be attended
35. Change dressing or appliances as frequently as required to effectively remove excessive
exudate or infected material
36. Document in patient’s clinical record and wound care chart:
 a description of the wound
 type of dressing applied
 any change of dressing
 the reason for the change
 if using VAC® therapy consider type of sponge, cycle, pressure, dressing change
interval and initial cycle
 signs of wound infection and actions taken (where noted)
Section 1.2 Wound Probing

 Examine and determine the depth and direction of a wound, sinus or cavity
 Promote optimal management strategies and healing outcomes for a patient with a
wound bed involving a sinus
 Provide information on depth to assist in the decision making of product choice
Equipment Acute and Ambulatory Care Setting

 Sterile single use wound probe
 Sterile gloves
 Disposal measuring device, e.g. paper ruler
 Sharps bin
 Normal saline warmed to body temperature
 Appropriate dressing
 Adhesive tape or bandages
 Clean gloves x2
 Personal protective equipment (PPE) including safety glasses, goggles or shield
 Clean dressing trolley (clean with detergent impregnated wipes).

CHHS14/042

NOTE:
Single use only equipment will be used as per the manufacture’s recommendation, and
dispose appropriately. Identify suitable clean surface in the home setting.
Procedure
 Ensure the following principles in Wound Management are followed.
 Assessment and evaluation of the healing rate and treatment plans are important
components of wound care. By using the technique of wound probing in conjunction
with wound tracing a two dimensional measurement of the wound can be created and
recorded.
ALERT:
 Clinicians who perform wound probing should be familiar with the underlying anatomical
structures that are in proximity to the wound in order to avoid injury
 Never use force when introducing a probe into a wound.
 Do not use cotton tipped swabs or applicators as they may shed cotton fibres into the
wound
1. Attend hand hygiene before touching the patient by either hand washing or
using ABHR
2. Explain procedure and obtain verbal consent
3. Ensure privacy
4. Position the patient to ensure comfort during the procedure
5. Ensure the patient has adequate analgesia for dressing change
6. Ensure the process is timely as to avoid lengthy exposure thus cooling the
temperature of the wound
8. Prepare and set up equipment on clean dressing trolley or suitable surface
11. Don goggles and gloves
12. Expose the wound site by removing the dressing
13. Remove gloves
14. Discard dressing, forceps and gloves in clinical waste receptacle
17. Clean wound with normal saline warmed to body temperature (warm
N/Saline by immersing in bowl of warm water)
18. Introduce probe through opening of wound; gently guide probe along track of
the wound or sinus

CHHS14/042
19. Note any tracking or shelving, including the direction of insertion

20. Place finger at skin level against the probe to indicate depth, do not move
finger
21. Remove the probe and measure depth by placing probe next to measuring
device (alternative probe have measuring scales )
22. Discard probe in sharps bin
23. Observe the wound for:
 Colour
 Depth
 Exudate (be descriptive)
 Granulation tissue, epithelialising, slough, necrotic, hypergranulation
 Peri wound skin
 Undermining or sinus
25. Discard equipment into clinical waste receptacle
26. Use appropriate dressing to ensure patient comfort and compliance, while
maintaining optimal healing environment
27. Ensure patient is comfortable with new dressing change
28. Remove gloves and discard into clinical waste receptacle
30. Remove glasses or goggles and use ABHR
31. Document in patient clinical record and wound care chart, a description of the
wound and any change in type of dressing and reason for change
32. Report any concerns to the Medical Officer
33. Communicate change of dressing product to community nurses if applicable
34. Change dressing or appliance as frequently as required
Section 1.3 Wound Debridement

Wounds are debrided to remove devitalised tissue from the wound bed to optimise wound
healing. The presence of devitalised tissue slows the healing process and increases the risk of
infection.
Methods of Debridement
1. Autolytic Debridement:
Autolysis uses the body’s own enzymes and moisture to re-hydrate, soften and finally
liquefy hard eschar and slough. Autolytic debridement is selective; only necrotic tissue is
liquefied. It is also virtually painless for the patient. Autolytic debridement can be
achieved with the use of occlusive or semi-occlusive dressings that maintain wound fluid
in contact with the necrotic tissue.
Advantages:
 Very selective with no damage to surrounding tissue
 A safe process using the body’s own defence mechanisms to clean the wound of
necrosis
 Effective, versatile and easy to perform

CHHS14/042
 Little or no pain to patient
Disadvantages
 Not as rapid as surgical/sharp debridement
 Wound must be monitored closely for signs of infection
 May promote anaerobic growth if an occlusive hydrocolloid is used
2. Conservative Sharp Wound Debridement (CSWD)

Clinicians who are familiar with the anatomical structures can debride loose, sloughy or
necrotic tissue from the wound bed. If tissue is adhered to the wound bed, do not
debride as this may cause damage to adjacent tissues and structures. Refer to Medical
officer/Specialist, Nurse Practitioner Wound Management, CNC Wound Management or
Podiatrist.
 Clinicians performing CSWD must have a good knowledge of the anatomy and
physiology of the area being debrided. Sloughy tissue may be similar in appearance to
tendon or adipose (fatty) tissue and other structures. If in doubt do not debride,
consult with Medical Officer/Specialist, Nurse Practitioner Wound Management, CNC
Wound Management or Podiatrist.
 Aseptic non touch technique and sterile surgical equipment is to be used at all times,
and disposed of appropriately. Adequate lighting, positioning of the patient and
analgesic prior to the procedure is essential.
Advantages: Fast, can be extremely effective
Disadvantages: May be painful for patient, danger of damage to healthy tissue
Do not debride:
 Ischaemic ulcers that are covered with hardened eschar such as dry gangrene. There
may be insufficient blood supply to support infection control and wound healing.
 Diabetic and neuropathic foot ulcers. Patients with diabetic and neuropathic foot
ulcers should be referred to an appropriate podiatrist. Podiatry services are available
for eligible clients at the High Risk Foot Clinic or through the Community Care
Podiatry Service
 Patients with impaired blood clotting or who are taking anticoagulant medication.
Procedure for Conservative Sharp Wound Debridement

 Sterile single debriding instruments (sterile scissors, forceps, or sterile scalpel blade
and handle)
 Sterile gloves
 Disposable measuring device, e.g. paper ruler
 Sharps bin
CHHS14/042

 Appropriate dressing
 Adhesive tape or bandages
 Clean gloves x2
 Personal protective equipment (PPE) including safety glasses, goggles or shield
 Clean dressing trolley (clean with detergent impregnated wipes).
 Tracing sheet or probe for measuring wound
 Camera – take a photo before and after debridement

Procedure
Use an aseptic non touch technique when performing CSWD
Be aware of underlying and adjacent anatomical structures
1. Identify and assess area of loose sloughy or necrotic tissue
2. Gently cut away loose tissue, be conservative
3. Flush wound with tepid sterile saline to remove any loose debris
3. Mechanical Debridement
There are various forms of mechanical debridement
 Syringing out the wound with normal saline under pressure performs some degree
of debridement of loose tissue.
 Showering may also provide some degree of debridement.
 The technique of allowing a dressing to proceed from moist to wet, then manually
removing the dressing causes a form of non-selective debridement. Healthy or
healing tissue can be debrided along with slough. This method can be time
consuming and painful for the patient. This method is not recommended.
 Hydrotherapy is also a type of mechanical debridement. Its benefits vs. risks are an
issue. Hydrotherapy can cause tissue maceration. Also water borne pathogens may
cause contamination or infection. Disinfectant additives may be cytotoxic.
Section 1.4 Wound Swabbing

To obtain a wound specimen for clinical analysis when a clinical wound infection is
suspected.

 Normal Saline, 30mls warmed to body temperature
 Appropriate swab container and medium

CHHS14/042
 Underpad eg. Absorbent pad

 Gauze swab
 Personal protective equipment (PPE) including, safety goggles, glasses or shield and clean
gloves
 General waste receptacle.

2. Explain procedure and obtain patient consent
3. Ensure privacy
5. Position the patient to ensure that the patient will be comfortable during the procedure
6. Ensure that the process is timely as to avoid lengthy exposed thus cooling the
temperature of the wound
7. Attend hand hygiene by either hand washing or using alcohol ABHR
8. Prepare and set up equipment on a cleaned dressing trolley
11. Don clean gloves and goggles
12. Expose the wound site, by removing the dressing
13. Discard
14. Sampling should take place after wound cleansing and if appropriate debridement
15. Irrigate the wound with normal saline solution at body temperature to remove wound
debris and/or contaminates
ALERT:
If the wound is dry, moisten the swab with normal saline. If the wound is moist, a dry swab
should be used.
Remove excessive debris and all dressing residue without unduly disturbing the wound
surface using gentle stream of warmed normal saline. Wait for 1-2 minutes before taking the
swab.
16. Remove swab-stick from sterile container

17. Moisten wound swab with normal saline, or transport medium (not dry swab)
18. To swab the suspected infection site, use the Levine technique. The swab is rotated over
a 1 cm square area with sufficient pressure to express fluid from within the wound
tissue. This technique is believed to be more reflective of tissue bioburden than swabs of
exudate or swabs taken within a broad Z-stroke. The Levine technique is the best
technique for wound swabbing, provided the wound is cleansed first and the area
sampled is over viable tissue, not necrotic tissue or eschar
19. Place swab specimen in container and labelled. Details required:
 Patient’s name
 UR number

CHHS14/042
 Date
 Time
 Anatomical site
 Full clinical details to ensure that the most appropriate staining, culture and
antibiotic susceptibility analyses are performed and that the laboratory is able to
provide clinically relevant advice
20. Arrange immediate delivery to pathology with completed request form
a. Apply the appropriate wound dressing. Note: dressing if antimicrobial eg silver
impregnated dressing/ wound honey / iodine / chlorhexidine base
b. Discard in clinical waste receptacle
c. Attend hand hygiene
d. Document in the patients clinical record
e. Ensure that ongoing wound assessment and evaluation of the effectiveness of
treatment are documented
Refer to the Infection Control documents for swabbing for MRSA and VRE patients, where
"attention infection control" must be written on the pathology form
ALERT:
Some wound dressings may not be appropriate to apply to an infected wound.
Section 1.5 Wound suture and staple removal

 To remove sutures or staples with minimal trauma to the patient.
 Medical officer prescribes the removal of sutures and or staples.
Note:
In the Canberra Hospital Orthopaedic Fracture Clinic there is a standing order supported by
the Clinical Director to allow RNs to remove sutures from two week post-operative review
patients prior to their review by the Registrar, if wounds:
 are clean and dry,
 have no signs of infection, and
 have no evidence of dehiscence.
The technique used for removing sutures will depend on the:

 Type of sutures used either interrupted, continuous
 Style of insertion.
Alternative sutures and staples are removed first. If the wound union is satisfactory the
remainder of the sutures and staples are then removed as prescribed unless otherwise
ordered. Rationale: The method of alternative suture or staple removal may prevent wound
dehiscence.
Surgical wounds usually heal by primary intention, this is where there is a minimal tissue loss
and the edges of the wound are held in close apposition by sutures or staples, resulting in
minimal scarring. The edges of the wound are held together by using sutures, staples and
glues to effect primary closure.
CHHS14/042
Ensure prior to removal of sutures or staples appropriate length of healing time has taken
place. The length of time a sutured wound will take to heal depends not only on the general
health of the individual but also on the anatomical site of the incision.

CHHS14/042
ALERT:
If the wound is unsatisfactory notify the medical officer prior to removal of any sutures or
staples. If wound edges separate when suture or staples are removed do not continue to
remove sutures or staples. Notify the medical officer.

 Detergent impregnated wipes to clean trolley
 Personal protective equipment (PPE) including, safety glasses, goggles or shield and clean
gloves
 Sterile gloves
 Paper bag for the disposal of used/soled materials
 Dressing equipment as per care plan, (NB: Dressing type will require review once sutures
or staples are removed and document in clinical record
 Normal saline packaged 30mls, warmed to body temperature
 Appropriate under pad of collection of excess saline e.g. gauze or absorbent pads
 Sterile suture removal set, as appropriate. This maybe metal forceps and sterile stitch
cutter or sterile staple remover.
 Check patients clinical record for any medical orders

Procedure
2. Ensure Privacy
3. Explain the process and purpose of the dressing change
4. Obtain verbal consent
5. Confirm allergies to dressings or tapes
6. Ensure adequate analgesic cover prior to dressing change
7. Ensure the patient is placed in a comfortable position
9. Clean trolley with detergent impregnated wipes and wipe dry
10. Set up equipment on trolley at the patient’s bedside
14. Attend hand hygiene by either hand washing or using ABHR,
CHHS14/042

20. Open additional sterile equipment after reviewing the wound
21. Add solution into the appropriate areas of dressing pack (tray)
22. Use wound cleansing solutions at body temperature, irrigate with saline solution, to
remove debris and contaminates
24. Don PPE
25. Clean the wound surface by:
26. Swabbing (in one direction only, clean to dirty) with normal saline soaked gauze, or
irrigating with normal saline
27. Observe the wound for: unity of skin edges and peri wound appearance
28. Remove sutures or staples
Sutures
1. Lift the knot using forceps
2. Using a stitch cutter, cut between the knot and the skin, on one side as close to the skin
as possible
3. Remove the suture by pulling the unexposed material through the wound
Staples
1. Using staple remover, slide the flat edge of the staple remover under the staple
2. Close staple remover in scissor like motion, using steady and firm pressure (the sides of
the staple will move in an upward direction
3. Ensure the staple remover is fully closed and remains secure on the staple
4. Using a rocking movement gently free the staple from one side of the incision line then
the other
5. Apply steri strips if required
6. Leave wound undressed or otherwise use appropriate dressings to ensure patient
comfort and compliance
8. Clean trolley with detergent impregnated wipes
10. Ensure patient is comfortable with the dressing change and understands management of
their scar
12. Document in patient’s clinical record and wound care chart: a description of the wound,
type of dressing applied, any change of dressing and the reason for the change
13. Signs of wound infection and actions taken (where noted)
14. Where applicable notify the community nurses of a change of dressing products /
wound management plan to maintain continuity of care.

CHHS14/042
Section 1.6 Wound and sinus packing

To provide guidelines that outline the packing of a wound this is performed to:
 Promote healing by secondary intention in those wounds, which are described as a cavity
of sinus
 Absorb exudate
 Prevent abscess formation
 Prevent premature closure of the wound surface
 Control odour if present
 Protect the surrounding skin
 Protect wound from pathogens and further trauma.

 Sterile scissors
 Appropriate secondary dressing for exudates management
 Packing materials (e.g. x-ray lined packing gauze, VAC ® GranuFoam™ , VAC®WhiteFoam™),
VAC® SilverFoam™)
 Adhesive tape or bandage to secure dressing
 Personal protective equipment (PPE) including safety goggles or shield and clean gloves
 Sterile gloves
 Sterile probe

Procedure
2. Explain procedure to the patient and the purpose of packing a wound/sinus
3. Ensure privacy
4. Position patient to ensure comfort during the procedure
5. Ensure the patient has adequate analgesia cover for dressing change if required or
requested
6. Ensure that the process is timely as to avoid lengthy exposure thus cooling the
temperature
7. Open the basic dressing pack and position sterile equipment.
9. Don PPE
10. Expose the wound site by removing the dressing and packing material
11. Discard the dressing, forceps and gloves in the clinical waste receptacle
CHHS14/042

13. Don sterile gloves
14. Clean wound with warm normal saline
15. Assess the wound for clinical signs and symptoms of infection. Notify the medical officer
if appropriate
16. Repack wound with appropriate packing material, the amount of packing material should
be recorded. A sterile disposable probe or forceps may need to be used to assist in
inserting the packing material into the wound
17. Leave a small wick of packing material exposed to facilitate easy removal. Cut the
remaining packing material with sterile scissors
18. Apply appropriate secondary dressing and secure with tape or bandage
19. Discard equipment
21. Ensure client is comfortable with dressing and understands management regime
22. Change secondary dressing as frequently as required to effectively remove excessive
23. Document in patient’s clinical record and wound care chart, assessment, dressing regime,
amount and number of packing used and any change of dressing regime.
ALERT:
Wound sinus should be loosely packed to prevent damage to granulating cells and retard
healing.
Section 1.7 Wound drainage tube shortening and removal

 To provide guidelines for the shortening and removal of drainage tubes
 This document pertains to adult or paediatric patient’s that require shortening or
removal of drainage tubes at the Canberra Hospital and Health Services
Wound drainage systems are used to remove collections of fluid from around surgical
incisions or wound in order to reduce:
 Tension placed on the wound by accumulated fluid that prevents healing
 Medium for growth of microorganisms to prevent infection
Shortening a drainage tube is performed to:

 Facilitate tissue granulation
 Remove excess drainage
 To remove the drain without trauma

 Personal protective equipment (PPE) including safety glasses, goggles or shield and clean
gloves and gown

CHHS14/042
 Sterile metal forceps
 Sterile safety pin (if shortening the drain)
 Sterile Dressing towel
 Combine dressing and gauze swabs
 Sterile gloves
 Stitch cutter (if drain is sutured in)
 Solution normal saline x 30mls body temperature warmth
 Adhesive tape
 Appropriate dressing to manage exudate, or redress the drain site.

Procedure
1. Check the medical officer's orders regarding removal of the drainage tube or the amount
of tube to be shortened
3. Explain procedure and obtain patient consent
4. Ask the patient if they have any allergies to dressings or adhesive tapes
5. Ensure privacy
6. Ensure the patient has adequate analgesic cover prior to dressing change if required or
requested
8. Clean dressing trolley with detergent impregnated wipes and wipe surface dry with
disposable paper towel
9. Gather required equipment
11. Ensure that the patient is positioned in a comfortable position for the procedure
12. Position patient with wound drain area exposed
13. Place under-pad in position in proximity to the drain site
15. Don gown prior to opening sterile equipment
16. Don clean gloves and safety glasses
17. Set up equipment at the patient's bedside
19. Open and add additional sterile equipment
20. Discard packaging into general waste receptacle
21. Pour solution into appropriate area of dressing pack
22. Remove the soiled dressing with setting-up forceps.

CHHS14/042
24. Perform procedural hand washing

26. Clean the drain site and wound, when swabbing discharging wounds, swab from the
non-discharging area to the discharging area and discard swab in clinical waste
receptacle
27. Swab gently and in one direction only (clean to dirty)
28. Observe the wound and at completion of procedure document in notes findings such as
union of wound, signs of infection, exudate, inflammation and healing including:
a. The colour and depth of the wound
b. The amount, characteristics of wound exudate
c. Condition of surrounding skin (peri wound)
d. The amount of drainage tube shortened or the removal of the drainage tube
e. The condition of the tube (eg if removed not that tip is intact)
ALERT:
Do not use cottonwool swabs. Use gauze swabs only for the cleansing of the wound and
Report any concerns to the medical officer
To Shorten a Drainage Tube

Follow steps 1-28 of above procedure
29. Remove suture holding drain insitu, with stitch cutter if present
30. Withdraw drainage tube gently, using a rotating movement to the prescribed length
31. Secure drainage tube with a sterile safety pin by inserting the pin in the drainage tube
flush to the skin and at right angles to the wound
32. Cut the drainage tube 4cm above the level of the safety pin. (The pin will prevent the
drain tube from slipping back into the wound; however will not stop the drain from
falling or being pulled out)
33. Place drain dressing around the drainage tube under the safety pin
34. Apply dressing secondary dressing
35. Secure with adhesive tape if necessary
36. A wound drainage bag may be applied if drainage is excessive
37. Discard equipment and gloves into the clinical waste receptacle
dressing change will be
40. Document in the patient’s clinical record and nursing care plan that the drain tube has
been shortened.
To Remove a Drainage Tube

Follow steps 1-28 of above procedure
29. Remove suture, with stitch cutter if present
30. Withdraw drainage tube gently using a rotating movement
31. Swab wound, if required
32. Apply exudate absorbing dressing, secure with adhesive tape if necessary
33. A wound drainage bag may be applied if drainage is excessive
34. Discard equipment and gloves into the clinical waste receptacle
CHHS14/042

dressing change will be
37. Document in the patient’s clinical record and nursing care plan that the drain tube has
been removed.
38. Record and monitor exudate drainage in the clinical record.
ALERT:
When a drainage tube, which has been inserted by a surgeon in the Operating Room is
removed at Canberra Hospital, a second nurse who may be a registered nurse or an enrolled
nurse must witness the removal of the drainage tube. Both nurses must sign the Registered
Nurse Operating Theatre Report.
Back to Table of Contents
Section 2 – Managing Specific Wound Types
Section 2.1 Skin Tears

To promote evidence base practice to the classification and management and prevention of a
specific wound aetiology defined as skin tear.
Skin tear is defined as “a traumatic wound occurring principally on the extremities of the
older adult, as a result of friction alone or shearing and friction forces.
Both shearing and friction forces separate the epidermis from the dermis (partial thickness
wound) or which then separates both the epidermis and the dermis from underling
structures (full thickness wound).
Validated tool to describe the extent of skin trauma is known as the Payne and Martin
Classification System, 1993.
Skin tears require classification as part of the assessment of the wound.
Classification of skin tears is described in three categories as below;

Category I (skin tear without tissue loss)
 Skin flap can be approximated so that no more than one millimetre of dermis is exposed.
Category II (skin tear with partial tissue loss)
 Scant tissue loss. Partial thickness in which 25% of less of the epidermal flap is lost and at
least 75% or more of the dermis is covered by the flap.
 Moderated to large tissue loss. Partial thickness wound in which more than 25% of the
epidermal flap is lost and more than 25% of the dermis exposed.
Category III (skin tear with complete tissue loss)
 Epidermal flap is absent

CHHS14/042

 Safety glasses or goggles
 Clean gown and gloves
 Sterile gloves
 General waster receptacle
 Appropriate primary and secondary dressing (Refer to Appendix 1)
 Underpad for collection of excess saline eg gauze or absorbent pads
 Gauze swab moistened with saline to cover the wound prior to redressing
 Wound grid and tracing pen, disposable ruler (if appropriate) or camera.

Procedure
2. Check medical orders in patients clinical record
3. Obtain the patients consent
4. Ensure Privacy
5. Explain to the patient the process and purpose of the dressing change
6. Ask the patient if they have any allergies to dressings or tapes
requested
12. Don safety glasses and gown prior to opening sterile equipment
CHHS14/042

sterile.) Alternatively measure with a disposable ruler or use camera to photograph the
wound ensuring patient has consented prior to the photo being taken and confidentiality
is maintained. Digital photographs require downloading to medical records, with
patient’s UR number, date and time
25. Use wound cleansing solutions at body temperature irrigate with normal saline solution
26. Clean the wound surface, floating the skin across the wound to approximate the skin
edges using the body temperature saline solution. Roll skin flap into place to obtain
optimum skin coverage.
27. Protect the peri wound skin with skin prep.
ALERT: Use gauze swabs only for cleaning of the wounds.
28. Swab gently in one direction only

29. Classify skin tear into category using (Payne and Martin Classification System)
30. Observe the wound for: colour, depth, exudate, (describe the amount, colour and
character from the wound), granulation tissue, epitheliating, slough, necrotic,
hypergranulation and peri wound skin
31. Assess the wound for clinical signs and symptoms of infection. If signs of infection notify
the Medical Officer
32. Apply new dressing (appendix A), silicone interfaced.
33. Document on dressing removal date and arrow to indicate “arrow head to face intact
skin “
34. Remove dressing from arrow head to reduce further trauma to skin tear, use saline to
assist with removal if required
36. Remove goggles
37. Attend hand Hygiene by either hand washing or using ABHR
41. Document in patient’s clinical record and wound assessment and management chart: a
description of the wound and location, type of dressing applied and any change of
dressing and the reason for the change
42. Notify the community nurses of a change of dressing products to maintain continuity of
management
43. Preventative management strategies, tubular bandage for protection of the limbs eg
forearms and shin areas
CHHS14/042
ALERT: Most skin tears occur during routine handling of patients
Preventative strategies should:

1. Identify patients at risk
2. Implement strategies that prevent falls and other trauma
3. Gently handing of the patient and the use of transfer and repositioning devices that
reduce friction and shear
4. Cover vulnerable skin surfaces with clothing and skin protection devices
5. Avoid adhesive dressing on fragile skin consider lightweight roller or tubular bandages
6. Optimise nutrition and hydration status
7. Avoid the use of drying of pH altering soaps and pharmaceuticals use emollients
8. Moisturise the skin regularly
9. Discuss with the patient, family and carers information and education on prevention of
skin tears.
Referral to multidisciplinary teams should be considered eg Occupational Therapist for

further preventive strategies and management, Physiotherapist, Dieticians for nutritional
supplements and/or social worker. Eg protected bed rails, wheelchair plate covers.
 The patient’s wound is dressed with minimal discomfort and no adverse effects
 Wound healing is enhanced through appropriate dressing selection.
Alert
Patients who have an allergy to silicone products use products which provide moist interface,
protect the fragile skin environment and absorb exudates. eg, tulle grass and non adherent
foam.
Section 2.2 Management of Burns

To describe the procedure and provide guidance to clinical staff responsible for the
management of burns dressings
This document pertains to all patients who require management of burns dressings at the
Canberra Hospital and health services, excluding the Emergency Department (ED).

 Personal protective equipment (PPE) including safety glasses, goggles or shield, gown and
clean gloves
 Sterile gloves
 General waster receptacle
CHHS14/042
 Sterile drapes (green)Sterile scissors

 Appropriate primary and secondary dressing (Refer to Attachment 1)
 Adhesive tapes or bandages to secure dressing (minimise adhesive tapes where possible)
 Underpad for collection of excess saline e.g. gauze or absorbent pads
 Gauze swab moistened with saline to cover the wound prior to redressing
 Wound grid and tracing pen, disposable ruler or camera

Procedure
Ensure the principles of Wound Management principles are maintained.
2. Check medical orders in patients clinical record
3. Obtain the verbal consent
4. Ensure Privacy
5. Explain to the patient the process and purpose of the dressing change
6. Ask the patient if they have any allergies to dressings or tapes
requested
sterile.) Alternatively use camera to photograph the wound ensuring patient has
consented prior to the photo being taken and confidentiality is maintained. Digital
photographs require downloading to medical records, with patient’s UR number, date
and time

CHHS14/042

25. Use wound cleansing solutions at body temperature irrigate with normal saline solution
26. Clean the wound surface, swabbing from the non-discharged area to the discharging
area (clean to dirty) and discard swab (into clinical waste receptacle) or using gentle
irrigation method (allowing a controlled pressure of saline using a syringe) by using
warmed normal saline to achieve cleansing.
ALERT: Use gauze swabs only for cleaning of the wounds.
27. Swab gently in one direction only

28. Observe the wound for: colour (red, yellow, green, black, pink), depth, exudate (describe
the amount, colour and character from the wound), granulation tissue, epitheliating,
slough, necrotic, hypergranulation and the peri wound Assess the wound for clinical
signs and symptoms of infection. If signs of infection notify the Medical Officer
31. Remove goggles
32. Attend hand Hygiene by either hand washing or using ABHR
36. Document in patient’s clinical record and wound care chart: description of the wound,
type of dressing applied, any change of dressing and the reason for the change
37. if using VAC® therapy consider type and number of sponge, cycle, pressure, dressing
change interval and initial cycle
38. Notify the community nurses of a change of dressing products to maintain continuity of
management if appropriate.
ALERT: Silver Impregnated Products

Silver impregnated products need to be removed prior to:
 Radiation treatment
 Medical Resonance Imaging (MRI)
39. Referral to multidisciplinary teams should be considered eg Occupational Therapist for

scar management, Physiotherapist, Dieticians for nutritional supplements and/or social
worker.

CHHS14/042
Section 2.3 Management of lower leg ulceration

Causes of Leg Ulcers
 Vascular disorders
 Lymphatic disorders
 Autoimmune disorders
 Haematological disorders
 Metabolic disorders
 Tumours
 Infections
 Trauma
 Allergic responses
Treatment of the leg ulcer involves

 Removing or treating the cause
 Promoting circulation and improving venous return
 Promoting healing
 Promoting preventative care
Management of leg ulcers

The management of a leg ulcer is influenced by the patient’s co-morbidities; therefore a
holistic assessment is required for any patient who presents with a leg ulcer, in addition to a
comprehensive wound assessment. This information is to be documented on the wound
assessment form
A holistic assessment includes

 Clinical history
 Clinical examination
 Palpation of pedal and leg pulses
 Hand held Doppler ultrasound
Vascular assessment
The aim of a vascular assessment is to distinguish arterial aetiologies from venous and other
aetiologies and assess the extent of venous insufficiency.

CHHS14/042
Investigations that can assist in the diagnosis of ulcer aetiology
Blood pressure (BP) Measures the pressure of the blood on the vessel walls using a
sphygmomanometer. It provides an indication of the possible
presence of a range of cardiovascular diseases. The systolic BP is used
in the calculation of ABPI.
Ankle brachial A non invasive vascular test using Doppler ultrasound that identifies
pressure index (ABPI) large vessel peripheral arterial disease in the leg. It is used to
determine adequate arterial blood flow in the leg before use of
compression therapy. Systolic BP is measured at the brachial artery
and also at the ankle level. Using these measurements ABPI is
calculated as the highest systolic blood pressure from the foot arteries
(either dorsalis pedis or posterior tibial artery) divided by the highest
brachial systolic pressure, which is the best estimate of central systolic
blood pressure.41 An ABPI of 0.8 to 1.1 is usually considered indicative
of good arterial flow in the absence of other clinical indicators for
arterial disease. An ABPI of less than 0.8 and a clinical picture of
arterial disease should be considered as arterial insufficiency. An ABPI
above 1.2 is suggestive of possible arterial calcification.
ABPI = highest systolic foot pressure
Highest systolic brachial blood pressure
Duplex ultrasound A non invasive test that combines ultrasound with Doppler
ultrasonography in which the blood flow through arteries and veins
can be investigated to reveal obstructions.
Photoplethysmograp A non invasive test that measures venous refill time by using a small
hy (PPG) light probe that is placed on the surface of the skin just above the
ankle. The test requires the patient to perform calf muscle pump
exercises for brief periods followed by rest.43 The PPG probe
measures the reduction in skin blood content following exercise. This
determines the efficiency of the musculovenous pump and the
presence of abnormal venous reflux. Patients with problems with the
superficial or deep veins usually have poor emptying of the skin and
abnormally rapid refilling usually less than 25 seconds
Pulse oximetry A non invasive test that measures the red and infrared light
absorption of oxygenated and deoxygenated haemoglobin in a digit.
Oxygenated haemoglobin absorbs more infrared light and allows
more red light to pass through a digit. Deoxygenated haemoglobin
absorbs more red light and allows more infrared light to pass through
the digit. There is insufficient evidence to recommend this
investigation as the primary diagnostic tool.
Toe brachial pressure A non invasive test which measures arterial perfusion in the toes and
index (TBPI) feet. A toe cuff is applied to the hallux (or second toe if amputated)
and the pressure is divided by the highest brachial systolic pressure,
which is the best estimate of central systolic blood pressure. The TBPI
is used to measure arterial perfusion in the feet and toes of patients
CHHS14/042
with incompressible arteries due to calcification as may occur in

patients with diabetes and renal disease.
Transcutaneous Measures the amount of oxygen reaching the skin through blood
oxygen (TCPO2) circulation. There is insufficient evidence to recommend this
investigation as the primary diagnostic test.
(Reproduced with permission of the Australian Wound Management Association. All rights reserved)
Ankle/Brachial Pressure Index

Registered Nurses and Allied Health must be assessed as competent in this procedure prior
to attending an ABPI.
Equipment
 Hand held Doppler
 Ultrasound gel
 Tissues
 Sphygmomanometer cuff
 Doppler ABPI guide
 Hand wipes
Procedure
1. Explain procedure to the patient and obtain consent
2. Perform hand hygiene
3. Place the patient in the supine position, allay anxiety and encourage relaxation for at
least 15 minutes to stabilise blood pressure
4. Obtain the brachial systolic pressure as follows
a. Place sphygmomanometer cuff around the arm
b. Palpate the brachial pulse
c. Hold Doppler probe between forefinger and thumb at 45-degree angle (pointed
towards the heart) and place over brachial pulse until blood flow is maximally heard
d. Inflate the cuff until the ‘Doppler’ sound disappears; slowly deflate the cuff until the
sound returns
5. Repeat this process on the other arm
6. The higher of these 2 readings is acknowledged as the brachial systolic pressure
7. Obtain the ankle systolic pressure as follows
a. Place the sphygmomanometer cuff around the leg just above the ankle. If the
wound is at this site, cover it with plastic wrap or a sterile dressing
b. Locate the dorsalis pedis pulse on the same side
c. Apply gel over pulse
d. Hold Doppler probe between forefinger and thumb at 45-degree angle and place
over dorsalis pedis pulse until blood flow is maximally heard
e. Inflate cuff until Doppler sound disappears; slowly deflate cuff until sound returns
8. Repeat this process for the posterior tibial pulse
9. Wipe the gel from the pulse sites
10. Acknowledge the higher of these 2 readings as the ankle systolic pressure for that
particular leg

CHHS14/042
11. Calculate the patient’s ABPI by using the Doppler ABPI guide. If no guide is available,
then calculate it manually as follows:
Ankle-Brachial Pressure Index (ABPI) = ankle systolic pressure
brachial systolic pressure
12. Repeat the procedure on the other leg
13. Document findings on wound clinical pathway and on leg ulcer assessment form
14. Clinical observation must be used in addition to the ABPI prior to the commencement of
compression therapy
15. Consult with the patient’s Medical Practitioner regarding the results of the ABPI and a
diagnosis of venous/arterial ulceration
If a patient’s ABPI is unable to be determined, eg. due to pain or difficulty obtaining an

accurate reading, their Medical Practitioner must be notified. The patient may be referred on
for further investigations such as a Duplex Arterial Ultrasound.
Compression Therapy
 Registered Nurses who have been assessed as competent in obtaining an ABPI recording
can instigate compression bandaging if the ABPI reading falls between 0.8 and 1.2mmHg
and a comprehensive holistic assessment has been performed.
 Registered Nurses and Enrolled Nurses must be assessed as competent in applying
compression bandaging prior to attending this procedure
 When ABPI is < 0.8 or > 1.2, consult with the patient’s GP or Medical Specialist prior to
applying compression bandaging and obtain a written order:
The medical order must specify
 Type of compression therapy for e.g. high stretch or short stretch, two layer or four
layer bandage or stockings
 Amount of pressure to be applied
 Which limb to apply compression therapy
 Where possible use two layer bandages and change weekly
 Notify the GP if a leg ulcer shows no signs of healing after three months or if there is
a cause for concern prior to this
 A non healing leg ulcer should be referred to the Nurse Practitioner Wound Clinic.
(See Wound Management Service Referrals in the Community Care Program SOP)
 Please note if the Nurse Practitioner is away e.g., on leave, the GP should be notified
and assess the patient and refer onto appropriate Medical Specialist or health
facility
Do not apply compression bandaging to a patient if the ABPI is less than 0.8 or above 1.2
without a medical order from their GP/Medical Specialist/Nurse Practitioner Wound
Management/CNC.
 ABPI < 0.8: liaise with patient’s Medical Practitioner regarding the possibility of further
investigations to accurately determine the aetiology
 ABPI < 0.5 liaise with patient’s Medical Practitioner - advise the patient to seek an urgent
referral to a vascular surgeon

CHHS14/042
 ABPI > 1.2 may indicate uncompressible arteries; therefore seek advice from the medical
practitioner or Nurse Practitioner Wound Management prior to commencing
compression therapy
Venous Leg Ulcers

 Generally located lower 1/3 of leg – anterior to medial malleolus
 Patient may have a history of deep venous thrombosis, valvular incompetence, obesity or
a deficit in calf muscle pump function
Management of venous leg ulcers

1. Assess and document leg ulcer on wound assessment form
2. Photograph leg ulcer every two weeks or if there is a deterioration in the ulcer
3. Cleanse wound and leg at dressing change
4. Encourage patient to shower leg and ulcer prior to dressing change – ensuring there is
no contamination of the ulcer
5. Apply moisturiser to the leg
6. Apply appropriate dressing according to the wound assessment and treatment orders
7. Ensure patient has been assessed for peripheral arterial disease and that it is safe to
apply compression therapy
8. Apply compression therapy as per treatment orders and as per the manufacturer’s
recommendation
9. Apply an elastic retention tube to assist the bandage to stay in place if required.
10. The compression bandage may be left intact for up to 7 days.
11. More frequent changes may be necessary if there is excessive exudate or if clinical signs
of infection are present.
12. The bandage may need to be loosened if there is discomfort or tingling/numbness in
foot/toes
13. Refer patient to dietitian if ulcer present for > three months or wound healing delayed
14. Ensure patient has adequate pain control
15. Advise patient to
a. walk regularly or perform calf/foot exercises
b. elevate feet above level of heart when sitting
c. inspect skin integrity daily, and moisturise skin
d. stop smoking
e. lose weight if obese
f. follow a nutritional diet
16. Venous leg ulcers usually recur unless preventative measures are maintained. Patients
should continue wearing compression hosiery as prescribed and purchase new stockings
at least every six months
Advise the patient to remove the bandage if they experience an increase in pain or
discomfort, notice discolouration, coolness or pain in their foot/toes.
Manual Handling Risk - Technique for applying graduated compression bandage

CHHS14/042
Manual Handling (MH) risks are associated with dressing and bandaging of patients’ lower
limbs.
At the initial patient assessment a Community Manual Handling Risk Assessment Tool is to be
completed and the care plan is adjusted accordingly.
In order to minimise the risks to the clinician the following should be considered:
Working at waist height, avoid stretching/twisting/turning
 Treating the patient in the Ambulatory Care Clinic (where adjustable bed/equipment
is available)
 Using equipment/aids such as leg lifter, stool and height adjustable hospital bed
 Two staff members attending to dressing/bandaging (especially for obese and
bariatric patients)
 Reducing the frequency of dressing and bandaging, using two layer and four layer
bandaging and try to leave intact for seven days
When more frequent changes are ordered by the treating doctor, the case manager can
contact the doctor and discuss alternatives.
Examples of available compression systems
Also referred to as Description and function

Two, three and four A compression system with more than one layer or aspect. Most
layer bandaging bandaging systems include at least a padding layer and bandages so
are classified as multi-component systems.
Can also refer to a system that consists of several layers which use a
combination of elastic and inelastic bandages (ie. four layer bandage
system). This system is also available as kits.
Short stretch bandages Bandages with minimal or no elastomers. Low extensibility and high
stiffness (high SSI). Low resting pressure and high working pressure.
Compression bandaging system that has only one layer or aspect to
the system. Most bandage systems currently used in practice include a
padding layer and so are not described as single component systems.
Tubular stockings, Available in a range of compression levels. International consensus on
compression stockings, compression scales is lacking and different scales are used around the
multi-layer hosiery world. Two scales and/or classifications of compression hosiery
systems commonly used by Australian and New Zealand manufacturers
include:
Scale one:120
 extra light (5mm Hg)
 light (15 mm Hg)
 mild (18—24 mm Hg)
 moderate (20—40 mmHg)
 strong (40—60 mmHg)
 very strong (>60 mmHg)
Scale two:
 Class I
 Class II
CHHS14/042
 Class III
 Class IV
Unna’s boot Although there are several systems referred to as Unna’s boot it is
commonly a gauze bandage impregnated with zinc paste under a
cohesive inelastic bandage.
Pump compression Pressure is applied via a boot inflated by a machine either
continuously, intermittently or in sequential cycles.
(Reproduced with permission of the Australian Wound Management Association. All rights reserved)
Arterial Leg Ulcers

Arterial leg ulcers occur due to peripheral arterial disease and are frequently located
between toes and at tip of toes, over phalangeal and metatarsal heads, on side or sole of
foot.
Management of Arterial Ulcers

1. Assess and document leg ulcer on wound assessment form
2. CCP
3. Photograph leg ulcer every two weeks or if there is a deterioration in the ulcer
4. Cleanse wound and leg at dressing change
5. Encourage patient to shower leg and ulcer prior to dressing change – ensuring there is
no contamination of the ulcer
6. Apply moisturiser to the leg and foot
7. Apply appropriate dressing according to the wound assessment and treatment orders
8. No compression bandaging of limb as this will reduce the blood supply
9. If the ABPI is < 0.8, advise the patient to seek an urgent referral to a vascular surgeon
10. Liaise with patient’s Medical Practitioner regarding a referral to a vascular surgeon
11. Refer patient to a Podiatrist
12. Refer patient to a Dietitian
13. Refer patient to a Occupational Therapist if pressure injury prevention strategies are
indicated
14. Ensure patient has adequate pain control
15. Advise the patient to
16. exercise as tolerated
17. inspect skin integrity daily, and moisturise skin
18. avoid tight clothing/shoes
19. avoid trauma to the skin (including adhesive tapes and thermal extremes)
20. stop smoking
21. ensure that legs are in a neutral or dependant position whilst sitting or lying
22. lose weight if obese
23. follow a nutritional diet
Do not debride ischaemic ulcers that are covered with hardened eschar, such as dry
gangrene. There may be insufficient blood supply to support infection control and wound
healing.

CHHS14/042
For arterial ulcers – Do not apply compression bandaging of limb as this will further reduce
the blood supply to the lower leg.
Mixed Arterial/Venous leg Ulcers

 Ulcers are considered to be mixed when more than one factor is operative, eg. Venous
leg ulcers associated with diabetes, peripheral arterial disease, or rheumatoid arthritis
 Compression therapy may be contra-indicated in these patients due to poor peripheral
arterial circulation
 If light compression is prescribed by the Medical Practitioner or Specialist, the circulation
of the patient’s leg/feet must be monitored at each visit to prevent and detect any early
signs of ischaemia
 Advise the patient to remove the bandage if they experience an increase in pain or
discomfort, notice discolouration, coolness or pain in their foot/toes
 Consultation should be sought with a vascular surgeon
Possible indicators for specialist referral include:

(Reproduced with permission of the Australian Wound Management Association.
All rights reserved)
 Diagnostic uncertainty
 Atypical ulceration distribution
 Suspicion of malignancy
 For treatment of underlying conditions including diabetes, rheumatoid arthritis
and vasculitis
 Peripheral arterial disease indicated by an ABPI less than 0.8
 ABPI above 1.2
 Contact dermatitis
 Ulcers that have not healed within 3 months
 Recurring ulceration
 Healed ulcers with a view to venous surgery
 Antibiotic resistant infected ulcers
 Ulcers causing uncontrolled pain
Section 2.4 Managing Skin Grafts and Donor Sites

Skin grafting, also known as skin transplants or auto-grafts, is a surgical procedure in which a
piece of skin is transplanted from one location of the body to another area of a patient’s
body to cover a wound that involves a defect in skin and/or subcutaneous tissue. Skin
grafting is used to replace skin lost by injury. The area where the skin is removed from is
called the donor site.
Skin grafts are used to speed up the healing and reduce the risk of infection. Care of a skin
graft depends on the type of graft.
There are two types of skin grafting procedures: split-thickness and full-thickness. Split-
thickness skin grafts (STSG) include the upper layer (epidermis) and most of the lower layer

CHHS14/042
(dermis) of the skin. A full-thickness skin graft (FTSG) transfers all layers of the donated skin
to the wound. A FTSG offers more durable coverage and more sensation than a STSG.
A split-thickness skin graft can be meshed or non-meshed prior to placement. The process of
meshing allows fluid from within the wound to escape through the fenestrations, thus
decreasing the risk of graft failure due to the pressure of trapped wound fluids. Meshing the
skin also increases the amount of area that can be covered as the skin can be expanded up to
nine times.
A full-thickness skin graft is harvested by excision. A FTSG is closed primarily with skin
closure devices and the incision can be cared for with a topical ointment. This wound should
heal with a fine line scar. A FTSG is taken from areas that most closely match the area where
they are to be transplanted. For example, a defect on the face can be covered by skin from
behind the ear.
Postoperative Care
Split skin graft (or split thickness graft)
The donor and grafts sites must be protected and the pain controlled. The graft site is
elevated and never left in a dependent position. While the skin graft is adhering to the
wound bed, the graft must be protected from fluid collection, tension and movement.
Collection of wound fluid, blood and serum beneath the skin graft can separate it from the
wound bed. This collection of fluid prevents revascularization, therefore inhibiting nutrient
and oxygen from interfacing with wound bed and grafted tissue. Fluid collections can be
evacuated by piercing the graft with a 25g needle, then using a sterile applicator to wick out
the fluid. A Medical Officer’s order is required prior to removing any collection of fluid.
Revascularization begins within 36 hrs. The surgeon will usually remove the surgical dressing
3 to 5 days after surgery. At this time the graft should appear pink as capillary buds are
formed and circulation is maintained. If no blood supply is present, the grafted area will
appear white. If infection is present, the graft will have a red or inflamed appearance with
graft loss.
When the graft is harvested it can be applied to the bed immediately or it can be stored to
be applied later, this is called ‘delayed grafting’. The skin can be preserved for up to 2 weeks,
by storing the donor skin on normal saline soaked gauze in a sterile container in the fridge.
Donor Sites
Following harvesting of the donor site, primary dressings are placed on the wound and
pressure bandaging applied, because the donor site is a superficial wound that is likely to
bleed. The pressure bandages remain intact for usually in excess of 24-48 hours. Primary
dressings should remain intact until the dressings can be removed without trauma, usually in
10-14 days.
If leakage occurs, and clinical assessment does not indicate infection, the primary dressing
should be reinforced. If leakage persists, the primary dressing should be removed and the

CHHS14/042
site assessed for signs of infection. Redress the site with the primary dressing as per Medical
Officer’s orders.
If the donor site has healed, leave exposed and teach patient/carer to apply a non perfumed,
water based cream (Aqueous cream) 3 times per day. The donor site area once healed may
be hypersensitive to touch, advise patient/carer that touching the area will help with de-
sensitising. Advise the patient to avoid UV exposure to the donor site and apply sun screen
when outdoors.
Full Thickness Grafts (Wolfe Graft)

These grafts are sutured to immobilise the graft. Follow Medical Officer’s orders regarding
removal of sutures and dressing instructions.
Depending on the size of the graft, the donor site may be closed by primary intention or
covered with a split skin graft.
Dressing procedure
Skin grafts and donor sites are considered acute wounds and an aseptic non touch technique
is used when attending to dressings.
Section 2.5 Postoperative managing of Skin Flaps
Skin flaps
A flap is a surgical relocation of tissue from one part of the body to another part. Flaps
contain skin and subcutaneous tissue but can also contain underlying fascia, muscle or bone.
This relocation will create a secondary defect that will require grafting or primary closure
Indication for flaps:

 Reconstructive surgery following major surgery such as tumour resection (e.g
mastectomy)
 Extensive trauma or surgical management of a chronic wound (e.g pressure injury)
 Areas of prior infection
 Replants of a traumatically severed or complete amputation of body part most commonly
fingers.
The most common types of flaps are:

 Free- flap: relocation of skin and subcutaneous tissue with an anastomosis of its blood
vessels to the receiving area’s blood vessels.
 Pedicle- flap: transfer of skin and subcutaneous tissue but blood supply is maintained
until a new blood supply is established. The pedicle is then freed.
 Rotational- flap: local pedicle flap whose width is increased by having the edge distal to
the defect form a curved line; the flap is then rotated and a counter incision is made at
the base of the curved line, which increases the mobility of the flap.

CHHS14/042
 DIEP (Deep Inferior Epigastric Perforator) Flap: based on the deep inferior epigastric
vessels, an artery and vein at the bottom of the rectus abdominis muscle. These vessels
provide the primary blood supply to the skin and fat of the lower abdomen. The lower
abdominal skin and fat is removed without having to harvest any of the rectus abdominis
muscle. Blood supply is provided through the perforator vessels that are teased out form
the rectus muscle, using a muscle incision.
Post-operative management of skin flap (not including DIEP flap)
Equipment:
 PPE including clean gloves
 Doppler
 Lubricant
 Tissue
Procedure:
1. Explain procedure to the patient and obtain consent
3. Ensure privacy
4. Position the patient to ensure comfort during the procedure
5. Don PPE (as indicated)
6. Expose flap site
7. Perform and document flap observations as per Limb Observation Chart-Skin Flap form.
Refer to The Canberra Hospital – Limb Observation Chart – Skin Flap and ACT Health –
Neurovascular Observations Chart which can be found on the Clinical Forms Register
8. Ensure no pressure is applied anywhere near the flap
9. Attend capillary refill, flap temperature, colour, peripheral temperature, urine output,
blood pressure, doppler thrill and drain output
10. To check for doppler sounds, locate the area where it is marked by the Surgeon

CHHS14/042
NOTE:
Frequency of flap observations is dependent on the Plastic VMO orders. Daily review,
documentation of the treatment, and ongoing management plan for flap is required by the
treating team. If any change in condition, the treatment must be reviewed more frequently
as required. The Plastic VMO may order a 1:1 special nurse, skilled in microvascular
observations, if the flap requires closer and more frequent observations
11. Wipe excess lubricant from doppler site

12. Cover flap if necessary
13. Remove PPE
15. Record observations attended.
16. Any changes from previous observations should be reported to the Plastics registrar on
duty
17. Keep patient warm and comfortable
18. Cleanse doppler with neutral detergent wipes
20. Skin flaps will be sutured, check Surgeons orders regarding removal of sutures.
ALERT:
Contact the treating Plastic Registrar when:
 Flap becomes congested, blue or white
 Capillary return is sluggish, brisk (<1 second) or absent
 There is a reduction in temperature at the flap site
 There are signs of infection
Normal Abnormal
Capillary refill 2-3 seconds Sluggish ≥3 seconds
(ischaemic)
Brisk ≤ 1 second (congested)
Flap temperature (use back Warm Cool, Cold
of hand or finger to assess)
Colour (note: can vary based Pink Purple/Blue-possible clots
on the donor, please consider (venous occlusion)
to compare the colour of the White – no blood supply
flap with the donor) (arterial occlusion)- inform
Plastic Registrar
Peripheral Temperature >36.5° C <36.5°C – vasospasm
Keep patient warm, use bair
hugger
Doppler Biphasic Monophasic – call Plastic
Registrar for review

CHHS14/042
Normal Abnormal
Urine Output 0.5-1 ml/kg/hr – or Drop in urine output inform
depending on Surgeon’s Plastic Registrar
preference
Systolic Blood Pressure >100mmHG or depending on Drop in blood pressure
Surgeon’s accepted value inform Plastic Registrar
Post operative management of a DIEP flap
ALERT:
A DIEP flap will always require a 1:1 special nurse, skilled in post microvascular observations,
for a minimum of 48hrs post op. The 1:1 special nurse can only be ceased by the Plastic
VMO.
Frequency of observations
 15 minutely for first 6 hours
 30 minutely for the next 12 hours
 Review by consultant to determine ongoing frequency
Equipment:
 Clean gloves
 Doppler
 Lubricant
 Tissue
 Bair hugger
 Alternating air mattress (reactive)
Procedure:
1. Increased Patient Care/ Supervision Request Form must be completed by the ward CNC or
the Team Leader on the shift. Refer to ACT Health Increased Patient Care / Supervision
Request Form which can be found on the Clinical Forms Register. Requirement of the
special can be changed according to frequency of observations (e.g hourly flap
observations)
2. Staff to organise alternating air mattress, calf compressors, and bair hugger from Central
Equipment Stores, prior to the patient coming to the ward. Alternating air mattress can
be requested to be sent to Recovery so that patient can be transferred directly to this
post surgery (Patients will require to be resting in bed for 48 hours or as directed by the
Plastic surgeon)
On admission to the ward:

3. Special Nurse together with the ward Nurse In-charge will receive handover from
Recovery nurse, making sure flap hand over and observation is performed in front of the

CHHS14/042
receiving nurse and documented. If doppler is required, ensure exact location where to
use doppler and doppler sounds have been handed over.
4. Post operative observations to be attended as per protocol. Refer to ACT Health Post
Operative Handover and Observations – Adult patients (first 24 hours) which can be
found on the policy register
5. Monitor Observations as per Limb Observation Chart – Skin Flap. Refer to Post operative
management of skin flap for management of skin flap observations
6. Frequency can change depending on Plastic Surgical team instructions.
7. Flap observations are to be handed over at the bedside. The outgoing nurse to handover
the flap observations along with the location of the flap and also the Doppler sound to be
handed to the incoming nurse.
8. To check for doppler sounds, locate the area where it is marked by the Surgeon
9. Connect the bair hugger and maintain desired temperature of patient (as directed by
surgeon)
10. Monitor urine output every hour and Intravenous fluid therapy can be titrated according
to the output but only if advised by the Plastic Registrar
11. Check, monitor, and date the drains. Change the drain bag and record the output every
24 hours. Document the drain output on the Fluid Balance Chart. (Monitor and ensure
the drain patency as these patients are at high risk of seroma)
12. Ensure patient has adequate analgesia
13. Do not apply pressure on the flap
14. Monitor donor site for bleeding or ooze
15. Monitor Haemoglobin level
Other types of microvascular surgery:

Replantation: the restoration of any body part to its original site. This also requires repairing
of blood vessels, nerves and tendons. It is commonly used in post traumatic injury such as
finger amputation. Bone is often shortened to allow extra length of vessels for tension free
anastomosis. K wires are used to join the bone, usually retained for 4-6 weeks until the bone
unites.
Management:
 Refer to Flap post-operative observations
 If replantation deteriorates, may require leech therapy ordered by the Plastic VMO. Refer
to Medicinal Leech Therapy Clinical Procedure for management.
Section 2.6 Managing Malignant Wounds

Malignant wounds develop by direct extension from a tumour to the skin, as a secondary
tumour, or as a result of lymph nodes that are involved with disease.
These lesions mainly occur with cancers of the breast, kidney, head and neck, lung, ovary,
colon, penis and bladder. They may also occur with lymphoma, leukaemia and melanoma.
Initially they will appear as a firm, flesh coloured nodule and may eventually turn red or blue.
These lesions quickly develop a necrotic core because of poor oxygenation and metabolite
toxicity. The skin will eventually break down.
CHHS14/042
Chemotherapy or radiation therapy is sometimes used to reduce the size of the mass, limit
the bleeding, or control the pain.
Vigorous cleaning should be avoided as this will predispose the wound to bleeding.
Sharp debridement is contraindicated because of the persistent nature of the necrosis and
the friability of the underlying tumour.
Following discussion with the patient, the primary goals are:

 Reducing odour
 Managing exudate
 Promoting comfort
 Preventing bleeding
 Preventing Infection
 Maintaining aesthetics
Malodour
Malodour is a frequent problem in fungating wounds, and is caused by bacterial activity in
the devitalised tissue. Odour may be controlled by the topical application of Metronidazole
or Manuka honey. Carbon based dressings may also be used for odour control however in
case of excessive exudate the charcoal will be inactivated by the moisture. Dressings may
need to be changed daily, depending on the odour and the amount of exudate.
Environmental factors such as good ventilation and room deodorants may assist with odour
control.
Exudate management
Excessive exudate may occur due to the increased permeability of blood vessels within the
tumour and the secretion of vascular permeability factor by tumour cells. Suitable dressing
products for a highly exudating malignant wound include: alginate, hydrofibre, foams, or
non-adherent contact dressings with an absorbent secondary dressing. Drainage bags may
be required to collect high volume exudate.
Pain
Pain may be caused by the tumour itself, or by adherence of the dressing to the wound.
Ensure the patient has adequate pain relief, particularly prior to dressing change. Choose an
appropriate dressing product that will not cause pain upon removal such as: non-adherent
dressing, impregnated gauze, calcium alginate, hydrocolloids, hydrogels, and foams.
Cleansing the wound by irrigation or showering will be less painful for the patient than a
swabbing technique.
Bleeding
Malignant wounds frequently bleed due to erosion of blood vessels. The risk of bleeding can
be minimised by using non-adherent dressings and avoiding trauma to the wound. Bleeding

CHHS14/042
may be controlled by the application of alginate dressings or stomahesive powder. Refer the
patient to their Medical Practitioner if continual heavy bleeding occurs, as cautery or ligation
may be necessary. Where possible, secure the dressings with a tubular dressing (mesh) to
prevent any additional skin damage from repetitive tape removal.
Aesthetics
Malignant wounds can affect a patient’s self esteem. Appropriate wound management
techniques can have a positive effect on self-esteem. Promote quality of life by using
dressings that minimise disfigurement, such as skin coloured dressings. Referral to Palliative
Care Service may be required for a multi-disciplinary approach to patient care.
Infection
Malignant wounds are susceptible to infection because of devitalised or decayed state of the
tissue. Topical antiseptic dressings such as cadoexemer iodine, honey, silver, polyhexamethyl
biguanide can assist in the control of infection. Systemic antibiotics may need to be
prescribed.
Implementation
These procedures will be implemented and communicated through all educational wound
care days facilitated through the Staff Development Program in the Staff Development Unit
and Practice Development Program in the Community Care Program (CCP). Clinical
Development Nurses and Allied Health Educators will be alerted to these procedures in the
clinical areas.
Evaluation
Outcome Measures
 Adults and children with a wound will be assessed and managed safely
 Wound management is practiced according to the best available evidence for optimising
healing acute or chronic wounds
 Clinicians adhere to the general principles of care and management of patients with a
wound and to the procedures outlined in this document
 Wound management plans are developed in consultant with patient and carers
 Increase aseptic non touch technique for wound dressing technique compliance
Method
 Compliance with assessment and management of a wound will be conducted through
the annual clinical record documentation audits, audit angels, and feedback is reported
at team/unit meetings

CHHS14/042
 Ongoing assessments are performed and documented on the wound assessment chart to
provide evidence of wound healing or deterioration in wound healing which may
influence the management plan and product choice.
 Riskman clinical incident reports are monitored and any issues relating to wound
management are assessed by the relevant nursing and allied health managers and
discussed with relevant clinicians
 Riskman clinical incidents reports are monitored by the Tissue Viability Unit at Canberra
Hospital and the Nurse Practitioner – Wound Management and CNC in the CCP and
discussed with the relevant clinicians and managers
 Consumer engagement - liaise with relevant managers regarding patient feedback
Related Policies, Procedures, Guidelines and Legislation
 ACT Health Infection Prevention and Control Policy

 ACT Health Waste Management Policy
 Canberra Hospital & Health Services Personal Protective Equipment SOP
 ACT Health Nursing and Midwifery Continuing Competence Policy and SOP
 Non-Diagnostic Digital Photography Images and/or Recordings Policy, SOP and Consent
 Canberra Hospital & Health Services Aseptic Non Touch Technique -SOP
 Hand Hygiene SOP
References
Australian Wound Management Association Inc, (2009) AWMA Position Document: Bacterial
impact on wound healing: From contamination to infection. AWMA.
http://www.awma.com.au/awma/index.php
Australian Wound Management Association Inc ,(2001)the Australian and New Zealand
Clinical Practice Guideline for Prevention and Management Venous Leg Ulcers. Cambridge
Media Osborne Park, WA.
Australian Wound Management Association Inc, (2010) Standards for Wound Management
http://www.awma.com.au
Bale S; Jones, V. (2006), Wound Care Nursing – A patient –centred approach 2nd Edition
Carville, K. (2005), Wound Care Manual 5th Edition, Silver Chain Nursing Association WA
European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel Pressure
Ulcer Prevention and Treatment Clinical Practice Guidelines (2009) accessed 1/8/14
http://ewma.org/english/publications.html
CHHS14/042
Dealey, Carol. (2013), The care of wounds: a guide for nurses, Wiley-Blackwell, UK
Flanagan, M, (2013) Wound Healing and Skin Integrity, Principles and Practice, Wiley & Sons.
National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan
Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Emily Haesler
(Ed.). Cambridge Media: Perth, Australia; 2014.
New South Wales Severe Burn Injury Service: accessed 10 August 2014
http://www.health.nse.gov.au/gmct/burninjury
Principles of best practice; Wound Infection in clinical practice. (2008), An international

consensus. London: MEP Ltd.
Sargent, R. L. (2006), Management of blisters in the partial-thickness burn: an integrative

research review. Journal of Burn Care & Rehabilitation. Vol 1. 66-81.
Wound Healing and Management Node Group, 2012. Evidence summary: Wound infection -
iodophors and biofilms, The Joanna Briggs Institute/Curtin University.
Wound Healing and Management Node Group, 2012. Evidence summary: Wound infection
-silver products and biofilms, The Joanna Briggs Institute/Curtin University.
Wound Healing and Management Node Group, 2012. Evidence summary: Wound
Management Dressing - Alginate, The Joanna Briggs Institute/Curtin University.
Management: Debridement - wet to dry moistened gauze The Joanna Briggs Institute/Curtin
University.
Wound Healing and Management Node Group, 2014. Recommended Practice: Ankle Brachial
Pressure Index: Using a hand held Doppler. The Joanna Briggs Institute/Curtin University.
Management: Autolytic, The Joanna Briggs Institute/Curtin University.
World Union of Wound Healing Societies (2008). Principles of Best Practice, Diagnositics and
Wounds. A consensus Document London MEP Ltd.

CHHS14/042
Search Terms
 Wound  Burns
 Wound Management  Skin tears
 Acute wounds  Leg ulcers
 Chronic wounds  Malignant wounds
 Painful wounds  Wound drains
 Wound Infection  Wound swab
 Wound debridement  Packing a sinus
 Compression bandaging  Removal of sutures/staples
Consultation
Name/position/Division Feedback Feedback Comment

of person(s) consulted Received incorporated
Yes/No Yes/No
NP Wound Yes Yes

Management
Rehabilitation Aged
and Community Care
(RACC) Community
Care Program
CNC Tissue Viability Yes Yes
Unit Canberra
Hospital
CNC Wound Yes Yes
Management (RACC)
Community Care
Program
CDN 11B Canberra Yes Yes
Hospital
CNC (RACC) Yes Yes

Community Care
Program

CHHS14/042
Nurse Manager Yes Yes

Tuggeranong Health
Centre Nursing Team
(RACC) Community
Care Program
Nurse Manager Yes Yes
Phillip Health Centre
Nursing Team (RACC)
Community Care
Program
Nurse Manager City Yes Yes
Health Centre
Nursing Team (RACC)
Community Care
Program
RN Level 2 Belconnen Yes Yes
Nursing Team (RACC)
Community Care
Program
Allied Health Yes Yes

Manager (RACC)
Community Care
Program
Office of the Chief Yes Yes

Allied Health Officer
Health Care Yes Yes

Improvement Unit
Calvary Hospital Yes Yes

CHHS14/042
Attachments
Attachment 1 Dressings of choice for burns

Attachment 2 Burn Assessment Tool
Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for
its own use. Use of this document and any reliance on the information contained therein by any third party is at
his or her own risk and Health Directorate assumes no responsibility whatsoever.
Date Amended Section Amended Approved By

26 September 2017 Section 1.5 CHHS PC
11 October 2017 Section 2.5 Postoperative CHHS PC
managing of Skin Flaps
added

CHHS14/042
Attachment 1 Dressings of choice for burns
Non infected wounds

Generic Dressing Company name Notes
Silicone interface with Mepilex® Superficial to mid dermal burns
/or without foam Mepitel® Do not use if infected
Change 2-4 days dependant on exudate
Mepitel requires secondary dressing
Hydrogel sheets AquaClear® Superficial to mid dermal burns
Initial treatment in cooling
Minimal exudate
Do not use if infected
Hydrocolloid DuoDerm® or Devitalised tissue sloughy wound
Comfeel® Low to moderate exudate
Do not use if infected
Change 2- 5 days dependant on exudate
Infected wounds
Generic Dressing Company name Notes
Vaseline gauze with Bactigras Apply directly to wound bed in 2-3 layers
chlorhexidine Avoid if patient has a chlorhexine
impregnated sensitivity or allergy
Soak off if adhered to wound bed
Change 1-3 days
Silcone interface with Apply directly to wound bed

Foam and silver Mepilex® A G
Temporary skin staining
Silver sheets- Acticoat 3 day / or Moisten dressing with H2O apply to

nanocrystalline Ag Acticoat Flex 3 wound bed
coated mesh with inner Acticoat 7 day / or Avoid if patient has an allergy to silver
rayon layer Acticoat Flex 7 Keep 7 day moistened
Change secondary dressing as required
Temporary skin staining

CHHS14/042
Attachment 2 Burn Assessment Tool
Severity of the burns injury is determined by assessment of surface area and depth of the
burn.
Surface area of the burn is determined by the “Rule of Nines” and depth of the burn into 5
classifications:
 Epidermal
 Superficial Dermal
 Mid-Dermal
 Deep Dermal
 Full Thickness
Table 1 Burn Assessment by depth

Depth Colour Blisters Capillary Healing Scarring
Refill
Epidermal Red No Brisk 1-2 sec Within 7 None
days
Superficial Red/ Pale pink Small Brisk 1-2 sec Within 14 None slight
Dermal days colour
mismatch
Mid-Dermal Dark pink Present Sluggish > 2 2-3 weeks Yes ( if
sec grafting may healing >3
be required weeks)
Deep Dermal Blotchy Red/ White +/- Sluggish > 2 Grafting Yes
sec / absent required
Full White/Brown/Black No absent Grafting Yes
Thickness (charred)/ Deep Red required
“Rule of Nines” by %

CHHS14/042
Burns patient who require admission to the Plastic Surgical Ward area often have epidermal,
superficial dermal or mid- dermal injuries.
Blisters
Dependent on the mechanism blisters are often lance or aspirated. Lift a section of the skin
to view wound bed and ascertain capillary refill.
Blisters that are de-roofed to allow appropriate treatment of the underlying tissue. Use
appropriate dressings.
Capillary refill
Lift small area of skin, apply pressure and observe for capillary refill, replace the skin as a
biological dressing if there is acceptable refill time


Wound Management Procedure

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Wound Management Procedure

Încărcat de

Drepturi de autor:

Formate disponibile

CHHS14/042

Canberra Hospital and Health Services

Doc Number Version Issued Review Date Area Responsible Page

Section 1 – Key Principles for Wound Management

1. There is a collaborative practice and interprofessional care approach to promote optimal

Doc Number Version Issued Review Date Area Responsible Page

2nd edition, March 2010)

Ongoing Assessment of Wound Healing Process

Individualised Care Plan

A clinician comprehends the importance of and is able to:

Optimum Healing Environment

Maintaining a constant wound temperature consistent with optimal healing

Maintain a neutral or slightly acidic pH consistent with optimal healing

Doc Number Version Issued Review Date Area Responsible Page

Prevent and manage infection

Protect the wound environment

Maintain the integrity of wound management products, pharmaceuticals and devices

Minimise the actual and potential impact of pain

Doc Number Version Issued Review Date Area Responsible Page

Section 1.1 Basic Dressing Technique

Equipment Acute and Ambulatory Care setting

Equipment Community setting

5. Obtain verbal consent

28. Observe the wound for:

Doc Number Version Issued Review Date Area Responsible Page

Section 1.2 Wound Probing

Equipment Acute and Ambulatory Care Setting

Doc Number Version Issued Review Date Area Responsible Page

Equipment Community setting

Doc Number Version Issued Review Date Area Responsible Page

19. Note any tracking or shelving, including the direction of insertion

Section 1.3 Wound Debridement

Doc Number Version Issued Review Date Area Responsible Page

 Little or no pain to patient

2. Conservative Sharp Wound Debridement (CSWD)

Advantages: Fast, can be extremely effective

Disadvantages: May be painful for patient, danger of damage to healthy tissue

Procedure for Conservative Sharp Wound Debridement

 Basic dressing pack

Equipment Community setting

Section 1.4 Wound Swabbing

Equipment Acute and Ambulatory Care setting

Doc Number Version Issued Review Date Area Responsible Page

 Underpad eg. Absorbent pad

Equipment Community setting

16. Remove swab-stick from sterile container

Doc Number Version Issued Review Date Area Responsible Page

Section 1.5 Wound suture and staple removal

The technique used for removing sutures will depend on the:

Doc Number Version Issued Review Date Area Responsible Page

Equipment Acute and Ambulatory Care setting

Equipment Community setting

16. Expose the wound site

Doc Number Version Issued Review Date Area Responsible Page

Section 1.6 Wound and sinus packing

Equipment Acute and Ambulatory Care setting

Equipment Community setting

12. Attend hand hygiene by either hand washing or using ABHR

Section 1.7 Wound drainage tube shortening and removal

Shortening a drainage tube is performed to:

Equipment Acute and Ambulatory Care setting

Doc Number Version Issued Review Date Area Responsible Page

Equipment Community setting