Praymer+Tungkol+Sa+Pagpapasuso+Sa+Sanggol miemie122390741

8/11/2019 Praymer+Tungkol+Sa+Pagpapasuso+Sa+Sanggol miemie122390741

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


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Wound Managementin General Practice

Provision of Clinical Care 2.3

April 2009


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Learning objectives

Outline the principles of wound management in the general practice

setting

Identify factors relating to delayed wound healing

Outline strategies to manage: skin tears

burns and blisters

lower leg ulceration

diabetic foot ulceration

Specify various dressings and techniques for their application

Be cognizant of wound management MBS.


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Principles of Wound Management

define aetiology

control factors influencing healing

select appropriate dressing or device

plan for maintenance.


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Wounds seen in General Practice

trauma: abrasions and cuts

superficial partial thickness

burns

venous leg ulcers

arterial leg ulcers

foot wounds often associated with

neuropathy and neuro-ischaemia

skin cancers.

Generally do not see: pressure injuries or dehisced surgical wounds


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Decision Making Tools

Tissue colour

Wound depth

Exudate level

Periwound skin condition Predicted weartime

Skill of carer

Availability/cost of product

Select the most appropriate dressing according to:


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T.I.M.E

Source: http://www.ewma.org


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10


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11


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Dry necrosis

A 75 yr old male who is a smoker and

has type 2 diabetes, presents with the

following:

What would you do?

A. moisten to encourage autolytic

debridement

B. moisten to facilitate sharpdebridement

C. refer for surgical debridement

D. none of the above.


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World of Wounds


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World of Wounds 15


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World of Wounds 16


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17

Matching Colour and Product

Black.. if aiming to heal: cleansing dressing

Green. antimicrobial dressing

Wet yellow. antimicrobial dressing

Dry yellow. rehydrating dressing

Red protect

Hypergranulation. antimicrobial dressing

Pink. protect.

This is not a prescription but a guide to where to start


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Ideal Dressing

provide mechanical protection

protect against secondary infection

non adherent and easily removed without trauma

leave no foreign particles in the wound

remove excess exudates

cost effective

offer effective pain relief.


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Generic Names

impregnated mesh dressings

low adherent lightly absorbent pads

super absorber pads

protective film wipes

film sheets

foam and foam like absorbent dressings

hydrocolloid wafers and paste

hydrogel sheets and amorphous gels with or without additives.


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calcium alginates

hydrofibre

hypertonic salt

cadexomer iodine

silver

medicated honey

zinc bandages

Generic Names


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Purchasing Products

most practices have agreements with distributors

the fee for dressings is either born by the practice or passed on to

the patient

if asking the patient to purchase their own dressings perhaps look

at distributors that will offer products at reasonable prices


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Rebate schemes

Department of Veterans Affairs (DVA) patients will be able to secure

most dressings as long as the general practitioner writes the required

item on a script

11996 is the Medicare item number to be used for the nurse

performing wound care

AWMA is seeking to have products listed on PBS


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Case Studies

skin tear

burn

venous ulcer

arterial ulcer

foot wound.


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Star skin tear classification system


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STAR Tool

utilise the STAR tool to classify skin tear severity

the STAR tool can be downloaded from the Silver Chain website at:

http://www.silverchain.org.au/Research/Research-Projects/STAR-Project/


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Skin Tear: 1a


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Skin Tear: 1b


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Skin Tear: 2a


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Skin Tear: 2b


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Skin Tear: 3


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Key Points for Skin Tears

develop your own set of protocols for managing skin tears

write these up and add to your wound resource folder

companies do have protocols for you to follow


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Burns: First Contact

Assessment

site

depth

surface area involved

age of patient

other influencing factors


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What is reasonable to care for ingeneral practice?

small superficial partial burns not involving face, feet, hands,

perineum, genitalia on the very young or the elderly

further guidelines and very good advice may be found on the NSW

DoH Website for Severe Burn Injury or ringing Concord Burns Unit


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Superficial Burn Characteristics

epidermis only

erythema (vasodilatation)

tenderness (nerve irritability)

oedema.


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Superficial Partial Burn Characteristics

epidermis and outer dermis

blisters (fluid shift)

shedding of skin

painful exposed (nerve endings to kinins)

bleeds when pricked with needle

hair present (hard to pull out)

full sensation

blanches on pressure.


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Burn Surface Area Wallaces rule of nines

Lund and Browder chart

closed palmar hand of victim= 1% of body surface area.


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Anatomical Site Considerations

hands

feet

face

perineum

genitalia

joints

circumferential burns


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Other Considerations

extremes of age: very young or very old will need special care

co-morbidities

medications.


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What to do about blisters?

controversial: removal causes pain

tense blisters can interfere with

dermal circulation, restrict movement

beware of blisters with red rings

blisters can hide deep burns

popped blisters may need to bedebrided.


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Key Points for Burns

have standard policies and procedures

know where nearest specialist burns centre is and how long it takes

by road or air

liaise with burn centre for care in interim

closely monitor patient for signs of impending infection and sepsis.


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Example of a Burn Protocol

superficial partial thickness burns of less than 10% body surface

area, not involving feet, face, hands, genitalia, over joints, the

very young and the elderly, can be nursed in the practice

deeper partial thickness burns of less than 5% body surface area

will be treated in the practice BUTif no response within one week

should be referred on


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Useful Websites

http://www.ameriburn.org

http://www.anzba.org.au

http://www.worldburn.org

http://www.journalofburns.com

http://www.burnsurgery.org

http://www.skinhealing.com

http://www.worldwidewounds.com


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Lower Leg Ulceration

Statistics

venous 70%

arterial 10%

mixed 10%

skin cancers 2%

others 8%


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Venous Ulcer Characteristics

firm brawny oedema

inverted champagne bottle leg

irregular shape

medial or lateral aspect lower third of leg

wet, shallow, minimal necrotic tissue

atrophie blanche

venous eczema, staining, lipodermatosclerosis

palpable pulses, minimal pain, relieved when elevated.


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World of Wounds 45


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Arterial Ulcer Characteristics usually located between ankles and toes or high up on leg orposterior leg

deep, punched out regular shape, often dry

thin, shiny, non hair bearing skin

thickened toenails

diminished or absent foot pulses

elevation pallor, dependant rubor necrotic tissue, infection

pain, especially at night or when elevated.


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World of Wounds


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Venous Ulcer Management

ensure adequate dressing to assist in managing wound exudate

if thinking some bacteria present use an anti microbial, cover with

absorbent pad apply light crepe bandage toes to knee

then cover the bandage with different length layers of straight

elasticated tubular bandage or shaped tubular bandage


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3 layers of straight elasticated bandage


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Arterial Ulcer Management

have the patient reviewed by a vascular surgeon

use Iodosorb powder if the wound is wet or if the area is dry

then paint it with Betadine

if the surgeon can not revascularise, then the wound is maintenance

or palliative and the aim is to keep it infection free and stable


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Foot Wounds

The high risk foot:

diabetes neurovascular disease

neuropathic diseases

congenital or other foot abnormalities


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Monofilament Testing

Semmes-Weinstein monofilament is often used to assess protective

sensation in the feet of patients with diabetes

nylon filament mounted on a holder

10 gram force

assess 10 sites over the foot, randomly so the

patient cannot anticipate the next sitehttp:/ndep.nih.gov/resources/feet/index.htm


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Areas at risk of damage

Using the monofilament


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Diabetic Foot Examination

D deformity

I infection

A atrophic nails

B breakdown of skin

E oedema

T temperature

I ischaemia

C callosities

S skin colour


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Diabetic Foot Examination

Deformity charcots, pes cavus, claw toe, hammer toe

Infection crepitus, fluctuation, deep tenderness

Atrophic nails fungal infections and sub ungal ulcers

Breakdown of skin ulcers, fissures, blistersIschaemia pulses may be weak or absent

Callosities plantar surface, metatarsal heads

Skin colour red = charcots

pale = ischaemiapink, with pain and absent pulses = ischaemia


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Dressings for Diabetic Foot Ulcerations

Antimicrobial Iodosorb Hypertonic salt: Mesalt, Curasalt

Silver products: Acticoat, Aquacel Ag, Atrauman Ag,

Contreet, even silver lined socks and hosiery

Absorbent Exudry, Mesorb, Zetuvit, Dry-Max

Allevyn, Biatain, Lyofoam Extra

Aquacel

Algisite M, Kaltostat, Calcicare, Sorbalgon

Padding or

cushioning

Podiatry felt

Silipos

Dermal pad

Debriding Iodosorb Mesalt

TenderWet

Hydrocolloid paste.
http://images.google.com.au/imgres?imgurl=http://brighamrad.harvard.edu/education/online/private/clerkship/bone_anat/foot/lat.gif&imgrefurl=http://brighamrad.harvard.edu/education/online/private/clerkship/bone_anat/foot/lat.html&h=286&w=504&sz=69&hl=en&start=7&tbnid=oQjpimS1E4E8tM:&tbnh=74&tbnw=130&prev=/images%3Fq%3Dthe%2Bfoot%2Banatomy%26svnum%3D10%26hl%3Den%26sa%3DG


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Key Points for Diabetic Foot Ulcerations

remember diabetics may have micro or macro vascular disease or both

always be suspicious of infection

do not use occlusive dressings on foot wounds

HBO is often helpful in diabetic vascular wounds and osteomyelitis

Assistance is available via the SSWAHS High Risk Foot Service


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Conclusions

wounds in general practice are varied

it is ideal to have treatment cards for most common types of

wounds seen

product range needs to be kept to a minimum but cover all generic

types of wounds and an antimicrobial

always establish the underlying diagnosis of the wound and reassess

if failing to follow normal healing pathways


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Resources

http://www.woundpedia.com

http://www.worldwidewounds.com

http://www.globalwoundacademy.com

http://www.ewma.org

http://www.wuwhs.org

Useful book: Wound Care Manual by Keralyn Carville

http://www.silverchain.org.au/html/WoundCareForm.htm


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Clinical Friends of World of Wounds

Visit the website and enrol an expression of interest

Can provide clinical advice via email for $10 per consult

Website: http://www.worldofwounds.com/Home/
http://www.worldofwounds.com/


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Wound Management Competency

Standards for General Practice Nurses Wound management competency standards for general practice nurses have

been developed as part of the Nursing in General Practice Program at General

Practice NSW and funded by the Australian Government Department of Health

and Ageing

Cpetency standards should be used as a framework to assess competence and

should be read in conjunction with:

the Australian Nursing and Midwifery Council competency standards

the Competency Standards for Nurses in General Practice the Australian Wound Management Association standards

Standards may be accessed on the APNA website:

http://www.apna.asn.au/displaycommon.cfm?an=1&subarticlenbr=294

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