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Clinical Pathways

Wound Care
Wound Care

Red Flags

(Nursing) Patients/clients who present with the following should have immediate care via GP:
  • Minor Acute Burns
  • Minor animal/human bite
  • Cellulitis
(GP's) Patients/clients who present with the following should have immediate care via Emergency Department:
  • Degloved limb or digits/toes
  • Extensive avulsion/laceration
  • Excessive bleeding
  • Toxic cellulitis
  • Extensive cellulitis
  • Extensive skin tear
  • Gangrene
  • Necrotising Fasciitis
  • Pyoderma gangrenosum
  • Penetrating wounds
  • Sudden necrosis of limb
  • Sudden painful cool/cold leg, foot or toes.
  • Underlying structures or bone visible
  • Suspected Cancer/BCC/SCC referral to appropriate speciality.
Malignant lesions

Background

  1. Wound Management:

  2. Tissue Viability/Wound Care/Podiatrist Specialist Advisors:

Assessment

  1. Clinical Assessment

Management

    1. Burns
    • Click here for First Aid
    • Wound Care
      • Clean
      • dress products
      • frequency
    • Patient Care
      • Mobility
      • Nutrition
      • Fluid
      • Lifestyle
      • Pain

  2. Diabetic Wounds & Foot Ulcers

  3. Leg Ulcer

  4. Pressure Injuries

  5. Skin Tears

    • Assess whether partial thickness (separation of epidermis from dermis) or full thickness (separation of epidermis and dermis from underlying tissue). Classify according to STAR system, or skin tear decision algorithm.
    • Control bleeding with pressure, elevation.
    • Clean wound – Clean or irrigate with warm water or saline until debris is removed (5-10 mins). Potable tap water is safe to use directly on wounds. Cold saline slows the healing process for several hours. Pat the wound dry, dress with an appropriate product. Mark with an arrow the direction in which dressings should be removed.
    • Assess for risk factors - patient:
      • Age/gender
      • Previous skin tears
      • Dry fragile skin
      • Medications – especially steroids
      • Ecchymosis
      • Impaired mobility/vision
      • Poor nutrition/hydration
      • Cognitive/sensory impairment
      • Co-morbities Smoking status, peripheral vascular disease, diabetes, vascular insufficiency, oedema, cardiac failure, malnutrition, immunosuppressants, corticosteroids. These are red flags for       potential delayed wound healing.
      • Dependency – especially showering, dressing, transfers
    • Lacerations below the knee
      • Simple, linear wounds involving skin and sub-cut only – suture. Involvement of deeper structures may need referral to ED.
      • Proximally based flaps – if the blood supply is good, replace to cover as much of the defect as possible without any tension. Hold the flap in place with the dressing. If the blood supply is poor, manage as for a distally based flap.
      • Distally based flaps - carefully remove all underlying fat until and replace the skin over defect to provide as much cover as possible. No sutures or steri-strips. Make small vertically orientated perforations in flap (this is effectively a full thickness graft). Hold the flap in place with the dressing. Elevation is crucial.
      • STAR Classification Tool

  6. Traumatic

    • ACC and District Nursing:
    • Patients who have their wounds managed under ACC must have an approval number.
    • If you refer a patient to District Nursing services, you must provide the approval number on the referral.
    • For further advice or information, you can contact the ACC website.
    • Tetanus up-to-date

  7. Primary Care Skin Surgery

Information

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.