Nurse Practitioner Wound Management Clinical Practice Guidelines Health Service Rehabilitation Aged and Community Care Speciality Area Community setting – patients of all ages Setting The Nurse Practitioner – Wound Management works within a collaborative multidisciplinary team consisting of nurses, doctors and allied health professionals to deliver health services to people with a chronic or complex wound, where healing is delayed or an expert opinion and assessment is required. The service/consultancy is available to the ACT community in the following settings: Ambulatory Care Clinics in the Community Health Centres Specialised Nurse Practitioner Wound Clinics Services to patients in the home setting Outpatient clinics Canberra Hospital Transitional care program Aged care facilities Appropriate referrals to the Nurse Practitioner from other sources will also be accepted 1 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Nurse Practitioner Role The Nurse Practitioner – Wound Management provides a comprehensive assessment of the patient and implements a management plan, including the appropriate treatment, ordering of diagnostic investigations, prescribing of medications, referral to specialists, educating and supporting patients and carers, discharge planning and evaluating outcomes to ensure the best possible outcomes for patients with a chronic or complex wound. Other aspects of the Nurse Practitioner role involve educating and supporting staff, conducting research and ensuring best available evidence in wound care. The Nurse Practitioner is able to work in the community and network closely with ACT hospitals and other appropriate health professionals, providing specialised treatment to minimise episodes of admission and/or facilitate early discharge from hospital. In the case of a medical emergency the Nurse Practitioner’s role is that of basic life support and to facilitate appropriate and immediate transfer to acute care services. Client/Patient Population Patients with a chronic or complex wound can be of any age and may require management of one or more co morbidities. Date of approval Review date 2 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Contents Overview Health service –specialty area and setting Nurse Practitioner - Wound Management role Patient population Local Service Area Clinical Practice Guideline Advisory Committee Members 1-3 4 Introduction Assessment Physical examination 5-6 Conditions for Referral Emergency Department Urgent Conditions for referral to another health professional 7 Management 8 - 11 Treatment options and conditions for Nurse Practitioner treatment Diagnostic investigations Health promotion/illness prevention Non pharmacological approaches Medication intervention Follow up management Medication Formulary 12 - 14 Plans Dissemination of Clinical Practice Guidelines Implementation of Clinical practice guidelines Review of Clinical Practice Guidelines 15 References 16 - 17 3 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Local Service Area Clinical Practice Guideline Advisory Committee Members Name Position Professional Qualifications Organization Signature Date Nurse Practitioner Wound Management Senior Registered Nurse Royal Perth Hospital 21 Sept 2012 ACT Health Directorate – Rehabilitation, Aged and Community Care ACT Health Directorate – Rehabilitation, Aged and Community Care Canberra Hospital 30 Jan 2013 Donna Angel Nurse Practitioner Maxine Scicluna Director of Community Care Marina Boogaerts Clinical Nurse Consultant Research and Quality Senior Nurse Clinician Ann Marie Dunk Clinical Nurse Consultant Tissue Viability Unit Medical Officer Clinical Nurse Consultant Research Vascular Surgeon ACT Health Directorate – Director of the Wound Clinic 20 Dec 2012 Ben Gilbert Pharmacist B. Pharm MPS University of Canberra 17 Dec 2012 Ngaire Whitehead Consumer Health Care Consumers ACT Association 13 Nov 2012 Professor David Hardman 10 Oct 2012 15 Oct 2012 4 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Introduction These Clinical Practice Guidelines outline the extended scope of clinical practice within the ACT for the Nurse Practitioner – Wound Management. These guidelines enable the Nurse Practitioner to work safely and appropriately in the delivery of nursing practice to patients who are referred for consultation. The Nurse Practitioner works within the community and outpatient setting. The Nurse Practitioner provides holistic nursing care to patients of any age with an acute or chronic wound. These guidelines include the management and treatment of referred patients with vascular leg ulcers, complex wounds, including pressure injuries, burns, surgical wounds/ fistulas and the high-risk foot, including neuropathy and diabetic foot ulcers. Autonomous practice in collaboration with appropriate specialist health professionals will occur with all conditions covered in these guidelines. This document reflects what is currently regarded as safe clinical practice. However, as in any clinical situation there will be factors, which cannot be covered by a single set of guidelines. In these situations the Nurse Practitioner will exercise the judicious application of clinical judgement specific for each individual presentation. Assessment This would include, but not be limited to Comprehensive patient history Family history Presenting signs and symptoms Wound history 5 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Previous diagnostic investigations Allergy history, including nature and significance of the allergy Pharmacological history, including complementary and over the counter medicines Prompt medications such as puffers, creams, eye drops Pain assessment Activities of daily living/functional history Mobility/gait assessment Social, occupational and cultural history Other specialist referrals and services in place Physical examination This would include, but not be limited to General health assessment Assessment of wound bed, location, tissue loss and surrounding skin, noting characteristic features Assess clinical presentation - raised unusual purpura, vasculitic nodules - suspicion of neoplastic disease - senescent tissue - hypergranulation tissue - non healing despite optimum treatment - presence of infection - presence of contamination/dead material e.g. devitalised tissue Examine and assess amount/type of wound exudate Assessment – duration of wound and history of previous wounds 6 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Assessment of allergies including adverse reactions to wound products and creams Pressure injury risk assessment using the Waterlow Risk Assessment Tool Presence of other wounds Signs of topical wound infection Signs of systemic infection e.g. cellulitis, lymphangitis, lymphadenopathy Signs of osteomylitis Examination of femoral, popliteal and pedal pulses Assessment of peripheral neuropathy Assessment of wound bed/tissue for possible neoplastic disease Conditions for Urgent Referral to Emergency Department This would include but not be limited to Immediate transfer for Medical emergency e.g. cardiac arrest, respiratory arrest, myocardial infarction, suspected pulmonary embolism, deep venous thrombosis or sepsis. Conditions for referral to another health professional – compromising exacerbation or new presentation of Urgent conditions – ischaemia limb/s or serious infection Diabetic ulcers and neuropathy/Charcot’s Tissue loss – exposed bone, tendon or muscle Surgical intervention required Ankle brachia index < 0.7mmHg or ankle systolic <80mmHg 7 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Suspected neoplastic pathology Venous disease/hypertension – varicose veins Burns according to severity - body percentage, partial, full thickness burns, location, age Wound infection Wound fistulaes – intracavity contents exposed – (dehiscence) Recommendation to GP for a referral to an accredited pharmacist for a Home Medicines Review (e.g. to address medication management issues, review new/existing medications relevant to both wound care and general health conditions). Management Treatment options and conditions for Nurse Practitioner treatment This would include but not be limited to Lower leg ulceration High risk foot – Charcot Pressure injuries Surgical wounds Skin grafts/flaps - donor site Traumatic wounds Minor burns Wound fistulas/stomas Cancerous/fungating wounds Diagnostic Investigations Investigations for consideration by Nurse Practitioner This would include but not be limited to 8 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Ankle brachial index/Doppler signal characteristics Full blood examination, full blood count , electrolytes, liver function test, erythrocyte sedimentation rate, C-reactive protein, total protein, albumin, lipids, thyroid function Blood glucose levels HBA1C Urinalysis Wound swab/s - microbiology, culture and sensitivity Wound punch biopsy - attended in OPD at CH - histological examination to confirm wound aetiology - microbiological examination to identify organisms and sensitivities Medical imaging – plain x- ray, bone scan, venous/arterial duplex scan Health promotion/illness prevention Hygiene Dietary education Weight management Smoking cessation Daily foot/leg inspection Foot wear - orthotics Bandaging technique Exercise regimes Pressure injury prevention – access to appropriate equipment Support groups Life style modifications Advanced care directives 9 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Pain Management Prevention of recurrence and assessment of potential hazards Disease process and health maintenance Management of the non-healing wound Psychosocial support Provision of consumer health promotion literature Promotion of Quality Use of Medicines Non-pharmacological approaches Appropriate use of dressings and compression bandages Appropriate use of drainage appliance and devices including negative pressure systems and dynamic bed systems Wound debridement/curette Offload pressure – appropriate foot wear/contact casting Skin care and moisturisers Medication Intervention – see Medication Formulary Analgesia - pain management Antimicrobial - treatment of wound infection Local anaesthetic – wound debridement Corticosteroids - topical - treatment of skin conditions/irritations Antibiotics – oral and topical - treatment of wound infection and cellulitis without systemic complication Antifungal topical creams - treatment of fungal infection Provision of Consumer Medicine Information (CMI) Explanation of CMI 10 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Referral to community pharmacist for further management of medicines and ancillary treatments Follow up management Review appropriately in a timely manner according to clinical condition Review treatment plan in accordance with assessment and diagnostic results Evaluate therapeutic response Drug therapy assessment Monitor test results – order as appropriate Management of abnormal results within scope of practice Monitor wound progress Maintenance of healed wound Pressure injury prevention Specialist referral for treatment that is outside the scope of Nurse Practitioner practice Reinforcement of health promotion/illness prevention message Continuity of care and communication/collaboration with the GP/Specialists and/or other health professionals Co-ordinate case conference specific to complex wound management as appropriate 11 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Medication Formulary Analgesia 1. Paracetamol (eg. Panadol) 2. Paracetamol with codeine S3 (eg. Panadeine Extra) 3. Paracetamol with codeine S4 (eg. Panadeine Forte) Antibiotics 1. Amoxycillin (eg. Amoxil) 2. Amoxycillin & Clavulanate (e.g Augmentin Forte) 3. Cephalexin (eg. Keflex, Ibilex) 4. Dicloxacillin (eg. Diclocil) 5. Ciprofloxacin (eg. Ciproxin) 6. Clindamycin (eg. Dalacin) 7. Doxycycline (eg. Vibramycin, Doxylin) 8. Metronidazole (eg. Flagyl) Topical antimicrobial 1. Flamazine - Silver Sulfadiazine (SSD) 2. Metronidazole gel (eg. Rozex) 3. Mupirocin (eg. Bactroban) 12 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Topical corticosteroid & antimicrobial 1. Neomycin/Triamcinolone/Nystatin/Gramicidin (e.g. Kenacomb) Antifungal 1. Nystatin (eg. Nilstat, Mycostatin) 2. Clotrimazole (eg. Canesten) 3. Terbinafine (eg. Lamisil) 4. Imidazole (eg. Bifonazole) Topical corticosteroids 1. Betamethasone dipropionate (eg. Diprosone, Betnovate) 2. Betamethasone valerate (eg. Celestone) 3. Methyprednisolone aceponate (eg. Advantan) 4. Mometasone furoate (eg. Elocon) 5. Triamcinolone acetonide (eg. Aristocort, Kenocort A) Local Anaesthetic 1. Lignocaine (eg. Xylocaine) 2. Lignocaine & Prilocaine (eg. EMLA) 3. Lignocaine with adrenaline) (eg. Xylocaine & Adrenaline) 4. Bupivacaine (eg. Marcain) Hypergranulation 1. Topical silver nitrate Trace Elements, Minerals and Vitamin Supplements 1. Zinc (eg. Zincaps) 13 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 2. Iron (eg. Ferro-Gradumet) 3. Vitamin C (eg. Ascorbic Acid) 4. Multivitamin & Minerals (eg. Centrum) 5. Alginade 14 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Plan for the dissemination, implementation, review and evaluation of the Clinical Practice Guidelines 1. Copy held at Rehabilitation, Aged and Community Care 2. Copy held in office of the Chief Nurse, ACT Health directorate 3. Copy held at ACT Division of General Practice 4. Copy lodged with Australian Nurse Practitioner Association 5. Implementation will be immediate 6. Formal review and evaluation of the Clinical Practice Guidelines is scheduled for August 2015 7. Interim updates to the ACT Clinical Practice Guidelines are required annually (or earlier if there is a change in population or practice) to ensure that they remain at the level of best practice. 8. Notify Chief Pharmacist 15 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 References Australian Capital Territory Health Directorate (2011). Wound Care Manual. Community Care, ACT Health Directorate, ACT Australian Capital Territory Nursing and Midwifery office (2008). Nurse Practitioner in the Australian Capital Territory – The Framework, ACT Australian Wound Management Association and the New Zealand Wound Care Society 2011. Australian and New Zealand Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers. Cambridge Publishing, Perth Australian Wound Management Association (2012). Standards for Wound Management (2nd Ed) Cambridge Publishing, Perth WA Australian Wound Management Association (2012). Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injuries Cambridge Publishing, Perth WA Carville, K. (2012). Wound Care Manual (6th Ed) Silver Chain Nursing Association, Perth, WA Cullum, N; Nelson, EA; Fletcher, AW & Sheldon, TA. (2005). Compression for venous leg ulcers, A Cochrane Review. The Cochrane Library MacLellan, L; Gardner, G & Gardner, A (2002). Designing the future in wound care: the role of the nurse practitioner. Primary Intention 10(3) p. 97-106. Cambridge Publishing, Perth WA 16 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012 Marley, J. (2009). (Ed). Therapeutic Guidelines: Dermatology. Version 3. Therapeutic Guidelines Limited. North Melbourne Medicines, Poisons and Therapeutic Goods Act 2008 http://www.legislation.act.gov.au/a/2008-26/default.asp Medicines, Poisons and Therapeutic Goods Regulation 2008 http://www.legislation.act.gov.au/sl/2008-42/default.asp National Institute of Clinical Studies. (2005). Applying compression therapy to treat chronic venous leg ulcers. Evidence gaps report Vol 2 Nelson, EA, Bell-Syer & Cullum, NA. (2006). Compression for preventing recurrence of venous ulcers – The Cochrane Database of Systematic Reviews Pagana, M. & Pagna, C. (2006). Mosby's Manual of Diagnostic and Laboratory Tests. (3rd ed). Mosby, USA Palfreyman, SJ; Nelson, EA; Lochiel, R; Michaels, JA. (2006). Dressings for healing venous leg ulcers. Cochrane Database of Systematic Reviews. 3:CD001103 Rossi, S. (Ed). (2013). Australian Medicines Handbook. Pharmaceutical Society of Australia. SA Therapeutic Guidelines (Antibiotic) Version 14 (2010) 17 Nurse Practitioner Wound Management Clinical Practice Guidelines Rehabilitation, Aged and Community Care December 2012