| TOPIC | Wound Care/Basic Dressing Technique Procedure | ||
| AREA | Service Delivery | TYPE | Procedure |
1. Purpose
Mobility is committed to providing safe and effective clinical care to consumers.
The purpose of this procedure is to describe the process for undertaking a basic wound dressing that promotes:
- Provide an environment that promotes patient comfort and healing when a basic wound dressing is performed
- the use of appropriate dressing material, optimal wound moisture balance, protection, and wound temperature.
2. Scope
This procedure applies to all Registered Nurses (RN) who assist consumers with wound care and management.
3. Definitions
| Acute wound | a wound of less than six weeks duration that progresses through the phases of healing without delay |
| Aseptic non touch technique | · refers to the identification of ‘key parts’ by not touching them either directly or indirectly. This is the single most important step in achieving asepsis. Key parts refer to the parts that if contaminated with micro-organisms increase the risk of infection.
· is achieved by using sterile equipment and ensuring that the sterile component of the product does not come into contact with a non-sterile surface. · includes performing hand hygiene at the following times: prior to setting up for the procedure and prior to application of non-sterile/sterile gloves and at completion of procedure This is to protect the practitioner and client from cross-contamination as per standard precautions. |
| Chronic wound | a wound that deviates from expected sequence of repair in terms of time, appearance and response to appropriate treatment; and does not demonstrate significant signs of healing in six weeks. |
| Delayed healing | Healing progresses at a slower rate than expected. As a guide:
· in open surgical wounds healing mainly by epithelialisation, the epithelial margin advances at about 5mm per week · clean pressure ulcers with adequate blood supply and innervation should show signs of healing within two to four weeks · a reduction in venous leg ulcer surface area of >30% during the first two weeks of treatment is predictive of healing. |
| Full thickness wound | a wound where tissue damage extends beyond the skin and extends at least into the subcutaneous layer. Tissue damage may also extend to muscle, tendon and/or bone. |
| Skin integrity | may relate to the normal function of skin as complete healthy tissue, without injury or breaks in continuity |
| Skin tear | is a traumatic wound occurring principally on the extremities of older adults, as a result of friction alone or shearing and friction forces which separate the epidermis from the dermis (partial thickness wound) or which separate both the epidermis and the dermis from underlying structures (full thickness wound). |
| Wound | an occurrence where skin integrity has become injured or broken in continuity1. |
4. Roles and Responsibilities
It is the responsibility of Registered Nurses whom provide wound care to Mobility Consumers to complete the following:
4.1. Performs in accordance with relevant legislation, regulations, scope of practice and polices of Mobility
- Functions in accordance with the relevant scope of practice as determined by regulatory authorities and within the scope of employment as defined by the wound service provider.
- Meets regulatory requirements of relevant registering authorities.
- Has appropriate qualifications, clinical skills and level of practice to perform professional and/or practice role related to wound care
- Is accountable for practice.
- Recognises limitations of scope of practice for regulated and non-regulated
- Has knowledge of, and compliance with, policies and procedures of Mobility
4.2. Delivers evidence-based wound care.
- Accesses current evidence from reputable sources in order to maintain a knowledge base appropriate to professional and/or practice role.
- Makes care decisions that reflect evidence-based practice.
- Evaluates the benefits and risks of using wound-related products, pharmaceuticals, therapies and devices
4.3. Provides care within an ethical practice framework.
- Recognises the responsibility to prevent harm to the consumer and their family carers.
- Recognises the rights and responsibilities of the consumer , family carers and the multidisciplinary team.
- Delivers evidence-based wound prevention and management that is sensitive to beliefs, values, ethnicity, culture and dignity
- Considers moral and ethical dilemmas in delivery of wound care
- Maintains trust, privacy and confidentiality of the consumer and family carers.
- Considers equitability and sustainability in the delivery of wound care.
5. Procedure
When performing a wound dressing hand hygiene and aseptic non-touch technique principles must be adhered to
5.1 Equipment in Client Home
- Alcohol based hand rub (ABHR)
- Identify suitable clean surface in the home setting.
- Detergent impregnated wipes (to clean suitable surface)
- Personal protective equipment (PPE) includes, safety goggles or face shield and gown as required
- 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
- Additional gauze swab (optional)
- Dressing equipment as per clients 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 and wound grid and tracing pen (optional) or camera as required
5.2 Process
- Ascertain treatment plan and dressing changes regime, as well as assessing the clients need for appropriate pain relief prior to dressing (e.g. pre-procedural analgesia or distraction technique).
- Wash hands.
- Clean the environment with alcohol impregnated wipes.
- Open up dressing pack, using standard precautions.
- Open up appropriate dressings, cleaning solutions, gauze, scissors and gloves using ANTT .
- Using aseptic technique, remove old dressing and discard. If dressing does not lift easily it may require soaking to avoid trauma to the wound.
- Wound cleaning should be performed in a way that minimises trauma to the wound bed. Irrigation is the preferred method, otherwise each wipe/swab should be used only once, start at the top of the wound and finish at the lower edge on linear wounds and from wound edges inwards on others.
- Once the wound has been cleaned, change gloves.
- Ensure the wound is dry before applying appropriate dressing.
- Discard soiled materials and environment surface. Soiled wound dressings are to be considered contaminated waste and disposed of accordingly.
- Wash hands.
- Document the wound status/ assessment in the report before you clock off..
5.3 Wound management plan: Evaluate at each dressing change
The clinician will use the following, the Wound Management Guideline and Appendix A in determining what actions need to be taken and what dressing type is to be used unless it is already directed by a Medical Officer.
The frequency of dressing changes will dictate an individualised wound management plan. The frequency of such dressing changes will be directed by the clinician co-ordinating the consumers care, but must take into consideration the dressing properties and the stage of wound healing. The choice of dressing is determined by the individual needs of the consumer and the wound and the type of dressing used may differ as the healing process progresses. When evaluating the wound management plan, consider:
- Is the dressing providing an environment that supports and is beneficial to the healing process?
- Is the wound progressing in a timely manner through the stages of wound healing?
- Are there any signs of clinical infection?
- Note any adverse reactions to dressings or tapes used.
If the wound is deteriorating or showing no expected signs of healing then re-assessment must be performed by an appropriately trained clinician and an alternative wound management plan prescribed.
5.4. Antimicrobial stewardship
The prevention of wound infection is an important step also in antimicrobial stewardship. The clinician will work with the relevant prescribing Medical Officer to promote antimicrobial stewardship.
5.6 Incident Reporting
Identification of all new infections must be reported as an incident via Mobilitys incident management system.
6. Related Documents
Internal
- Service Delivery Policy
- Infection Control Procedure
- Wound Management Guideline
- Antimicrobial Stewardship Procedure
- Hand Hygiene Work Instruction
- Nutrition and Hydration Procedure
External
- Home Care Packages program operational manual a guide for home care providers March 2021
- Home care packages program (HCP) my aged care provider journey
- Aged Care Quality Standards
- Aged Care Quality and Safety Commission Act 2018
- Aged Care Quality and Safety Commission: Clinical governance in aged care
- Charter of Aged Care Rights (Clth)
- Australian Aged Care Act 1997 (Clth)
- Privacy Act 1988, Schedule 1, (Clth)
- Australian Privacy Principles 2014 (Clth)
- Controlled Substances Act 1984 (SA)
- Regulation 9 (Poisons) 2011
- Health Practitioner Regulation National Law (SA) Act 2010 and Regulation 2018
- Mahoney, Kirsty; Journal of Community Nursing, Understanding the basics of wound care iin the community setting. Jun/Jul2014; 28(3): 66-75.
- Principles of Wound Management | Clinical Gate Accessed 3/8/22
- Standards for Wound Prevention and Management (Third Edition) (2016). Woundsaustralia.com.au. (2022).
- Wood, Joseph; Holden, Jane; Grob, Marion and Soldin, Mark (June 2019) Management of wounds in the community: Five principles, Community Wound Care.
- Wound Care: A Guide to Practice for Healthcare Professionals. Ausmed.com.au. (Accessed 3/8/22).
- Wound management | Agency for Clinical Innovation. Aci.health.nsw.gov.au. (2022). Accessed 3/8/22, from https://aci.health.nsw.gov.au/networks/spinal-cord-injury/pi-toolkit/management/cleanse-the-wound.
7. Document History
Reviewed by: Group Quality And Safeguarding Manager
Authorised by: The CEO
Date Adopted: August 2022
Next Review Due: May 2025
Version Control
| Version | Date | Change |
| 1 | 3/8/22 | New |