Wounds Nurse Management Guidelines

Red Flag Exclusion Criteria

  • Child at risk of significant harm

  • Suspected non-accidental injury

  • Unplanned repeat ED presentation

  • Infant ≤ 12 months

  • Foreign Bodies (refer to Foreign Body NMG)

  • Burns (refer to Burns (minor) NMG)

  • Wound > 3cm in length and/or full dermal thickness

  • Wound/s involving

    • Eyelids

    • Lips

    • Face (other than superficial)

    • Hands

    • Genitalia

    • Joints

    • External auditory canal

  • Significant bleeding not controlled by direct pressure / compression bandage (excludes minor bleeding / ooze from wound)

  • Neurovascular compromise

  • Loss, decrease of function distal to wound and pain on movement (suspicion of tendon injury)

  • Grossly contaminated wounds

  • Infected or necrotic wounds

  • Animal bite or scratch wound

  • Human bite wound

  • Any penetrating wounds to head, neck or torso

  • Possible concomitant fracture

  • History of workplace injury

  • Yellow or Red Zones observations or additional criteria outlined in the NSW Health Standard Observation Charts

Additional Observations

If limb affected, conduct a full set of neurovascular observations.

Additional History

  1. Establish mechanism of injury

  • How was injury / wound sustained

  • Date and time of injury

  • Site/s and type of injury (laceration, abrasion)

  • General appearance of wound including cleanliness, length, depth and shape of wound

  1. First aid treatment initiated prior to ED presentation

  2. Tetanus immunisation status

Management Principles

  1. Jewellery (rings / watches etc.) must be removed from affected limb (cut jewellery if required)

  2. Provide analgesia as required according to pain scale. Refer to Pain (any cause) NMG

  3. Apply direct pressure and / or elevate wound where possible to stop bleeding

  4. Clean wound/s with sterile water or 0.9% sodium chloride

  5. If wound requires simple (non-invasive) closure, apply either

  • sterile skin closures (e.g. Steri-Strips™)

  • tissue adhesive for clean cut wounds

  1. Apply appropriate dressing to wound/s

  2. Consider administration of Tetanus Toxoid as per immunisation history and Tetanus Toxoid Standing Order

  3. Document assessment findings, interventions and outcomes

References / Further Resources

  1. ECI Patient Factsheet - Wound Care

  2. Cole, E (2003) Wound management in the A&E department, Nursing Standard 17, (46) 45-52, Royal College of Nursing, Cardiff

  3. Caton-Richards, M. (2011) Closure of minor wounds with tissue adhesive, Emergency Nurse, Volume (18)9 pgs. 3-39 February 2011. ISSN: 1354-5752

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