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
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
First aid treatment initiated prior to ED presentation
Tetanus immunisation status
Management Principles
Jewellery (rings / watches etc.) must be removed from affected limb (cut jewellery if required)
Provide analgesia as required according to pain scale. Refer to Pain (any cause) NMG
Apply direct pressure and / or elevate wound where possible to stop bleeding
Clean wound/s with sterile water or 0.9% sodium chloride
If wound requires simple (non-invasive) closure, apply either
sterile skin closures (e.g. Steri-Strips™)
tissue adhesive for clean cut wounds
Apply appropriate dressing to wound/s
Consider administration of Tetanus Toxoid as per immunisation history and Tetanus Toxoid Standing Order
Document assessment findings, interventions and outcomes
References / Further Resources
ECI Patient Factsheet - Wound Care
Cole, E (2003) Wound management in the A&E department, Nursing Standard 17, (46) 45-52, Royal College of Nursing, Cardiff
Caton-Richards, M. (2011) Closure of minor wounds with tissue adhesive, Emergency Nurse, Volume (18)9 pgs. 3-39 February 2011. ISSN: 1354-5752