Procedure for Removal of Sutures Equipment required: Dressing trolley – cleaned as per infection control policy, suture removal pack / suture remover and sterile gloves normasol, sterile gauze, appropriate dressings. Procedure Clean the dressing trolley Gather and open the required equipment using a sterile technique – normasol gauze, suture remover, basic dressing (or suture removal pack if available) Wash hands and open stitch cutter Assess wound to ensure suture removal is appropriate and to anticipate whether a dressing / steristrips may be required. Count the number of stitches to be removed Grasp the side of the suture with the knot on and gently lift away from skin Using the stitch cutter, cut the stitch as close to the skin as possible Gently pull the stitch through the skin, do not use undue force At any point, if you are concerned about the integrity of the wound, review whether removal is appropriate If in doubt, seek more advice from experienced Practitioner regarding removal of alternate sutures / steristrips etc. Count the number of stitches removed If necessary, clean the wound gently and apply and appropriate Dispose of sharps in sharps bin and other equipment in clinical waste bag Wash hands Document procedure in patient notes
Acute Wound Primary Dressing Sheet Matrix Lacerations Abrasions Puncture wounds / Bites Burns scalds Contusion /haematoma Avulsion / degloving Superficial Low Adherent Low adherent/Film Consider hydrocolloid/hydrogel for removal debris if needed Dressing only if required. Low adherent/film Leave free when possible Low adherent NB If haematoma still forming compression in the form of crepe or elastic tubular bandage may be applied to reduce this. Not applicable Partial thickness superficial Skin Closure of choice Low Adherent Low adherent/Film Consider hydrocolloid/hydrogel for removal debris if needed Low adherent/Film Low adherent / film/ Silicone if appropriate Foam if high exudate. Foam high exudate Low adherent / film Silicone if appropriate Not applicable Not applicable Partial thickness Deep Skin closure choice Low adherent /silicone Low adherent/Film Consider hydrocolloid/hydrogel for removal debris if needed Foam if high exudate Low adherent/Film Foam high exudate Low adherent / film Silicone if appropriate Not applicable Not applicable Full thickness Skin closure choice Low adherent assess/silicone Low adherent/Film Consider hydrocolloid/hydrogel for removal debris if needed Low adherent/Film Consider hydrocolloid /hydrogel for removal debris if needed Foam if high exudate Cling film for emergency transfer Not applicable Silicone/low adherent Special considerations dependent on area and patient Skin tears tibia:- Elevation limb Elasticated bandage/ crepe exclude deeper structure injury Hydrogel+/- antimicrobial if indicated debridement and removal of ingrained debris -Hydrogels Clinically infected wounds -oral antibiotic is indicated Prophylactic Antibiotic cover Consider toileting /Film or Low Adherent if patient requires transfer. Topical antimicrobial if clinical infected and oral antibiotics may be indicated as these are acute presentations. Consider evacuation of large haematomas - Appropriate dressing and Referral For transfer to specialist
Anti-Tetanus Toxoid and Human Anti Tetanus Immunoglobulin guidance LWIC Practitioners will immunise patient according to both their immunisation status and the identification of a tetanus prone wound Immunisation status Clean wound Vaccinated with Tetanus Toxoid Tetanus prone wound Tetanus Toxoid Immunoglobulin Human Tetanus Fully immunised Patient has received a total of five doses of vaccine at appropriate intervals Not required Give if high risk i.e. • wounds or burns that require surgical intervention and when treatment is delayed for more than six hours. • wounds or burns that show any of the following characteristics: a significant degree of devitalized tissue, puncture-type injury particularly in contact with soil or manure • wounds containing foreign bodies • compound fractures • wounds or burns in patients who have systemic sepsis. Primary immunisation complete, boosters incomplete but up to date None required (unless next dose due soon and convenient to give now) Primary immunisation incomplete or boosters not up to date A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity) Yes: one dose of human tetanus immunoglobulin in a different site Not immunised or immunisation status not known or uncertain An immediate dose of vaccine followed, if records confirm this is needed, by completion of a full course to ensure future immunity
Differential diagnoses Viral infection the symptoms are usually milder and often related to the common cold Coxsackie virus, small blisters develop on the tonsils and the roof of the mouth. The blisters erupt in a few days and are followed by a scab, which may be very painful. Infectious mononucleosis (glandular fever) Patients are quite unwell with very large and purulent tonsils and a long-lasting lethargy – over 10/7. An enlarged spleen is classically described and infrequently found mostly in teenagers. Herpes simplex virus (HSV) infection, especially in adolescents and young adults. Streptococcal infection - sore, swollen throat with coated tonsils, high temperature, and halitosis. The differences are variable and it is impossible to tell on inspection if the infection is viral or bacterial. Check that the patient is not taking a drug that may cause agranulocytosis. Epiglottitis requires immediate admission. Unusual bacteria may be involved including gonococcal infection. Unilateral enlargement of the tonsils, especially in the elderly, may indicate malignancy. It is not uncommon for HIV infection to present with ENT symptoms, especially in children. The most common presentations are cervical lymphadenopathy, candidiasis and otitis media. Diagnostic criteria Culture of Group A beta-haemolytic streptococcus (GABS) is inefficient as a diagnostic criterion, as it is too slow and it fails to differentiate between infection and carriage. There are four Centor Criteria that may be used. •History of fever •Tonsillar exudates •No cough •Tender anterior cervical lymphadenopathy Patients with one or none of these criteria are unlikely to have GABS. Consideration of antibiotic prescription should be limited to patients with three or four criteria. If the patient does not fit the criteria the practitioner will advise on conservative management. Another option if there is a possibility of symptoms increasing the practitioner may decide to give a delayed prescription taking in to account the individuals patients circumstances and including the rationale within their documentation.
Threshold Assessment Grid (TAG) NONE MILD MODERATE SEVERE VERY SEVERE Safety Domain 1 Intentional self No concerns about risk of deliberate self-harm or suicide attempt Minor concerns about risk of deliberate self-harm or suicide attempt Definite indicators of risk of deliberate self-harm or suicide attempt High risk to physical safety as a result of deliberate self-harm or suicide attempt Immediate risk to physical safety as a result of deliberate self-harm or suicide attempt Domain 2 Un-intentional self harm No concerns about risk to physical safety Minor concerns about risk to physical safety Definite indicators of risk to physical safety High risk to physical safety as a result of self-neglect, unsafe behaviour or inability to maintain a safe environment Risk Domain 3 Risk from others No concerns about risk of abuse or exploitation from other individuals or society Minor concerns about risk of abuse or exploitation from other individuals or society Definite risk of abuse or exploitation from other individuals or society Positive evidence of abuse or exploitation from other individuals or society High risk Domain 4 Risk to others No concerns about risk to physical safety or property of others Antisocial behaviour Risk to property and/or minor risk to physical safety of others High risk to physical safety of others as a result of dangerous behaviour Immediate risk to physical safety of others as a result of dangerous behaviour
Needs and Disabilities Domain 5 Survival No concerns about basic amenities, resources or living skills Minor concerns about basic amenities, resources or living skills Marked lack of basic amenities, resources or living skills Serious lack of basic amenities, resources or living skills lack of basic amenities, resources or living skills Domain 6 Psychol-ogical No disabling or distressing problems with thinking, feeling or behaviour Minor disabling or distressing problems with thinking, feeling or behaviour Disabling or distressing problems with thinking, feeling or behaviour Very disabling or distressing problems with thinking, feeling or behaviour Domain 7 Social No disabling problems with activities or in relationships with other people Minor disabling problems with activities or in relationships with other people Disabling problems with activities or in with other people Very disabling problems with activities or in relationships with other people No of ticks TAG score 0 points for each None rating 1 point for each Mild rating 2 points for each Moderate 3 points for each Severe 4 points for each V Severe TAG Score 1. Intentional Self-Harm 2. Unintentional 3. Risk From Others Individual factors: 􀂁expressing suicidal intent 􀂁clear plan 􀂁available means 􀂁preparations 􀂁hopelessness 􀂁no confidant, e.g. Consider self-neglect: 􀂁lack of self-care 􀂁not eating or drinking appropriately Consider unsafe behaviour: 􀂁not seeking help for problems posing risk Consider different types of abuse or exploitation: 􀂁physical 􀂁sexual 􀂁emotional 􀂁racial 􀂁financial
partner, friends, professionals 􀂁poor coping resources 􀂁lack of blocks to Consider risk factors: 􀂁past history of deliberate selfharm 􀂁(i) alcohol/drug abuse OR (ii) diagnosis (eg depression, personality disorder, schizophrenia ) 􀂁(i) AND (ii) = increased risk 􀂁physical illness/disability 􀂁recent GP contact 􀂁recent psychiatric hospitalisation 􀂁recent loss 􀂁no friends/family 􀂁living alone 􀂁unskilled worker 􀂁unemployment 􀂁older people 􀂁male (especially young males) 􀂁refusing appropriate help eg not taking medication 􀂁not claiming benefits 􀂁lack of awareness of own safety in home e.g. fire risk 􀂁risky sexual behaviour 􀂁substance misuse 􀂁wandering Consider the inability to maintain a safe environment: 􀂁unable to manage accommodation 􀂁not paying rent 􀂁running up debts 􀂁neglect Consider risk from: 􀂁staff 􀂁relatives 􀂁friends 􀂁neighbours 􀂁strangers 􀂁treatments Consider risk of abuse by carer: 􀂁severe stress 􀂁mental illness/alcohol / drug abuse in carer 􀂁carer refusing help 􀂁history of abuse by or to Carer Consider risk from society: 􀂁history of abusive / exploitative relationships 􀂁harassment from public 􀂁use of home by unwanted others 􀂁inadequate home security 􀂁fear of retaliation for reporting abuse 4. Risk To Others 5. Survival 6. Psychological Consider risk to: 􀂁children & other dependents 􀂁partners 􀂁carers 􀂁staff 􀂁neighbours 􀂁strangers Consider risk factors: 􀂁current threats, especially to Consider whether the person has problems with: 􀂁a home 􀂁heating for the home 􀂁essential amenities (e.g. washing facilities, toilet, cooker, bed) 􀂁the ability to look after their home Consider: 􀂁overactive, aggressive, Disruptive or agitated behaviour 􀂁problems with hallucinations & delusions 􀂁cognitive problems with memory, orientation & understanding 􀂁mood problems e.g. depressed, manic,
a named person 􀂁history of violence to people/property 􀂁carer’s concern 􀂁access to weapons 􀂁no blocks to violence e.g. fear of consequences 􀂁history of arson 􀂁unemployment 􀂁drug/alcohol abuse 􀂁stress 􀂁voices telling person to harm someone 􀂁paranoia 􀂁risky sexual behaviour 􀂁anti-social behaviour e.g. unsafe driving 􀂁lack of information about person’s history 􀂁no trusting relationship with professionals 􀂁the ability to keep adequately clean and tidy 􀂁enough food & fluids 􀂁clothing 􀂁enough money to live on 􀂁mobility 􀂁the ability to use public transport 􀂁the ability to cope with physical health problems anxious 􀂁problems with reading or writing 􀂁a lack of coping strategies 􀂁attitude to problems 􀂁help seeking behaviour 􀂁spiritual problems 􀂁feelings of alienation 7. Social Consider problems in relationships with others: 􀂁lack of ability to make or maintain friendships 􀂁lack of supportive relationships 􀂁lack of intimate relationship problems problems to handle daily hassles Consider problems in activities: work work of personally meaningful life HRESHOLD ASSESSMENT GRI Sexual Health Emergency Contraception For any patients requesting emergency contraception, it is vital that the following information be recorded and confirmed: Patient under the age of 16 must have it recorded in their notes whether Fraser Guidelines have been followed and the age of the partner must also be obtained to comply with Trust Safeguarding procedures. Patients under the age of 13, refer to Trust Safeguarding Children Policy and discuss with Nurse in Charge, Safeguarding Link Nurse or Trust Safeguarding Team for further advice
Dry mucous membrane Poor feeding in infants CRT ≥ 3 seconds Reduced urine output OTHER None of the amber or red signs or symptoms Age 3-6 months, temperature ≥ 390c Rigors Fever to ≥ 5 days Swelling to limb or joint Non-weight bearing/not using an extremity Age 0-3 months, temperature ≥ 380c Non blanching rash Bulging fontanelle Neck stiffness Status epilepticus Focal neurological signs Focal seizures Children with any ‘RED’ features but who are not considered to have an immediately life threatening illness should be referred urgently to the care of a paediatric specialist. Children with any ‘AMBER’ features and no diagnosis has been reached, healthcare professionals should provide patients or carers with a ‘safety net’ or refer to a specialist paediatric care for further assessment Children with ‘GREEN’ features only can be managed at home with appropriate advice for parents and carers, including when to see further attention from the healthcare services. When assessing children with learning disabilities, take the individual child's learning disability into account when interpreting the traffic light table Do not use duration of fever to predict the likelihood of serious illness. However, children with a fever lasting more than 5 days should be assessed for Kawasaki disease http://www.nhs.uk/conditions/Kawasaki-disease/Pages/Introduction.aspx (see recommendation 1.2.3.10 NICE 2013) Recognise that children with tachycardia are in at least an intermediate-risk group for serious illness. Use the Advanced Paediatric Life Support (APLS) criteria below to define tachycardia: [NICE guidance .2.2.13 new 2013] Age Heart rate (bpm) <12 months >160 12–24 months >150 2–5 years >140 Recognise that a capillary refill time of 3 seconds or longer is an intermediate-risk group marker for serious illness ('amber' sign).
Absence of a cough Current pyrexia > 38oC the Centor Criteria has a negative value of 80% Treatment If an antibiotics is indicated Phenoxymethylpenicillin QDS for 10 days Clarithromycin (if the person is allergic to penicillin) bd for 5 days See Children’s BNF or PGD for doses Tonsillitis Care Pathway Urinary Tract Infection Guidelines A urinary tract infection (UTI) is one of the most significant bacterial infections in childhood. Consider a UTI in children with the following symptoms:- Age group Symptoms and signs Most common ------------------> Least common Infants younger than 3 months Fever Vomiting Lethargy Irritability Poor feeding Failure to thrive Abdominal pain Jaundice Haematuria Offensive urine Infants and children, 3 months or older Preverbal Fever Abdominal pain Loin tenderness Vomiting Poor feeding Lethargy Irritability Haematuria Offensive urine Failure to thrive
Paediatric skin rash assessment http://patient.info/doctor/common-childhood-rashes Distinguishing Features of the Acute Generalised Rash in Childhood and Effects in Pregnancy Type of Rash Other features Incubation infection period Risks in Pregnancy Measles Macularpapular Begins on face Koplick spots, coryza, cough and conjunctivitis, ill child 7-18 days 4/7 prior to rash and 4/7 after Pneumonia in Mothers 0-40 weeks, low birth weight, severe measles in Peri natal period. Advise MMR x 2doses for Mother Rubella Macular Tiny pink, starts face and trunk works downwards Well child, lymphadenopathy sometimes 14-21 days 7days before and 10 days after rash < 11/40, 90% 11-16 /40 20% can get congenital rubella syndrome 16-20 /40 small risk of deafness Rosella Macular Faint pink rash on trunk Rash occurs after fever 5-15days In febrile phase but not once rash has appeared Common childhood illness so most women exposed prior to pregnancy Rarely Possible miscarriage in 1st trimester and foetal deformities late
Scarlet fever Macularpapular Fine puncatate rash with sandpapery feel, followed by peeling Strawberry tongue, perioral pallor, tonsillitis 12hrs -7 days 12hrs post exposure to 12hrs post fever Can be passed during childbirth. Rare Miscarriage, early labour or still birth Fifths disease Macularpapular ‘slapped check appearance ’lace like rash on arms and face Well child can last weeks 13-18 days 10 before to onset of rash <20/40 9% excess foetal loss, 3 % develop Hydrops with 50% mortality. Chicken pox Vesicular Occurs in crops on face and trunk Papules, vesicles and crusts are present Shallow ulcers of the mucous membrane 10-21 /7 48 hours before rash and until all lesions are crusted Severe illness in mothers 5x greater risk of pneumonitis, 0-20/52 congenital varicella (0.4-2%) 13 -14 weeks shingles in infancy, (1-2%) 4 days pre to 2 days post severe neonatal varicella (20%) Urticaria Wheals Well circumscribed Itchy wheals of different sizes Rarely accompanied by wheezing or anaphylactic shock