The grades of evidence (A1, A2, B1, B2, C1, C2, D) are defined at the end of the "Major Recommendations" field.
Assessment Tool
Bates-Jensen Wound Assessment Tool
The Bates-Jensen Wound Assessment Tool (BWAT) is designed to be used for initial wound assessment and for follow-up assessments. The BWAT is to be used by school nurses only for any students presenting to the office with an abrasion. Each characteristic of the wound is measured and graded (See Appendix A in the original guideline document).
Description of the Practice
Wound Evaluation
School age children presenting to the office with wounds will be evaluated by the school nurse whenever possible. School nurses are a group of registered nurses specifically trained to meet the health needs of school age children (Adams & McCarthy, 2005. Evidence Grade = D).
When school nurses are unavailable, students may be evaluated and treated by trained office personnel. Persons other than the school nurse may use the excerpts taken from the Emergency Guidelines for Schools to assist with evaluation of injured students. These guidelines are located in Appendix B of the original guideline document.
Cleaning Solution
School age children presenting to the office for wound care will have wounds cleaned with liquid antibacterial soap and tap water only. Tap water is recommended as an effective solution for wound cleansing. It is cost effective, readily accessible and efficient. Tap water should never be used in cases where a full thickness injury has been sustained and tendons, blood vessels or bone have been exposed (Fernandez, Griffiths, & Ussia, 2004. Evidence Grade = A1). It is acceptable to use normal saline to irrigate wounds as mentioned earlier. However, it is understood that normal saline may not be as readily available as tap water.
Solutions that should not be used for the treatment of wounds include: povidone-iodine, Dakin's solution and hydrogen peroxide. These solutions are as likely to damage normal tissue as they are to destroy unwanted bacteria that may be present in or around the wound (Atiyeh, et al., 2002. Evidence Grade = B1). Antibiotic creams and other topical medications should only be used if standing orders are on file.
Dressings
School age children sustaining partial thickness abrasions in the school setting should receive a moist wound dressing immediately, or within two hours of injury. This dressing must stay in place no less than forty-eight hours and as long as seven days in order to enhance optimal wound healing and healing time. (Eaglstein, 2001. Evidence Grade = B1). Moist wound dressings, also referred to as moisture retentive dressings (MRDs) should contain hydrogel or hydrocolloids that enhance wound healing (Wiechula, 2003. Evidence Grade = A1). Moist wound dressings work by allowing rapid resurfacing or re-epithelialization of wound surfaces. Also, a moist wound surface allows for easier migration of proteins necessary for wound healing to take place (Eaglstein, 2001, Evidence Grade = B1). MRDs can be found in the definition of key terms section in the original guideline document.
A variety of dressings are commercially available that contain hydrocolloids and hydrogels. Some of these dressings include Carrasyn, Lamin, IntraSite gel, Solosite, Comfeel, and RepliCare (Eaglstein, 2001. Evidence Grade = B1). These dressings are readily available at pharmacies and in school health supply magazines.
Wound Care Procedure
Please refer to Definition of Key Terms section in the original guideline document to differentiate between lacerations, abrasions, partial thickness wounds and full thickness wounds.
- All students requiring treatment for full thickness injuries should be referred to the doctor or emergency room for further evaluation (Bren, 2002. Evidence Grade = D).
- Trained personnel and school nurses may refer to Emergency Guidelines for Schools in Appendix B in the original guideline document for care of students with bleeding injuries.
- When appropriate, and according to school policy, parents are to be notified by telephone and informed regarding the type of wound that has been sustained.
- If the school nurse is unavailable, other trained personnel will care for the student's wound. If emergency care is not indicated according to the Emergency Guidelines for Schools (Appendix B in the original guideline document), use the following information to guide actions.
- Apply pressure to partial thickness lacerations until bleeding stops and dress with band-aid or dry gauze dressing. These injures should heal by first intention as described in Definition of Key Terms in the original guideline document (Eaglsein, 2001. Evidence Grade = B1).
- Students entering the clinic requiring partial thickness abrasion care will have their wound graded using the Bates-Jensen Wound Assessment Tool by the school nurse (Bates-Jensen, 2001).
- Wounds are to be washed with liquid antibacterial soap and water as described in the Overview section in the original guideline document under Cleansing. The wound can be placed directly under running tap water and washed with gloved hands or by the student. Gauze can be used to wash the wound if wound cannot be placed under tap (Fernandez, Griffiths, & Ussia, 2004. Evidence Grade = A1).
- After partial thickness abrasions have been cleaned, a moist wound dressing is to be applied. This dressing can be a hydrogel or hydrocolloid dressing and can be any of a variety of brand-name products as identified under the Definition of Key Terms section in the original guideline document (Eaglstein, 2001. Evidence Grade = B1).
- Both parents and student will be given verbal instructions that the dressing is to remain in place for seven days or until wound is healed. Dressing may be wrapped with plastic for bathing purposes. The student will be given an extra dressing to take home in the event that his/her dressing falls off, is lost or damaged and needs replaced. Parents are to be included in this instruction process.
- The student will report to the clinic each day to have wound and dressing evaluated or replaced as needed.
- After seven days, the partial thickness abrasion will be re-evaluated using the Bates-Jensen Wound Assessment Tool. If at the end of seven days re-epithelialization has occurred, no further dressing or clinic evaluations will be required.
- If after seven days the laceration or abrasion is not healing, the student is to be referred to his/her doctor.
Definitions:
Grades of Evidence
A1 = Evidence from well-designed meta-analysis or well-done systematic review with results that consistently support a specific action (e.g. assessment, intervention, or treatment)
A2 = Evidence from one or more randomized controlled trials with consistent results
B1 = Evidence from high quality evidence-based practice guideline
B2 = Evidence from one or more quasi experimental studies with consistent results
C1 = Evidence from observational studies with consistent results (e.g. correlational, descriptive studies)
C2= Inconsistent evidence from observational studies or controlled trials
D = Evidence from expert opinion, multiple case reports, or national consensus reports
