• Assessment and treatment of minor skin tears, abrasions and lacerations.
  • Significant wounds meeting anatomical criteria of Major Trauma Guidelines
  • Time critical patients
  • Significant burns requiring large dressings
Key aseptic terms for minor wound care
Key sites: Wound
Key parts: Dressing, tweezers
 Patient Factors & Considerations
  • Always take a full history, specifically identifying if patient is taking any anti-coagulation medications (eg. Warfarin, Aspirin etc). This will delay clotting times and may predispose patient to unidentified bleeds (especially in head injuries). Also consider patients taking steroids or other immunosuppressive medications as this may affect wound healing and mask signs of infection.
  • Identify and document the mechanism of injury, including any contributing factors such as neurological or cardiac causes.
  • Treatment of wounds is a procedure that has the potential to expose the patient to infection. Always utilise aseptic technique to mitigate infection risk to patient.
  • Avoid performing wound care in proximity of potential contaminants. This may require removal of patient from surroundings to maintain a sterile field.
  • Consider if patient is appropriate for Uncomplicated Wound Care Pathway
  • Any injury that occurs whilst in care of St John WA must be documented and logged as a Clinical Incident.
  • Elderly patients are at particular risk of skin tears during patient movement procedures, such as transferring from stretcher to bed.
  • Consider consultation of Falls Prevention Guideline for elderly patients to determine risk of falls causing injury.
  • Utilise Trauma Management Principles as required and consider Major Trauma Guidelines

Gain patient consent:

  • Explain procedure to patient and gain consent where applicable. Note this may require informing the patient of the requirement to move to a more appropriate location

Assess the patient:

  • Assess for wound type (laceration, abrasion, skin tear). Document size and location of wound, and type of skin tear if applicable.
  • Perform hand hygiene
  • Assess and, if necessary, control any haemorrhage
  • Assess neurovascular observations distal to injury, document if any compromise
  • Consider use of cophenylcaine if indicated
  • Determine cause of injury
  • Assess wound and determine if any requirement for wound cleaning or irrigation

Prepare the equipment:

  • Perform Hand Hygiene
  • If using sterile dressing pack: 
    • Clear/clean area suitable to place dressing pack
    • Appropriately sized non-adherent dressing that will cover wound. 
    • 2 x 10mL sterile Sodium Chloride 0.9% (if wound irrigation required. If not, only 1 needed)
    • Appropriately sized crepe bandage
    • 10mL syringe
    • Open dressing pack with the tips of your fingers and spread out on clean work surface.
    • Draw up Sodium Chloride 0.9%  into 10mL syringe for irrigation
    • Pour 10mL Sodium Chloride 0.9% into appropriate area on dressing tray.
    • Open dressing and place on to dressing pack without touching dressing
    • Using sterile tweezers, place non-woven dressings into Sodium Chloride 0.9%
  • If not using sterile dressing pack:
    • Clear/clean area suitable to place clean absorbent pad 
    • Appropriately sized non-adherent dressing that will cover wound
    • Appropriately sized crepe bandage
    • 2 x 10mL sterile Sodium Chloride 0.9% (if wound irrigation required. If not, only 1 needed)
    • 10mL syringe (if wound irrigation is required)
    • If wound irrigation required, draw up 10mL of Sodium Chloride 0.9% into 10mL syringe


  • Consider use of analgesia prior to performing procedure
  • Place clean absorbent pad underneath wound site if required.
  • Perform hand hygiene
  • Don all relevant PPE
  • Irrigation:
    • Utilising drawn up Sodium Chloride 0.9% in 10mL syringe, irrigate wound with gentle pressure to clear foreign body from site. Be mindful of potential for splash.
  • If using sterile dressing pack:
    • If skin tear present:
      • Using sterile tweezers, place skin flap back across wound as anatomically correct as possible, however do not force into place.
      • Using sterile tweezers place non-adherent dressing on to wound.
      • Utilising aseptic technique, use gentle pressure to keep dressing in place whilst covering dressing site with crepe bandage.
  • If sterile dressing pack unavailable:
    • Open dressing without touching dressing
    • Moisten dressing with sterile Sodium Chloride 0.9%
    • Only touching the edges of the dressing, place the dressing on the wound. DO NOT TOUCH THE DRESSING WHERE IT WILL MEET THE WOUND
    • Utilising aseptic technique, use gentle pressure to keep dressing in place whilst covering dressing site with crepe bandage
    • Assess distal neurovascular observations. If there is change, reassess crepe bandage tightness and adjust if required.
    • If bleeding recommences and there is noticeable bleeding through the dressing, place a combine on top of the crepe bandage. Do not remove the initial dressing.
  • Wound is dressed appropriately with no signs of continued bleeding
  • Distal neurovascular observations are not compromised post application of dressing
  • If bleeding recommences apply dressing on top of in place dressing
  • If changes to distal neurovascular observations adjust dressing as required. This may require re-application of dressing

SJWA Minor Wound Referral Pathways

Please follow the link below to determine if your patient is eligible to be referred to an alternate care pathway.

Uncomplicated Wound Care Pathway

Additional Information
Minor wound definition chart
Skin tear
  • A traumatic wound generally suffered by older adults as a result of friction, or a combination of friction and tearing forces which separate the epidermis from the dermis (partial thickness), or which separate the epidermis and dermis from the underlying structures (full thickness).
  • Traumatic wound caused by abrasive shearing forces on to the skin.
  • Can be classified as superficial, partial thickness or full thickness.
  • Traumatic injury caused by either blunt or sharp objects causing a cut or tear in the skin.
Signs and symptoms of wound infection
Wound type Localised infection Spreading infection Systemic infection
Acute wound
  • New or increasing pain
  • Erythema
  • Local warmth
  • Swelling
  • Purulent discharge
  • Pyrexia
  • Abscess
  • Malodour
As per localised infection plus:
  • Spreading erythema
  • Lymphangitis
  • Crepitus in soft tissue
  • Wound breakdown
  • Malaise or decline in patient condition
  • Sepsis
  • Septic shock
  • Organ Failure
  • Death
Chronic wound
  • New, increased or altered pain
  • Delayed healing
  • Increased or change in malodour
  • Wound bed discolouration
  • Increased or altered purulent discharge
  • As per localised infection plus:
  • Spreading erythema
  • Lymphangitis
  • Crepitus in soft tissue
  • Wound breakdownMalaise or decline in patient condition
  • Sepsis
  • Septic shock
  • Organ Failure
  • Death
Skin Tear Audit Research (STAR): Skin Tear Assessment Tool
Category 1A Category 1B Category 2A Category 2B Category 3
  • Edges of skin tear can be realigned to the normal anatomical setting without undue stretching.
  • Skin flap does not show signs of poor perfusion. Eg pale, cyanosed, dusky.
  • Edges of skin tear can be realigned to the normal anatomical stretching without undue stretching
  • Skin flap shows signs of poor perfusion
  • Edges of skin tear cannot be realigned to the normal anatomical position
  • Skin flap does not show signs of poor perfusion
  • Edges of skin tear cannot be realigned to the normal anatomical position
  • Skin flap shows signs of poor perfusion.
  • Skin tear with skin flap completely absent

    Extended Care:
    Colour assist:


    Barr N, Mason M, Clegg L, Randall F. Maintaining asepsis in paramedicine: a Delphi study: Asepsis in paramedicine. Australas j paramed . 2022;19. Available from: https://ajp.paramedics.org/index.php/ajp/article/view/954

    Unsworth J, Collins J. Performing an aseptic technique in a community setting: fact or fiction? Prim Health Care Res Dev. 2011;12(1):42–51. Available from: https://www.cambridge.org/core/journals/primary-health-care-research-and-development/article/performing-an-aseptic-technique-in-a-community-setting-fact-or-fiction/FE590986EF818149DA7B3F0EBF5B173F

    Sonoiki T, Young J, Alexis O. Challenges faced by nurses in complying with aseptic non-touch technique principles during wound care: a review. Br J Nurs. 2020;29(5):S28–35. Available from: http://dx.doi.org/10.12968/bjon.2020.29.5.S28

    Australian Commission on Safety and Quality in Healthcare. NSQHS Standards Implementation guide for Action 3.11 Aseptic Technique. December 2022.  https://www.safetyandquality.gov.au/sites/default/files/2022-01/nsqhs_standards_implementation_guide_for_action_3.11_aseptic_technique_-_december_2021.pdf

    Silver Chain Nursing Association and Curtin University of Technology School of Nursing and Midwifery. STAR Skin Tear Classification System. February 2010.

    Document Control

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    Head of Clinical Services


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