Wound Management Formulary NHS Peterborough

LOCAL HEALTH CARE WOUND MANAGEMENT

FORMULARY

2010

VERSION 2 – July 2010

Introduction i

INTRODUCTION

This manual has been developed to enable healthcare staff to manage wounds and select appropriate

dressings according to best-recognised practice. Wounds are an expensive and growing problem: today

over 2,000 wound management products are available on the market. In addition, all members of the

healthcare team can be involved in woundcare in a variety of settings, with patients often moving between

professionals and environments. This manual will help ensure best practice and minimise the potential for

inconsistency of care locally.

The manual was compiled by the Peterborough Healthcare Wound Management Committee, comprising a

multidisciplinary group of healthcare staff who are actively involved in delivering patient woundcare (contact

details can be found in the next section). Our aim is to promote effective wound management and ensure a

seamless service for all patients. Knowledge of the many factors relating to wound healing will aid holistic

care and ultimately ensure the best possible outcomes for patients.

All of the main themes relating to wound management are covered in this manual including:

• the wound healing process

• the assessment of wounds

• the preparation of wounds

• the management of infection

• the selection of dressings

In addition, the manual contains an algorithm to select appropriate treatments, a formulary of woundcare

products and illustrated wound assessment charts.

The layout of the manual has been designed to allow the reader to quickly locate the information they need:

• Each section has a detailed list of contents.

• Special topic boxes, indicated by�, expand the information in the text.

• Key references are supplied for further reading.

The appendices contain some of the more practical items including a quick reference chart, wound

assessment charts, a request for non-formulary dressing form, and a feedback sheet. A patient-held

communication sheet has also been included. This may be copied and used by any professional involved in

woundcare because we believe that as well as a more consistent approach, good communication between

professionals involved in wound management is essential.

Finally, the Committee recognises that some very new or less commonly used therapies are in use in

woundcare management. We have included an overview of some of these in Section 12, such as larval

therapy, vacuum assisted closure and laser ablation. Once these new therapies are adopted as part of the

Committee’s recommended best practice, they will be included in updates of this manual.

©Peterborough Healthcare Wound Management Committee, June 2004

Committee members ii

woundcare manual ii

Nicki Ayres RGN, RSCN, DN Diploma

Service Manager, Integrated Nurse Teams

Peterborough Community Services

Rachel Sylvester

RGN BSc (Hons) Health Studies

District Nurse


Jayne Clark RGN

Senior Sister

Rivergate Primary Care Centre

Linda Coultrup

RGN, Dip Critical Care BSc (Hons) Nursing

Professional and Practice Development Leader Peterborough and Stamford Hospitals NHS Foundation Trust

Jo Dale

RGN

Clinical Nurse Leader Peterborough and Stamford Hospitals NHS Foundation Trust

Sheila Duggan RGN, NDN, Dip ENT

Practice Nurse


Zoë Fullagar

RN, Dip HE (Part 12)

Team Leader

Cambridgeshire and Peterborough Mental Health Partnership

NHS Trust

Jo Hood

BSc (Hons) MChS SRCh

Head of Podiatry Services/Diabetic Foot Specialist


Liz Huggins

RGN DN Cert Dip Tissue Viability

Health Visitor


Sarah King

Clinical Nurse Manager

Rivergate Primary Care Centre

Val Shaw

B Pharm (Hons) MR PharmS

Pharmacy Services Manager

Peterborough and Stamford Hospitals NHS Foundation Trust


Contents iii

woundcare manual iii

i Introduction

ii Peterborough Woundcare Manual Committee Members

iii Contents

SECTION 1 THE WOUND HEALING PROCESS Jayne Clark and Sarah King

SECTION 2 FACTORS AFFECTING WOUND HEALING Zoë Fullagar

SECTION 3 WOUND ASSESSMENT Jo Dale, Rachel Sylvester and Sheila Duggan

SECTION 4 WOUND PREPARATION Jo Dale and Jo Hood

SECTION 5 WOUND INFECTIONS Jo Dale and Jo Hood

SECTION 6 DIABETIC FOOT WOUNDS Jo Hood and Liz Huggins

SECTION 7 THE IDEAL WOUND DRESSING Val Shaw

SECTION 8 WOUND ASSESSMENT/TREATMENT ALGORITHM

SECTION 9 FORMULARY OF WOUNDCARE PRODUCTS Criteria for Formulary Inclusion, Disclaimer Initial Community Dressings

SECTION 10 WOUNDCARE PRODUCT ASSESSMENT

SECTION 11 PRODUCT MONOGRAPHS

SECTION 12 NEW THERAPIES

Appendix I PATIENT- HELD COMMUNICATION SHEET

Appendix II WOUND MANAGEMENT CHART – Peterborough and Stamford Hospitals NHS Foundation Trust

WOUND MANAGEMENT CHART – Greater Peterborough Primary Care Partnership

Appendix III LEG ULCER ASSESSMENT FORM

Appendix IV ORGANISMS ENCOUNTERED IN WOUND MANAGEMENT

Appendix V MANAGEMENT OF TETANUS PRONE WOUNDS

Appendix VI FAX-BACK COMMENT SHEETS

Appendix VlI DRESSING REQUEST FORM

Appendix VIlI NON-FORMULARY DRESSING REQUEST FORM

Appendix IX DRESSING CHANGES RECORD FORM

Appendix X GLOSSARY

Appendix XI ACKNOWLEDGEMENTS

Appendix Xll GUIDELINES

Wound healing process 1

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� Growth Factors

Growth factors are classified

as cytokines, which are

proteins that act as

intercellular signals to allow

cells to communicate with

one another. Growth factors

are involved in all stages of

wound healing and also have

the ability to regulate many

other functions within cells

including protein synthesis.

They are specific for

attracting useful cells and

proteins to the wound,

including immune cells to

fight infection and other cells

to form connective tissue.

Growth factors also stimulate

an increased production of

connective tissue; create a

new supply of blood vessels

to nourish the site, thus

promoting maturation.

1 THE WOUND HEALING PROCESS Jayne Clark and Sarah King

Wound healing is a complex series of events that begins at the moment of injury, and

can continue for months or even years. Wound healing is complete when the strength

and continuation of damaged tissues are regenerated by the formation of connective

tissue and the regrowth of epithelium.

1.1 The stages of wound healing

The physiology of wound healing involves four main active stages.

The inflammatory phase (0 – 3 days)

• Formation of blood clots.

• Bacteria are attacked.

• Orderly recruitment of keys cells into the wound site.

• Vasodilation leading to heat and redness.

• Increased capillary permeability causing swelling.

The destructive phase (1 – 6 days)

• Neutrophils engulf and digest dead tissue and bacteria (phagocytosis).

• Macrophages regulate all stages of healing producing growth factors that

stimulate new tissue. �

• Macrophages stimulate the formation and multiplication of fibroblasts.

The proliferation phase (3 – 24 days)

• A combination of regenerative processes is involved.

• Cells necessary for wound closure proliferate at the wound site to make

new tissue and capillaries (part of granulation tissue).

• New capillary loops branch out from walls of damaged capillaries until they

meet uninjured tissue.

• A network of blood vessels fills the wound bed (angiogenesis).

Wound healing process 1

woundcare manual

Further reading:

The Royal Marsden Hospital

Manual of Clinical Nursing

Procedures, 5th Edition,

edited by Jane Mallet and

Lisa Dougherty, 2000.

Tissue maturation (24 days – 2 years)

• Remodelling of the tissues occurs.

• New collagen forms which increases the tensile (elastic) strength of the

wound.

• The scar is initially raised and reddish but with maturity the blood supply will

reduce this appearance.

• The scar eventually becomes paler and flatter.

• A mature scar is never as strong as the original intact skin.

1.2 Cellular activity during wound healing

Macrophages secrete fibroblast-stimulating factor which when combined with a growth

factor released by dead platelets cause fibroblasts to migrate into the wound bed soon

after damage has occurred. The fibroblasts are then activated and divide and produce

a network of collagen fibres that increase the strength of the wound. During this phase

it is essential that adequate nutrition and oxygenation be received in order to promote

wound healing.

Angioblasts are required for this stage of wound healing to form new blood vessels

that grow into the wound. The vessels branch and link up with other vessels forming

loops. These delicate capillary loops are held within the newly secreted framework of

collagen. This complex is known as granulation tissue.

Factors affecting wound healing 2

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��Vitamins, trace elements and wound healing

Vitamin A deficiency slows

epithelialisation, decreases

collagen synthesis and

increases susceptibility to

infection. Vitamin C is an

essential co-factor during

collagen synthesis; its

deficiency leads to scurvy

and delayed healing. Vitamin

K deficiency results in the

insufficient production of

essential clotting factors.

Zinc deficiency is the most

important clinically, as it may

be associated with a host of

abnormalities, including

impaired immune responses

and decreased protein and

collagen synthesis. In the

absence of proven

deficiency, the administration

of vitamins A, C, K and zinc

sulphate do not improve

wound healing and in fact

excess zinc can be

detrimental.

2 FACTORS AFFECTING WOUND HEALING Zoë Fullagar

2.1 Intrinsic Factors Ageing and metabolic rate Metabolic rate changes during life and affects wound healing.

• Healing in young children and pregnant women is accelerated due to

increased metabolic rate.

• Older patients experience reduced healing rate as their metabolic rate

gradually reduces with age.

Impaired nutritional status Well nourished individuals have a plentiful supply of the proteins, carbohydrates,

fats, vitamins and minerals that are essential for normal wound healing. Thorough

nutritional assessment and, if necessary, referral to a dietician are therefore

important in wound management.

Protein deficiency Protein deficiency delays fibroblast migration and may occur after:

• major trauma

• surgery, or

• during sepsis

Vitamin deficiencies �� Deficiencies in these vitamins have been associated with delayed wound healing:

• vitamin A

• vitamin C

• vitamin K

Trace elements and minerals �� Some trace elements and minerals are also necessary as co-factors for enzymes

important in wound healing. These include:

• zinc

• copper

• iron

• manganese


woundcare manual

��Disease processes delaying wound healing

Anaemia

Arthritis

Chronic pulmonary disease

Chronic renal failure

Coagulation disorders

Congenital defects

Congestive heart failure

Cushing’s syndrome

Diabetes mellitus

Hypertension

Hyperthyroidism

Ischaemia

Jaundice

Liver cirrhosis

Malignancy

Malnutrition

Neurological disease

Ulcerative colitis

Vasculitis

��Smoking and wound healing

Nicotine is a potent

vasoconstrictor and can

reduce peripheral blood flow

by up to 50% for more than

an hour after smoking one

cigarette.

Dehydration The metabolic processes of an individual require about 2500 ml of water every 24

hours. A dehydrated patient will not be able to metabolise efficiently and this will

adversely affect the healing process.

Disease processes �� The generalised metabolic effects of a number of disease processes can delay

healing.

Fever Febrile patients have an increased metabolic rate and use vast amounts of energy

in both generating and dissipating heat. This reduces the amount of energy they

can use for wound healing.

Smoking �� Smoking adversely affects wound healing in a number of ways.

2.2 Extrinsic Factors Poor surgical technique

• Tissues damaged during surgery can result in haematoma.

• Infection can occur if breakdown of the haematoma takes place.

• Dead space may occur where tissues are misaligned during surgery -

this can also lead to infection.

• Sutures inserted too tightly can lead to tissue damage and death.

Drug treatments �� A whole range of drug therapies can affect wound healing.

Inappropriate wound management Wound healing may be adversely affected by:

• the use of poor dressing technique

• the wrong dressing

• the use of antiseptic where it is not needed

Adverse psychosocial factors A wide variety of psychosocial factors may effect wound healing including:

• a lack of understanding and acceptance of the treatment regime

• anxiety associated with changes in work, income, relationships and

self-image.


woundcare manual

��Drug treatments delaying wound healing

Corticosteroids - reduce

inflammatory response and

inhibit epithelial

regeneration.

Anticoagulants- bleeding

complications and

haematomas.

Cyclosporin A and cytotoxics

- impair cell immunity and

resistance to infection.

Colchicine- inhibits

contractions & reduces scar

tissue.

NSAIDS - impairs

inflammatory response.

Penicillamine - reduces

wound strength.

Zinc sulphate (high doses) -

impairs immune response.

Alcohol

Smoking - nicotine is a

vasoconstrictor.

Regular injections -

ischaemic areas, especially

in drug misusers.

Diuretics - hypovolaemia.

Further reading

Alexander M, Fawcett J,

Runciman P. Nursing

practice: hospital and home.

Churchill Livingstone,

London 1994: Chapter

23:702-703

Pressure The cause of any pressure must be removed. Infection This is the most important factor that can delay or prevent wound healing (see

Section 5).

Wound assessment 3

woundcare manual

3 WOUND ASSESSMENT Jo Dale, Rachel Sylvester and Sheila Duggan

3.1 Assessment Before treating a wound, it is essential to assess the patient and the wound holistically

taking into account intrinsic and extrinsic factors (see Section 2).

Accurate wound assessment is important to provide baseline information about the

state of the wound to:

• enable appropriate evidence based treatment of the wound;

• monitor progress;

• evaluate the effectiveness of management;

• improve morale of staff and patients; and

• provide an effective teaching tool.

The use of a logical and systematic wound assessment chart (see Section 8) will:

• improve documentation and thus aid communication between clinical staff;

• identify treatment needsand incorporates dressing selection; and

• provide a more objective method of wound management [1]

3.2 Wound type

Wounds can be classified as:

• acute

• post-operative

• chronic [2]

3.2.1 Acute wounds Acute wounds, such as cuts, abrasions, lacerations and burns, usually:

• are caused by trauma;

• respond rapidly to treatment and heal without complication;

• heal by primary or secondary intention.

3.2.2 Post-operative wounds Post-operative wounds are intentional acute wounds.

• They usually heal by primary intention, where the skin edges are held

in approximation with sutures, clips or tape.

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• There is normally no tissue loss; therefore healing should be more

rapid.

• Some surgical wounds are left open to heal by secondary intention,

usually to allow drainage of infected material. If these are later sutured

this is called tertiary intention. This is also the name for wounds that

are sutured first, but the wound re-opens (dehisces) and is then left to

heal by secondary intention.

3.2.3 Chronic wounds Chronic wounds include pressure ulcers, leg ulcers and acute wounds that have

been present for more than six weeks.

Chronic wounds usually:

• are of long duration or frequent recurrence [3];

• heal by secondary intention, where the wound bed will be filled with

granulation tissue and epithelial tissue migrates across the wound

until it has healed;

• take longer to heal than post-operative wounds as there is tissue loss

(the edges are far apart).

In addition, the patient may have multifactorial problems that affect their ability to heal

wounds (see Section 2).

3.3 Wound history

In order to take any necessary action and plan effective treatment for wounds, it is

important to be aware of the:

• aetiology

• duration

• treatment history

3.3.1 Aetiology Dirty wounds; e.g. a dog bite or a gardening injury, will have a greater risk of

contamination and/or infection, therefore consider the need for tetanus and/or

antibiotic therapy (see Appendix IV).

Ulcers; e.g. arterial, venous, mixed, diabetic, rheumatoid or malignant, will all

require different management.

Foreign bodies; e.g. fibre or grit, will initiate or prolong the inflammatory phase

and delay healing and therefore need to be removed.

Wound assessment 3

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�� Ulcers

For example, venous leg

ulcers tend to be situated in

the gaiter region around the

medial or lateral malleolus

and are large, shallow and

highly exuding.

� Wound measurement

Wounds should be

measured using the

perpendicular method [3]: the

longest measurement of the

wound is deemed to be the

length (regardless of

orientation) and the longest

measurement perpendicular

to the length is the width. To

assess wound surface area

the greatest width is

multiplied by the greatest

length.

3.3.2 Duration If a contaminated wound is more than 6 hours old [4], it may require antibiotic

cover. It should be left to heal by secondary intention.

If a wound is not healing as expected, management may need to be modified;

e.g. ischaemic ulceration may need vascular intervention.

3.3.3 Treatment history

Knowledge of treatment history will facilitate healing; e.g.:

• previously successful treatments

• avoidance of failed treatments

• avoidance of products to which the patient is allergic

3.4 Local wound environment Local wound assessment provides information relevant to three areas:

• wound characteristics

• stage of wound healing

• surrounding skin

3.4.1 Wound characteristics Clinical diagnosis is assisted by assessment of:

• site

• shape ��

• size

• depth

• exudance

Site

This should be considered to identify potential problems such as :

• contamination - sacral area

• mobility - foot wounds

• application and retention of dressings - difficult areas

• pressure - foot, sacral area

Shape

This may affect healing time; e.g. round wounds usually take longer to heal than

narrow wounds, as the epithelial cells have further to migrate across the wound.

Wound characteristics (continued)

Size ��

Wound assessment 3

woundcare manual

Wound tracing is also

useful and acetate grids are

available for this purpose.

They are laid across the

wound so that the edges can

be traced and its area

measured. It is also a good

idea to trace around any

particular area of defined

tissue or cavity existing

within the wound, e.g.

necrotic, granulating, etc.

Photography provides a

record of the type and extent

of tissue covering the wound.

Cameras that use film with a

grid can be used to estimate

wound area. However care

should be taken with

reference to focal length as

this may distort the image.

NB: Informed consent must

be obtained prior to the use

of photography.

��Exudate

Exudate production (which is

most prolific during the

inflammatory phase of

healing) bathes the wound

with nutrients and actively

cleanses the wound surface.

It acts as a growth medium

for phagocytic cells and

accelerates epithelialisation.

However, if excessive, it can

cause skin sensitivities,

tissue maceration, plus leach

away essential nutrients and

growth factors [5].

Wound measurement allows monitoring of progress. Ultimately, successful

wound healing is demonstrated by a reduction in wound size [6].

A measurement system should:

• be precise and accurate

• be easy to use

• not come into contact with the wound

Depth

If it is not possible to measure wound depth without disturbing the wound bed,

then this should be estimated as:

• superficial

• shallow

• deep

• sinus cavity

If a wound is estimated to be deep or have a sinus, specialist advice should be

sought; e.g. podiatrist for foot wounds.

There are specific dressings available for cavity wounds, which should be

utilised to prevent the creation of a ‘dead space’ which otherwise will be filled

with devitalised tissue and excess exudate.

Care should be taken in selecting the correct cavity dressing; e.g. use of

alginates in a low exuding wound may cause plugging and subsequent tissue

necrosis.

Exudate level �

There is a need to monitor quantity, colour and type of exudates; e.g. serous

fluid or pus. It is also important to define quantity. As a rough guide [7]:

• light exudate requires dressing changes every 4 -7 days

• moderate exudate requires dressing changes every 1-3 days

• heavy exudate refers to wounds requiring daily or more frequent

changes due to saturation of an appropriate dressing

3.4.2 Stage of wound healing The condition of the wound bed and the local wound environment will provide

information about the stage of healing. If the tissue is predominantly necrotic or

sloughy, or if it is infected, the wound is likely to be in the inflammatory phase of

healing. Granulation and epithelial tissue are evidence of proliferation.

Wound bed classification

Wound assessment 3

woundcare manual

For further advice consult

appropriate professional

References:

1. Collier M. Nursing Times

Essential Guide to Wound

Assessment. London, 2001

2. Dealey C. The care of

wounds. Blackwell Science,

Oxford, 1995: pp 65-666

3. Fowler E. Chronic

wounds. In: Krasner D. (Ed).

Chronic wound care. A

clinical sourcebook for

healthcare professionals.

Health management

Publications, King of Prussia,

PA, USA, 1990

Wounds may be:

• necrotic

• sloughy

• infected

• granulating

• epithelialising

3.4.3 Surrounding skin Assess skin surrounding wound for:

• colour

• moisture

• suppleness

The shape of the wound edge may help with the diagnosis; e.g. deep and

punched-out for arterial ulcers, rolled for malignancy.

Points for consideration are:

• maceration (excessive moisture in the surrounding tissue)

• retention of dressing

• type of tape to be used (if any)

• possibility of contact dermatitis

• dryness – skin scales

• hygiene

• varicose eczema

• fragile skin

3.5 Pain

Pain is an integral part of wound management and is associated with the:

• type of injury

• location of the wound

• presence of infection

• healing process

• approaches to wound management

Pain should be quantitatively assessed and documented using an appropriate visual

analogue scale; e.g. 0 = no pain, 10 = worst pain.

3.5 Pain(continued) Chronic wound pain [8] can be divided into:

Wound assessment 3

woundcare manual

References [contd]

4. Pritchard B. Yates DW

and Redmond AD. Lecture

notes on accident and

emergency medicine.

Oxford: Blackwell Scientific,

1985

5. Bryant JL et al. Reliability

of wound measuring

techniques in an outpatient

wound centre. Ostomy

Wound Management 2001;

47(4): 44-51

6. Miller M, Glover D. Wound

management: theory and

practice. Nursing Times

Books, London, 1999

7. Bale S, Harding K, Leaper

D. An introduction to

wounds. Churchill

Livingstone Edinburgh 2000

8. Krasner , D, Chronic

Wound Care: A clinical

source book for Health Care

Professionals; Health

Management Publications,

Pennsylvania 1997

9. Sibbald et al; Preparing

the wound bed –

debridement, bacterial

balance and moisture

balance; Ostomy wound

management 200;46(11): 14-

35

• incident pain

• recurrent episodic pain

• continuous pain

Incident pain results from debridement or trauma to the wound. It can be relieved by

use of analgesia based upon the WHO pain ladder.

Recurrent episodic pain is frequently experienced by the patient during dressing

changes. If the dressing is very painful then the patient may not comply.

Continuous pain may indicate that the underlying cause of the wound has remained

untreated, or that the wound has become extensively infected. It is essential to

determine whether it originates from the wound or the surrounding tissue [9]. ��

3.6 Odour It is important to identify whether the presence of odour is due to:

• bacterial invasion

• necrosis

• poor hygiene

If the wound is infected it should be treated appropriately (see Section 5).

Wound preparation 4

woundcare manual

�Eschar

Sloughed off dead tissue

caused by burn or

cauterisation

OR

An eschar is a hard plaque

covering an ulcer implying

extensive tissue necrosis,

infarcts, deep burns, or

gangrene.

�Autolytic debridement

It is a naturally occurring

process, where

macrophages and

endogenous proteolytic

enzymes liquefy and

spontaneously separate

necrosis.

Hydrocolloids may also

facilitate autolytic

debridement in wounds

where exudate is present.

4 WOUND PREPARATION

Jo Dale and Jo Hood

Appropriate wound-bed preparation is an essential part of wound management as

it ensures that the maximum benefit can be gained from the many woundcare

products available and facilitates the healing process.

Wound-bed preparation should address the following factors:

• debridement

• exudate management

• bacterial balance (1)

4.1 Debridement

Chronic wounds have a ‘necrotic burden’ made up of:

• necrotic tissue

• devitalised tissue

• exudate

Chronic wounds can be intensely inflammatory and thus produce substantial

amounts of exudate that may interfere with healing or with the effectiveness of

therapeutic products, including growth factors and bio-engineered skin.

It is therefore necessary to remove eschar��, non-viable tissue and exudate

components in order to promote healing.(1) Consequences of non-debridement

• unable to assess wound size and depth

• masking of abscess or fluid collection

• prevention of wound apposition secondary to splinting effect of necrotic

tissue

• optimum conditions for bacterial growth

• odour management

• increased psychological stress due to ‘dirty’ wound

Methods

Autolytic: �

This is the most frequent form of debridement. It can be accelerated with a moist

interactive dressing, e.g. hydrogel. However, if no change is apparent within 72

hours then other methods should be considered.

Wound preparation 4

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�� Bacterial burden

It has been said that some

chronic wounds are “stuck” in

one of the phases of the

normal healing process,

such as the inflammation or

proliferative phases.

Eliminating the bacterial

burden by the use of

debridement or slow-release

iodine products can help this

situation [1].

Methods (continued)

Chemical

Larvae (see section 12)

Sharp/surgical

This should only be undertaken by suitably qualified practitioners. Factors influencing choice of debridement Factors that influence the choice of debridement method are:

• practitioner’s skill and knowledge

• speed of debridement

• presence of infection

• cost-effectiveness

• acceptability to patient

• suitability of patient in terms of risk

4.2 Exudate management

The presence of excess exudate can interfere with the biological micro-

environment of the wound and delay healing. Prolonged excess exudate may

indicate that the underlying cause is not being addressed.

Action required includes:

• treatment of underlying cause; e.g. venous insufficiency with

compression, infection ;

• cleansing of wound; and

• use of absorbent dressings to manage exudate, e.g. foams, alginates

(Refer to the Formulary of Woundcare Products – Section 9)

4.3 Bacterial balance The correction of the bacterial burden decreases the possibility of infection but

also diminishes the ongoing inflammation that often characterises many chronic

wounds. ��

Wound preparation 4

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4.3 Bacterial balance (continued) Methods of addressing the bacterial balance include:

• wound cleansing

• topical treatment with antimicrobials

• systemic treatment with antibiotic therapy

• removal of excess exudate from the wound environment

• use of secondary dressings to protect from external contaminants

4.4 Wound cleansing

If a wound is clean with little exudate and is healthily granulating, no cleansing is

required. (2)

In chronic wounds it is recognised that sterility of the wound surface is not

necessary for healing nor is it possible.

Wounds should only be cleaned prior to the application of a dressing to provide

optimum local conditions for wound healing; i.e.:

• to remove excess exudate and cell debris

• to reduce bacterial burden

Considerations and risks for wound cleansing

Safe practices

• Clinical risk – beware of splashback.

• Avoid traumatising newly produced and delicate tissue by reducing the

surface temperature of the wound or by rough handling of gauze swabs

Suitable solutions

• Avoid causing damage to friable tissues from antiseptics or pressurised

irrigation

Appropriate practice

• Gentle irrigation is the preferred method of cleansing a wound, as

swabbing may be traumatic and is more likely to result in redistribution of

micro-organisms around the wound rather than their removal.

• Cotton wool should not be used as it may shed fibres into the wound.

• A sterile solution of 0.9% sodium chloride warmed to between

30-34ºC is the most appropriate cleansing agent.

• Cooling the wound inhibits cell mitosis and potentially delays healing.

Appropriate practice (continued)

Wound preparation 4

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References:

1. Baharestani M., Goltrup

F., Holstein, P. Vansceidt W.

(eds). (1999) The clinical

relevance of debridement.

Springer-Verlag, Berlin

2. Bale, S and Jones, V.

2000. Wound Care Nursing –

A Patient-Centred Approach

Bailliere Tindall

Further reading:

Collier.M, 2002

Wound-bed Preparation

Nursing Times plus

Vincent Falanga, 2001

Introducing the Concept of

Wound Bed Preparation.

An International Forum on

Wound Care, Issue No 16

Williams, N.A. and Leaper,

D.J, 1998

Wounds – Biology and

Management

Oxford Medical Publications

��For advice contact Infection Control.

• Warm fluid is more comfortable for the patient.

• Antiseptic solutions now have little place in wound management.

Exceptions to this may be:

• wounds where MRSA has been isolated; and

• infected ischaemic wounds where systemic antibiotics are unlikely to

reach the wound site�.

Ordinary tap water should not cause contamination or infection if used on large

chronic wounds e.g. leg ulcers, pressures sores. These wounds may benefit from

bathing or showering.

4.5. Topical treatment with antimicrobials

The use of antimicrobials, such as cadexomer iodine and silver sulphadiazine has

been revisited to address wounds with ‘critical colonisation’; i.e. wounds that are

moving between the spectrum of colonisation and local infection. (See Section 5).

Wound infections 5

woundcare manual

5 WOUND INFECTIONS

Jo Dale and Jo Hood

The skin is home to a wide variety of bacteria. The ‘normal’ flora, as is it known,

generally causes the host no problems when the skin is intact. However, many

bacteria can become pathogenic, multiply and ‘invade’ if conditions are

favourable. When the skin’s barrier is disrupted with a wound, it provides an

ideal point of entry for pathogenic bacteria. The presence of bacteria in a wound

does not necessarily indicate that infection has occurred or leads to impairment

of wound healing. However, increased bacterial load can lead to reduced or no

healing [1, 2].

Wounds provide an ideal culture medium for the growth of bacteria because they

have:

• the optimum temperature for bacterial growth;

• a frequent supply of nutrients in the form of organic debris ; and

• a moist environment

5.1 Classification

Wounds can be classified depending on the amount of bacteria present and the

type of pathogens likely to be present. The main types are:

• contaminated wounds

• colonised wounds

• infected wounds

Contaminated wounds Bacteria are present in low numbers but there is no multiplication.

Colonised wounds There is multiplication of bacteria but no host reaction.

Infected wounds There is deposition and multiplication of bacteria in the tissue with an associated

host reaction.

It has been considered that a bacterial content of greater than 105//g tissue

comprises clinical infection and may delay healing. ��

Before wound infection is apparent, the bacterial burden can increase to a level

where there is a covert infection which is sufficient to inhibit wound healing [3].

Wound infections 5

woundcare manual

�� Probability of infection

=

(Dose of bacteria x

Virulence) ÷ Host reaction

Infected wounds (continued) Infection causes delay of healing and hospital-acquired (nosocomial) infections

are associated with more virulent organisms than those indigenous to patients.

Specific bacteria are usually involved in wound infection (See Appendix III). 5.2 Recognising infection Clinical infection is recognised by these well-defined criteria:

• local pain

• swelling

• heat

• redness

However, the above are also signs of inflammation, part of the normal wound

healing process, therefore the additional criteria below should also be

considered:

• Bridging of soft tissue and the epithelium – may occur when bacteria

impede the progress of epithelialisation.

• Delayed healing – wound not healing at the expected rate or a sudden

reduction in progress.

• Discoloration of the wound – deep red colour may indicate infection.

Green staining of dressings may indicate the presence of Pseudomonas

aeruginosa.

• Friability of granulation tissue – tissue becomes friable and bleeds

easily on light pressure.

• Odour – may indicate the presence of certain types of bacteria,

especially anaerobic bacteria.

• Pocketing at the wound base – problematical in deep wounds such as

pilonidal sinus wounds.

• Unexpected pain – caused by increase in pressure; may often have a

definite start point.

• Wound breakdown – organisms weaken the newly repaired tissue.

A major wound infection is characterised by:

• systemic toxicity (pyrexia and tachycardia)

• local pain

• wound breakdown

• extensive cellulites

Wound infections 5

woundcare manual

�� Tip: “treat the patient

not a bacteriological

swab”.

Recognising infection (continued) In some instances there may be an absence of clinical cellulitis, due to a lack of

a ‘typical’ immune response as the patient may be immuno-compromised due to:

• medication

• systemic disease

• ageing

• ischaemia

• peripheral vascular disease

In these cases it is important to recognise one or more other clinical signs:

• presence of pus

• increased wetness

• change in pain

• change in appearance of granulation tissue

• odour

5.3 Specimen collection Treatment should be based on the signs of clinical infection. �

However, a swab performed in the presence of the above clinical signs may be

beneficial to manage the infection by identification of the causative organism and

its sensitivity to antiseptics.

Best practice for specimen collection:

• If the wound does not have excessive amounts of pus or exudate then it

should not be cleaned prior to swabbing.

• The swab should be moistened in the transport medium if necessary

and then rotated in the fingers to ensure all sides of the swab come into

contact with the wound.

• The swab should be zigzagged across the wound to ensure the entire

wound is covered.

• If a deep wound is being irrigated with sodium chloride 0.9%, culture of

the effluent will provide a more meaningful result than a swab.

5.4 Treating patients with infected wounds Before considering the local treatment of any wound, it is important to ensure that

any risk factors associated with infection are controlled or eradicated. Correct

identification of the cause of the wound will lead to a rational treatment approach

and subsequent healing.

Wound infections 5

woundcare manual

��Predisposing medical conditions:

Diabetes

Cancer

Rheumatoid arthritis

Excessive alcohol intake

Malnourishment

Conditions which lead to

suppressed or non-

functioning of the immune

system

Systemic use of steroids

or antibiotics

Co-existing distant skin

lesions such as exfoliative

dermatitis (themselves a

target for infection) (4)

Treating patients with infected wounds (continued)

Factors increasing the risk of infection include:

• the presence of a foreign body in the wound; pieces of discarded

dressing, especially gauze and tulle, dirt, suture material, drains;

• the presence of dead tissue may act as a focus for infection, as fewer

bacteria are needed to cause infection;

• contused tissue;

• tissue ischaemia;

• previous or current irradiation;

• presence of a haematoma;

• the use of vasoconstricting drugs; and

• pre-operative shaving.

Predisposing medical conditions There are a number of medical conditions that are known to predispose patients

to infection. �

5.5 Local management of infected wounds

• Should be considered in conjunction with the use of systemic antibiotics

where required.

• Wounds should only be dressed using products licensed for infected

wounds.

• Dressings should be changed more frequently to allow the removal of

infected material.

• Surgical wounds require drainage of pus (either by surgery or by

removal of stitches), prescription of systemic antibiotics and, if

appropriate, bed rest and elevation of the affected limb.

5.6 Topical antiseptics to be avoided (See also Section 10)

Antiseptics have been shown to be destructive to normal tissue (in vivo and in

vitro). Their ability to kill bacteria is compromised in the presence of blood,

wound exudate or tissue, so unlikely to be effective against bacteria established

in tissue.

Hypochlorite:

• Irritatant to skin due to high pH

• Often selected for Gram negative

Wound infections 5

woundcare manual

Opinion

“It may be as troublesome

to the patient to be treated

for an infection that is not

present, as it is to overlook

the infection that is there.”

[6] �� Exception:

Use of topically applied

metronidazole gel for

grossly malignant wounds,

e.g. fungating malignant

lesions, where it will

reduce or prevent the

odour. References

1. Kerstein, M. A

Symposium: Wound

Topical antiseptics to be avoided (continued)

Hydrogen peroxide:

• Desloughs for a few seconds

• Harms healthy tissue

Proflavine:

• Bacteriostatic against Gram positive only

Chlorhexidine:

• Gram +ve and –ve effective

• Residual tissue toxicity

Acetic acid:

• Low pH effective against Pseudomonas

• Selects out S.aureus and Proteus

Povidone iodine:

• Broad spectrum but activity decreased in the presence of pus

Cetrimide.

• Effective against Gram –ve and +ve

• Detergent effect – high tissue toxicity (5)

5.7. Effective antimicrobial dressings

These antimicrobial products will reduce the numbers of bacteria within a wound

and may subsequently eliminate any infection, however there may still be a need

for antibiotics:

• Cadexomer iodine (slow release therefore no tissue toxicity)

• Silver sulphadiazine

• Nanocrystalline silver

5.8 Antibiotic Therapy

Considerations

• Bacterial resistance

• Patient allergies

• Side effects

• Sensitivity of organism

Wound infections 5

woundcare manual

infection and occlusion –

separating fact from

fiction. American Journal

of Surgery 1999 167: (1A)

(supplement), S7- S11

2. Dow et al. Infection in

Chronic Wounds;

controversies in diagnosis

and treatment. Ostomy

Wound Management;

1999; 45(8); 23-40

3. Thompson, P et al;

Wound bacterial

colonisation and infection

in biology and

management. Mulder GD

(ed) Oxford Press 1993

4. Cutting KF, Harding KG

Criteria for identifying

wound infection. Journal of

Woundcare

1994;3(4):198-201 5. Cutting K. Factors

affecting wound healing.

Nursing Standard 1994;

8(50): 33-37

6. Wound Bed Preparation

Presentation notes (2002):

Pam Spruce. Education

and research Manager,

Smith and Nephew

Healthcare.

Miller, M. and Glover, D

1999

7. Wound Management -

Theory and Practice

Nursing Times Books

Williams N.A, Leaper DJ.

Wounds – Biology and

Management:

Oxford Medical

Publications Journal of

Wound Care 1998

5.8 Antibiotic therapy (continued) Actions of antibiotics

• Bacteriostatic – stop bacteria reproducing and rely on host defences to

eliminate them.

• Bactericidal – attack and kill bacteria only when they are dividing –

ineffective against dormant bacteria.

Combinations of antibiotics Bactericidal and bacteriostatic antibiotics do not usually mix well as the ‘static’

drug may force the bacteria into a dormant non-dividing state on which the ‘cidal’

drug cannot act.

• Bactericidal drugs used together may enhance each others action; i.e.

they are synergistic.

• Bacteriostatic drugs when used together are usually additive, so the

effect of using two together can be achieved by using more of one drug.

Ideal antibiotic An ideal antibiotic is only of use if it does not harm the host significantly.

The ideal antibiotic should:

• be selective for disease causing and not harmful to the normal flora;

• not be impaired by body fluids or by tissue enzymes;

• reach adequate levels in the appropriate part of the body; i.e. the wound

- this will depend on the drugs absorption, distribution and excretion;

and

• be bactericidal The use of topical antibacterials may lead to:

• local cell and tissue damage;

• systemic toxicity;

• the development of contact sensitivity and allergic reactions;

• disturbances in the normal skin ecology, leading to super-infection and

the possibility of developing antibiotic resistance; and

• interactions with concurrent drug therapy, especially steroids

Systemic antibiotics At present, the use of systemic antibiotics is only advocated in the presence of a

host reaction, therefore it is always important to seek advice from the Infection

Control Team before prescribing antibiotic therapy [5].

Diabetic foot wounds 6

woundcare manual

6 DIABETIC FOOT WOUNDS Jo Hood and Liz Huggins

The diabetic foot is a unique entity in terms of the challenges it presents for wound

management. There are multiplicities of factors that can prevent effective healing

which can be slow and deterioration rapid if these factors are not recognised and

managed appropriately. So diabetic foot wounds require specific assessment and

treatment in addition to normal woundcare protocols. 6.1 Specific Assessment

It is important that both feet are thoroughly checked in case of any further undetected

wounds.

Assessment of patients Specific assessment of patients with diabetic foot wounds should include:

• neurovascular status

• blood sugar control

• cardiac or renal disease

• ulcer history

• medical and pharmacological history

Assessment and classification of wounds Wounds should be assessed in terms of:

• Site: plantar surface/bony prominence

• Dimensions: may be masked by the presence of callus/necrotic tissue

• Infection: causative organism, extent, e.g. soft tissue/bone

Assessment of aetiology Possible aetiological factors include:

• foot deformity

• functional foot problems

• hosiery, footwear

• poor self-care

• trauma


woundcare manual

�� Input from a state-

registered podiatrist via

referral to the Podiatry

Department is

recommended.

6.2 Treatment

Diabetic foot wounds require factors additional to normal wound management. ��

Pressure relief Redistribution of pressure if required via padding, insoles or footwear modification.

Prevention Treatment of any other foot pathology.

Education Foot care and footwear advice should be given.

Other action

• Review glycaemic control

• Treatment of hypertension and hyperlipidaemia

Debridement Callus, necrotic tissue, slough and bony sequestrum must be removed by a suitably

qualified practitioner. Regular maintenance of such wounds is usually required.

Onward referrals Onward referrals to other professionals will be needed when:

• there is no improvement or deterioration of the wound or medical input is

required;

• hospital investigations or tests are required;

• ischaemic pain is present; and

• specialist footwear is required 6.3 Infection

Infections must be treated according to clinical signs. NB: Infection may be masked

in patients with ischaemia.

Actions to consider:

• Take wound swab if appropriate.

• Refer for X-ray if bony involvement suspected.

• For first-line treatment use a broad spectrum antibiotic; e.g. co-amoxiclav

for a minimum of 10 days for all foot infections (or erythromycin if penicillin

allergy). If bony involvement suspected, minimum course is six weeks.

• Anaerobic infection may require the addition of metronidazole.


woundcare manual

Further reading Boulton, A., Connor, H.,

Cavanagh, P. (eds) (1995)

The Foot in Diabetes. Wiley,

Chichester

Edmonds, M., Foster, A.

(2000) Managing the

Diabetic Foot. Blackwell

Science, London

6.4 Dressing considerations Selection of dressings should take into account the:

• site of the ulcer; e.g. plantar, dorsal, interdigital

• appearance; e.g. necrotic, sloughy, etc.

• aetiology; e.g. pressure

Points to consider in dressing selection:

• Dressings need to conform to site.

• Appropriate for level of exudate (greater for ulcers on the plantar surface).

• Shock absorbing properties; e.g. if plantar or interdigital.

• Adhesive dressings: consider surrounding skin quality.

• Method of securing: consider skin quality (to avoid trauma on removal),

space in shoes, plus ensuring retention. Minimal tape should be used

especially for digital dressings (constricts circulation).

• Protect surrounding skin.

• Consider potential for maceration of surrounding skin especially if wound is

on a weight-bearing area or pressure point as this could potentially cause

further breakdown or infection.

• Frequent dressing changes are required to allow continual monitoring of

the wound – this may have cost implications. 6.5 Advice to patients The patient should be advised to:

• rest the foot and lower limb whenever possible, and keep the dressings

dry; and

• seek help as soon as possible if there is any increase in pain, swelling,

odour or strike-through on dressing.

The ideal wound dressing 7

woundcare manual

�Exudate

Wound exudate, in

reasonable quantities,

provides optimum conditions

for wound healing and

should be allowed to remain

in contact with the wound

surface. However, excess

exudate should be removed

to prevent maceration of the

surrounding healthy tissue.

In a chronic wound, excess

exudate may delay the

healing process.

References

1. Hansson, C. Interactive

wound dressings. A practical

guide to their use in older

patients. Drugs Ageing 1997;

11(4):271-84

2. Morgan, D. A. In:

Formulary of Wound

Management Products - A

Guide for Healthcare Staff,

8th edition, 2000. Euromed

Communications Ltd.,

Haslemere, UK

7 THE IDEAL WOUND DRESSING Val Shaw 7.1 General considerations

The ideal wound dressing should provide the optimum environment for wound

healing and protection from further injury. The properties of an ideal wound

dressing do not change with the introduction of new types of dressing, but the

range of effects on wound healing increases.

The adoption of novel dressings into the formulary should be based on

scientific evidence, but the number of double blind, placebo-controlled trials

conducted are very few and make this process difficult [1].

Dressing changes should be minimised, the wound kept moist but the

surrounding skin dry.

The high cost of interactive dressings is a potential disadvantage of their use.

However, if the wound can be dressed less frequently and if healing occurs

faster, their use may be cost-effective, associated with less pain and provide a

better quality of life for the patient.

7.2 Characteristics of an ideal dressing [2]

• Provides a moist environment at the wound/dressing interface.

• Provides thermal insulation as wound healing is temperature dependent.

• Impermeable to micro-organisms in both directions.

• Transparent, to allow monitoring of the wound without removing the

dressing.

• Allows removal without trauma.

• Free from particulate contaminants.

• Safe to use: non-sensitising, non-toxic, latex-free dressings and

packaging.

• Allows gaseous exchange of oxygen, carbon dioxide and water vapour.

• Absorbs excess exudate and toxic substances. �

• Should not be flammable.

• Available in hospital and community in a range of sizes and forms.

• Requires infrequent changes: products should be left in place as long as

possible.

• Cost-effective.

• Non-adherent: many products are described as this but are actually low

adherent.

The ideal wound dressing 7

woundcare manual

7.2 Characteristics of an ideal dressing [2] (continued)

• Acceptable to the patient.

• Conformable and mouldable: especially over heels, elbows and sacrum.

• Provides mechanical protection.

Wound algorithm 8

woundcare manual

8a NON-INFECTED WOUND ASSESSMENT AND TREATMENT ALGORITHM

WOUND TYPE DRESSING AIM EXUDATE

LEVEL RECOMMENDED

DRESSING

NB: If wound is infected/colonised, see Section 5

H = high M = medium L = low

See formulary for choice of dressing presentation

Necrotic Black or brown

No ⇓⇓⇓⇓

Yes ⇒⇒⇒⇒

Debridement or Protection

L -

Hydrogel plus hydrocolloid +/- other 2° dressing Foam or other non-adherent dressing

Sloughy yellow or white, slimy No ⇓⇓⇓⇓

Yes ⇒⇒⇒⇒

Debridement and Absorption

H

M L

Hydrofibre or alginate or foam +/- 2° dressing Hydrofibre or alginate or foam or hydrogel or hydrocolloid +/- 2° dressing Hydrogel or hydrocolloid +/- 2° dressing

Granulating red No ⇓⇓⇓⇓

Yes ⇒⇒⇒⇒

Protection and Absorption

H M

L

Hydrofibre or alginate or foam +/- 2° dressing Hydrocolloid or foam or non-adherent dressing +/- 2° dressing Hydrogel or non-adherent dressing or foam +/- hydrogel +/- 2° dressing

Epitheliasing Pink

Yes ⇒⇒⇒⇒

Protection

-

Low adherent dressing or foam

Wound algorithm 8

woundcare manual

8b INFECTED WOUND ASSESSMENT AND TREATMENT ALGORITHM


LEVEL RECOMMENDED

DRESSING

NB: Consult with Microbiologist and consider antibiotic therapy if appropriate



Infected For clinical signs of infection see Section 5

Yes ⇒⇒⇒⇒

Eliminate infection, Control odour, Absorption, +/- Debridement

H M L

Cadexomer iodine paste or silver/odour absorbing dressing + 2° dressing Cadexomer iodine paste or silver/odour absorbing dressing or povidine iodine dressing + 2° dressing Silver/odour absorbing dressing or povidine iodine dressing + 2° dressing

8c FUNGATING WOUND ASSESSMENT AND TREATMENT ALGORITHM


LEVEL RECOMMENDED

DRESSING



Fungating

Yes ⇒⇒⇒⇒

Absorption, Odour Control, Protection

H M L

Metronidazole gel 0.8% plus odour absorbing dressing +/- cavity dressing + 2° dressing

Formulary of woundcare products 9

woundcare manual

Criteria for formulary inclusion of a product

1. The underlying cause and the nature of the wound;

• the stage of healing

• cleansing/removal of debris

• exudate management

• granulation/vascularisation

• epithelialisation

2. Sizes of dressings available

3. Ease of dressing application/removal

4. Frequency of dressing change

5. Comfort and cosmetic consideration

6. Product availability on FP10

7. Cost effectiveness

8. The dressing and packaging should be latex-free whenever possible


woundcare manual

PETERBOROUGH HEALTHCARE WOUND MANAGEMENT FORMULARY

As part of the discharge planning process, a maximum of 7 day’s supply of dressing(s) will be issued

from the hospital. The exact quantity supplied will be based on the clinician’s judgement of the wound at the time of discharge.

Disclaimer

Due to a paucity of evidence in the field of woundcare, the clinician must make a thorough assessment

of the patient, wound type, and stage of healing, to make a clinical judgement of the most suitable dressing. At present, it is impossible to state that a particular dressing in one group is better than one in another for a particular wound type. The most cost-effective product with the most ideal characteristics

should be selected for application.

DRESSING SIZE (all sizes in cm unless otherwise

stated)

COMMENTS

NON-ADHERENT DRESSINGS

Low Exudate

NA-Ultra

9.5 x 9.5

19 x 9.5

Absorbs exudate into secondary dressings, for use under compression bandaging

Tricotex 9.5 x 9.5 Not for routine use

LOW ADHERENT DRESSING

Release

5 x 5 Podiatry only – spreads exudate leading to acute wound maceration

ADHESIVE DRESSING

Low Exudate

Mepore +Mepore Ultra

7 x 8 10 x 11 11 x 15 9 x 20 9 x 25 9 x 30

If applied under tension-shearing force will cause skin damage Latex present in packaging Nil – low exudate Not suitable for acrylic adhesive sensitivities Can be left in place for a week or more

Opsite Post-op 6.5 x 5 9.5 x 8.5 15.5 x 8.5 20 x 10 25 x 10 30 x 10 35 x 10

Post-operative dressing. Waterproof


woundcare manual

ADHESIVE DRESSING

Low Exudate

Tegaderm Plus Pad

5 x 7 9 x 10 9 x 15 9 x 20 9 x 25 9 x 35

For Orthopaedic surgery only

VAPOUR PERMEABLE ADHESIVE FILM DRESSING Low Exudate

Tegaderm

6 x 7 10 x 25 12 x 12 15 x 20 20 x 30

Prevention of pressure sores on fragile skin only – DO NOT use as a secondary retention dressing Do not leave in place longer than 7 days with hydrogel

Opsite (Hospital use if included above)

6 x 7 10 x 12 12 x 25 15 x 20

As above Theatre - Use as a drape

HYDROGEL Low to moderate exudate

ActivHeal Hydrogel 15g Cheapest hydrogel – first choice Avoid for 24 hours if using maggots

Purilon gel

8g 15g

For debridement – contains alginate for wet/cavity wounds The only safe hydrogel for use prior to larval therapy

Intrasite gel 8g 15g

Avoid for 24 hours if using maggots

Intrasite Conformable 10x10

10x20

ALGINATE Not for low exudate wounds

ActivHeal alginate 5x5 10x10 10x20

Cheapest alginate – first choice

Sorbsan

5 x 5 10 x 10 10 x 20

HYDROFIBRE

Aquacel (hydrofibre) Sheet 5 x 5 10 x 10 15 x 15

Not occlusive Moderate-heavy exudate Can remain for up to 7 days


woundcare manual

HYDROCOLLOID DRESSINGS

ActivHeal Hydrocolloid 5x 7.5

10x10

15x15

15x18 sacral

Cheapest hydrocolloid – first choice

Granuflex 10 x 10 15 x 15 15 x 20

Low to medium exudate – contains pork Waterproof – can remain for maximum of seven days

Bordered Granuflex 6 x 6 10 x 10 10 x 13 15 x 15 15 x 18

Low to medium exudate – contains pork Waterproof – can remain for maximum of seven days

Duoderm Extra Thin

5 x 10 7.5 x 7.5 10 x 10 5 x 20 15 x 15

For superficial wounds and low exudate

Comfeel plus

10 x 10 15 x 15 20 x 20

Impermeable dressing – facilitates rehydration. For medium to high exudates No gelatine - suitable for use on vegetarians

POLYURETHANE / HYDROCELLULAR FOAM DRESSINGS All exudates

ActivHeal Non-adhesive Foam Dressing

5x5 10 x 10

7.5x7.5 18 x 10

20 x 20

Cheapest non-adhesive foam – first choice

Biatain Non-adhesive

5cm diameter 8cm diameter

Podiatry only – heavily exudating wounds

Lyofoam

7.5 x 7.5 10 x 10 17.5 x 10 25 x 10 (hospital only) 20 x 15

Secure dressing with adhesive tape, do not use occlusive tape or film Light exudates Cost effective if frequent dressing changes needed; e.g. infected wounds

Lyofoam T 9 x 6.5 Around tracheostomies etc

ActivHeal Foam Island Dressing

10x10

12.5x12.5

15x15

20x20

Cheapest adhesive foam – first choice

Allevyn

5 x 5 10 x 10 10 x 20 20 x 20

Allevyn Adhesive 7.5 x 7.5 12.5 x 12.5 12.5 x 22.5

Podiatry use only. Very expensive

Allevyn heel dressing Not for pressure relief

Can remain for a maximum 5 days

Tielle 7 x 9 11 x 11 15 x 15 18 x 18


woundcare manual

CAVITY DRESSINGS

ActivHeal alginate Rope 2cm x 30cm Cheapest cavity dressing – first choice where appropriate

Moderate to heavy exudate

Sorbsan (alginate) Ribbon 40 cm long (1g)- with probe Packing 30cm long (2g)

Moderate to heavy exudate

Aquacel ribbon (hydrofibre)

Ribbon 2m x 25cm

Allevyn Cavity (foam) Circular 5 cm 10 cm Tubular 9 x 2.5 12 x 4

Useful for large cavities Alternatively line with a large Aquacel sheet and fill cavity with dry gauze and film

OVERGRANULATION

Lyofoam All sizes Under light compression

Silver Nitrate 75% sticks 10 Use with extreme care. For small areas (1.5 cm) of overgranulation on suture lines only

MULTILAYER COMPRESSION

K- 4 # 1 K-Soft # 2 K –Lite # 3 K- Plus # 4 Ko-Flex

Wound contact layer

Doppler before using compression bandages and holistic assessment Correct pressure essential for good healing

SKIN PROTECTION

Cavilon Barrier Film 1ml / 3ml single use applicators 28ml spray

For skin protection, including delicate skin against adhesive dressings / tapes

Cavilon Barrier Cream

2g sachets

92g tube

For skin protection (incontinence etc)

Opsite spray

100 ml

For post –op wounds which cannot be dressed. Painful if no anaesthetic!

BURNS/SCALDS

Silver Sulphadiazine 1% Cream

50 g Argyria can be a problem with excessive use

Mepitel 5 x 7.5 7.5 x 10 10 x 18 20 x 30

Expensive – not for frequent dressing changes

Jelonet 5 x 5 10 x 10

Limited use only where daily dressings required


woundcare manual

DRESSINGS FOR INFECTED / MALODOUROUS WOUNDS

Aquacel Ag 10x10 15x15 2cm x 45cm ribbon

Has adhesive border, therefore secondary dressing not required

For cavities

Actisorb Silver 200 6.5 x 9.5 10.5 x 10.5 19.5 x 10.5

More expensive as secondary dressing for retention required

Metronidazole Gel

Anabact 0.75% Metrotop 0.8%

15g, 30g 30g

Cost-effective (Anabact) Not for use on patients with metronidazole sensitivity. Use on anaerobic wounds only (See limited use section)

Inadine (povidone iodine) 5 x 5 9.5 x 9.5

Maximum of 4 dressings at any one time

Iodoflex (cadexomer iodine)

5g sachet 10g 17g

Maximum of 150g in 1 week Single 50g in one application Maximum of three months in any single course Care in severe renal failure

HONEY Activon manuka honey

Activon (manuka honey) tulle dressing Algivon (manuka honey) alginate dressing

25g tube 5 x 5 10 x 10 5 x 5 10 x 10

Tulle dressing

Alginate dressing

NON-ADHERENT SILICONE (OR SIMILAR) DRESSING

Atrauman (Impregnated with triglycerides)

5x 5

10x20

7.5x10

20x30

MUCH cheaper alternative to mepitel.

Not appropriate for burns, skin grafts etc

Mepitel (Impregnated with silicone)

5 x 7.5 7.5 x 10 10 x 18 20 x 30

Should be left in place for 7 to 10 days, otherwise consider alternative dressing. Changing the simple secondary dressing (Ramgee) is more cost effective. Should not be considered if frequent changes will be made = expensive. Useful for burns, chronic arterial leg ulcers. Not to be used on infected wounds Wet fingers with saline before handling the new dressing

Mepilex (silicone plus foam dressing)

10 x 10 10 x 20 15 x 15

Cover with simple absorbent secondary dressing

Mepilex Bordered

7.5 x 7.5 10 x 10 15 x 15 15 x 20

Adhesive dressing


woundcare manual

Activheal hydrocolloid 5 x 7.5 10 x10 15 x 15 15 x 18

Activheal 5 x 5 10 x 10 2 x 30

Cavity Dressing

Activheal (Non Adhesive) 5 x 5 7.5 x 7.5 10 x 10 20 x 20

Activheal (Adhesive) 10 x 10cm square drug tariff (wcp 5x5cm + border 2.5cm)

12.5 x 12.5cm square

15 x 15cm square drug tariff (wcp 11x11cm + border 2cm)

K Two bandage kit Size 18-25cm

Atrauman 5 x 5cm 7.5 x 10cm 10 x 20cm 20 x 30cm

Activon manuka honey 25g tube

Activon (manuka honey) tulle dressing

10cm x 10cm Tulle dressing

Activon (manuka honey) tulle dressing

5cm x 5cm Tulle dressing

Algivon (manuka honey) alginate dressing

5cm x 5cm

Algivon (manuka honey) alginate dressing

10cm x 10cm

Actico compression bandage

10cm x 6m

K4 bandages ?? 12cm x 6m

Comfifast 10m 3.5cm (red line) 5cm (green line) 7.5com (blue line) 10.75cm (Yellow line)

Steri-strip 6 x 75mm x 3 strips

Acti V.A.C 300ml Canister with gel

Granufoam Small 10 x 7.5 x 3.3 com Medium 18 x 12.5 x 3.3 cm

Dressing Packs Pack sterile wound care community specification 1 pr small accelerator free nitrile lilac gloves 1x laminate sheet 1 x white poly bag 1 x dressing towel 5x10x10cm 4 ply non woven swabs 27x52" white poly apron 1 x sterile field 1 x wound measure guide Shermond 6075AF

Dressing Packs Pack sterile wound care community specification 1 pair medium accelerator free nitrile lilac gloves 1 x laminate sheet 1 x white poly bagf 1 x dressing towel 5x10x10cm 4 ply non woven swabs 1 x 27x53" white poly apron 1 x sterile field 1 x wound measure guide Shermond 6076AF

Dressing Packs Pack sterile wound care community specification 1 pr large accelerator free nitrile lilac gloves 1 x laminate sheet 1 x white poly bag 1 x dressing towel 5x10x10cm 4 ply non woven swabs 1 x 27x53" white poly apron 1 x sterile field 1 x wound measure guide Shermond 6077AF


woundcare manual

Kerrammax

10 x 10 22 x 10 22 x 20

Super absorbent dressing for heavily exuding wounds.

Meefix adhesive tape 5 x 10 10 x 10

MEDICATED BANDAGES

Viscopaste (zinc paste) 7.5 x 6m Infected leg ulcer with varicose eczema

Ichthopaste 7.5 x 6m

Steripaste (zinc oxide 15%)

7.5 x 6m Use only if react to viscopaste. Preservative free

STERILE SECONDARY DRESSINGS

Non woven gauze swab (Topper 8)

7.5 x 7.5 4-ply Sterile

Wool pad (Mesorb)

10 x 10 10 x 20 20 x 30

Fluid repellent backing ideal for peri-anal wounds Specialist use – wound dictates Expensive

NON-STERILE SECONDARY DRESSINGS

Non woven gauze swab (Topper 8)

10 x 10 4 ply Non-sterile

Gamgee 500g pink or blue label Do not use directly against wound contains cotton wool

DRESSING RETENTION

Bandages 5cm x 4 m 7cm x 4 m 10cm x 4 m 15cm x 4 m

Use most cost-effective product K-Band in the community

Scanpor Tape 2.5 cm x 5 m Cost-effective tape

Micropore Hospital only

Microfoam 5cm x 5 m 7.5cm x 5 m 10 cm x 5 m

Theatre Use

WOUND CLEANSING SOLUTIONS

Normasol sachets (sodium chloride 0.9%)

25 ml

Steripod (sodium chloride 0.9%)

20 ml Community or A & E use - only if wash needed under pressure - expensive

Aquasol sachets (sterile water)

100 ml


woundcare manual

Irriclens (sodium chloride 0.9%)

1 x can 240 mls x 1 can

Named patient use only in hospital, otherwise community use only

LIMITED USE ITEMS

Potassium permanganate 400 mg (Permitabs)

1 tablet dissolved in 4 litres water provides a 0.01% (1:10,000) solution

Soaking macerated leg ulcers or infected highly exuding eczema Short soak only Stains clothing/containers

Chlorhexidine sachets 0.05%

25ml

100ml

Limited use - see infected wounds section

Used in theatre occasionally to soak specific items

Contreet For Podiatry only

Surgicel (Theatre and Mat Unit use only)

5 x 7.5 Absorbable haemostat

Adaptic Digit (A&E and Theatre use only)

Small, medium, large, extra large For fingers and toes

Cica-care (out patients only)

6 x 12 12 x 15

For management of scar Named patient only – very expensive

Jelonet (A&E and Theatre use only) Very limited use

5 x 5

10 x 10

Burn patients for review next day, where silver sulphadiazine not indicated Initial dressing for circumcision and haemorroidectomy – do not allow to dry out

Mupirocin (Bactroban) 15g For MRSA wounds less than 5cm

Silver Sulphadiazine 1% Cream

50g For larger MRSA wounds

Cutinova Hydro 2.5 x 5 ITU/SRU and HDU use only for skin protection when using CPAP

Povidone Iodine Aqueous Solution

500 ml Skin preparation before surgery

THEATRE USE ONLY

Cetrimide Solution Sachets 25 ml/100 ml Wound cleansing

Chlorhexidine in Spirit 0.5% in 70% DEB

600 ml Flammable

Hydrogen Peroxide 3% (10 volumes)

100 ml

Povidone Iodine Spray 100 ml N.B: Unlicensed use during hernia surgery if used internally

Licensed for external use only

Cavi-Care 20 g For hypospadias repair

Spongistan 7cm x 5cm x 0.1cm Tampon

For colorectal use

Kaltostat 5 x 5 7.5 x 12 10 x 20 15 x 25

For orthopaedic grafting and plastics only

Collatamp G 10 cm x 10 cm Infected deep surgical wounds; e.i. infected grafts, vascular and orthopaedic use

Velband 5, 7.5, 10 & 15 cms

Ribbon Gauze Roll 15 cm Vaginal pack post vaginal hysterectomy, not for longer than 24 hours post-op

Not to be used as an abdominal pack


woundcare manual

Initial Community Dressings

This initiative enables all community nurses to overcome the problem of illegal boot stock, nurse prescribing and hospital

discharges without dressings by giving the capacity to offer the patient an initial dressing prior to the in-depth wound

assessment.

INITIAL DRESSINGS – COMMUNITY ONLY

Aquacel 10 x 10

Granuflex Sacral 15 x 18

Biatain Heel

Duoderm Extra Thin 10 x 10

Biatain 10 x 10

Mepitel 7.5 x 10

Comfeel Plus 10 x 10

Tegaderm 12 x 12

Tegaderm 15 x 20

Sorbsan Plus 7.5 x 10

Inadine 9.5 x 9.5

Intrasite Conformable 10 x 10

Mepore 7 x 8

Mepore 11 x 15

NA - Dressing 9.5 x 9.5

Cavilon 1 ml

Steristrips 6 mm x 75 mm

Sodium Chloride 25ml Sachets 25 ml

K – Band bandage 10cm

Scanpore 2.5 cm roll

Woundcare product assessment 10

woundcare manual

References

1. Local application to wounds

1: cleansers, antibacterials,

debriders Drug and

Therapeutics Bulletin 29 (24):

93-5, 1991

2. Zaki I, Shall L, Dalziel KL

(1994) Bacitracin: a significant

sensitiser in leg ulcer

patients? Contact Dermatitis

31: 92-4

3. British medical Journal

Editorial: Topical Antibiotics.

Br Med J 1:494 1977

4. Kaye ET (2000) Topical

antibacterial agents. Infect Dis

Clin N Am 14 (2): 321-39

5. Morison M (1990) Wound

cleansing- which solution?

Nurse Stand 4(52): 4-6

6. Iwamoto Y, Ferguson LR,

Pearson A et al (1992) Photo-

enhancement of the

mutagenicity of 9-

anilinoacridine derivatives

related to the antitumour

agent amsacrine. J Mutat Res

268 (1): 35-41

7. DeMarini DM, Brock KH,

Doerr CL et al (1988)

Mutagenicity and

clastogenicity of proflavine in

L5178Y/TK cells. J Mutat Res

204(2): 323-8

8. Gupta R, Foster ME, Miller

E (1991) Calcium alginate in

the management of acute

surgical wounds and

abscesses. J Tiss Viabil 1(4):

115-6

9. White RJ, Cooper R,

Kingsley A (2001) Wound

colonization and infection: the

role of topical antimicrobials.

Br J Nurs 10(9)

10 WOUNDCARE PRODUCT ASSESSMENT Val Shaw

10.1 Topical antibiotics and antiseptics

The indiscriminate use of topical antibiotics is not recommended for the routine

treatment of colonised or infected wounds [1]. They can provoke delayed

hypersensitivity reactions [2], super infections and select for resistance [3], which

is a serious problem.

The use of topical antiseptics must be subject to a risk-benefit assessment of

possible local cellular toxicity with beneficial antibacterial action [4].

The ideal antiseptic should [5]:

• have a broad spectrum of activity

• have low potential for resistance

• be non-toxic

• be rapid acting

• not be an irritant or a sensitiser

• be effective, even in the presence of exudate, pus, slough, etc.

• not cause pain on application

10.2 Woundcare products to avoid Proflavine A slow acting, mildly bacteriostatic agent. An acridine derivative reported to

cause mutagenicity, both gene and chromosomal mutations in bacteria [6] and

cell cultures [7] raising questions about its safety. It has been shown to be

inferior to alginate dressings for wound packing [8] and there is no reliable

evidence that it is effective in this use, or that it has any clinical benefits [9].

Cicatrin Contains neomycin and zinc bacitracin. Application of large amounts, treatment

of large areas or chronic wounds or prolonged treatment leads to systemic

absorption, which may cause irreversible ototoxicity and nephrotoxicity. Use may

be harmful by encouraging the colonisation of the wound by resistant organisms

[10].


woundcare manual

10. Huavinen S, Kotilainen P,

Jarvinen H et al (1994)

Comparison of ciprofloxacin

or trimethoprim therapy for

venous leg ulcers: results of a

pilot study. J Am Acad

Dermatol 31: 279 - 281

11. Morgan D (2002) Wounds

– what should a dressings

formulary include? Hospital

Pharmacist 9: 261 - 266

12. Thomlinson D (1997) To

clean or not to clean? Nurs

Times 83 (9): 71 -5

13. Harris A, Rolstad BS

Hypergranulation tissue: a

non-traumatic method of

management. In: Harding,

KG, Cherry G, Dealdey C,

Turner TD, editors.

Proceedings of the Second

European Conference on

Advances in Wound

Management; October 1992,

Harrogate. London. MacMillan

Magazines Ltd., 1993: 35-2

14. Payne CMER, Bladin C,

Colchester ACF, Bland J,

Lapworth R, Lane D. Argyria

from excessive use of topical

silver sulphadiazine. Lancet

1992; 340: 126 (letter)

15. Mertz PM, Oliviera-

Gandia MF, Davis S (1999).

The evaluation of a

cadexomer iodine wound

dressing on MRSA in acute

wounds. Dermatol Surg 25

(2): 89 – 93

16. Scott Ward R, Saffle JR

(1995). Topical agents in burn

wound care. Phys Ther 75 (6):

526 – 538

Medicated tulle dressings E.g. Sofra-Tulle, Bactigras. These are not generally recommended. Sofra-Tulle

contains kaolin and the antibiotic framycetin, which can lead to skin sensitisation

and absorption which can cause systemic toxicity. Bactigras contains 0.5%

chlorhexidine; there is no evidence of any antibacterial efficacy [11].

Paraffin tulle dressings E.g. Jelonet, Unitulle. These dressings carry different weights of paraffin per unit

area to avoid adherence of the dressing to the wound. They require frequent

changes in order to avoid drying out and incorporation into granulation tissue.

Removal of the dressing may lead to trauma of the wound. Secondary dressings

are always required.

Antiseptic solutions as cleansing agents E.g. chlorhexidine. To be effective, these would need to be in contact with the

wound for extended periods [12] or in high concentration, which would cause

tissue toxicity. 10.3 Woundcare products for limited use Overgranulation Lyofoam can be used as a non-traumatic method of reducing hypergranulation

tissue [13].

Silver nitrate has an irritant effect and is used occasionally to reduce

hypergranulation in small areas (<1.5 cm) along a wound area. Silver may react

with environmental pollutants to form black silver sulphide, giving the skin a

general grey discolouration (argyria) which is largely a cosmetic problem [14].

Prolonged use often leads to argyria.

Iodine dressings E.g. Inadine, Iodosorb. Iodine is a useful bacteriostatic and bactericidal agent,

active against MRSA and other pathogens [15]. Its slow release from the

iodophor optimises activity and reduces toxicity. The iodinated dressings should

only be used on exuding wounds for best effect.

Hydrogen peroxide 3% (10 volumes) An aqueous solution used to clean necrotic, infected wounds. Acts as an

antiseptic due to the release of oxygen on contact with the tissues. There are

safety concerns about using hydrogen peroxide solutions on open wounds

because of reports of tissue embolism [16].


woundcare manual

17. Roe B, Cullum N (1995).

The management of leg

ulcers: current nursing

practice’. In: Cullum N, Roe B,

eds. Leg Ulcers: Nursing

Management. A Research-

based Guide. Scutari Press,

London

18. Goodman Gilman A

(1990). Antimicrobials.

Goodman and Gilman's The

Pharmacological Basis of

Therapeutics. 8th ed.

Pergamon Press, Oxford:

1047 – 1182

Potassium permanganate Weak solutions (one part in 10,000) are used as soaks to cleanse and deodorise

eczematous wounds and leg ulcers. There is no evidence published to support

this use [17].

Silver Bactericidal, safe, broad spectrum agent. Silver sulphadiazine cream 1%

releases the silver from the oil-in-cream formulation in concentrations that are

selectively toxic to bacteria, e.g. MRSA, gentamicin-resistant Pseudomonas,

Enterococcus and fungi [18].

Resistance has been reported, but is rare. Used as a mainstay for burns

treatment. Silver-containing dressings have been developed recently: they all

have different delivery systems but the mode of action is similar.

Metronidazole E.g. Metrotop (0.8%), Anabact (0.75%). Is used as a topical gel in the palliative

treatment of malodorous, malignant (fungating) wounds where odour is a

problem, but due to the terminal nature of the disease, antibiotic resistance is not

a problem.

Product monographs 11

woundcare manual

References

1. British National

Formulary; London: British

Medical Association and the

Royal Pharmaceutical

Society of Great Britain

2. Morgan DA; Formulary of

Wound Management

Products, 8th ed. (booklet).

Haslemere: Euromed

Communications, Sept 2000

3. www.smtl.co.uk

4. www.emc.vhn

(registration may be

required)

5. Val Shaw, Pharmacy

Services Manager (Tel:

01733 875436)

Jane Symons, Senior

Clinical Pharmacist (Tel:

01733 874009)

Medicines Information

Department (Tel: 01733

874468)

6. Department of Health and

National Assembly for

Wales. Drug Tariff. London:

Stationery Office

11 PRODUCT MONOGRAPHS General information about individual products is available from the:

• current British National Formulary [1]

• Formulary of Wound Management Products [2]

• Surgical Materials Testing Laboratory website [3]

• Electronic Summary of Product Characteristics [4]

• Pharmacy Departments [5], and

• package insert inside each product

Precise details of sizes, shapes and prices of products can be found in the

approved list of appliances, Part 1XA of the current Drug Tariff [6].

New therapies 12

woundcare manual

References:

[1] Larv E. Data Card,

Biosurgical Research Unit

(SMTL), Bridgend

[2] Edmonds, M., Foster, A.

(2000) Managing the

Diabetic Foot. P66. Blackwell

Science, London

12.1 Larval (maggot) therapy

The sterile larvae of the common green bottle Lucilia sericata can be used to

cleanse most types of sloughy, infected or necrotic wounds including leg ulcers

(venous and arterial), pressure sores, burns and diabetic foot ulcers [1].

The larvae secrete powerful proteolytic enzymes which breakdown slough and

necrotic tissue which is then ingested as a source of nutrient. When first applied to

a wound the larvae are only 2-3 mm long, but under favourable conditions they

increase in size rapidly, reaching 8-10 mm when fully grown.

In addition to cleaning the wound, maggots reduce or eliminate odour and combat

infection by ingesting and killing bacteria, including antibiotic resistant strains such

as methicillin-resistant Staphylococcus aureus (MRSA).

For further information please contact the Podiatry Department or the Biosurgical

Research Unit website: www.stml.co.uk .

12.2 Vacuum-assisted closure system (VACS)

VACS consists of a pump which applies gentle negative pressure to the wound

through a tube and foam sponge which are applied to the wound over a dressing

and sealed in place with a plastic film to create a vacuum. Exudate from the

wound is sucked along the tube to a disposable collecting chamber. The negative

pressure improves the vascularity and stimulates granulation of the wound [2].

This therapy is indicated in neuropathic, venous and decubitus ulcers but contra-

indicated for deep infection.

For further information visit STML website: www.stml.co.uk

12.3 Low-level laser therapy (LLLT)

LLLT has been developed over the last three decades. It is the application of red

and near-infrared light to wounds to stimulate healing and give pain relief. It is

also used by physiotherapists to aid in the management of a variety of joint and

soft-tissue conditions.

woundcare manual

Guidance for the use of Maggot Therapy Maggot therapy is widely used by health care practitioners throughout the UK in the management of infected or

necrotic wounds. Benefits of this therapy have been published in the medical and nursing press.

What should you do before ordering Maggots?

Assess the patient and the wound.

Suitable wounds – infected, sloughy, necrotic; e.g. leg ulcer, pressure ulcer, diabetic foot wound, infected wound.

Unsuitable wounds – dry necrotic, fistulae, wounds that bleed easily, if insufficient blood supply to allow healing.

If unsure contact Janet Small, Tissue Viability Nurse, on 01733 466642 or Dawn Purdom, Clinical Advisor

07976148609.

• Ensure you have a hydrocolloid dressing; e.g. granuflex or zinc paste, available for protecting

surrounding skin.

• Sleek tape to secure the net if using free range maggots.

• Intrasite gel should not be used 48 hours prior to application.

• Ensure your patients and consultants / GP consent.

Determine the amount and type of maggots you require – available free range or in new biofoam bags. (measure

the wound and estimate percentage of slough).

Larvae calculators are available.

Order via pharmacy for hospital use. Available on prescription in community - order telephone number is

08452301810.

Maggots need to be used on the day of delivery.

Application should be undertaken by someone who has experience in wound management and understands the

healing process.

Instructions for application come with the maggots but if help is required contact Janet Small or Dawn Purdom

before ordering.

A care plan and further information can be obtained from www.larve.com if required.

Prepared by Janet Small Tissue Viability Specialist Nurse - August 2006

Appendix l - Patient held communication sheet

woundcare manual

PATIENT NAME: ______________________________

ADDRESS: ______________________________

______________________________

______________________________

DATE OF BIRTH: ______________________________ GP: _________________________________

PRACTICE ADDRESS: __________________________

HEALTHCARE PROFESSIONAL: ________________________________________________________________

TREATMENT CURRENTLY RECEIVED BY PATIENT

TREATMENT PLAN/CHANGE FOLLOWING APPOINTMENT

DATE:

NAME: SIGNED

CONTACT NO: NEXT APPT:

SIGNED: DATE:

CONTACT NO: NEXT APPT:

Appendix II - Wound management chart (Peterborough and Stamford Hospitals

NHS Foundation Trust)

woundcare manual

Factors that may affect the Healing

process

Present (Tick)

Results

Advanced age Diabetes Blood sugar Anaemia Vascular disease Infection Decreased mobility Poor nutritional intake Incontinence Neurological disease Advanced cancer Medications Allergies

Fever Smoking Non-concurrence Waterlow score Others (State :)

INITIAL ASESSMENT

PATIENT’S NAME:

Initial assessment date: Signature: Print Name:

Location of wound(s) (Indicate on diagrams below) If more than one wound number accordingly

Appendix II - Wound management chart (Greater Peterborough Primary Care

Partnership)

woundcare manual

PATIENTS NAME: HOSPITAL NO:

POSITION AND TYPE OF WOUND WOUND NO:

(USE A CHART FOR EACH WOUND IF MORE THAN ONE WOUND IS BEING TREATED)

DATE

1 WOUND DIMENSIONS

Maximum length (cm)

Maximum width (cm)

Maximum depth (cm)

2 NATURE OF WOUND BED

Necrotic (black)

Sloughy (yellow)

Granulating (red)

Epithelialising (pink)

3 ODOUR

Y-Yes N-No

4 SURROUNDING SKIN

M-macerated O-oedematous

E-erythema F-fragile

X-eczema D-dry H-healthy

5 EXUDATE / DRAINAGE

H-High M-Moderate L-Low

6 CLIPS, SUTURES Date inserted:

Date removed:

7 DRAIN (Date removed)

8 PAIN (Assessment Chart: yes / no)

C-continuous D-dressing

N-none O-other times

Analgesia required prior to dressing

change (if yes please state what)

Appendix II - Wound management chart (Greater Peterborough Primary Care

Partnership)

woundcare manual

9 INFECTION

Granulation tissue bleeds easily

P-pocketing B-bridging

Wound breakdown

ACTION TAKEN

Swab sent for M, C&S? – date

10 TREATMENT OBJECTIVE (S):

Healing OR patient comfort (H or P)

D-debridement A-absorption

O-odour control P-protection

ASSESSED BY :

PRINT NAME:

SIGNATURE:

TREATMENT TO BE USED: Details of dressing used to include:

Size, quantity & secondary dressing?

Irrigation solution (if needed):

DOPPLER: A.P.I. LEFT

A.P.I. RIGHT

Wound map taken (yes / no)

DATE OF NEXT DRESSING:

RE-ASSESSMENT DATE:

Appendix III – Leg ulcer assessment form

woundcare manual

LEG ULCER

ASSESSMENT FORM (use separate chart for

other wounds)

SHEET NUMBER Name: Address: DoB: Number

Date of Assessment Sleeping Pattern: Bed Other Random Blood Sugar: mmols Hb recent test: YES / NO

Family History Smoker: YES / NO Bloods taken: YES / NO Allergies Smoking Cessation Advice ?ESR Urea, Creatinine Albumin, Rheumatoid Factor Occupation: Past / Present Weight: Over / Normal / Under Refer to Phlebotomist: YES / NO Mobility Concordance Urinalysis ULCER ARTERIAL RELATED Y N VENOUS RELATED Y N ULCER SITE Y N Diabetes Thrombophlebitis Past history of Ulcer Stroke/TIA Cellulitis Duration of present ulcer Hypertension Vein Surgery Waterflow Score Cardiac Failure Sclerotherapy Nutritional Score Ulcerative Colitis Varicose Veins Advice on Diet Past Arterial Surgery Leg Trauma/Injury Relevant Medication Rheumatoid Arthritis DVT Myocardial Infarction/Angina Abdominal/Orthopaedic Surgery Intermittent Claudication Pregnancy/How many Leg Cold to touch/Loss of hair atrophic - shiny skin Warm to Touch Foot White on elevation Varicose Staining Medial Malleolus Slow capillary filling Varicose Eczema External Malleolus Dusky pink/blue Atrophe blanche Pedal pulses present Left Pain on limb elevation / Ischaemic rest pain Pain on Standing Right Small with steep edges Shallow / flat Poor ankle movement Slough slow to separate Lipodermatosclerosis Deteriorates rapidly Ankle flare DOPPLER ASSESSMENT Brachial/Foot Pulses

Ankle Brachial Pressure Index ABPI

R B

R DP

R PT

R P

L B

L DP

L PT

L P

3-6 monthly Reassessments

R B

R DP

R PT

R P

L B

L DP

L PT

L P

Date Date ABPI Reassessments Date Date ABPI Reassessments Date Date

FINAL DIAGNOSIS/ULCER TYPE:

Leg Ulcer Assessment Chart to be used in conjunction with Guidelines on the Management and Assessment of Ulcers

woundcare manual

ONGOING ASSESSMENT

Date of Assessment

Wound Dimensions : cm/mm Max. Length

Max Width

Ankle Circumference

Appearance of Wound

Necrotic (black) Sloughy (yellow)

Epithelialising (pink)

Granulating (red)

Exudate Levels –High!

Moderate

Low

Surrounding Skin – Macerated!

Oedematous

Erythema!

Fragile!

Dry/Scaling

Healthy/Intact

Pain! Continuous

Specific Times

Dressing Change

None

Visual Assessment Map*

Photograph *

Swab taken *

Results

Referrals: Dietician GP Specialist

Other Referrals

SIGNATURE

* Tick when done ! May indicate wound infection Transfer outcomes to Care Plan. State type of dressing to be used. Give advice to patient re. exercise, elevation, nutrition etc.

Appendix IV– Organisms encountered in wound management

woundcare manual

Organisms

Microbiological characteristics

Sources

Examples

Effects

Staphylococci

Gram-positive cocci

form clumps

Nasopharynx of

15% of humans

Coagulase positive

S. aureus

Causes suppuration in

wounds

Coagulase negative

S. epidermidis

Causes opportunistic

infection – particularly

prosthetic vascular

and orthopaedic grafts

Streptococci

Gram-positive cocci

form chains

Lancefield A-G

groups

Pharynx group A

S. pyogenes

Cellulitis through release of

proteases

Bowel group D

S. faecalis

In synergy with others in

wound infections and

abscesses, particularly after

GI surgery

Clostridia

Gram-positive

bacilli

anaerobic spore

bearing

Faeces and soil

C. perfringens

Gas gangrene through

release of exotoxins and

proteases

C. tetani

Tetanus through release of

exotoxin

Bacteroides

anaerobic non-

spore bearing

Large bowel,

vagina, oropharynx

In synergy with AGNB cause

wound infections,

particularly after GI surgery

Aerobic Gram-negative bacilli (AGNB)

Faeces

E. coli, Klebsiella,

Proteus, etc.

Synergistic with Bacteroides

in wound infection

Pseudomonas

Colonise burns,

tracheostomy, and catheters

Appendix V – Management of tetanus-prone wounds

woundcare manual

Management of Tetanus-Prone Wounds

Wounds are considered to be tetanus-prone if they are sustained either more than 6 hours before surgical treatment of the wound; or at any interval after injury and are puncture-type, or show much devitalised tissue, or are septic, or are contaminated with soil or manure. All wounds should receive thorough wound toilet. For clean wounds , fully immunised individuals (those who have received a total of 5 doses of tetanus vaccine at appropriate intervals) and those whose primary immunisation is complete (with boosters up to date), do not require tetanus vaccine; individuals whose primary immunisation is incomplete or whose boosters are not up to date require a reinforcing dose of an appropriate strength of combined diphtheria and tetanus vaccine (followed by further doses as required to complete the schedule)|; non- immunised individuals (or whose immunisation status is unknown) should be given a dose of the vaccine immediately (followed by a completion of the full course of the vaccine if records confirm the need). For tetanus-prone wounds, management is as for clean wounds with the addition of a dose of tetanus immunoglobulin of human origin (HTIG) which should be administered at a different site, in addition to wound toilet and, where appropriate, antibacterial prophylaxis with benzylpenicillin, co-amoxiclav or metronidazole. In fully immunised individuals and those whose primary immunisation is complete (see above) the immunoglobulin is only needed if the risk of infection is particularly high (e.g. contamination with manure). For recommended doses see the current edition of the BNF1. For babies and children with a potentially tetanus-contaminated injury use of adsorbed diphtheria and tetanus vaccine (DT/Vac/Ads (Child)) is recommended. For adults and adolescents previously un-immunised against tetanus, and where booster doses of tetanus are indicated, following a tetanus-prone wound use adsorbed diphtheria (low dose) and tetanus vaccine for adults and adolescents (DT/Vac/Ads (Adult)). Tetanus immunoglobulin, together with metronidazole and wound toilet should also be used for the treatment of established cases of tetanus.

Immunisation Status Clean Wound Tetanus Prone Wound

Vaccine Vaccine Human tetanus immunoglobulin

Fully immunised

None required

None required

Only if risk especially high (e.g. contaminated with stable manure)

Primary immunisation complete, boosters incomplete but up to date

None required (unless next dose due soon and convenient to give now)

None required (unless next dose due soon and convenient to give now)

Only if risk especially high (see above)

Primary immunisation incomplete or boosters not up to date

A reinforcing dose of combined tetanus/diphtheria vaccine and further doses as required to complete the recommended schedule (to ensure future immunity)

A reinforcing dose of combined tetanus/diphtheria 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 3-dose course of combined tetanus/diphtheria vaccine to ensure future immunity.

An immediate dose of vaccine followed, if records confirm this is needed, by completion of a full 3-dose course of combined tetanus/diphtheria vaccine to ensure future immunity

Yes: one dose of human tetanus immunoglobulin in a different site

References: 1. British National Formulary (BNF) March 2004 47 British Medical Association, Royal Pharmaceutical Society of Great Britain, London. 2. Immunisation against Infectious Disease 1996 HMSO: London.

Appendix VI – Fax-back comment sheet

woundcare manual

Section 1:

Section 2:

Section 3:

Section 4:

Section 5:

Section 6:

Section 7:

Section 8:

Section 9:

Section 10:

Section 11:

Appendix VI – Fax-back comment sheet

woundcare manual

Section 12:

Appendices 1-10:

Contact details (optional)

Fax to: Ann Heitmann, Pharmacy Department, Edith Cavell Hospital, Tel: 01733 875617

Your feedback would be welcome on any aspect of this manual. These comments will be forwarded to the Committee and considered for inclusion in its development.

Appendix VlI – Dressing request form

woundcare manual

Request may only be made by a member of the Tissue Viability Group or Nurse Practitioner, and will only be

considered if patient benefits and expenditure implications are clearly identified and supported by relevant

literature. The Tissue Viability Specialist may request further information from applicants if necessary.

Name of Dressing

Company Producing Dressing

Size (s)

Indication

How will the new dressing improve

wound healing?

Summary of references showing the

benefits the new treatment will have

compared to current dressings

Key references reviewed.

These should included independent

reports and evidence based data where

available

List any training implications for staff

Estimated number of patients to receive

treatment per month

Approximate monthly cost per patient,

compared with alternative treatment

including any non-dressing costs/savings

Is this dressing available on FP10

prescriptions?

If so what is the cost per patient per

month?

Are there any other costs; e.g. blood

tests?

The pharmacist will provide help with costing and may b able to obtain references. Please contact Val

Shaw/Jane Symons for advice.

Name of Applicant: ____________________________ Base: _______________________

Signature: ______________________________ Date: _______________________

When completed, please forward this form with any relevant references to Linda Coultrup, Level 6, Peterborough

District Hospital.

Appendix VIlI - Non-formulary dressing request form

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Patient Name: _________________________________ Hospital No: _________________________

Consultant: ____________________________ Ward: _________________________

Dressing Requested: ________________________ Date: _________________________

Company Supplying Dressing: ________________________________________________________________

Reason for Request (please tick):

Continued Use on Admission/Discharge New Request

If new request, list dressings already used from Peterborough Health Care Wound Formulary in the same group

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Reason for choosing Non-formulary Dressing:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

This request may be followed up by the pharmacist to ascertain how useful it has been. You may then be asked

to submit a formal request to the Tissue Viability Group

Please return this form to Linda Coultrup, Level 6, Peterborough District Hospital.

Appendix IX - Dressing changes record form

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DATE

SIGNATURE

DATE

SIGNATURE

DATE

SIGNATURE

Appendix X - Glossary

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TERM DEFINITION

aetiology Cause of a disease or condition

alginate Gel extracted from the cell walls of algae, used in swabs,

dressings, etc.

angiogenesis Process of vascularisation of a tissue involving the development

of new capillary blood vessels

autolytic Spontaneous lysis (rupture) of cells or organelles produced by

the release of internal lysosomal hydrolytic enzymes

bactericidal Agent capable of killing bacteria

bacteriostatic Agent that inhibits the growth or multiplication of bacteria

bio-engineered skin Living replacement for skin, manufactured in tissue culture

bony sequestrum Piece of dead bone that has become separated during the

process of necrosis from sound bone

callus 1. Mass of new bony trabeculae and cartilaginous tissue

formed by osteoblasts early in the healing of a bone fracture

2. Area of hard or thick skin especially on the hand or sole of

the foot caused by continual friction or pressure(may

precede or mask ulceration)

cellulitis An acute, diffuse, spreading, oedematous, suppurative

inflammation of the deep subcutaneous tissues which may be

associated with abscess formation

clotting factors Proteins and vitamins involved in the clotting of blood, e.g.

thrombin, factor VIII, vitamin K

collagen Fibrous protein that gives tensile strength to connective tissues,

e.g. dermis, tendons, arterial walls

colonised

Invaded by micro-organisms without any host response, e.g.

inflammation

connective tissue Loose mesodermally derived tissue, e.g. cartilage, bone, blood,

dermis, rich in extracellular matrix (collagen, proteoglycan) that

surrounds ordered tissues and organs


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TERM DEFINITION

contact sensitivity Allergic response to contact with irritant, usually a

hypersensitivity

debridement Removal of necrotic, infected or foreign material from a wound

dehisce Premature bursting open or splitting along natural or surgical

suture lines. A complication of surgery that occurs secondary to

poor wound healing

Doppler Ultrasound technique for imaging deep tissues

elastin Fibrous protein that allows elasticity in connective tissues, e.g.

dermis, arterial walls

epithelium Tissue covering of internal and external surfaces of the body,

including the lining of vessels and other small cavities

eschar Dry scab that forms on skin that has been burned or exposed to

corrosive agents; hard plaque covering an ulcer

exudate Material such as fluid, cells or cellular debris which has escaped

from blood vessels and has been deposited in tissues or on

tissue surfaces, usually as a result of inflammation

fibroblasts Connective-tissue cells that make collagen and elastin, involved

in wound healing

first (primary) intention Healing of clean, aseptic, surgical wounds that have been closed

with sterile suture

fungating

Wound caused by malignant cells having penetrated into the

epithelium

gamgee tissue/dressing

A thick layer of absorbent cotton between two layers of

absorbent gauze, used in surgical dressings

granulation tissue Highly vascularised tissue that replaces the initial fibrin clot in a

wound. Rich in leukocytes and fibroblasts that secrete

connective tissue

growth factors Proteins and hormones secreted by cells that have a stimulating

effect on other cells, e.g. interleukins, tumour necrosis factor


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TERM DEFINITION

haematoma

A localised collection of blood, usually clotted, in an organ, space

or tissue, due to a break in the wall of a blood vessel

holistic Treating the whole symptoms/disease in a patient

hospital-acquired infections Infection acquired by patient as a result of admittance to hospital

hydrocolloid Gelatinous watery substance useful in dressings because of its

dimensional stability under controlled conditions

immunocompromised Condition in which the immune system is not functioning

normally

inflammation Localised protective response elicited by injury, infection or

destruction of tissue, involving exudation of fluid and leukocytic

migration. Characterised in the acute form by the classical signs

of pain, heat, redness, swelling and loss of function

ischaemia Low oxygen state usually due to obstruction of the arterial blood

supply or inadequate blood flow leading to hypoxia in the tissue

maceration Softening of a tissue by soaking until the connective tissue fibres

are so dissolved that the tissue components can be teased

apart. Usually caused by excess exudate

macrophage Phagocytic cell derived from blood monocyte. Plays an important

role in killing of micro-organisms and tumour cells, antigen

presentation and releases substances that stimulate other

immune cells

MRSA

Methicillin-resistant Staphylococcus aureus. Non-susceptibility of

a microbe to the action of methicillin, a semi-synthetic penicillin

derivative. Many commonly prescribed antibiotics are also not

effective against MRSA bacteria

necrosis Morphological changes indicative of cell death and caused by

the progressive degradative action of enzymes

neutrophil Type of phagocytic leukocyte characterised by cytoplasmic

granules and a multilobed nucleus

normal flora Normally resident (non-pathogenic) microbes


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TERM DEFINITION

nosocomial infections Infection not present or incubating prior to admittance to the

hospital, but generally occurring 72 hours after admittance, the

term is usually used to refer to patient disease, but hospital

personnel may also acquire nosocomial infection

phagocytosis Ingestion (killing) of bacteria and cellular debris by white blood

cells

pilonidal sinus Presence of hair in a dermoid cyst or in a sinus opening on the

skin

presentation Appearance or characteristics of a wound upon admission

primary (first) intention Healing of clean, aseptic, surgical wounds that have been closed

with sterile suture

scurvy Disease caused by vitamin C deficiency affecting collagen

synthesis and the consequent failure of fibroblasts to produce

mature collagen for wound healing

second (-ary) intention Healing of a wound without the benefit of surgical closure. The

wound is allowed to close by contraction and filling with

connective tissue. These wounds are more open, more prone to

infection, and take longer than primary intention healing

sloughy Releasing yellow or white, slimy, viscous tissue debris

strike-through Leakage of fluids through dressing

vasodilation Increase in the internal diameter of a blood vessel those results

from relaxation of smooth muscle within the wall of the vessel.

This causes an increase in blood flow, but a decrease in

systemic vascular resistance

WHO pain ladder World health Organisation index of the degree of pain and a

guide to pain relief by analgesics

wound bed Base of wound closest to healthy tissue from which healing

occurs

wound sinus Cavity in a wound, formed as a result of new tissue growing over

a space

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Appendix Xl - Acknowledgements

The Committee would like to acknowledge the contribution made by the companies below to support our printing costs and launch days.

3M Health Care Limited

Bio Diagnostics

Coloplast

Convatec

Medlock Medical

Molnlycke Healthcare Limited

Parema Medical Limited

Smith & Nephew Healthcare Limited

Unomedical

Grateful thanks to Anne Heitman for all her help and support with the document

woundcare manual

Appendix Xll – Guidelines

Wound Management Guidelines.

Necrotic wounds. (1).

Aim: Debridement – by providing a moist environment.

Is the wound on the heel or toe? Yes refer to guideline 2 No Is the wound infected? - Yes refer to Guideline 5 No Low Exudate Medium Exudate High Exudate Hydrogel (Activ heal, Intrasite, purilon) AND Hydrocolloid (Activ heal or Duoderm)

Hydrofibre (Aquacel) AND Hydrocolloid (Activ heal, or Duoderm or Granuflex)

Hydrofibre (Aquacel) AND Foam (Activ heal or Allevyn)

Apply gel to wound bed, cover with hydrocolloid. Change when exudate 1cm from dressing edge or if leaking.

Cover or loosely pack wound with hydrofibre. Cover with hydrocolloid. Change when exudate 1cm from dressing edge.

Cover wound or loosely pack with hydrofibre. Cover with foam or padding.

Obtain specialist advice from TVN if required.

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Protect surrounding skin if needed – Cavilon Remember to assess nutritional intake. Protein supplements if large / highly exuding wounds. Seek specialist advice (TVN ) for diabetic and arterial patients. Black heels and Toes. (2). Aim: Protect / prevent infection. Is wound infected? - Yes Refer to guideline 5 No Is the patient diabetic? - Yes Refer to Podiatry / Foot Clinic Keep dry NA Dressing. No Is arterial disease suspected? Yes Referral to vascular team. Dress as above No Ensure pressure is relieved For heels If hard, dry and necrotic leave, and monitor. ( EPUAP guideline 09).

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If wound is a blister (blood or clear fluid) Leave intact and allow natural absorption, no dressing needed. Take care not to bandage too tightly! Seek specialist advice (TVN or Podiatry) for Diabetic and arterial patients Remember to assess nutritional intake, may need protein supplement.

Sloughy Wounds. (3) Aim: To debride by providing a moist environment. Is the wound infected? Yes Refer to guideline 5 No Is the slough dry? Yes Treat as necrotic guideline 1 No Low Exudate Moderate Exudate High Exudate Hydrogel (Activ heal or Intrasite) AND Hydrocolloid (Activ heal

Hydrofibre (Aquacel) AND Hydrocolloid (Activ heal or granuflex)

Hydrofibre (Aquacel) AND Foam (Activ heal or allevyn)

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or Duoderm) Consider topical negative therapy or wound bag.

Apply gel to wound bed Cover with hydrocolloid. Change when exudate 1cm from edge of dressing or if leaks.

Apply Aquacel to wound bed or loosely pack. Cover with hydrocolloid. Change when exudate 1cm from edge of dressing or if leaks.

Apply Aquacel to wound bed or pack loosely. Apply foam or padding. Contact TVN re other options.

Protect surrounding skin with Cavilon barrier film If debrdement slow, consider Larvae. Remember to assess nutritional intake. May need Protein supplements for cavity or highly exudating wounds. Consider Topical Negative pressure, refer to TVN Seek specialist advice (TVN or Podiatry) for patients with diabetic or arterial problems. Granulating Wounds. (4). Aim: Promote granulation and epithelialisation. Is the wound infected? Yes Refer to guideline 5 No Is the wound over granulating? Yes Check for infection Contact TVN for advice No

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Low Exudate Moderate Exudate High Exudate Hydrocolloid (Active heal or Duoderm) OR Foam (Activ heal / Allevyn)

Hydrofibre (Aquacel) AND Hydrocolloid (Activ heal or granuflex)

Hydrofibre (Aquacel) AND Foam or padding.

Apply hydrocolloid / foam to wound bed. Change when exudate 1cm from edge of dressing. Can stay in place for 5-7days.

Apply aquacel to wound bed. Cover with hydrocolloid. Change when exudate 1cm from dressing edge.

Apply aquacel to wound bed. Cover with a foam or padding.

Protect the surrounding skin with cavilon if wound exuding. Assess nutritional status, may need protein supplements. Seek specialist advice (TVN or Podiatry) for patients with diabetic or arterial problems. Infected Wounds (5) Aim: To treat infection systemically and decrease the bacterial burden at the wound site.

Is the wound infected? Yes Swab / treat infection with systemic Antibiotics.

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Low Exudate Moderate Exudate High Exudate Inadine OR Actisorb silver

Iodoflex OR Aquacel Ag OR Activon Tulle

Iodoflex OR AquacelAg OR Biatain Ag OR Algivon

Apply inadine Or Actisorb silver. Foam or padding. Change inadine when yellow colour disappears. Actisorb silver change every 2nd or 3rd day.

Apply iodoflex into the wound cover with foam or padding change 2- 3 days or when yellow colour disappears.OR Apply Aquacel Ag and foam and padding leave aquacel ag insitu for 3 days outer padding can be changed. OR Activon tulle cut to size of wound redress 1-2 days depending on exudate.

Apply iodoflex OR Aquacel Ag OR Biatain ag OR Algivon. Change as necessary according to odour or exudate. These dressings can stay insitu for up to 7 days but in wounds with high exudate will need changing more often depending on clinical judgement.

Consider Topical negative pressure Review after 2 weeks if no change contact TVN for advice. Remember nutritional assessment, may need protein supplements. Seek specialist advice for patients with diabetic or arterial problems. Epithelialising Wound. (6). Aim: To provide a moist environment and protection to allow healing.

Epithelial Regeneration: Epithelial Regeneration:

Pink woundPink wound

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Is the wound reducing in size ? No Refer to TVN Yes Low exudate Moderate Exudate High Exudate Hydrocolloid OR Atrauman and padding

Reasses unlikely to be epithelialising

Reassess unlikely to be epithelialising.

Apply hydrocolloid change every 5 – 7 days. OR Apply Atrauman and padding re dress every 2-3 days.

Consider Mepitel if skin fragile – can be left in place for up to 7 days. Remember nutritional assessment

Skin tears (7). Aim: To provide a moist environment, promote healing and prevent further trauma.

Is the wound a large area or deep tissue exposed? Yes

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Apply a non- adherent dressing and Refer to A&E immediately. Is the wound bleeding? - Yes Apply non adherent dressings and padding Elevate the area refer to A&E if persists. Can the wound edges be brought together without force? Yes Steri strip , apply atrauman or Mepitel and foam or padding. No Is there partial or Complete skin loss? do not steri strip Apply low adherent dressing. Consider Mepilex border if fragile skin. Elevate and apply light bandage toe to knee. Refer to TVN after 2 weeks if not healing. Remember nutritional assessment. Seek specialist advice (TVN) if patient diabetic or has arterial problems. Non complex burns for management in Primary Care. Superficial burn. Moisturise – Aqueous cream Skin is dry / intact. OR Minimal tissue damage Non adherent dressing Painful (Atrauman)

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Or Superficial partial thickness? Low adherent dressing (Mepitel) Blisters Padding Red, moist and exuding Check after 48hours mepitel can be Painful left insitu for up to 7 days. Consider Flamazine if antibacterial needed. All other burns apply non- adherent dressing and refer to A&E. Seek specialist advice (TV) for patients with diabetic or arterial problems.

Wound Management Formulary NHS Peterborough

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