Wound Management Formulary NHS Peterborough
-
Upload
brian-harris -
Category
Documents
-
view
100 -
download
9
Transcript of 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
Peterborough Community Services
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
Peterborough Community Services
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
Peterborough Community Services
Liz Huggins
RGN DN Cert Dip Tissue Viability
Health Visitor
Peterborough Community Services
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
Peterborough Community Services
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
woundcare manual
� 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
woundcare manual
����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
Factors affecting wound healing 2
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.
Factors affecting wound healing 2
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.
Wound assessment 3
woundcare manual
• 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
woundcare manual
���� 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
woundcare manual
���� 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
woundcare manual
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
woundcare manual
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
Diabetic foot wounds 6
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.
Diabetic foot wounds 6
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
WOUND TYPE DRESSING AIM EXUDATE
LEVEL RECOMMENDED
DRESSING
NB: Consult with Microbiologist and consider antibiotic therapy if appropriate
H = high M = medium L = low
See formulary for choice of dressing presentation
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
WOUND TYPE DRESSING AIM EXUDATE
LEVEL RECOMMENDED
DRESSING
H = high M = medium L = low
See formulary for choice of dressing presentation
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
Formulary of woundcare products 9
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
Formulary of woundcare products 9
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
Formulary of woundcare products 9
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
Formulary of woundcare products 9
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
Formulary of woundcare products 9
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
Formulary of woundcare products 9
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
Formulary of woundcare products 9
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
Formulary of woundcare products 9
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
Formulary of woundcare products 9
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 product assessment 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 product assessment 10
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
woundcare manual
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
woundcare manual
DATE
SIGNATURE
DATE
SIGNATURE
DATE
SIGNATURE
Appendix IX - Dressing changes record form
woundcare manual
DATE
SIGNATURE
DATE
SIGNATURE
DATE
SIGNATURE
Appendix IX - Dressing changes record form
woundcare manual
DATE
SIGNATURE
DATE
SIGNATURE
DATE
SIGNATURE
Appendix X - Glossary
woundcare manual
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
Appendix X - Glossary
woundcare manual
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
Appendix X - Glossary
woundcare manual
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
Appendix X - Glossary
woundcare manual
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
woundcare manual
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.
woundcare manual
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).
woundcare manual
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)
woundcare manual
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
woundcare manual
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.
woundcare manual
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
woundcare manual
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
woundcare manual
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)
woundcare manual
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.