wound care policy · • initial assessment of wound (appendix 2) and complete wound assessment...

Guideline Number: CLIN/0072/v1(1) Issue/Version No.: 1

GUIDELINES FOR WOUND CARE MANAGEMENT

Current Status: Ratified

Compliance All members of Tees, Esk and Wear Valleys Foundation NHS Trust staff will adhere to the parameters of trust guidelines. The consequences of non-compliance may include disciplinary action and/or legal action.

No: CLIN/0071/v1(1) 1 February 2014 Guidelines for Wound Care Management

DOCUMENT CONTROL Application These guidelines pertains to all areas,

departments and services of Tees, Esk and Wear Valleys NHS Foundation Trust

Associated guideline reference and title

IPC Standards (Universal) Infection Prevention and Control Precautions IC/0002/v3 Aseptic Technique Policy IC/0020/v2. Guidelines for the Collection, Handling and Transportation of Specimens to the Pathology Departments IC/00017/v2. Manual Handling Policy (People and Loads) HS/004v/2

Date of Ratification 6 February 2014

Date of Review 31 March 2017

Replacing CLIN/0072/v1 Guidelines for Wound Care Management

Lead Chris Stanbury, Director of Nursing and Governance

Members of working party Alexia Hardy, Karen Wilkinson, Anne Marie Jackson, Lesley Chapman, Joanne Jacobs

These guidelines has been agreed and accepted by: (Director) Name Designation

Date

Chris Stanbury

Director of Nursing and Governance

6 February 2014

These guidelines have been ratified by: Trust Board or Trust Board Sub Committee (specify)

Date of Trust Board or Sub Committee

Quality Assurance Committee 6 February 2014

These guidelines have gone through an equality impact assessment (EqIA)

Date of EqIA

7 June 2011

Amendments February 2014 Addition of signature and date to wound assessment tool January 2017 Review date extended to end of March to enable review to be completed


1 Introduction

3

2 Scope

3

3 Definition/Glossary 3.1 Stages of Healing 3.2 Types of wounds 3.3 Staging of wounds 3.4 Description of wounds

3

3 3 4 4

4 Responsibilities

5

5 Key Themes 5.1 Assessment of a Wound 5.2 Wound Management 5.3 Management of Self Harm Wounds 5.4 Dressing Wounds: Standard Procedures 5.5 Selecting a Dressing

5

5 6 7 8 8

6 Implementation

10

7. Audit

10

8 Related Policies

10

9. References

10

10. Appendices Appendix 1 Waterlow Score Appendix 2 Flow Chart Appendix 3 Wound Assessment Tool Appendix 4 Wound Care Chart Appendix 5 Wound Care Dressing Choice

11 12 14 15 19 21


1. INTRODUCTION

A wound can be defined as an injury to the body that involves a break in the continuity of tissue or of body structures.

2. SCOPE

These guidelines apply to all clinical staff employed by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) or working on sites where the Trust provides services. All staff should be aware of their limitations and should seek advice and support if needed from the Infection Prevention and Control and Physical Healthcare Team. Mental illness can have a negative affect on the patient’s physical well being. The immune system can become less effective, increasing the patient’s risk of infection. It is therefore important that the physical healthcare of the patient is maintained or improved while providing physical care such as wound care (Pogram and Bloomfield 2010).

3. DEFINITIONS 3.1 Stages of healing

Primary intention is when no tissue loss has occurred and the edges have been brought together via clips or sutures. The wound then begins to heal in the deeper tissues within the closed cavity. Secondary intention is when some loss of tissue has occurred such as a leg ulcer. The wound heals from the inside out by using specific dressings. Tertiary healing is when the wound is left open until the risk of infection or foreign body has gone, only then can the wound be closed.

3.2 Types of Wound • Pressure wounds – A pressure sore/ulcer is an area of localised damage

to the skin and underlying tissue caused by pressure, shear, friction and/or combination of these.

• Arterial leg ulcers – Arterial leg ulcers usually occur as a result of arterial

disease, whereby the perfusion of blood to the lower limb is affected resulting in tissue damage. The ankle and the foot are normally affected.

• Venous leg ulcers – Venous leg ulcers usually occurs secondary to

underlying venous disease whereby there is damage to the deep or superficial veins which leads to venous hypertension. The wounds typically occur on the lower leg.


• Burns/Scalds- Burns can be sustained in a number of ways: scalds

involving hot liquids or flame burns, other causes include chemical contact, electrical and friction damage. The damage to the skin can be superficial resulting in redness or blisters or deep tissue damage.

• Lacerations – This includes either unintentional or intentional lacerations

caused by sharp instruments or tools.

• Minor skin wounds – This includes lacerations blisters, grazes, skin tears and bites.

3.3 Grading of wounds

Stage Description

Stage 1 Intact skin with darkly pigmented skin, may not have visible blanching when pressed.

Stage 2 Partial loss of dermis (2 layers of skin) shows shallow open wound which may look pink/red. May also present as blood stained blister.

Stage 3 Full thickness loss (subcutaneous layer), slough/necrotic may be present, no bone or tendon should be shown.

Stage 4 Full thickness loss, with bone/tendon exposed. Slough/necrotic tissue may be evident.

Unstageable Depth of wound cannot be determined until debridement of slough and necrotic tissue has been achieved.

3.4 Description of Wounds

Superficial Not deep Granulation Wound bed looks pink/red and looks bumpy on the surface – a

healing wound. Epithelisation Wound has skin growing over it and looks pink and healthy – a

wound that is almost healed. Slough Thick, yellow substance which cannot easily be removed. Do

not mistake for bone. Needs debridement. Necrotic Tissue

Black dry, dead tissue, which needs debridement, which will then probably show slough underneath.

Debridement The removal of tissue via surgery or special dressings Exudate Discharge from wound. May be stained with blood giving it a

pink/brown colour. Macerated White soggy skin due to increase of exudate Excoriated Red itchy looking skin, which can be wet in areas. Cavity Deep wound


4. RESPONSIBILITY

The Executive Director for Nursing and Governance has overall responsibility for ensuring these guidelines are implemented. There is corporate responsibility for ensuring these guidelines are supported by appropriate training, policy distribution and awareness and incorporation into the Clinical Governance agenda in terms of audit. There is an individual responsibility to adhere to professional codes of practice and ensure their clinical competency.

5. KEY THEMES 5.1 Assessment of a Wound

The healing of wound can be a complex process as many factors can affect it. It is important to take a holistic approach to the assessment of underlying health problems, contraindications and patient compliance can cause barriers to effective wound management.

The holistic approach to wound assessment

• Assessment of the patients nutritional status using the MUST scoring tool. A patient who scores HIGH will be both at risk of developing a wound or having a wound which will not heal due to malnutrition.

• The Waterlow score (see Appendix 1) must be assessed and regularly

reviewed on patients who are at risk of developing a pressure sore and those who have a pressure sore. National Institute for Health and Clinical Excellence (NICE) recommend patients should receive an initial and ongoing risk assessment in the first episode of care (within 6 hours). Pressure relieving equipment such as pressure relieving mattresses and cushions must be provided to any patient who scores high. These aids are available for hire via Huntleigh Healthcare (NICE 2005 and Manual Handling Policy (People and Loads) HS/004/v2).

• Medications such as steroids and can be a predisposing factor to

wounds as they cause the skin to become thin and fragile. Some medications affect healing for example non-steroidal anti-inflammatory drugs (NSAIDS). Contact the Medicines Information Service (0191 441 5778) for further information on medicines affecting wound healing.

• Underlying health problems can both cause or inhibit the healing process

such as Diabetes, incontinence, vascular disease, self-harming, oedema, cellulitis, skin allergies and poor mobility.


• If there is a concern that a wound or tissue damage could have been

caused as a result of poor practice or neglect a referral to Safeguarding Adults Service must be completed.

Wound specific assessment

• Type of wound – acute or chronic • Location of the wound • The length, width and depth of the wound • The wound bed: is it necrotic, sloughy or infected or is there healthy

granulation and evidence of epithelisation? (indicating a wound is healing well).

• Identify the stage of a pressure sore ie Grade 1 – 4. Any pressure sore identified as either a Grade 2, 3 or 4 must be reported using IR1 forms.

• Surrounding skin • Amount and colour of exudate • Odour • Pain Clinical signs and the management of an infected wound

Signs and symptoms:

• Increased exudate, redness and swelling of the wound. An offensive smell, increased heat and pain to the area.

• The patient may have a temperature and feel unwell. • Redness and heat at an early stage is a normal sign of the inflammatory

process. Redness around wound edges of around 1cm is normal and does not always indicate a sign of infection.

• Always refer wounds that are MRSA positive to the Infection Prevention and Control Team and refer to the IPC Policy and Protocol for the Management of Patients with Meticillin Resistant Staphylococcus Aureus (MRSA) IC/0005/v3.

5.2 Wound Management

• Complete Waterlow and nutritional assessments and act accordingly. • Initial assessment of wound (Appendix 2) and complete wound

assessment tool (Appendix 3). • If the patient is admitted from the community with a wound and has been

seen by the district nursing team via the PCT contact the district nurses for advice on the current wound care management.

• Dressings should be ordered from CARDEA, please ensure a suitable supply is available.

• Dress wound according to wound care chart. • Only prescription wound care dressings to be prescribed on prescription

administration record.


• Obtain swab from wound if showing signs of clinical infection. Complete

the microbiology form providing details such as recent or current antibiotics therapy and the condition of wound. Follow the IPC policy Guidelines For The Collection, Handling And Transportation Of Specimens To The Pathology Departments IC/00017/2

• If antibiotic therapy is required ensure medical staff have observed the wound and have liaised with microbiology to ensure correct treatment is prescribed. Colonised wounds do not require oral antibiotics.

• Follow the manufacturer’s guidelines on how long the wound dressing should be left in place between dressing changes.

• Monitor the wound and evaluate the effectiveness of the dressing used on the wound assessment chart.

• Change the dressing using aseptic technique. Follow the Trust Aseptic Technique Policy No IC/0020/v2.

• Elevate the affected area if appropriate • Provide pressure relief for the patient, this may include a pressure

relieving mattress or cushion. If the patient is bed bound assist in regular turns to relieve pressure.

• Administer pain relief on a regular basis. • Encourage rest • Consider dressings containing silver/antimicrobials if the wound is

colonised with bacteria. These dressings should not be used for more than 10-14 days at a time. Ensure medical staff have observed the wound and sought advice from the microbiology department.

• Contact IPC and Physical Healthcare Team, or Physical Healthcare Practitioners for MHSOP if support and advice is needed.

• Ensure when a patient is discharged with a wound the information is given to the district nursing team to follow up. Alternatively, if a patient is discharged to a nursing home ensure that wound care management information is provided to the nursing home staff.

• Compression bandaging should not be applied unless clinical staff have received training and competency based assessments due to the complications that can occur if applied incorrectly. If a patient requires compression involve specialist teams eg district nurses.

• Sharp debridement of a wound should not be attempted unless staff have received training in this technique.

• Neglect in treating an infected wound could result in Septicaemia (infection of the blood stream)

• Inappropriate and overuse of oral antibiotics can result in antibiotic resistance.

• Wounds that do not heal over a 6 week period on the lower leg should be referred to the Vascular Team at the Acute Hospitals for assessment.

5.3 Management of Self Harm Wounds

Assessment and management for self harm wounds follows the same principles as those in any other wound care outlined in these guidelines,


including assessment of wound site, dimension, amount and colour of exudate, appearance of surrounding skin and intensity of any pain. Appropriate treatment should be provided without unnecessary delay. See Appendix 2. The management of superficial uncomplicated injuries 5cms or less in length the use of skin closure strips (steri strips) should be used. More complicated wounds 5cms or more in length or deeper injuries may need surgical assessment or possibly exploration.

5.4 Dressing wounds: Standard Procedures

• All wounds should be dressed using an Aseptic Technique, to minimise the risk of cross contamination. Refer to policy Aseptic Technique: IC/0020/V2.

• Patients with leg ulcers and pressure sores can have a shower or bath

prior to the aseptic technique procedure. All other wounds can be irrigated gently with 0.9% Normal Saline applied at room temperature.

• Only wash the wound if exudate, necrotic or sloughy tissue needs to be

removed, if the wound is infected or a dressing has adhered to the wound bed. Wounds that are cleaned unnecessarily may cause trauma and may remove good skin cells.

• Ensure all equipment has been collected prior to commencing the

Aseptic Technique. This will include a sterile dressing pack, sterile dressings, sterile/single use scissors and any other equipment required for the procedure such as a wound swab, bandage and tape.

• Carry out the procedure as quickly and efficiently as possible to reduce

any anxiety the patient maybe feeling and to reduce the risk of cross contamination. Also needs to be done quickly to prevent the wound from cooling down too much. Healing is slowed when the wound cools.

5.5 Selecting a Dressing

Choosing the right dressing is a fundamental part in effective wound management see Appendices 4 and 5. The nurse should have some basic knowledge in how wounds heal and be able to recognise what product is required to aide the healing process. A dressing consists of two parts: the wound contact layer (primary dressing) and the secondary dressing. The primary dressing provides the wound with the right environment for healing, the secondary dressing is used to hold the first layer in place and or absorb exudate. In some dressings both layers are in the same dressing eg adhesive foam dressing.


These are some questions the nurse should ask themselves when selecting a dressing.

• What is the action of this dressing? • When should it be used? • Will it absorb all the exudate? • Will it keep the wound moist (essential for healing)? • Will it protect the wound from infection? • What are the contraindications for using this dressing? • Will it cause trauma to the wound when it is removed? • Do I need a secondary dressing to keep it in place? • Is it patient friendly? • Is it cost effective?

The choice of dressing should not be changed too soon unless an allergy has occurred or it has become infected or it is unsuitable for another reason. Dressings need a chance to work over a period of 1-2 weeks so the nurse needs to be able to justify why they have decided to change to another type of dressing. If the status of the wound has not changed over 2-3 weeks then re-assess the wound and consider taking a wound swab and change to another dressing.

Wound dressings should be used in accordance with the manufacturer’s instructions. All packaging must be sealed and in date to ensure the dressing is sterile. Documentation

• Patients who are admitted or transferred from another hospital, nursing

home or their own home with a wound should be documented on admission.

• To ensure all wound care is documented regularly and clearly to aide

continuity of care wound assessment tool must be completed.

• Each wound must have a separate care plan completed. • It is likely a number of staff on the ward will be involved in the care of a

patients’ wound, so to ensure continuity of care is maintained, it is important to keep a detailed account of the progress of the wound. It is also a legal requirement.

• All assessment details should be noted and supported if possible by

diagrams and measurements of the wound.


• A plan of treatment needs be clear and understandable for other

members of staff to follow and implement. Dressings should be prescribed on the prescription and administration record.

• A clear and concise evaluation of the progress of the wound and how it is

being managed after each dressing change must be documented and made accessible to all staff involved. Document on PARIS.

• A review of the wound should be done weekly unless otherwise

indicated. 6. IMPLEMENTATION

Ward Managers and Heads of Service should ensure that all clinical staff are made aware of the guidelines and its content. Training can be accessed by Trust staff in order to assist in the implementation of these guidelines.

7. AUDIT

Ward/Unit Managers will ensure training records are maintained and competence is reviewed annually at appraisals.

8. RELATED POLICIES

IPC Standards (Universal) Infection Prevention and Control Precautions IC/0002/v3 Aseptic Technique Policy IC/0020/v2. Guidelines for the Collection, Handling and Transportation of Specimens to the Pathology Departments IC/00017/v2. Manual Handling Policy (People and Loads) HS/004v/2 IPC Policy and Protocol for the Management of Patients with Meticillin Resistant Staphylococcus Aureus (MRSA) IC/0005/v3.

9. REFERENCES Wilson, J 2006. Infection Control in Clinical Practice. Bailliere Tindal ABC of wound healing: Wound assessment 2006. vol 14 at studentbmi.com Richardson, R. 2004 Acute wounds: an overview of the physiological healing

process. Nursing Times vol 100, issue 04, p-50

NHSSB Wound Management Manual (Northern Health and Social Services Board) NHS Choices. Your health, your choices at http:/nhs.uk/page/home page. Aspx. www.worldwidewounds.com

http://www.worldwidewounds.com/


National Institute for Health and Clinical Excellence 2005 The prevention and treatment of pressure ulcers

Pegram A. Bloomfield J 2010. Would Care: Principles of Aseptic Technique Mental Health Practice Vol 14 (2).

10. APPENDICES

Appendix 1 Waterlow Score

Appendix 2 Flow Chart Appendix 3 Wound Assessment Tool Appendix 4 Wound Care Chart Appendix 5 Wound Care Dressing Choice


APPENDIX 1

WATERLOW PRESSURE ULCER RISK ASSESSMENT CHART

WATERLOW CONTINUOUS ASSESSMENT CHART

ID LABEL

SEVERAL SCORES PER CATEGORY CAN BE CALCULATED

Categories Body Mass Index (kg/m2)

Date Date Date Date Date Date Date Score Score Score Score Score Score Score

Scores

Average 20-24.9 0 Above Average 25-29.9 1 Obese >30 2 Below Average <20 3 Continence Scores Complete/Catheterised 0 Incontinence of urine 1 Incontinent of faeces 2 Doubly incontinent 3 Mobility Scores Fully mobile 0 Restless/Fidgety 1 Apathetic 2 Restricted 3 Bed bound 4 Chair Bound 5 Skin type visual risk areas

Scores

Healthy 0 Tissue Paper 1 Dry 1 Oedematous 1 Clammy/pyrexia 1 Discoloured – stage 1 2 Pressure Ulcer – stage 2-4

3

Nutritional Status Obtain nutritional score from MUST screening tool

Score

0-5


Categories

Date Date Date Date Date Date Score Score Score Score Score Score

Sex/Age Scores Male 1 Female 2 14 to 49 1 50 to 64 2 65 to 74 3 75 to 80 4 81 plus 5 Tissue Malnutrition Scores Eg terminal Cachexia

8

Single Organ failure 5 Multiple organ failure 8 Peripheral vascular disease

5

Anaemia (HB<8) 2 Smoking 1 Neurological deficit Scores Diabetes Multiple Sclerosis Motor/sensory paraplegia

4-6

Cerebro vascular accident

Major surgery/Trauma

Scores

On table >2 hrs (past 48hrs)

5

On table >6 hrs (past 48 hrs)

8

Orthopaedic spinal 5 Medication Scores Cytotoxics Steroids 4 Anti-inflammatory Total Risk Category 10+ at risk 15+ High Risk 20+ very high risk

Signature


APPENDIX 2

INITIAL WOUND ASSESSMENT

WOUND IDENTIFIED

CAN YOU TREAT IT?

YES Dress wound following Trust Guidelines and Policy. Act promptly.

NO – WHY?

• If deep laceration or burn access A&E

• Complex wound contact IPC or Physical Healthcare Practitioners for MHSOP

Document wound care on PARIS and Wound Care Chart. Ensure it is clear, precise and relevant.

Dress wound with non adhesive dressing and bandage until help arrives.

Order dressings from CARDEA

Do not attempt compression bandaging. Contact specialist services at Acute Trust or PCT

Share information in handover. IPC must be

contacted if MRSA identified in wound

If no improvement noted after one week contact IPC.


WOUND ASSESSMENT TOOL APPENDIX 3 WRITE, IMPRINT OR ATTACH LABEL

Surname…………………………. NHS No ………

Forenames ……………………… Sex …………….

DoB ………………………….

Ward………………………………………….

Assessment Chart for Wound Management For multiple wounds complete formal wound assessment for each wound. Add Inserts as needed. Factors which could delay healing: (Please tick relevant box) Immobility Poor Nutrition Diabetes Incontinence Respiratory/Circulatory Anaemia Medication Wound Infection Disease Anti-Coagulants Oedema Steroids Other ………………………… Allergies & Sensitivities …………………………. Body Diagram Front Back

Mark location with ‘X’ and number each wound

Feet Diagram Right Left

Mark location with ‘X’ and number each wound

Signature: ................................................................. Date: .....................................


WOUND ASSESSMENT AND REVIEW Need: Patient requires wound management and care to the following wound / wounds: (please identify) Site/Number……………………………………..…………………………………………. NB: For best practice, please complete separate care plans for each wound.

Goal(s): To promote moist wound healing, prevent clinical infection.

Date of Assessment

Date of Review

Date of Review

Date of Review

Type of Wound Site Number:

History of Wound:

Size of Wound:

Appearance: Red, pink. yellow, black Granulation Epithelisation

Surrounding Site What colour is it? Does it look healthy? Is it intact?

Exudate How much? Colour? Odour?

Signature: .................................................................... Date: ..................................


CARE PLAN

Action / Interventions / Advise via Health Care Staff Date Signature • Map wound size and depth and record weekly. • Record pain using the pain chart, if appropriate. • Irrigate wash with saline, if required or wash ulcerated legs in

shower

• If air flow mattress required record serial number …………………………………………………………………………

• Dress wound using an aseptic technique.

• Record the frequency of dressing changes • Choice of dressing and reason why • Effectiveness of dressing

• Assess on dressing change for signs of improvement and deterioration e.g. infection (change in colour, heat, increase in exudate, odour, reduced circulation). If changes noted, seek advice if needed, take a swab, if required.

• Encourage effective use of medication e.g. pain relief / antibiotics if advised by microbiology

Please add further specific instructions for this patient: • diabetic, chronic circulation problems, medication –

(steroids), Waterlow score, MUST score, and any known allergies.

Complete Evaluation Sheet at each Dressing Change and document on PARIS


Date/Time EVALUATION SHEET Signature


APPENDIX 4 WOUND CARE CHART

REMEMBER TO ALWAYS USE ASEPTIC TECHNIQUE

TYPES OF WOUNDS

PRIMARY DRESSINGS SECONDARY DRESSINGS

GUIDANCE NOTES

Blister – intact Blister – open

Atraumen (non adhesive dressing) Atraumen or If very wet use Aquacel.

Softpore or Mepilex Border (if skin is fragile) Or Sterile padding and bandage. Softpore or Mepilex Border (if wet and fragile)

Do not apply adhesive dressing directly to wound as it will cause trauma on removal. Try to pull skin flap back over wound if possible in a newly opened blister. Change dressings every 48-72 hrs unless infection evident or heavy exudate then change daily. If no improvement after 1 week seek advice. Consider diuretics if blister is due to oedema.

Laceration – superficial Laceration – deep Seek medical help.

Steristrip if possible if not apply Atraumen (non adhesive) dressing prior to secondary dressing if wound continues to bleed slightly. Apply pressure and cover with sterile padding until help arrives.

Softpore or Mepilex Border (if wet and fragile) or Sterile padding and bandage

Try to pull skin flap back over wound bed prior to applying Steristrips. Ensure bleeding has stopped by applying pressure before applying secondary dressing or it will stick to the wound. Change every 48/72hrs.


TYPES OF WOUNDS

PRIMARY DRESSINGS

SECONDARY DRESSINGS

GUIDANCE NOTES

Necrotic/slough – dry or low exudating wound. Dry area to heels.

Intrasite Gel or Intrasite Conformable or Hydrocollied ie Granuflex or Comfeel or Activon –Tulle (Sterile Honey) Daily washing and moisturising with Doublebase or Eparderm.

Softpore or Mepilex Border or Allevyn Heel or Sterile padding and bandage. No dressing required.

Relieve pressure from affected area (elevation). Change every 48/72 hrs Refer to specialist Podiatrist if diabetic foot. Must monitor daily progress and relieve pressure.

Medium to high exudating wounds with or without slough

Aquacel dressing to wound bed only. Consider using a barrier cream or spray (Cavilon) to surrounding tissue to prevent maceration

Mepilex Border Or KerraMax sterile padding and bandage if very wet and seek advice

Ensure secondary dressing is containing exudate well. Change every 24/48hrs if exudate is high or more if indicated, Elevate if possible and encourage rest.

Itchy red rash to lower legs which may weep slightly.

Consider steroidal creams for 1-2 weeks. Daily skin care required

Sterile padding and bandage

Could be Varicose Excema ( not to be confused with Cellulitis)

Infected wound. Signs and symptoms

• Increased pain

• Increased exudate

• Increased redness

• Offensive odour

• Hot to touch • Swelling • High

temperature Nausea/or vomiting

Flaminal on a superficial wound or Aquacel AG or Silvercel on a wet infected wound. or Activon-Tulle (Sterile Honey) if wound is not too wet. Flaminal or Bactroban (mupirocin 2%) can be used on wounds colonised with MRSA. Bactroban must be prescribed on the prescription and administration chart

Mepilex Border Or KerraMax Sterile padding and bandage if very wet and seek advice.

Take a swab. May need antibiotic therapy if advised from microbiology. Clean and change daily. Use silver dressings for 1 – 2 weeks then reassess. Elevate infected area and encourage rest. Increase fluid intake and give pain relief. Contact IPC nurse if advice is needed. Follow IPC trust policies.


APPENDIX 5 TYPES OF DRESSINGS

Primary Dressings Alginates - Aquacel, Kaltostat Highly absorbent, biodegradable

dressing made from seaweed. It turns to a gel like substance when mixed with fluid helping to maintain a moist atmosphere. It also desloughs and granulates tissue. It easy to use and can be applied to large areas and cavities. It should not be applied to dry or very low exudating wounds as needs fluid to work effectively. Can be left in place for up to seven days but this depends on how wet the wound is.

Flaminal ®– is an alginate gel Contains an antimicrobial enzyme system, enabling it to kill antibiotic resistant bacterial strains such as MRSA. Flaminal has been proven to not only kill off bacterial cells but it does not damage healthy human cells required for the healing process. Flaminal is available two prescriptive ways:

• Flaminal Forte gel – for moderately to heavily exuding wounds.

• Flaminal Hydro gel – for light to moderately exuding wounds.

Hydrocolloid Dressings – Granuflex, Comfeel

Contains gel forming agents when mixed with fluid which helps contain the exudate. It desloughs and granulates tissue. It is a semi permeable dressing so it allows water vapour to escape to help enhancing its ability to retain exudate. It adheres well to skin but can cause contact dermatitis. Use on low to moderate exudating wounds and change every 3 – 5 days. You can also use on dry and necrotic tissue to help soften and debride affected area.


Hydrogel – Intrasite gel and Intrasite Conformable

Colourless transparent gel which absorbs low amount of exudate and will maintain a moist environment. Can be applied to many types of wounds and is good to use on dry necrotic tissue or dry sloughy wounds. Can be used with Metronidazole to treat an infected wound. Will require a secondary dressing. Change daily if wet or infected, otherwise every 2-3 days. Each container of Intrasite Gel is for single use only and should be discarded after each dressing change.

Silver dressings - Aquacel AG, Silvercel, Allevyn Ag

Silver is released when mixed with liquid allowing antimicrobial activity to take place against a wide range of pathogens. It is only used on infected wounds and should be changed 1-3days unless otherwise indicated. Wound bed may appear black in places, this is normal and will go when treatment of silver has been stopped. Do not confuse black areas with Necrotic tissue.

Flamazine Cream (Silver sulfadiazine 1%)

Also contains silver and is good on burns or short term on leg ulcers. Be aware of skin contact as it could cause maceration. Change 1-2 days depending on extent of exudate. Flamazine has a short life expectancy so be aware of the expiry date. Flamazine must be prescribed on the prescription and administration chart.

Activon Tulle - Honey dressing

Is an ancient remedy for treatment of infection. It comes from the Manuka bees in New Zealand. Only use sterile honey not from a jar from the supermarket. It will debride, cleanse and deodorize, and has been known to help stop a bleeding wound. It will help treat MRSA and other infections due to its antimicrobial qualities. Can be painful due to its drawing quality and will produce more exudate so is not


ideal for heavily exudating wounds. Can be left in place for up to seven days. Will require a secondary dressing. If diabetic monitor blood sugar regularly.

Charcoal – Actisorb plus, Carboflex and Clinisorb

Charcoal comes as a cloth covered in a knitted viscose rayon fabric and is not adhesive. It helps deodorize wounds by removing molecules and toxins from the wound. Needs secondary dressing. Change 1-3 days. Can be used with other products.

Secondary dressings Mepore or Primapore or Softpore Absorbent perforated cotton dressing

with adhesive border. Good for dry or low exudating wounds. Use with caution on fragile skin. Can be left in place for up to 7 days

Mepilex Border Is very absorbent and has a perforated silicone wound contact layer with a gentle adhesive to whole dressing. Good on fragile skin and maintains moisture. Can be left in place for up to 7 days.

Allevyn Adhesive Similar type of secondary dressing as Mepilex Border.

Sterile padding

Gauze and surgipads can be used on dry to very low exudating wounds. KarraMax to be used only on very wet wounds.

Allevyn non adhesive This can be used on low to moderate exudating wounds

Mesorb and Sorbsan This can be used on heavy exudating wounds.

Retention bandage This can be used to retain primary dressing. Apply toe to knee or wrist to elbow and secure with Micropore tape.

Do not use compression bandages unless you have had training You may need to access other dressings if:

• The patient is allergic to one of the dressings, an equivalent would be required

• The dressing is non effective • An underlying health problem prevents a dressing being used (diabetes,

liver problems, Thyroid problems) • Wound has become much more complex or is not healing please seek

advice.

wound care policy · • initial assessment of wound (appendix 2) and complete wound assessment...

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