THE WALTON CENTRE WOUND MANAGEMENT GUIDELINES

AND FORMULARY.
General Guidance

For further information see Hospital Intranet or contact, Sue Noon Tissue
Viability Nurse (extension 5599 bleep 5437)
The following notes summarise the key principles of wound care and are
followed by a listing of the products recommended for use within The Walton
Centre.

Hand washing/Cleansing

See the Walton Centre Control of Infection Guidelines

Thorough hand washing is one of the most important factors in preventing
wound infection; hands should be washed and dried before and after contact
with any wound.

Covering of wounds

Wounds, once covered, should be exposed as infrequently as possible.

Reasons for exposing a wound include:
> Observation of the wound for complications.
> Removal of excess exudate.
> Removal of dead tissue.
> Removal of drains or sutures.
> Treatment of local infection

For a discharging wound the dressing must be changed often enough to avoid
contamination of its surface. However, dressings should always be carried out
with minimum disruption to the healing wound, and it should be remembered
that antiseptics may damage healing tissue as well as killing bacteria. The
dressing of a wound should not be carried out within 30 minutes of dusting or
bed making.

Criteria for Choosing a Dressing In Order of Importance (Miller & Collier,

1997)

1. Choose a dressing that maintains a moist environment at the wound bed.

1. (The only exceptions are peripheral necrosis secondary to arterial disease).
2. Choose a dressing that is able to control (remove) exudate. A moist wound
environment is good; a wet environment is not beneficial
3. Choose a dressing that does not stick to the wound and cause trauma on
removal
4. Choose a dressing that protects the wound from the outside environment
5. Choose a dressing that will aid debridement if there is necrotic or sloughy
tissue in the wound. (With exception of ischaemic wounds)
6. Choose a dressing that will keep the wound close to normal body
temperature
7. Choose a dressing that is acceptable to the patient
8. Choose a dressing that is cost-effective
9. Diabetes – choose a dressing that will allow frequent inspection

Wound Cleansing

Normal saline has been identified as the treatment of choice for most wound
cleansing (Dealey 1999) as it is isotonic so does not donate or withdraw fluid
from the wound (Davies 1999)
In cases where wound cleansing is necessary, warm normal saline should be
used. Cell mitosis is inhibited by cooling the wound and may actually delay
healing (Lock, 1980).

TIME Concept

Wound Bed Preparation uses four principles in the acronym T.I.M.E which
provides a systematic approach to the management of wounds, by focussing
on each stage of wound healing. By removing these local barriers, the wound
can progress to healing. T.I.M.E is based on intervention in four clinical areas
and leads to an optimal, well vascularised wound bed.

T Tissue non-viable or deficient

Does the wound contain non-viable tissue such as necrotic tissue, slough,
non-viable tendon or bone?

I Infection or Inflammation
Does the wound have signs of bacterial contamination, infection or
inflammation?

M Moisture Imbalance
Does the wound have excess exudate or is the wound too dry?

E Edge of wound non advancing or undermined

Are the edges of the wound undermined and is the epidermis failing to
migrate across the granulation tissue?
Wound healing continuum

The wound healing continuum – uses colour to show the tissue present in the
wound and how the wound should progress.

The normal progression of a wound is to move from black to pink. An estimate

of the amount of each colour can be given to indicate an improving wound.
Exact amounts are not required as long as the general movement is from left
to right and in an expected time given in the care plan. Levels and thickness
of exudate provide a key indication of the presence of bacteria. Thick exudate
in high volumes can be expected if you have large amounts of necrotic
sloughy tissue present. However as the wound progresses exudate should
become thin and reduce in amount. If the exudate from the wound increases
or becomes more purulent/offensive this can be a sign of infection.

Offensive Odours
1. May indicate that the frequency of dressing change needs to be increased.
2. May indicate infection and the patient may require a systemic antibiotic.
3. In exceptional circumstances metronidazole solution may be prescribed
to irrigate the wound. Do not soak gauzes in the solution and apply - this
will cause resistance.

For fungating malodorous tumours the use of metronidazole gel

(Metrotop®) should be considered.
TISSUE TYPES

Hard Black Eschar

Stable (dry, adherent, intact without erythema or fluctuance) eschar on the

heels serves as “the body’s natural (biological) cover” and should not be
removed(EPUAP 2009)

Description Objective Dressing options

Hard black /brown To rehydrate eschar and Hydrogel

appearance reduce risk of infection
Hydrocolloid

Necrotic lesions in diabetic foot ulcers should be treated cautiously.

Dry necrotic toes should be left dry and allowed to separate naturally.
Due to the increased risk of infection and amputation, necrotic lesions on feet
should be left dry until a full foot assessment has been performed by Podiatry.
Referral to Tissue Viability for assessment is essential.
Black wet necrotic wound

Description Objective Dressing options

Black, green, yellow wet Hydrate to assist removal Hydrogels,

tissue. of devitalised tissue
Hydrocolloids,
Malodourous Remove slough to enable
wound to granulate Hydro-fibre,

Prevention of infection Antimicrobials

(with caution and TVN
Odour and exudate advice)
management
Larvae therapy (TVN
Protection of surrounding advice only)
skin using barrier

Exception
Due to the increased risk of infection and amputation, necrotic lesions on feet
should be left dry until a full foot assessment has been performed. Referral to
Tissue Viability for assessment is essential.
Yellow sloughy wound

Description Objective Dressing options

Yellow/green/black slough Remove slough to Hydrogels/hydro-fibre with

encourage wound to foam secondary dressing
Wet and possibly Granulate
malodorous. Hydrocolloid
Prevention of infection
Antimicrobial dressings
Odour and exudate (TVN advice)
management
Larvae therapy (TVN
Protection of surrounding advice only)
skin using barrier
 Red granulation tissue

Description Objectives Dressing options

Red colour with visible Maintain a moist wound Hydro-fibre/alginate

granulation buds. healing
environment, Foam secondary dressing
No slough or discoloured
tissue. Encourage granulation If cavity present;
tissue Hydro-fibre to loosely fill
the wound to encourage
Reduce exudate. granulation tissue, will also
aid autolytic debridement if
Protect from sloughy
infection and trauma
V.A.C (TVN assessment
only)

Hydrocolloid for superficial

wounds.
 Epithelial
tissue

Description Objectives Dressing options

Pink, fragile tissue Reduce friction and Hydrocolloid

maintain skin integrity

To continue to
encourage new tissue
and allow final stage of
healing
Hyper-granulation Tissue - is believed to occur as a result of an extended
inflammatory response.
Granulation usually occurs in an orderly, if occasionally, slow manner in the
majority of wounds, in others it can become disorganised resulting in the
production of a protruding mass of granular tissue, which appears to inhibit
wound closure. This ‘over-granulation’ can be unsightly and distressing to
patients, as well as posing a management challenge to clinicians.

There appear to be a number of factors that could initiate an over-granulation

response and will dictate how it is treated

Infection/high bio-burden - If the precipitating factor is the presence of high

bacterial burden, either as critical colonisation or local, sub-clinical wound
infection, there is a need to redress the bacterial balance. Systemic antibiotics
are effective in reducing bacterial load but may be associated with systemic
complications and are not indicated for the treatment of colonisation and
localised wound infection (World Union of Wound Healing Societies
[WUWHS], 2008; Best Practice Statement, 2010), unnecessary treatment with
antibiotics may also contribute to antibiotic resistance.

Reaction to foreign bodies - The presence of foreign material within a wound

can lead to prolonged inflammation as the body seeks to overcome a
perceived threat to tissue integrity. Repeated trauma through friction and
traction on the wound can lead to inflammatory reactions (Hanlon and
Heximer, 1994) such irritation can be commonplace in gastrostomy and
tracheostomy site wounds and may account for the frequency with which
over-granulation is seen in these wounds (Vuolo (2010)

Allergy/hypersensitivity -
A number of wound products, such as adhesives and some antimicrobial
agents have the potential to trigger an immune reaction in some susceptible
individuals. This immune response acts as a focus of continued inflammation
until the causative ingredient is removed.
Poor moisture control – if the principle cause of over-granulation is poor
moisture control and oedema, steps should be taken to manage this. The use
of higher absorbency or less occlusive dressings enable improved exudate
management, thereby preventing tissues becoming saturated with fluid
(Dunford, 1999).

Treatment options

The use of higher absorbency or less occlusive dressings enable improved

exudate management,

The application of local pressure may also assist in forcing fluid out of the
tissues and so ‘flattening’ any raised areas, use of double (plain) foam
dressings can assist with this.

In the absence of infection, the use of topical steroids should be considered

Topical antimicrobial products have a more localised effect and may be

effective at reducing bacterial burden without affecting systemic flora. This
makes them an effective tool in wound care; however, their use should be
limited to a 10–14-day period
Skin tears

At risk/fragile skin

The epidermis (outer layer of the skin) is separated from the dermis (inner
layer of the skin), or both the dermis and the epidermis are separated from the
underlying tissue. Tears can be simple such as a linear injury, or be more
complex, with include tissue loss haematoma and bruising. Skin tears mainly
occur on the arms and legs, but can occur on any area that is knocked or
scraped.
Description Objectives Dressing options

A skin tear usually Control bleeding Non adhesive silicone

occurs in the elderly or based dressing with foam
those with fragile skin, Cleanse wound with saline secondary dressing.
as a result of a knock or to remove any debris (It is important to avoid
vigorous washing and present. harsh adhesive dressings)
drying of the skin.
If possible and the flap is Light retention bandage
viable gently ease the skin
flap back in to place

Encourage moist wound

healing environment

Infected Wounds:
Before commencing any topical or systemic therapy, swabs should be taken
for culture and sensitivity.
Where wounds are only colonised or have superficial local infection present,
topical antimicrobials may be used. Antibiotic therapy is generally not required
or prescribed for wound colonisation alone, further advice should be sought
concerning systemic therapy, from the Infection Control Team, if there is
evidence of spreading cellulitis.
Antiseptic dressings, for example, those impregnated with silver or iodine may
be helpful for wounds infected or heavily colonised with MRSA (White et al,
2001) and their use should be considered if appropriate for the wound type.
Superficial MRSA wound colonisation may occur without undue complications
or delayed wound healing.

Antibiotic applications to wounds:

Antibiotic applications should be avoided, since they can lead to the
emergence of resistant organisms and cause sensitisation. In particular,
agents that are also used systemically (e.g. gentamicin, fusidic acid)
should only be used on the authority of a Microbiologist or
Dermatologist)
 Infected Wounds
Type Indicator/descriptor Management aims

Colonised Multiplications of Prevent Infection

organisms with, as yet,
no host reaction Reduce bacterial
numbers
Positive swab/biopsy
Prevent bacterial
proliferation

Critically Colonised Sufficient organisms Reduce bacterial

present to interfere with numbers
healing but not invading
surrounding tissue, Prevent bacterial
therefore no infection
inflammation
Remove barriers to
Characteristics: healing
Pain, excess exudate,
Dull, dark red
granulation tissue,
wound is static and
delayed healing

Clinically Infected Deposition and Resolve deep infection

multiplication of bacteria using systemic
with host reaction antibiotics

Characteristics of Reduce bacterial

infection: numbers
Pain, Erythema,
Inflammation, Pyrexia, Treat symptoms
Pus, Odour, Heavy
exudate, Non-healing Prevent septicaemia

Remove Barriers to
healing

In cases of clinical infection, systemic antibiotics must be used

When assessing a wound, check for signs of a spreading infection:
• Pyrexia
• Localised heat and swelling around the wound margins
• Pain
• Friable wound bed, pus, green slough and offensive odour may be present

Please refer to the Infection Control protocols on the Walton Centre Intranet
BURNS

Classification of Burns

Burns are classified as first-, second-, or third-degree, depending on how

deep and severe they penetrate the skin's surface.

First-degree (superficial) burns

First-degree burns affect only the epidermis, or outer layer of

skin. The burn site is red, painful, dry, and with no
blisters. Mild sunburn is an example. Long-term
tissue damage is rare and usually consists of an
increase or decrease in the skin colour.
Symptoms may include:

 redness
 dry skin
 skin that is painful to touch
 pain usually lasts 48 to 72 hours and then subsides
 peeling skin

Second-degree (partial thickness) burns

Second-degree burns involve the epidermis and part of the

dermis layer of skin. The burn site appears red,
blistered, and may be swollen and painful.
Symptoms may include:

 blisters
 deep redness
 burned area may appear wet and shiny
 skin that is painful to the touch
 burn may be white or discoloured in an irregular pattern

Third-degree (full thickness) burns

Third-degree burns destroy the epidermis and dermis.

Third-degree burns may also damage the
underlying bones, muscles, and tendons. The
burn site appears white or charred. There is
no sensation in the area since the nerve
endings are destroyed. Symptoms may
include:

 dry and leathery skin

 black, white, brown, or yellow skin
 swelling
 lack of pain because nerve endings have been destroyed
Burns require specialist input, a copy of the Northern Burn Care Network
protocol is included on the Tissue viability/Infection Control website for
information, however always refer to the Tissue Viability Nurse.

PRESSURE ULCERS

Common Definition of Pressure Ulcers

A pressure ulcer is localized injury to the skin and/or underlying tissue usually
over a bony prominence, as a result of pressure, or pressure in combination
with shear. A number of contributing or confounding factors are also
associated with pressure ulcers (EPUAP 2009)

Assess the risk for new pressure ulcer development using a structured,
consistent approach which includes a validated risk assessment tool and a
comprehensive skin assessment, refined by using clinical judgment.

Spinal-Cord-Injured Individuals
Ideally, Ischial ulcers should heal in an environment where the ulcers are free
of pressure and other mechanical stress. Total bed-rest may be prescribed to
create a pressure-free wound environment. However, this approach comes
with potential physical complications (e.g., muscle wasting, deconditioning,
respiratory complications), psychological harm, social isolation, and financial
challenges for the individual and his/her family. Balancing physical, social,
and psychological needs against the need for total offloading (i.e., total bed-
rest) creates a challenging dilemma for the individual and the professional.
Use of a wheelchair is imperative for spinal-cord-injured individuals. Sitting
time may need to be restricted when ulcers are present on sitting surfaces.
Seating cushions must be high-immersion, uniform-loading distribution
cushions. Refer to the Consortium on Spinal Cord Injury Medicine guidelines
for additional information (EPUAP 2009)

Bariatric patients
Pressure ulcers may develop in unique locations, such as beneath folds of
skin and in locations where tubes and other devices have been compressed
between skin folds. Pressure ulcers develop over bony prominences, but may
also result from tissue pressure across the buttocks and other areas of high
adipose tissue concentration (EPUAP 2009).

Refer to ‘Pressure Ulcer Guidelines – The Prevention and Management’ on

the Walton Centre intranet
 Pressure Ulcers

Intact skin with non-

blanchable erythema of
a localized area usually
over a bony Ensure pressure
prominence. removed from the
area.
Discoloration of the
Grade 1
skin, warmth, oedema, Monitor
hardness or pain may
also be present. Apply skin protection
barriers as needed
Darkly pigmented skin
may not have visible
blanching.

Partial thickness loss of

dermis presenting as a
shallow open ulcer with
Ensure pressure
a red pink wound bed,
removed from area
without slough.
Grade 2
May also present as an
Hydrocolloid or dry
intact or open/ruptured
dressing
serum or sero-
sanguineous-filled
blister.
 Pressure to keep off
the area at all times.
Full thickness skin loss.
Subcutaneous fat may
Loosely fill the cavity
be visible but bone,
with hydro-
tendon or muscles are
fibre/alginate
not exposed.
dressing to promote
Grade 3 granulation and aid
Some slough may be
autolytic debridement
present.
if wound sloughy.
Foam dressing to
May include
secure.
undermining and
tunnelling.
VAC therapy (TVN
advice only)

Full thickness tissue Pressure to be kept

loss with exposed bone, off area at all times
tendon or muscle.
Loosely fill the cavity
Slough or eschar may with hydro-
be present. fibre/alginate
Grade 4 dressing to promote
Often includes granulation and aid
undermining and autolytic debridement
tunnelling. if wound sloughy.
Foam dressing to
secure

VAC therapy (TVN

advice only).
 Purple or maroon Ensure pressure kept
localized area of off the area at all
discoloured intact skin times.
Deep tissue injury or blood-filled blister
(term used in USA) due to damage of Protect and monitor
underlying soft tissue
from pressure and/or
shear.

Full thickness tissue loss

in which actual depth of
the ulcer is
completely obscured by Ensure pressure kept
slough (yellow, tan, gray, off the area at all
Ungradeable green or brown) and/or times.
eschar (tan, brown or
Depth unknown
black) in the wound bed.
(term used in USA)
Until enough slough
and/or eschar are
removed to expose the Monitor and grade at
base of the wound, the earliest opportunity
true depth cannot be
determined; but it will
be either a
Category/Stage III or IV.
LEG ULCERS:

A leg ulcer is a long-lasting (chronic) wound on the lower leg or foot that
takes more than six weeks to heal.

The symptoms of a venous leg ulcer include pain, itching and swelling in the
affected leg. There may also be other signs, such as discoloured or hardened
skin around the ulcer. A venous leg ulcer is the most common type of leg
ulcer, accounting for 80-85% of all cases. Venous leg ulcers develop when
persistently high blood pressure in the veins of the legs (venous hypertension)
causes damage to the skin, which eventually breaks down and forms an ulcer.

Other common types of leg ulcer include:

arterial leg ulcers – caused by poor blood circulation in the arteries

diabetic leg ulcers – caused by the high blood sugar associated with
diabetes

vasculitic leg ulcers – associated with chronic inflammatory disorders such

as rheumatoid arthritis and lupus

traumatic leg ulcers – caused by injury to the leg

malignant leg ulcers – arising from a tumour of the skin of the leg

Leg ulcers should be assessed by a suitably qualified professional with

experience in leg ulcer management, as the treatment of these requires
additional training.

Refer to Tissue Viability for advice and support ext 5599 or bleep 5437
Surgical wounds
Surgical and acute wound management focuses on restoration of function and
physical integrity with the minimum deformity and without infection. A holistic
approach to assessment and management of surgical and acute wounds is
essential.

Classifications of surgical wounds

_ Clean: an incision in which no inflammation is encountered in a surgical

procedure, without a break in sterile technique, and during which the
respiratory tract, alimentary or genitourinary tracts are not entered.

_ Clean-contaminated: an incision through which the respiratory, alimentary,

or genitourinary tract is entered under controlled conditions but with no
contamination encountered.

_ Contaminated: an incision undertaken during an operation in which there is

a major break in sterile technique or gross spillage from the gastrointestinal
tract, or an incision in which acute, non-purulent inflammation is encountered.
Open traumatic wounds that are more than 12–24 hours old also fall into this
category.

_ Dirty or infected: an incision undertaken during an operation in which the

viscera are perforated or when acute inflammation with pus is encountered
(for example, emergency surgery for faecal peritonitis), and for traumatic
wounds where treatment is delayed, there is faecal contamination, or
devitalised tissue is present.

Debridement The excision or wide removal of all dead (necrotic) and

damaged tissue, that may develop in a surgical wound.
Healing by primary intention Occurs when a wound has been
sutured/stapled after an operation and heals to leave a minimal, cosmetically
acceptable scar.

Healing by secondary intention

Occurs when a wound is deliberately left open at the end of an operation. Heals
by contraction, granulation and epithelialisation. The healing duration will depend
on the amount of tissue that must be replaced. The resulting scar may be quite
extensive
Delayed Primary (Tertiary) Intention

The wound is kept open to allow for drainage of exudate, and control of
contamination. At a later date the wound is surgically closed (usually within 7
days)

Changing dressings
Use an aseptic non-touch technique for changing or removing surgical wound
dressings. Use an appropriate interactive dressing to manage surgical
wounds healing by secondary intention.

Refer to a tissue viability nurse (or another healthcare professional with tissue
viability expertise) for advice on appropriate dressings for the management of
surgical wounds that are healing by secondary intention.

Postoperative cleansing
Use sterile saline for wound cleansing up to 48 hours after surgery if
indicated

Advise patients that they may shower safely 48 hours after surgery.

Complications of surgical wounds

Surgical site (wound) infection This occurs when pathogenic organisms

multiply in a surgical wound giving rise to local signs and symptoms, for
example, heat, redness, pain and swelling, and (in more serious cases) with
systemic signs of fever or a raised white blood cell count.
Infection in the surgical wound may prevent healing taking place so that the
wound edges separate or it may cause an abscess to form in the deeper
tissues.

Heamatoma
Hematoma after surgery or postoperative hematoma is basically a localized
collection of blood at the surgery site. It is defined as the collection or pooling
of blood under the skin, in body tissues or an organ. Hematoma may develop
a few hours (or even days) after the surgery, due to some kind of damage to
the surrounding blood vessels during the surgery. Often mild cases of
hematoma get reabsorbed, and do not require surgical intervention. If this is
not the case then surgical intervention may be required.

Dehisced Wound
Wound opens
Sinus
A wound sinus is a discharging blind-ended track that extends from the
surface of an organ (the skin) to an underlying abscess or cavity. The track is
usually lined with granulation tissue. (Butcher, 1999)

A thorough examination of the wound is essential to observe the condition of the

surrounding tissue for signs of maceration, excoriation and cellulitis. The nature of
the exudate, its volume, colour and consistency should also be noted. The
management of a sinus will depend on its underlying aetiology, ie infection,
liquefaction (natural breakdown of dead tissue) or foreign body.
Refer these wounds to tissue viability nurse for assessment and treatment plan.
PRODUCTS AVAILABLE FOR USE WITHIN THE WALTON CENTRE

Charcoal Clinisorb ®, Carboflex®

Hydrocolloid Duoderm® Extra thin
Hydrofibre Aquacel®, Aquacel® AG
Hydrogel Aquaform®, Intrasite ®
**Honey Medihoney Activon®, Algivon®
Paraffin Tulle
Polyurethane Foam 3M Foam
Iodine Inadine ®, Iodoflex ®
Silicon Non Adherent Silflex ®
Barrier Film Cavilon ® Cream, Spray, Stick
Protease Modulating Dressings Promogram®
Honey – see intranet
**Maggots (TVN assessment only)

** These products are ordered via tissue viability nurse, not from Pharmacy.

HYDROCOLLOIDS (Duoderm Extra Thin)

Consists of a foam sheet that is covered with hydrophilic particles. In contact

with wound exudate these particles swell forming a gel which promotes wound
healing. They hydrate necrotic/sloughy tissue encouraging autolysis,

1. Minimum 2cm overlap (3cm is recommended) - Do not use on fragile skin.

2. Warm the dressing with hands and mould to the wound to ensure that
adhesive sticks to the skin.
3. Leave on for 4-5 days; maximum 7 days. This is important: wound will not
heal if dressing is changed too frequently.
4. Note: wound may look worse on removal of dressing - this is part of the
healing process and can be due to the presence of exudate which should
be removed using warm saline.
5. Different sites require different types of i.e. Extra Thin, should be used on
awkward areas such as heels and sacrum and on superficial wounds with
minimal exudate.
6. An expensive dressing if used inappropriately.
7. Do not use if anaerobic infection is present.

NB Not to be used on heavily exudating wounds, caution with diabetic

patients.

Size - 5cm x 10cm, 7.5cm x 7.5cm, 10cm x 10cm. 15cm x 15cm, 9cmx 15cm,
9cm x 25cm, 9cm x 35cm
HYDRO FIBRE (Aquacel®, Aquacel® AG )
Interlocking weave of Hydrocolloid fibres (sodium carboxymethylcellulose)
allowing the absorption of excess exudate. Retains fluid within its structure
and reduces the risk of maceration and excoriation.
AG (silver) – impregnated useful for infected or malodorous wounds.

1. Cut Aquacel sheet to shape to allow a 1cm overlap.

2. Do not moisten prior to application or combine with any other primary
dressing, e.g. Inadine or Intrasite gel.
3. Cover with a moisture retaining secondary dressing.
4. Infected wounds should be changed daily.
5. Can be used on heavily exudating wounds.
6. Ribbon dressing to be used to loosely fill cavity wounds

NB: Do not use on dry wounds

Size - 5cm x 5cm, 10cm x 10cm, 15cm x 15cm, 2cm x 45cm. (“ribbon”)

HONEY (Actilite® Algivon®)

Actilite - is an antibacterial non adherent primary dressing impregnated with
manuka Honey and Manuka Oil. Depending on exudate levels from wound
can be left in place up to 7 days.
Algivon – is an alginate dressing impregnated with honey that will help to
maintain a moist wound healing environment, help reduce odour associated
with malodorous wounds, absorb exudate and assist to de-slough and de-
bride necrotic wounds.

1. Honey should not be used on patients who have an allergy to honey or

honey products.
2. Place directly onto wound bed, can be cut to size, change the dressing
when the colour changes significantly
3. Facilitate dressing removal by irrigating wound bed with normal saline.
4. Cover with secondary dressing

Size – 5cm x 5cm, 10cm x 10cm. Order via tissue viability nurse, not
pharmacy

SILICON NON-ADHERENT DRESSING (Silflex®)

Silflex
Soft silicone wound contact layer, to be used under secondary dressing or
with Vacuum Assisted Closure (VAC)
1. May be used on skin tears, abrasions, surgical wounds, burns, lacerations,
pressure ulcers and leg ulcers
2. Not to be used on patients who have sensitivity to silicone

Size - 5x7cm, 8x10cm,12x15cm,20x30cm,36x60cm

NO STING BARRIER FILMS – (Cavilon®)

A non sting protective transparent barrier film. Provides protection to the skin
from bodily fluids including wound exudates, and also from tapes and
dressings.

NB Should be applied every 3 days.

Size 1ml & 3ml “lollipops”, 28ml spray.

HYDROGEL (Aquaform ®)

Absorbs exudate and produces a moist environment at the surface of the

wound promoting rapid debridement by rehydration and autolysis of dead
tissue.
1. Apply a layer at least 5mm thick on wound only, as excess use on healthy
skin will cause maceration.
2. Consider protecting surrounding skin with white soft paraffin. Choice of
secondary dressing depends on amount of exudate produced.
3. The dressing may be left in place for up to 3 days or until strike through of
exudate appears on the secondary dressing. Change dressing daily if
infected.
4. Cleanse wound thoroughly with warm saline before re-applying.
5. The preservatives may be irritant for some patients: use cautiously.
6. Hydrogels interact with povidone-iodine and should not be used together. It
should not be used with dressings such as Aquacel.
7. Do not use two of 8g size. Order 15g pack.

Size - 8g,15g.

Flaminal Forte

Alginogel for use on medium to heavily exuding wounds. Consists of an

antibacterial enzyme system embedded in hydrated alginates. It is indicated
for moderately to heavily exuding wounds such as this helps;
1. Keep wounds moist and clean
2. Offers antimicrobial protection and can assist in reduction of wound odour
caused by bacteria
3. Safe for skin and wound tissue
Order via tissue viability nurse, not Pharmacy.

Tegaderm Foam ® - adhesive dressings

Foam dressings are hydrophilic and have a non-adherent surface.

1. Use for moderately exudating wounds.

2. Can be used as primary or secondary dressing.
3. Should not be used as pressure relieving pad.

Size – 6.9 x 6.9, 6.9 x 7.6, 8.8cm x 8.8cm, 10cm x 11cm, 14.3cm x 14.3cm,
14.3cm x 15.6cm, 19cm x 22.2cm, 13.9cm x 13.9cm (heel)

Biatain silicone ® foam dressings

These are to be used at recommendation of the Tissue Viability/Infection

Control team for patients that have very fragile skin or allergy to adhesive on
the Tegaderm foam. These are also to be used for head wounds were
appropriate due to ease of removal.

Size - .5x7.5cms ; 10x10cms; 12.5x12.5cms; 15x15cms;17.5x17.5cms. Order

via tissue viability nurse, not Pharmacy.

CADEXOMER IODINE (Iodoflex® paste)

1. Indicated for the treatment of sloughy, infected (including MRSA) wounds

with moderate to high exudate.
2. A single application should not exceed 50g.
3. The total amount of Iodoflex used in one week must not exceed 150g.
4. Dressings should be changed approximately 3 times per week or when the
Iodoflex has become saturated with wound exudate, indicated by a loss of
colour.
5. Duration of treatment must not exceed one week.
6. Contraindicated in patients with known or suspected iodine sensitivity,
Hashimoto’s thyroiditis and in patients with a past history of any thyroid
disorder. Do not use if patient is pregnant or breast feeding.

Size - 6cm x 4cm, 8cm x 10cm, 8cm x 6cm. Order via tissue viability nurse,
not Pharmacy.

POVIDONE-IODINE (Inadine®)

Inadine is a knitted viscose primary dressing impregnanted with 10%

povidone-iodine.
1. Inadine should only be used for infected superficial wounds.
2. Cover with secondary dressing depending on amount of exudate.
3. Antibacterial activity of dressing lasts for 2 days.
4. Change dressing type after controlling infection as povidone iodine can
slow healing.
5. Contraindicated in patients with known or suspected iodine sensitivity.
Hashimoto's thyroiditis and in patients with past history of any thyroid
disorder. Do not use if patient pregnant or breast feeding.

Size - 5cm x 5cm, 9.5cm x 9.5cm.

Aderma dermal pads

These are designed to help prevent pressure ulcers and should be used at
the early signs of pressure damage.

1. To be used on intact skin only

2. Can be cut with scissors
3. Can be washed and reused for the same patient.
Order via tissue viability nurse, not Pharmacy

V.A.C (KCI, vacuum assisted closure Tissue viability request)

The integrated V.A.C. Therapy System promotes wound healing through

Negative Pressure Wound Therapy (NPWT). Delivering negative pressure (a
vacuum) at the wound site through a unique, proprietary dressing helps draw
wound edges together, removes infectious materials and actively promotes
formation of the granulation tissue.
This should not be used on grossly infected or bleeding wounds, malignancy,
exposed vessels or organs, unexplored fistulae, extensive necrotic tissue or
non-concordant patients. (There is a separate assessment form for the use of
VAC therapy).

Larvea (Tissue Viability request)

Larval Therapy, also known as 'Maggot Therapy' involves the use of larvae of
the greenbottle fly, which are introduced into a wound to remove necrotic,
sloughy and/or infected tissue. Larvae can also be used to maintain a clean
wound after debridement if a particular wound is considered prone to re-
sloughing. Larvae can in some cases cleanse wounds much more rapidly than
conventional dressings and can improve the condition of a wound allowing the
process of healing to begin.

CAPILLARY ACTION DRESSING

Three layer dressing of polyester/cotton fibres pull interstitial fluid from the wound
surface to a central layer.
1. Must only be used after review by the wound care team.
2. Useful for highly exudating wounds.
3. Duration for dressing change to be specified by wound care team.
4. Do not use on heavily bleeding wound or if bone or tendons are exposed.

Bandages
K-Soft is a soft-absorbent sub compression bandage. It is also available as
a longer size for longer legs. They help to :
1.Absorb exudate
2. Redistributes pressure to help prevent damage to bony prominences
3. Helps to shape the leg
4.Soft and comfortable
5.Very comformable
6.Extra resilience and cushioning

Size - 10cm x 3.5cm, 10cm x 4.5cm (for longer leg)

K-Lite is a type 2 support bandage. It is also available as a longer size for

longer legs. Acts as a base for compression is comfortable and comformable.
Can be used for the treatment of Venous Leg Ulcers (2nd layer of K-Four
multilayer bandage system), light support for sprains and strains and can be
used for retention bandaging.

Size - 5cm x 4.5m, 7cm x 4.5m, 10cm x 4.5m, 15cm x 4.5cm, 10cm x 5.25cm
(for longer leg). Order via tissue viability nurse, not via Pharmacy.

Mild and moderate corticosteroid preparations - are associated with few

side effects but still need to be used with care. Topical corticosteroids should
be applied no more frequently than twice daily, once daily is often sufficient,
occlusion will increase the potency. Application of steroid preparations can be
measured in fingertip units with 1 fingertip unit enough to cover an area that is
twice the size of the flat adult palm, a single daily application should continue
for no more than 2 weeks.
Available in 30g tubes

Trimovate - Mild corticosteroid preparation with additional nystatin. This is

sometimes unavailable, in which case Terracortril is the usual alternative.

Timodene - Moderate corticosteroidsteroid preparation with additional nystatin

and oxytetracycline

References

Baronoski, S.(2003) Skin Tears staying on guard against the enemy of frail skin.
Travel Nursing; October: 14-19

Bianchi, J. (2012) Preventing, assessing and managing skin tears. Nursing Times;
108:13, 12-16

Butcher M. Management of wound sinuses. Journal of Wound Care Vol. 8 No

9, October 1999
European Pressure Ulcer Advisory Panel and National Pressure Ulcer
Advisory Panel. Treatment of pressure ulcers: Quick Reference Guide.
Washington DC: National Pressure Ulcer Advisory Panel; 2009.

Fleck, C. (2007) Preventing and treating Skin Tears. Advances in Skin and Wound
Care; 20: 6, 315-320

Lock, P.M. The effects of temperature on mitotic activity at the edge of

experimental wounds. In: Sundell, B. (ed) Symposia on wound healing; plastic
surgical and dermatological aspects. Molndal; Switzerland: Lindgren, A. &
Soner, A. B., 1980

Miller & Collier, (1997) Understanding Wounds. Professional Nurse

Supplement

McGrath A, 2011, Overcoming the challenge of overgranulation, Wounds uk,

Volume 7, No 1

NICE clinical guideline 74. Prevention and treatment of surgical site infection.
October 2008

Patel S, (2007) The Impact of MRSA on wound healing. Wound Essentials •

Volume 2

White RJ, Cooper R, Kingsley A (2001) Wound colonization and infection: the
role of topical antimicrobials. Br J Nursing 10(9): 563–78

Classification and treatment of Burns

http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/burns/classify.html

Non-complex Burn management protocol, Northern Burn Care Network, 2012

http://www.nbcn.nhs.uk/about-us

NHS Choices, Leg Ulcers, venous

http://www.nhs.uk/conditions/Leg-ulcer-venous/Pages/Introduction.aspx

Management of acute and surgical wounds. Worcestershire Acute Hospitals

NHS Trust
http://www.ips.uk.net/Admin/uploads/conference%20presentaions/national200
9/LouiseMorris.pdf

NICE clinical guideline 74 – Surgical site infection

http://www.nice.org.uk/nicemedia/pdf/CG74NICEGuideline.pdf

South West Regional Wound Care Toolkit

http://www.southwesthealthline.ca/healthlibrary_docs/E.2.1.LocalWoundCare
Cleansing.pdf