Wound Care Guidelines Dressing Formulary - and NHS Cambridgeshire and Peterborough CCG - Cambridgeshire and ...
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Wound Care Guidelines
and
Dressing Formulary
NHS Cambridgeshire and Peterborough CCG
Cambridgeshire Community Services
Cambridgeshire and Peterborough Foundation Trust
April 2018 – Version 4.0 Page 1 of 26
Background The Wound Care Guidelines have been written by the Tissue Viability Team, and is based on a wide range of clinical evidence and peer reviews. A group of district nurses, practice nurses, tissue viability nurses (TVN), clinical management and members of the Medicine Management Team (MMT) have selected the dressings for the Wound Care Formulary. The present products were selected on the current clinical evidence and cost consideration. A steering group meets four times a year to review any clinical evidence on new products as well as its cost implication. Any suggestions on new products can be made by contacting either the TVN or MOT; Medicines Optimisation Team Tissue Viability Team Tel: 01480 387125 Tel: 01223 266540 E-mail CAPCCG.prescribingpartnership@nhs.net E-mail: cpm-tr.tissueviability@nhs.net Tissue Viability Team Version 3.0 Date: January 2018 Review: January 2020 April 2018 – Version 4.0 Page 2 of 26
Contents
Page
Wound Assessment and Management Guidelines 4
TIME – Principals of Improved Wound Healing 8
Antibacterial Guidelines 9
Guideline 1: Necrotic Wounds 11
Guideline 2: Black Heels/Toes 12
Guideline 3: Sloughy Wounds 13
Guideline 4: Granulating Wounds 14
Guideline 5: Infected Wounds 15
Guideline 6: Epithelialising Wounds 16
Guideline 7: Skin Tears/Pre-Tibial Lacerations 17
Guideline 8: Non-Complex Burns (Suitable for Outpatient/Primary Care Management) 18
Supplementary Guideline for Complex Burns Assessment 19
Guidelines for the Assessment and Management of Leg Ulcers 20
Dressings Criteria/Characteristic 21
Formulary Choices 22
References 24
Appendix 1 – Wound Assessment Form 26
April 2018 – Version 4.0 Page 3 of 26
Wound Assessment and Management Guidelines
1. Scope
Cambridgeshire and Peterborough Foundation Trust, general practices and nursing homes for those caring for patients with
wounds, Cambridgeshire Community Services (children services).
2. Purpose
To ensure the correct assessment and management of patients with wounds.
3. Introduction
Choosing a wound dressing depends greatly on a holistic assessment of the patient and their wound; the patient should be at
the centre of all care decisions made.
Wound assessment should be a systematic process accurately documented on the wound assessment and management care
plan.
Dressings should be selected from the Trust Wound Care Formulary unless otherwise advised by a specialist.
Patients with complex needs should be referred to the most appropriate speciality.
4. Responsibilities
All health care professionals involved in the direct assessment and management of wounds.
5. Wound assessment
A documented holistic and wound assessment should be done as soon as possible after admission to the caseload.
The evaluation does not need to be completed at every dressing change if there is little change in the wound condition but
document “no change in wound condition”. Dressing change must be recorded, signed and dated.
Progress of the wound must be fully reassessed, signed and dated.
April 2018 – Version 4.0 Page 4 of 26
Any deteriorating wound must have a full re-assessment/evaluation completed and action taken (see general wound care
guidelines).
In the case of a chronic wound (at 2-4 weeks), the wound should be reassessed weekly (every two weeks at a minimum).
5.1 Completion guide for page one of updated wound assessment form
Patient details & date of initial assessment
All details must be completed.
Type of wound
Circle the relevant box
How long has the wound been present?
Write length of duration, not the date when the patient came on caseload unless they coincided
Factors which may delay wound healing
Tick all relevant boxes, add extra information as appropriate (check patient’s medical notes).
Medications
Tick all relevant boxes, add extra information as appropriate.
Date referred to
Tick all relevant boxes; discuss referrals with colleagues and GPs. Do not over-refer to similar specialities, e.g. plastics,
dermatology, tissue viability (see general wound care guidelines below for appropriate routes of referral).
Drawing/photograph
Please illustrate wound. Use photography (verbal or written consent) – tape measures are available in the dressing packs. Write
date, patient initials only and the NHS patient’s number four (4) last numbers on the tape measure. Download and attach to
SystmOne or protected system used.
Location of wound/s
Please indicate on body map where the wound is situated.
April 2018 – Version 4.0 Page 5 of 26
5.2 Completion guide for page two of wound assessment form
Wound dimension
Please measure as accurately as possible or indicate if this is an estimation.
Length = head to toe furthest points, measured in centimetres.
Width = side to side furthest points, measured in centimetres.
Depth = may be estimated as very difficult to assess safely and accurately. A sterile gloved finger or wound swab can be used
to probe.
Grade PU = if the wound is a pressure ulcer please indicate its grade.
Undermining = area tracking, measure with a probe and indicate direction.
Wound bed
Please estimate percentage of different tissue type in each box.
Suture/clips
Specify and indicate removal date.
Exudate levels
Please complete using the following guidelines:
High = needs daily or more dressing changes and saturated each time.
Moderate = needs dressing changes every 2-3 days and soiled but not soaked.
Low = needs weekly or less dressing changes and dressing dry or minimally soiled.
Wound edges/surrounding skin
Please indicate as outlined.
Pain
Please assess patient and indicate action. Please refer for medical intervention/pain team.
Clinical signs of infection
Please indicate and swab if necessary. If the patient is at risk of developing an infection, ensure that daily vital signs are taken.
April 2018 – Version 4.0 Page 6 of 26
Treatment objectives
These objectives should be suitable for most patients but a more individualised care plan may need to be added.
Use the appropriate objectives according to the phases of healing
1. Patient comfort – although could be used for most patient’s wound care it is more suitable for “end of life” patient where no
active treatment (e.g. debridement) is suitable. Can be associated with odour control
2. Absorption: for wound with large exudate where the main objective is containing the fluid.
3. Infection control: for infected wound. It can be associated with odour control
4. Odour control: see above
5. Debridement: active treatment
6. Promote granulation: active treatment – post or concurrent to debridement
7. Promote epithelialisation: active treatment – concurrent to granulation
Cleansing solution
Please document saline or water. Other solutions are not recommended unless required for a specific clinical need.
Clean surrounding skin and wound to remove some slough, dressing debris or exudate.
Dressing choice
Choose from Wound Care Formulary, review wound progress or deterioration and document the rationale for dressing changes
during period of care.
Frequency of dressing change
Please document, dependent on exudates, dressing used and progress of wound.
Signed/print name/designation
This is a legal requirement and must be accompanied by printing name legibly.
April 2018 – Version 4.0 Page 7 of 26
TIME – Principles of Improved Wound Healing (Wound Bed Preparation)
To use for chronic wounds alongside the current Wound Care Guidelines
Clinical Observations WBP clinical actions Impact of your clinical actions Clinical outcomes
Debridement (episodic or
continuous) Viable wound bed
T Restoration of wound base and
Autolytic, sharp surgical,
Tissue non-viable or deficient repair of the damaged tissue
enzymatic, mechanical or
biological
Reduced bacterial counts or
controlled inflammation:
Remove infected foci
Resolution of bacterial
I Topical/systemic antibiotics Inflammatory cytokines imbalance and reduced
Topical antimicrobials inflammation.
Infection or inflammation protease activity
Anti-inflammatories
growth factor activity
Apply moisture balancing dressings
Or Maceration avoided
Compression
Reduction in excessive fluid
M Or
Reduced oedema
Moisture balance
Moisture imbalance NPWT (negative pressure wound
therapy) Desiccation avoided
Or Restored epithelial cell migration
Other methods of removing fluid
Re-assess cause or consider
corrective therapies Migrating keratinocytes and
E Debridement responsive wound cells. Advancing edge of wound
Edge of wound non-advancing or
Skin grafts Restoration of appropriate
undermined Protease profile.
Biological agents
Adjunctive therapies
Adapted from: Wound Bed Preparation. Schultz et al (2003) Wound Rep Reg Vol 11 pp1-28 .Extending the TIME Concept. Leaper D et al (2012)
April 2018 – Version 4.0 Page 8 of 26Antibacterial Guidelines
Evidence concerning the efficacy of topical antimicrobial agents in the management of wounds remains inconclusive.
Independent and better designed trials to assess efficacy and cost implications are needed.
Reports of resistance are limited; but misuse of these products especially silver products must be avoided.
Reassess the management of all wounds treated with antibacterial products after two weeks.
Consider the clinical effectiveness (has the wound progressed?) as well as the cost effectiveness of the product.
Iodine products are recommended as first choice antibacterial dressings unless the patient has a history of allergy.
Iodine products should be used with caution and under close medical observation for patients with thyroid disease.
Inadine™ (Acelity/Systagenix) Suitable for superficial, low exudate wounds
Non-adherent dressing Useful for drying ischaemic wounds
impregnated with 10% povidine Dressing colour fading from dark brown to white indicates loss of antibacterial efficacy and needs
iodine ointment to be changed
Iodoflex™ (Smith & Nephew) Suitable for sloughy, exuding wounds
Cadexomer (starch) iodine Mouldable to shape of wound
(0.9%) paste. Dressing colour fading from dark brown to white indicates loss of antibacterial efficacy and needs
Iodine released is proportional to to be changed
the exudate absorbed by the
starch in the dressing
April 2018 – Version 4.0 Page 9 of 26Other Antimicrobials
Honey: Activon ™ Tulle Suitable for sloughy wounds, will debride effectively.
(Advancis) Might cause minimal discomfort at first due to osmotic effect.
Controls odour very effectively.
Cut to size so the tulle can be in direct contact with the wound base or use viscous honey (tube).
2d choice AB dressing Dressing colour will fade as the honey is absorbed
No toxicity. Suitable for diabetic.
Silvercel™ (Acelity/Systagenix) Useful for debriding wounds
Silver impregnated alginate Useful to control odour
dressing Pack wound lightly
Do not change daily. The silver in the dressing is active for 3 days
3d choice AB dressing Use only if other antibacterial dressings have been tried or are inappropriate.
Rapid release/ fast action silver
Acticoat™ (Smith & Nephew)
Can stain surrounding skin
Nanocrystalline silver coated low
adherent dressing Needs to be activated by water prior to use
Silver active for minimum of 3 days
Useful for managing overgranulation
Use only if other antibacterial dressings have been tried or are inappropriate.
Use for 2 weeks then review.
Toxicity of silver on the healing process is still unclear but caution in its usage is recommended.
Contact Tissue Viability Nurses if prolonged use is necessary as alternative products might be more suitable.
April 2018 – Version 4.0 Page 10 of 26Wound Care Guidelines
Guideline 1: Necrotic Wounds
Aim: To aid debridement by providing a moist
environment
Is the wound on the Yes Refer to guideline 2 (Black heels/ toes)
heel or foot?
No
Is the wound infected?
Yes Refer to Guideline 5 (Infected Wounds)
No
Is the wound exudate Dressing Choice Wound Care Notes
Depth: May be difficult to assess
fully until necrosis has lifted.
Apply gel to base of wound
Hydrogel (Aquaform®)
Yes Cover with hydrocolloid Surrounding Skin: If wound exuding
Low AND
Change when exudate marking is or skin is fragile, protect with no
Hydrocolloid (Tegaderm™
visible 1cm from edge of dressing sting barrier film.
Hydrocolloid / Granuflex®)*
or if leaking / dislodged
Nutrition: Assessment must be
Hydrofibre (Aquacel®) Loosely pack/cover wound with carried out and appropriate referral
Yes AND hydrofibre made.
Medium
Hydrocolloid (Tegaderm™ Cover with hydrocolloid
Hydrocolloid / Granuflex®)* Change as above Specialist Input:
Sharp debridement must be carried
Loosely pack/ cover wound with out by a doctor or Tissue Viability
Hydrofibre (Aquacel®)
Large hydrofibre Nurse only.
Yes AND
Cover with foam or padding and Seek further advice for patients
Foam (ActivHeal® / Biatain®) or
secure with diabetes or arterial problems.
Padding
Change as above
July 2018 – Version 4.0 Page 11 of 26Guideline 2: Black Heels/Toes
Aim: To protect and maintain infection free
Is the wound infected? Yes Refer to Guideline 5 (Infected Wounds)
No
Refer to Foot Clinic/ Dressing Choice Wound Care
Is the patient diabetic? Yes
Podiatry for further Inadine™ Apply Inadine™ to wound
investigation AND Notes
No
Padding Cover with padding
Bandages: Tight or
compression bandages
Check blood glucose Wool bandage Apply wool bandage
Yes must not be used for
for undiagnosed Crepe bandage or Tubular Secure with Tubular
patients with diabetes or
diabetes Yes Refer to bandage bandage (Comfifast®) or
arterial problems unless
physician Crepe bandage.
No under close supervision of
All bandages must be from
Specialist team.
Toe to Knee
Surrounding Skin: If wound
Refer to GP and TVN is exuding or skin is fragile,
protect with no sting barrier
film.
Pressure: must be relieved to prevent further damage by
using a Repose foot protector or pillow (see guideline) Nutrition: Assessment must
be carried out and
appropriate referral made.
Specialist Input:
Does the wound
Aim to keep blister intact Seek further advice for
present as a blister? Yes Remove source of
Do not apply dressing and allow natural re- patients with diabetes or
(Blood or clear fluid friction/ pressure
absorption arterial problems.
filled)
July 2018 – Version 4.0 Page 12 of 26Guideline 3: Sloughy Wounds
Aim: To aid debridement of slough by providing a moist environment
Is the wound infected? Yes Refer to Guideline 5 (infected wounds)
No
Is the slough dry? Yes Treat as necrotic (Guideline 1)
No Notes
Slow/static debridement: consider larvae
Is the wound exudate Dressing Choice Wound Care therapy.
Cavities: Consider Topical Negative
Pressure therapy, refer to Tissue Viability
Apply gel to base of wound
Hydrogel (Aquaform®) Nurse for advice.
Cover with hydrocolloid
AND
Low Yes Change when exudates marking Very High Exudate: consider above or
Hydrocolloid (Tegaderm™
is visible 1cm from edge of wound drainage bags, refer to Tissue
Hydrocolloid / Granuflex®)*
dressing or if leaking / dislodged Viability Nurse for advice.
Surrounding Skin: If wound exuding or skin
Hydrofibre (Aquacel®) Loosely cover/ pack wound with fragile, protect with no sting barrier film.
AND hydrofibre
Yes Nutrition: Assessment must be carried out
Medium Cover with hydrocolloid
Hydrocolloid (Tegaderm™ and appropriate referral made.
Change as above
Hydrocolloid / Granuflex®)*
Specialist Input: Sharp debridement must
Hydrofibre (Aquacel®) Loosely cover/ pack wound with be carried out by a doctor or Tissue
AND hydrofibre Viability Nurse only.
Large Yes Cover with foam or padding and
Foam (ActivHeal® / Biatain®) or
Padding or Superabsorbent secure Seek further advice for patients with
dressing Change as above diabetes or arterial problems.
July 2018 – Version 4.0 Page 13 of 26Guideline 4: Granulating Wounds
Aim: To promote granulation and provide a healthy base for epithelialisation
Is the wound infected? Yes Refer to Guideline 5 (infected wounds)
No
Is the wound hyper- Yes Check for infection and refer to TVN for advice
granulating?
No Notes
Bleeding: Use an alginate to act as a
Is the wound exudate Dressing Choice Wound Care haemostat (Kaltostat®).
Cavities: Consider Topical Negative
Apply Hydrocolloid or Foam Pressure therapy, refer to Tissue
Hydrocolloid (Tegaderm™ Change when exudates marking Viability Nurse for advice.
Yes Hydrocolloid / Duoderm®)* is visible 1cm from edge of Very High Exudate: Consider wound
Low dressing or if leaking / dislodged
OR drainage bags, refer to Tissue
Foam (ActivHeal® / Biatain®) Hydrocolloid can be in place 5-7 Viability Nurse for advice.
days
Surrounding Skin: If wound exuding
or skin fragile, protect with no sting
Hydrofibre (Aquacel®) Loosely pack/ cover wound with
barrier film.
AND hydrofibre
Medium Yes
Hydrocolloid (Tegaderm™ Cover with hydrocolloid Nutrition: Assessment must be
Hydrocolloid / Granuflex®)* Change as above carried out and appropriate referral
made.
Hydrofibre (Aquacel®) Loosely pack/ cover wound with Specialist Input: Seek further advice
AND hydrofibre for patients with diabetes or arterial
Foam (ActivHeal® / Biatain®) or Cover with foam or padding and problems.
Large Yes
Padding or Superabsorbent secure
dressing Change as above
July 2018 – Version 4.0 Page 14 of 26Guideline 5: Infected Wounds
Aim: To treat infection systemically and decrease bacterial burden at the wound site
- Take swab and treat infection with systemic antibiotics until symptoms resolve
Check guidelines for use of antibacterials; follow flow chart below for dressing
Does the wound look Yes choice
infected? (See notes) Treat wound for two weeks then review
Avoid topical antibiotics
Is the wound exudate Dressing Choice Wound Care
Iodine (Inadine™) Apply Inadine™ or honey Notes
Low Yes
OR Clinical signs of infection:
Activon Tulle Inflammation, erythema
Change Inadine™ daily, Honey every
Appropriate secondary dressing (redness), increased pain,
2 d to 3d day.
odour, pus, heat, pyrexia,
friable (bleeds easily).
Iodine (Iodoflex™) Apply Iodoflex™ or honey to the
OR wound Surrounding Skin: If wound
Medium Activon Tulle Cover with foam exuding or skin fragile, protect
Yes Foam (ActivHeal® / Biatain®) or Change every 2-3 days with no sting barrier film.
padding
Nutrition: Assessment must
be carried out and
Large appropriate referral made.
Specialist Input: Seek further
Yes advice for patients with
diabetes or arterial problems.
Is wound condition Silvercel® OR
Cut to size of wound and apply
unchanged after 2 Acticoat™ (must be activated with For further antibacterial
Yes Change every 3 days depending on
weeks of above care water before use) for 2 weeks advice refer to the TV Team
odour and amount of exudate
plan? Appropriate secondary dressing
July 2018 – Version 4.0 Page 15 of 26Guideline 6: Epithelialising Wounds
Aim: To provide a moist, atraumatic environment to complete healing
Is the wound reducing No Refer to TVN for advice
in size?
Yes
Is the wound exudate? Dressing Choice Wound Care
Apply hydrocolloid or low adherent to Notes
wound Protection: Of the wound site is
Hydrocolloid thin (Duoderm®)* essential for complete healing/
Change if exudates marking is 1cm
Low Yes OR maturation.
from edge of dressing or if the
Low adherent (Atrauman®) and
dressing is dislodged Surrounding Skin: If wound exuding
Foam/Cosmopore
Hydrocolloid can be in place for 5-7 or skin fragile protect with no sting
days. barrier film.
Nutrition: Assessment must be
carried out and appropriate referral
Reassess wound as unlikely to be made.
Medium Yes epithelialising and refer to
appropriate guideline Fragile/Sensitive Skin: Mepitel®
can be considered as alternative
dressing as it can remain on the
wound for 7 days.
Specialist Input: Seek further
Reassess wound as unlikely to be advice for patients with diabetes or
Large Yes
epithelialising and refer to arterial problems.
appropriate guideline.
July 2018 – Version 4.0 Page 16 of 26Guideline 7: Skin tears/ Pre-tibial lacerations
Aim: To provide a protective environment to promote healing and prevent further trauma
Is the wound
presenting a large Yes Refer to A&E or Plastic Surgeons
surface area or deep
tissue exposed?
Dressing Choice Wound Care
No
Kaltostat® Apply pressure when securing
Is the wound AND If bleeds through do not remove,
bleeding? Yes
Padding apply further padding on top and Notes
No
Appropriate secondary dressing refer to A&E if bleeding persists
Surrounding Skin: If wound
exuding or skin fragile, protect
Can wound edges be Steri-strip without tension Check wound after 2 days with no sting barrier film.
brought together Low adherent (Atrauman® / Leave Steri-strips for further 3-5 days Nutrition: Assessment must
Yes
without force Mepitel®) be carried out and
Padding appropriate referral made.
No Appropriate secondary dressing
Specialist Input: Seek further
advice for patients with
Do not attempt to steri-strip or force Can consider hydrocolloid diabetes or arterial problems.
edges together (Tegaderm™ Hydrocolloid or
Is there partial or Yes Low adherent (Atrauman® / Granuflex®)*, can be left in place up Lower limb injury: Secure
complete skin loss? Mepitel®) to 5 days. Use caution on fragile skin. dressing with wool bandage
Padding and crepe bandage applied
Appropriate secondary dressing from toe to knee.
Hydrogel (Aquaform®) - for open Apply gel to open haematoma only
Is there a significant wounds only Foam or padding to protect
haematoma with or Foam (ActivHeal® / Biatain®) or Contact TVN for use of another gel.
without skin trauma? Yes padding Refer to A&E or Plastic surgeons for
Appropriate secondary dressing debridement
July 2018 – Version 4.0 Page 17 of 26Guideline 8: Non-Complex burns (suitable for outpatient/ primary care management)
Aim: To provide a protective environment to promote healing and ensure appropriate referral for complex burns
Is the burn complex? (See guideline overleaf) Yes Refer to A&E or Plastic Surgeons
No
Is the burn superficial? Dressing Choice Wound Care
Skin is dry & intact Check wound after 48 hours
Red, blanches under pressure Yes
Topical moisturiser or
Should heal within 2-3 days
Minimal tissue damage Low adherent (Atrauman®)
Can consider a hydrocolloid
Painful with appropriate secondary
thin (Duoderm®) if no
dressing Notes
No blistering
Surrounding
Is the burn superficial-partial thickness? Low adherent (Atrauman®) Check wound after 48 hours Skin: If wound
Blisters immediately Gauze or absorbent padding, Should heal within 10-21 days exuding or skin
Red in areas, moist & exuding depending on exudate if no infection fragile, protect
Yes
Brisk capillary refill Yes Secure with appropriate Can consider Flamazine® if with no sting
Painful & sensitive to temperature changes Yes secondary dressing antibacterial is indicated barrier film.
No Nutrition:
Assessment
Is the wound deep-partial thickness (deep dermal)? must be carried
Pale/white/creamy in colour, may have large out and
blisters appropriate
Refer to Emergency
Less moist initially Yes referral made.
Low adherent (Atrauman®) Department for urgent
Difficult to assess capillary refill
Loosely applied cling film specialist Plastic Surgical
Sensitive to deep pressure but not to pin-prick advice See over for
No Burns
Is the wound full thickness? Refer to Emergency assessment
No
Low adherent (Atrauman®) Department for urgent guidelines.
May appear waxy white, cherry red, grey or
leathery
Yes Loosely applied cling film specialist Plastic Surgical
Minimal or no pain, no response to pressure or advice
temperature
May have less deep & very painful peripheries
July 2018 – Version 4.0 Page 18 of 26Supplementary Guideline for Complex Burns Assessment
Seek further advice for:
Patient 60yrs
Patient is 5% Total Body Surface Area (TBSA)
Patient is adult & burn is dermal or full thickness involving
>10% Total Body Surface Area (TBSA)
Burn is on face, hands, perineum, feet, flexures
Burn is circumferential dermal or full thickness to limbs,
torso or neck
Burn is chemical, acid, ionising radiation, high pressure
steam, electrical, suspicion of non-accidental injury
Burn is an inhalation injury
Patient also has; cardiac or respiratory problems,
immunological conditions, pregnancy, or associated injuries
July 2018 – Version 4.0 Page 19 of 26Leg ulcers guidelines: a holistic assessment, Doppler ABPI, treatment plan is to be performed at first/second
visit (a wound is considered chronic between 2 to 4 weeks duration.
VENOUS ARTERIAL OTHERS
DVT/PE Venous ulcers Phlebitis TIA Hypertension Rheumatoid arthritis
Family history Leg fracture Pregnancies CVA Claudication Diabetes
Varicose veins Previous venous surgery MI Arterial surgery Malignancy (ulcer associated)
Lymphoedema
Examination of foot and leg (disease indicators)
Varicose veins Woody, indurated skin Shiny/thin/hairless skin Night pain - Joint abnormalities
Ankle flare Eczema Skin cold/blue/white relieved when Evidence of Neuropathy
Brown pigmentation Poor capillary filling leg dependent Chronic oedema : large exudate
Thickened toenails Weak/no pulses
Examination of ulcers
Gaiter region / internal & external malleolus On foot or anywhere on lower limb High on calf /on foot
Sloping edge / irregular margin Deep and punched out Rolled edge
Chronic oedema: whole leg can be affected
Investigations Surrounding skin Pain
Doppler, BP, Blood sugar, HB/FBC, ESR, CRP Healthy, Oedematous, Red, Macerated Assess using pain scale
If available BMI, Urinalysis, Swab if clinically infected Eczematous / Contact dermatitis
Identify cause of ulcer. Treat wound according to guidelines. Treat underlying cause
ABPI 0.8 – 1.29 ABPI 0.6 – 0.79 ABPI < 0.6 ABPI > 1.3 Evidence of Vasculitis,
Evidence of Venous Disease With evidence Arterial Disease (arterial Malignancy or Contact
of venous disease calcification) dermatitis
Treat as Venous Ulcer Sub-acute infection
- Apply compression Refer to TVN / Routine Vascular Referral Refer to TVN / Vascular Refer to TVN
- Keep dressing simple Vascular referral –apply (URGENT if Non-adherent
Dressings Criteria
Impermeable to bacteria
Remove excess exudate and toxic components
Capable of maintaining a high humidity at the wound site while
Maintain high humidity at wound dressing interface removing excess exudate
Allows gaseous exchange Thermally insulating
Provide thermal insulation Non-toxic and non-allergenic
Impermeable to micro-organisms Comfortable and comformable
Free from Toxic contaminants Capable of protecting the wound from further trauma
Removable without causing trauma Requires infrequent dressing changes
Cost effective
Long shelf-life
Available both in hospital and in the community
Characteristics of the ideal wound dressing (Bryant R, Nix D, 2016)
July 2018 – Version 4.0 Page 21 of 26Formulary Choices
Cost per
Dressing Size NPC code Supplier Code Unit Issue
dressing
FOAM ACTIVHEAL FOAM (non adhesive) 5cm x 5cm ELA214 10009113 Pack of 10 £0.77
ACTIVHEAL FOAM (non adhesive) 10cm x 10cm ELA216 10009115 Pack of 10 £1.14
ACTIVHEAL FOAM (non adhesive) 18cm x 10cm ELA246 10009116 Pack of 10 £2.06
BIATAIN (non-adhesive) 10cm x 10cm ELA039 3410 Pack of 10 £1.82
ACTIVHEAL FOAM (adhesive) 10cm x 10cm ELA210 10009109 Pack of 10 £1.19
ACTIVHEAL FOAM (adhesive) 12.5cm x 12.5cm ELA211 10009110 Pack of 10 £1.52
BIATAIN SILICONE (adhesive) 7.5cm x 7.5cm ELA425 3343431006 Pack of 10 £1.40
BIATAIN SILICONE (adhesive) 10cm x 10cm ELA451 3343531006 Pack of 10 £2.03
BIATAIN SILICONE (adhesive) 12.5cm x 12.5cm ELA426 3343631006 Pack of 10 £2.56
HYDROCOLLOID GRANUFLEX (Modified) 10cm x 10cm ELM141 S150 Pack of 10 £1.99
GRANUFLEX (Bordered) 6cm x 6cm ELM151 S155 Pack of 5 £1.50
GRANUFLEX (Bordered) 10cm x 10cm ELM053 S156 Pack of 10 £2.13
GRANUFLEX (Bordered) 15cm x 15cm ELM155 S157 Pack of 5 £3.83
DUODERM (Extra Thin Film) 5cm x 10cm ELM317 S163 Pack of 10 £0.70
DUODERM (Extra Thin Film) 7.5cm x 7.5cm ELM311 S160 Pack of 5 £0.74
DUODERM (Extra Thin Film) 10cm x 10cm ELM050 S161 Pack of 10 £1.22
DUODERM (Extra Thin Film) 15cm x 15cm ELM051 S162 Pack of 10 £2.64
TEGADERM (Oval) 10cm x 12cm ELM084 90001 Pack of 5 £2.07
TEGADERM (Oval) 13cm x 15cm ELM373 9003 Pack of 5 £4.08
HYDROFIBRE AQUACEL EXTRA 5cm x 5cm ELY377 S7500 Pack of 10 £0.92
AQUACEL EXTRA 10cm x 10cm ELY378 S7501 Pack of 10 £2.21
AQUACEL RIBBON 1cm x 45cm ELY368 420127 Pack of 5 £1.82
AQUACEL RIBBON 2cm x 40cm ELY013 S7503 Pack of 5 £2.32
ALGINATE KALTOSTAT 5cm x 5cm ELS229 1004 Pack of 10 £0.67
SORBSAN RIBBON 1g x 40cm ELS016 1412 Pack of 5 £2.11
HYDROGEL AQUAFORM 8g tube ELG017 1419C Pack of 10 £1.82
ISLAND DRESSING COSMOPOR E 5cm x 7.2cm EIJ038 5000485091970 Pack of 50 £0.07
COSMOPOR E 8cm x 10cm EIJ039 5000485091987 Pack of 50 £0.10
COSMOPOR E 8cm x 15cm EIJ040 5000485091994 Pack of 50 £0.15
COSMOPOR E 10cm x 20cm EIJ041 5000485092007 Pack of 50 £0.23
NON ADHERENT ATRAUMAN 7.5cm x 7.5cm EKA032 499553 Pack of 50 £0.21
WOUND ATRAUMAN 10cm x 20cm EKA036 499536 Pack of 30 £0.44
AUTRAMAN 20cm x 30cm EKA016 499515 Pack of 10 £1.37
SEMI-PERMIABLE CLEARFILM 6cm x 7cm ELW646 815067 Pack of 100 £0.08
FILM CLEARFILM 10cm x 12cm ELW696 815101 Pack of 10 £0.29
CLEARFILM 15cm x 20cm ELW697 815152 Pack of 10 £0.67
OPSITE POST-OP (For surgical wounds only) 9.5cm x 8.5cm ELW051 66000709 Pack of 20 £0.66
OPSITE POST-OP (For surgical wounds only) 6.5cm x 5cm ELW052 66000708 Pack of 100 £0.20
July 2018 – Version 4.0 Page 22 of 26BACTERIAL INADINE 5cm x 5cm EKB501 P01481 Pack of 25 £0.41
CONTROL (Use INADINE 9.5cm x 9.5cm EKB502 P01512 Pack of 25 £0.60
according to ACTICOAT 10cm x 10cm ELY071 66000791 Pack of 12 £8.91
antibacterial ACTICOAT 5cm x 5cm ELY141 66000808 Pack of 5 £3.83
guidelines) SILVERCEL 11cm x 11cm ELS150 CAD011 Pack of 10 £3.79
SILVERCEL 5cm x 5cm ELS149 CAD050 Pack of 10 £1.65
ACTIVON TULLE 5cm x 5cm EJE027 CR3761 Pack of 5 £1.79
ACTIVON TULLE 10cm x 10cm EJE028 CR3658 Pack of 5 £2.96
IODINE PASTE 5g tube EKB007 66001301 Pack of 5 £4.63
DRESSING ICTHOPASTE 7.5cm x 6m EFA051 4959 Each £5.78
RETENTION VISCOPASTE 7.5cm x 6m EFA011 4948 Each £5.22
K-BAND 10cm x 4m EDB039 811040 Pack of 20 £0.15
COMFIFAST (Green) 5cm x 10m EGP006 F25 Each £2.20
COMFIFAST (Blue) 7.5cm x 10m EGP007 F35 Each £2.35
COMFIFAST (Yellow) 10.75cm x 10m EGP008 F45 Each £3.45
SKIN BARRIERS MEDI DERMA-S STERILE NON STING MEDICAL
1ml ELY532 MB61076 Pack of 5 £0.61
BARRIER FILM
MEDI DERMA-S BARRIER CREAM NON_STERILE 2g sachet ELY536 MB60338 Pack of 20 £0.17
MULTILAYER K-FOUR K-SOFT (Layer #1) 10cm x 3.5m EPA028 761035 Pack of 24 £0.56
BANDAGES K-FOUR K-LITE (Layer #2) 10cm x 4.5m ECA100 771045 Pack of 16 £0.76
K-FOUR K-PLUS (Layer #3) 10cm x 8.7m ECA162 781087 Pack of 24 £2.03
K-FOUR KO-FLEX (Layer #4) 10cm x 6m ECD018 791060 Pack of 18 £3.48
SHORT STRETCH ACTICO ACTIVA 8cm x 6m EBA032 314-0886 Each £4.10
COMPRESSION ACTICO ACTIVA 10cm x 6m EBA016 271-5431 Each £4.25
ACTICO ACTIVA 12cm x 6m EBA033 314-0894 Each £5.42
ADHESIVE MICROPORE 1.25cm x 9.14m EHU111 1530-0 Pack of 24 £0.19
SURGICAL TAPE MICROPORE 2.5cm x 9.14m EHU006 1530-1 Pack of 12 £0.38
SPECIALIST MEPITEL (For sensitive skin only) 5cm x 7cm EKH002 290500 Pack of 5 £1.47
DRESSINGS MEPITEL (For sensitive skin only) 8cm x 10cm EKH003 290700 Pack of 5 £2.93
MISCELLANEOUS KERRAMAX 22cm x 10cm EME023 PRD500-120 Pack of 10 £1.59
KERRAMAX 20cm x 30cm EME025 PRD500-380 Pack of 5 £2.89
NON WOVEN SWABS 10cm x 10cm ENK132 1870 Pack of 25 £0.07
365 STRIPS 6mm x 75mm EIR126 36519064 Pack of 50 £0.11
NORMASOL 25ml MRB358 99766774 Pack of 25 £0.13
10cm x 20cm EJA080 485-503 Pack of 30 £0.12
ABSORBANT DRESSING PAD
20cm x 40cm EJA082 485-510 Pack of 25 £0.36
Small EJA045 908810 Pack of 20 £0.42
SOFTDRAPE DRESSING PACK VITREX Medium EJA046 908820 Pack of 20 £0.42
Large EJA047 908830 Pack of 20 £0.42
July 2018 – Version 4.0 Page 23 of 26References
Bryant R, Nix D (2016) Acute and Chronic Wounds (5th ed) Mosby. USA
European Wound Management Association (EWMA). Position Document: Management of Wound Infection. London: MEP Ltd, 2006.
European Wound Management Association (EWMA). Position Document: Antimicrobials and non healing wounds. London: MEP Ltd, 2013.
European Wound Management Association (EWMA). Position Document: Debridement London: MEP Ltd, 2013.
Flanagan M (2013) Wound healing and skin integrity. Wiley-Blackwell, West Sussex
National Institute for Clinical Excellence (2014) The Prevention and Treatment of Pressure Ulcers. NICE, London. www.nice.org.uk
National Institute for Clinical Excellence (2013) Varicose Veins NICE, London. www.nice.org.uk
Royal College of Nursing (2006) Clinical Practice Guidelines: The Management of Patients with Venous Leg Ulcers. RCN, London.
Sign (2010) Management of chronic venous ulcer: a national clinical guideline 120.
Thomas S (2010) Wound dressing, London .
Turner T.D. (1982) Which dressing and why? Nursing Times 78: 29 (suppl.), 1-3
Wounds UK.(2016) Best Practice Statement: Care of the Older Persons Skin London :Wounds UK www.wounds-uk.com
Wounds Uk (2016). Best practice Statement: Holistic Management of Venous Leg Ulceration. London :Wounds UK www.wounds-uk.com
Wound Care Handbook (2017-2018). The comprehensive guide to product selection in association with the Journal of Wound care. MA
Healthcare LTD, London.
Resources : www.wounds-uk.com
www.worldwidewounds.com World Wide Wounds
www.ewma.org European Wound Management Association
July 2018 – Version 4.0 Page 24 of 26Appendix 1 – Wound Assessment and Management Chart
Name NHS No DOB
Address GP/Surgery Tel
DN Team Tel
Postcode Residential/Nursing Home Tel
Tel Ward Tel
Standard: In conjunction with Trust Wound Care Guidelines, an assessment and care-plan should
be completed for all patients with wounds.
Date of Initial Assessment DD/MM/YY
Type of Wound(s) Pressure Leg Moisture Skin
(Please circle) Surgical Burn Other
Ulcer Grading Ulcer Lesion Tear
How long has wound
been present?
Factors which may delay wound healing (tick if present, tick nil identified if no factors present)
Medical Conditions Medications
Rheumatoid Arthritis Immobility Steroids
Diabetes Mellitus Incontinence Immunosuppressive
Cardiac Disease Infection Biologics
Anaemia Obesity Anti coagulants
Chronic respiratory disease Malnutrition Cytotoxics
Venous/Arterial Disease Poor nutrition Non steroidal anti-inflammatory
Decreased sensation Smoking Other …………………………..
Allergies Alcohol
Skin sensitivities Concordance Issues Nil identified……………………
Severe acquired immune defects Please specify ……............
…………………………….....
Date referred to: Tissue Viability Team ...…/.…./…. Dietician...../…../.…..
Dermatology …../.…./…. Podiatry/Foot Team …../…../….. Vascular Surgeon …../…../….
Plastic Surgeon …../…../….. Others …../…../….. No specialist referral required.……………………..
Full pain assessment completed and appropriate actions taken Yes No N/A
Wound care-plan discussed/agreed with the patient Yes No Verbal Written
If pressure ulcer, Waterlow risk assessment, SSKIN and check list fully Yes No
completed and reviewed
If No to any of the above, reason for non-completion:
Is it necessary to raise a safeguarding concern? Yes No
Drawing/Photograph Number of Wounds ……………. Location of wound(s)
Lower limb un-healed wounds require full assessment with Doppler measurements at 4 weeks completed?
Yes/No
Reason for non-completion ……………………………………………………………
Name: ……………………………………….... NHS…………….……………………. DOB……………………
Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 25 of 26Please sign and date every dressing change. Reassess wound as needed using clinical judgement and record any changes. Wound dimensions need to be measured at least weekly. Ensure that a separate form is used for each wound. Dressing Change Date and Time DD/MM/YY 0.00hrs Wound Dimension (cm) Maximum length Maximum width Maximum depth Undermining Visible Tendon/bone Yes/No Wound Bed (approx % cover) Necrotic – black Sloughy – yellow green Granulating – red Epithelialising – pink Wound edges Healthy H Rolled RO Raised R Undermined U Suture/clips Yes/No/removal date Exudate levels High H Moderate M Low L Type and colour Surrounding Skin Macerated M Oedematous O Excoriated E Fragile F Dry D Eczema X Healthy H Wound Pain scale 1 -10 (10 high) Continuous C Dressing D None N Clinical signs of infection present: i.e. 2 or more of the following present; pus, odour, deterioration, spreading erythema, heat, increased pain, increased exudate, abscess, friable tissue. Infection present? yes/no If yes, swab taken (date) Antibiotic therapy commenced (date) Treatment Objectives Patient comfort PC Absorption A Infection Control IC Debridement D Odour Control OC Promote granulation G Promote epithelialisation E Cleansing Solution Dressing Choice (if Topical Negative Therapy in use, document details here) Skin Emollient/Cream Frequency of dressing change (number of days) Date of review or healed Signed Print name Designation Wound Care Guidelines and Dressings Formulary February 2017 Version 4.0 Page 26 of 26
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