LOCAL HEALTH CARE WOUND MANAGEMENT FORMULARY 2010

VERSION 2 July 2010

Introduction
INTRODUCTION

This manual has been developed to enable healthcare staff to manage wounds and select appropriate dressings according to best-recognised practice. Wounds are an expensive and growing problem: today over 2,000 wound management products are available on the market. In addition, all members of the healthcare team can be involved in woundcare in a variety of settings, with patients often moving between professionals and environments. This manual will help ensure best practice and minimise the potential for inconsistency of care locally. The manual was compiled by the Peterborough Healthcare Wound Management Committee, comprising a multidisciplinary group of healthcare staff who are actively involved in delivering patient woundcare (contact details can be found in the next section). Our aim is to promote effective wound management and ensure a seamless service for all patients. Knowledge of the many factors relating to wound healing will aid holistic care and ultimately ensure the best possible outcomes for patients. All of the main themes relating to wound management are covered in this manual including: the wound healing process the assessment of wounds the preparation of wounds the management of infection the selection of dressings In addition, the manual contains an algorithm to select appropriate treatments, a formulary of woundcare products and illustrated wound assessment charts. The layout of the manual has been designed to allow the reader to quickly locate the information they need: Each section has a detailed list of contents. Special topic boxes, indicated by , expand the information in the text. Key references are supplied for further reading. The appendices contain some of the more practical items including a quick reference chart, wound assessment charts, a request for non-formulary dressing form, and a feedback sheet. A patient-held communication sheet has also been included. This may be copied and used by any professional involved in woundcare because we believe that as well as a more consistent approach, good communication between professionals involved in wound management is essential. Finally, the Committee recognises that some very new or less commonly used therapies are in use in woundcare management. We have included an overview of some of these in Section 12, such as larval therapy, vacuum assisted closure and laser ablation. Once these new therapies are adopted as part of the Committees recommended best practice, they will be included in updates of this manual. Peterborough Healthcare Wound Management Committee, June 2004

Committee members

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Nicki Ayres RGN, RSCN, DN Diploma

Service Manager, Integrated Nurse Teams Peterborough Community Services

Rachel Sylvester RGN BSc (Hons) Health Studies

District Nurse Peterborough Community Services

Jayne Clark RGN

Senior Sister Rivergate Primary Care Centre

Linda Coultrup RGN, Dip Critical Care BSc (Hons) Nursing

Professional and Practice Development Leader

Peterborough and Stamford Hospitals NHS Foundation Trust

Jo Dale RGN

Clinical Nurse Leader

Peterborough and Stamford Hospitals NHS Foundation Trust

Sheila Duggan RGN, NDN, Dip ENT

Practice Nurse Peterborough Community Services

Zo Fullagar RN, Dip HE (Part 12)

Team Leader Cambridgeshire and Peterborough Mental Health Partnership NHS Trust Head of Podiatry Services/Diabetic Foot Specialist Peterborough Community Services

Jo Hood BSc (Hons) MChS SRCh

Liz Huggins RGN DN Cert Dip Tissue Viability

Health Visitor Peterborough Community Services

Sarah King

Clinical Nurse Manager Rivergate Primary Care Centre

Val Shaw B Pharm (Hons) MR PharmS

Pharmacy Services Manager Peterborough and Stamford Hospitals NHS Foundation Trust Peterborough Community Services

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Contents
i ii iii SECTION 1 SECTION 2 SECTION 3 SECTION 4 SECTION 5 SECTION 6 SECTION 7 SECTION 8 SECTION 9 Introduction Peterborough Woundcare Manual Committee Members Contents THE WOUND HEALING PROCESS FACTORS AFFECTING WOUND HEALING WOUND ASSESSMENT WOUND PREPARATION WOUND INFECTIONS DIABETIC FOOT WOUNDS THE IDEAL WOUND DRESSING WOUND ASSESSMENT/TREATMENT ALGORITHM FORMULARY OF WOUNDCARE PRODUCTS Criteria for Formulary Inclusion, Disclaimer Initial Community Dressings WOUNDCARE PRODUCT ASSESSMENT PRODUCT MONOGRAPHS NEW THERAPIES PATIENT- HELD COMMUNICATION SHEET Jayne Clark and Sarah King Zo Fullagar

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Jo Dale, Rachel Sylvester and Sheila Duggan Jo Dale and Jo Hood Jo Dale and Jo Hood Jo Hood and Liz Huggins Val Shaw

SECTION 10 SECTION 11 SECTION 12 Appendix I Appendix II

WOUND MANAGEMENT CHART Peterborough and Stamford Hospitals NHS Foundation Trust WOUND MANAGEMENT CHART Greater Peterborough Primary Care Partnership LEG ULCER ASSESSMENT FORM ORGANISMS ENCOUNTERED IN WOUND MANAGEMENT MANAGEMENT OF TETANUS PRONE WOUNDS FAX-BACK COMMENT SHEETS DRESSING REQUEST FORM NON-FORMULARY DRESSING REQUEST FORM DRESSING CHANGES RECORD FORM GLOSSARY ACKNOWLEDGEMENTS GUIDELINES
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Appendix III Appendix IV Appendix V Appendix VI Appendix VlI Appendix VIlI Appendix IX Appendix X Appendix XI Appendix Xll

Wound healing process

1 THE WOUND HEALING PROCESS Jayne Clark and Sarah King Wound healing is a complex series of events that begins at the moment of injury, and can continue for months or even years. Wound healing is complete when the strength and continuation of damaged tissues are regenerated by the formation of connective tissue and the regrowth of epithelium.

1.1 The stages of wound healing The physiology of wound healing involves four main active stages. The inflammatory phase (0 3 days) Formation of blood clots. Bacteria are attacked. Orderly recruitment of keys cells into the wound site. Vasodilation leading to heat and redness. Increased capillary permeability causing swelling. The destructive phase (1 6 days) Neutrophils engulf and digest dead tissue and bacteria (phagocytosis). Macrophages regulate all stages of healing producing growth factors that stimulate new tissue. Macrophages stimulate the formation and multiplication of fibroblasts. The proliferation phase (3 24 days) A combination of regenerative processes is involved. Cells necessary for wound closure proliferate at the wound site to make new tissue and capillaries (part of granulation tissue). New capillary loops branch out from walls of damaged capillaries until they meet uninjured tissue. A network of blood vessels fills the wound bed (angiogenesis).

Growth Factors Growth factors are classified as cytokines, which are proteins that act as intercellular signals to allow cells to communicate with one another. Growth factors are involved in all stages of wound healing and also have the ability to regulate many other functions within cells including protein synthesis. They are specific for attracting useful cells and proteins to the wound, including immune cells to fight infection and other cells to form connective tissue. Growth factors also stimulate an increased production of connective tissue; create a new supply of blood vessels to nourish the site, thus promoting maturation.

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Wound healing process

Tissue maturation (24 days 2 years) Remodelling of the tissues occurs. New collagen forms which increases the tensile (elastic) strength of the wound. The scar is initially raised and reddish but with maturity the blood supply will reduce this appearance. The scar eventually becomes paler and flatter. A mature scar is never as strong as the original intact skin. 1.2 Cellular activity during wound healing Macrophages secrete fibroblast-stimulating factor which when combined with a growth factor released by dead platelets cause fibroblasts to migrate into the wound bed soon after damage has occurred. The fibroblasts are then activated and divide and produce a network of collagen fibres that increase the strength of the wound. During this phase it is essential that adequate nutrition and oxygenation be received in order to promote wound healing. Angioblasts are required for this stage of wound healing to form new blood vessels that grow into the wound. The vessels branch and link up with other vessels forming loops. These delicate capillary loops are held within the newly secreted framework of collagen. This complex is known as granulation tissue.

Further reading: The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 5th Edition, edited by Jane Mallet and Lisa Dougherty, 2000.

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Factors affecting wound healing

2 FACTORS AFFECTING WOUND HEALING Zo Fullagar

2.1 Intrinsic Factors Ageing and metabolic rate Metabolic rate changes during life and affects wound healing. Healing in young children and pregnant women is accelerated due to increased metabolic rate. Older patients experience reduced healing rate as their metabolic rate gradually reduces with age.
Vitamins, trace elements and wound healing Vitamin A deficiency slows epithelialisation, decreases collagen synthesis and increases susceptibility to infection. Vitamin C is an essential co-factor during collagen synthesis; its deficiency leads to scurvy and delayed healing. Vitamin K deficiency results in the insufficient production of essential clotting factors. Zinc deficiency is the most important clinically, as it may be associated with a host of abnormalities, including impaired immune responses and decreased protein and collagen synthesis. In the absence of proven deficiency, the administration of vitamins A, C, K and zinc sulphate do not improve wound healing and in fact excess zinc can be detrimental.

Impaired nutritional status Well nourished individuals have a plentiful supply of the proteins, carbohydrates, fats, vitamins and minerals that are essential for normal wound healing. Thorough nutritional assessment and, if necessary, referral to a dietician are therefore important in wound management. Protein deficiency Protein deficiency delays fibroblast migration and may occur after: major trauma surgery, or during sepsis Vitamin deficiencies Deficiencies in these vitamins have been associated with delayed wound healing: vitamin A vitamin C vitamin K Trace elements and minerals Some trace elements and minerals are also necessary as co-factors for enzymes important in wound healing. These include: zinc copper iron manganese

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Factors affecting wound healing

Disease processes delaying wound healing Anaemia Arthritis Chronic pulmonary disease Chronic renal failure Coagulation disorders Congenital defects Congestive heart failure Cushings syndrome Diabetes mellitus Hypertension Hyperthyroidism Ischaemia Jaundice Liver cirrhosis Malignancy Malnutrition Neurological disease Ulcerative colitis Vasculitis

Dehydration The metabolic processes of an individual require about 2500 ml of water every 24 hours. A dehydrated patient will not be able to metabolise efficiently and this will adversely affect the healing process. Disease processes The generalised metabolic effects of a number of disease processes can delay healing. Fever Febrile patients have an increased metabolic rate and use vast amounts of energy in both generating and dissipating heat. This reduces the amount of energy they can use for wound healing. Smoking Smoking adversely affects wound healing in a number of ways.

2.2 Extrinsic Factors Poor surgical technique Tissues damaged during surgery can result in haematoma. Infection can occur if breakdown of the haematoma takes place. Dead space may occur where tissues are misaligned during surgery this can also lead to infection. Sutures inserted too tightly can lead to tissue damage and death. Drug treatments A whole range of drug therapies can affect wound healing. Inappropriate wound management Wound healing may be adversely affected by: the use of poor dressing technique the wrong dressing the use of antiseptic where it is not needed Adverse psychosocial factors A wide variety of psychosocial factors may effect wound healing including: a lack of understanding and acceptance of the treatment regime anxiety associated with changes in work, income, relationships and self-image.

Smoking and wound healing Nicotine is a potent vasoconstrictor and can reduce peripheral blood flow by up to 50% for more than an hour after smoking one cigarette.

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Factors affecting wound healing

Pressure The cause of any pressure must be removed.

Infection This is the most important factor that can delay or prevent wound healing (see Section 5).
Drug treatments delaying wound healing Corticosteroids - reduce inflammatory response and inhibit epithelial regeneration. Anticoagulants- bleeding complications and haematomas. Cyclosporin A and cytotoxics - impair cell immunity and resistance to infection. Colchicine- inhibits contractions & reduces scar tissue. NSAIDS - impairs inflammatory response. Penicillamine - reduces wound strength. Zinc sulphate (high doses) impairs immune response. Alcohol Smoking - nicotine is a vasoconstrictor. Regular injections ischaemic areas, especially in drug misusers. Diuretics - hypovolaemia. Further reading Alexander M, Fawcett J, Runciman P. Nursing practice: hospital and home. Churchill Livingstone, London 1994: Chapter 23:702-703

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Wound assessment

3 WOUND ASSESSMENT Jo Dale, Rachel Sylvester and Sheila Duggan

3.1 Assessment Before treating a wound, it is essential to assess the patient and the wound holistically taking into account intrinsic and extrinsic factors (see Section 2). Accurate wound assessment is important to provide baseline information about the state of the wound to: enable appropriate evidence based treatment of the wound; monitor progress; evaluate the effectiveness of management; improve morale of staff and patients; and provide an effective teaching tool. The use of a logical and systematic wound assessment chart (see Section 8) will: improve documentation and thus aid communication between clinical staff; identify treatment needsand incorporates dressing selection; and provide a more objective method of wound management [1] 3.2 Wound type Wounds can be classified as: acute post-operative chronic [2] 3.2.1 Acute wounds Acute wounds, such as cuts, abrasions, lacerations and burns, usually: are caused by trauma; respond rapidly to treatment and heal without complication; heal by primary or secondary intention. 3.2.2 Post-operative wounds Post-operative wounds are intentional acute wounds. They usually heal by primary intention, where the skin edges are held in approximation with sutures, clips or tape.

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Wound assessment

There is normally no tissue loss; therefore healing should be more rapid. Some surgical wounds are left open to heal by secondary intention, usually to allow drainage of infected material. If these are later sutured this is called tertiary intention. This is also the name for wounds that are sutured first, but the wound re-opens (dehisces) and is then left to heal by secondary intention.

3.2.3 Chronic wounds Chronic wounds include pressure ulcers, leg ulcers and acute wounds that have been present for more than six weeks. Chronic wounds usually: are of long duration or frequent recurrence [3]; heal by secondary intention, where the wound bed will be filled with granulation tissue and epithelial tissue migrates across the wound until it has healed; take longer to heal than post-operative wounds as there is tissue loss (the edges are far apart). In addition, the patient may have multifactorial problems that affect their ability to heal wounds (see Section 2).

3.3 Wound history In order to take any necessary action and plan effective treatment for wounds, it is important to be aware of the: aetiology duration treatment history 3.3.1 Aetiology Dirty wounds; e.g. a dog bite or a gardening injury, will have a greater risk of contamination and/or infection, therefore consider the need for tetanus and/or antibiotic therapy (see Appendix IV). Ulcers; e.g. arterial, venous, mixed, diabetic, rheumatoid or malignant, will all require different management. Foreign bodies; e.g. fibre or grit, will initiate or prolong the inflammatory phase and delay healing and therefore need to be removed.

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Wound assessment

3.3.2 Duration If a contaminated wound is more than 6 hours old [4], it may require antibiotic cover. It should be left to heal by secondary intention. If a wound is not healing as expected, management may need to be modified; e.g. ischaemic ulceration may need vascular intervention. 3.3.3 Treatment history Knowledge of treatment history will facilitate healing; e.g.: previously successful treatments avoidance of failed treatments avoidance of products to which the patient is allergic 3.4 Local wound environment
Ulcers For example, venous leg ulcers tend to be situated in the gaiter region around the medial or lateral malleolus and are large, shallow and highly exuding.

Local wound assessment provides information relevant to three areas: wound characteristics stage of wound healing surrounding skin 3.4.1 Wound characteristics Clinical diagnosis is assisted by assessment of: site shape size depth exudance Site This should be considered to identify potential problems such as : contamination - sacral area mobility - foot wounds application and retention of dressings - difficult areas pressure - foot, sacral area Shape This may affect healing time; e.g. round wounds usually take longer to heal than narrow wounds, as the epithelial cells have further to migrate across the wound.

Wound measurement Wounds should be measured using the perpendicular method [3]: the longest measurement of the wound is deemed to be the length (regardless of orientation) and the longest measurement perpendicular to the length is the width. To assess wound surface area the greatest width is multiplied by the greatest length.

Wound characteristics (continued) Size

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Wound assessment

Wound tracing is also useful and acetate grids are available for this purpose. They are laid across the wound so that the edges can be traced and its area measured. It is also a good idea to trace around any particular area of defined tissue or cavity existing within the wound, e.g. necrotic, granulating, etc.

Wound measurement allows monitoring of progress. Ultimately, successful wound healing is demonstrated by a reduction in wound size [6]. A measurement system should: be precise and accurate be easy to use not come into contact with the wound Depth If it is not possible to measure wound depth without disturbing the wound bed, then this should be estimated as: superficial shallow deep sinus cavity If a wound is estimated to be deep or have a sinus, specialist advice should be sought; e.g. podiatrist for foot wounds.

Photography provides a record of the type and extent of tissue covering the wound. Cameras that use film with a grid can be used to estimate wound area. However care should be taken with reference to focal length as this may distort the image. NB: Informed consent must be obtained prior to the use of photography.

There are specific dressings available for cavity wounds, which should be utilised to prevent the creation of a dead space which otherwise will be filled with devitalised tissue and excess exudate. Care should be taken in selecting the correct cavity dressing; e.g. use of alginates in a low exuding wound may cause plugging and subsequent tissue necrosis. Exudate level There is a need to monitor quantity, colour and type of exudates; e.g. serous fluid or pus. It is also important to define quantity. As a rough guide [7]: light exudate requires dressing changes every 4 -7 days moderate exudate requires dressing changes every 1-3 days heavy exudate refers to wounds requiring daily or more frequent changes due to saturation of an appropriate dressing 3.4.2 Stage of wound healing The condition of the wound bed and the local wound environment will provide information about the stage of healing. If the tissue is predominantly necrotic or sloughy, or if it is infected, the wound is likely to be in the inflammatory phase of healing. Granulation and epithelial tissue are evidence of proliferation.

Exudate Exudate production (which is most prolific during the inflammatory phase of healing) bathes the wound with nutrients and actively cleanses the wound surface. It acts as a growth medium for phagocytic cells and accelerates epithelialisation. However, if excessive, it can cause skin sensitivities, tissue maceration, plus leach away essential nutrients and growth factors [5].

Wound bed classification

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Wound assessment
Wounds may be: necrotic sloughy infected granulating epithelialising 3.4.3 Surrounding skin Assess skin surrounding wound for: colour moisture suppleness

The shape of the wound edge may help with the diagnosis; e.g. deep and punched-out for arterial ulcers, rolled for malignancy. Points for consideration are: maceration (excessive moisture in the surrounding tissue) retention of dressing type of tape to be used (if any) possibility of contact dermatitis dryness skin scales hygiene varicose eczema fragile skin 3.5 Pain Pain is an integral part of wound management and is associated with the: type of injury location of the wound presence of infection healing process approaches to wound management Pain should be quantitatively assessed and documented using an appropriate visual analogue scale; e.g. 0 = no pain, 10 = worst pain.

For further advice consult appropriate professional

References: 1. Collier M. Nursing Times Essential Guide to Wound Assessment. London, 2001 2. Dealey C. The care of wounds. Blackwell Science, Oxford, 1995: pp 65-666 3. Fowler E. Chronic wounds. In: Krasner D. (Ed). Chronic wound care. A clinical sourcebook for healthcare professionals. Health management Publications, King of Prussia, PA, USA, 1990

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

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References [contd] 4. Pritchard B. Yates DW and Redmond AD. Lecture notes on accident and emergency medicine. Oxford: Blackwell Scientific, 1985 5. Bryant JL et al. Reliability of wound measuring techniques in an outpatient wound centre. Ostomy Wound Management 2001; 47(4): 44-51 6. Miller M, Glover D. Wound management: theory and practice. Nursing Times Books, London, 1999 7. Bale S, Harding K, Leaper D. An introduction to wounds. Churchill Livingstone Edinburgh 2000 8. Krasner , D, Chronic Wound Care: A clinical source book for Health Care Professionals; Health Management Publications, Pennsylvania 1997 9. Sibbald et al; Preparing the wound bed debridement, bacterial balance and moisture balance; Ostomy wound management 200;46(11): 1435

incident pain recurrent episodic pain continuous pain

Incident pain results from debridement or trauma to the wound. It can be relieved by use of analgesia based upon the WHO pain ladder. Recurrent episodic pain is frequently experienced by the patient during dressing changes. If the dressing is very painful then the patient may not comply. Continuous pain may indicate that the underlying cause of the wound has remained untreated, or that the wound has become extensively infected. It is essential to determine whether it originates from the wound or the surrounding tissue [9].

3.6 Odour It is important to identify whether the presence of odour is due to: bacterial invasion necrosis poor hygiene If the wound is infected it should be treated appropriately (see Section 5).

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Wound preparation

4 WOUND PREPARATION Jo Dale and Jo Hood Appropriate wound-bed preparation is an essential part of wound management as it ensures that the maximum benefit can be gained from the many woundcare products available and facilitates the healing process. Wound-bed preparation should address the following factors: debridement exudate management bacterial balance (1) 4.1 Debridement Chronic wounds have a necrotic burden made up of: necrotic tissue devitalised tissue exudate Chronic wounds can be intensely inflammatory and thus produce substantial amounts of exudate that may interfere with healing or with the effectiveness of therapeutic products, including growth factors and bio-engineered skin. It is therefore necessary to remove eschar , non-viable tissue and exudate components in order to promote healing.(1) Consequences of non-debridement unable to assess wound size and depth masking of abscess or fluid collection prevention of wound apposition secondary to splinting effect of necrotic tissue optimum conditions for bacterial growth odour management increased psychological stress due to dirty wound Methods Autolytic: This is the most frequent form of debridement. It can be accelerated with a moist interactive dressing, e.g. hydrogel. However, if no change is apparent within 72 hours then other methods should be considered.

Eschar Sloughed off dead tissue caused by burn or cauterisation OR An eschar is a hard plaque covering an ulcer implying extensive tissue necrosis, infarcts, deep burns, or gangrene.

Autolytic debridement It is a naturally occurring process, where macrophages and endogenous proteolytic enzymes liquefy and spontaneously separate necrosis. Hydrocolloids may also facilitate autolytic debridement in wounds where exudate is present.

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Wound preparation

Methods (continued) Chemical Larvae (see section 12) Sharp/surgical This should only be undertaken by suitably qualified practitioners. Factors influencing choice of debridement Factors that influence the choice of debridement method are: practitioners skill and knowledge speed of debridement presence of infection cost-effectiveness acceptability to patient suitability of patient in terms of risk 4.2 Exudate management The presence of excess exudate can interfere with the biological microenvironment of the wound and delay healing. Prolonged excess exudate may indicate that the underlying cause is not being addressed. Action required includes: treatment of underlying cause; e.g. venous insufficiency with compression, infection ; cleansing of wound; and use of absorbent dressings to manage exudate, e.g. foams, alginates (Refer to the Formulary of Woundcare Products Section 9)

Bacterial burden It has been said that some chronic wounds are stuck in one of the phases of the normal healing process, such as the inflammation or proliferative phases. Eliminating the bacterial burden by the use of debridement or slow-release iodine products can help this situation [1].

4.3 Bacterial balance The correction of the bacterial burden decreases the possibility of infection but also diminishes the ongoing inflammation that often characterises many chronic wounds.

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4.3 Bacterial balance (continued) Methods of addressing the bacterial balance include: wound cleansing topical treatment with antimicrobials systemic treatment with antibiotic therapy removal of excess exudate from the wound environment use of secondary dressings to protect from external contaminants 4.4 Wound cleansing

If a wound is clean with little exudate and is healthily granulating, no cleansing is required. (2) In chronic wounds it is recognised that sterility of the wound surface is not necessary for healing nor is it possible. Wounds should only be cleaned prior to the application of a dressing to provide optimum local conditions for wound healing; i.e.: to remove excess exudate and cell debris to reduce bacterial burden Considerations and risks for wound cleansing Safe practices Clinical risk beware of splashback. Avoid traumatising newly produced and delicate tissue by reducing the surface temperature of the wound or by rough handling of gauze swabs Suitable solutions Avoid causing damage to friable tissues from antiseptics or pressurised irrigation Appropriate practice Gentle irrigation is the preferred method of cleansing a wound, as swabbing may be traumatic and is more likely to result in redistribution of micro-organisms around the wound rather than their removal. Cotton wool should not be used as it may shed fibres into the wound. A sterile solution of 0.9% sodium chloride warmed to between 30-34C is the most appropriate cleansing agent. Cooling the wound inhibits cell mitosis and potentially delays healing.

Appropriate practice (continued)

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Wound preparation

References: 1. Baharestani M., Goltrup F., Holstein, P. Vansceidt W. (eds). (1999) The clinical relevance of debridement. Springer-Verlag, Berlin 2. Bale, S and Jones, V. 2000. Wound Care Nursing A Patient-Centred Approach Bailliere Tindall Further reading: Collier.M, 2002 Wound-bed Preparation Nursing Times plus Vincent Falanga, 2001 Introducing the Concept of Wound Bed Preparation. An International Forum on Wound Care, Issue No 16 Williams, N.A. and Leaper, D.J, 1998 Wounds Biology and Management Oxford Medical Publications

Warm fluid is more comfortable for the patient. Antiseptic solutions now have little place in wound management.

Exceptions to this may be: wounds where MRSA has been isolated; and infected ischaemic wounds where systemic antibiotics are unlikely to reach the wound site . Ordinary tap water should not cause contamination or infection if used on large chronic wounds e.g. leg ulcers, pressures sores. These wounds may benefit from bathing or showering.

4.5. Topical treatment with antimicrobials The use of antimicrobials, such as cadexomer iodine and silver sulphadiazine has been revisited to address wounds with critical colonisation; i.e. wounds that are moving between the spectrum of colonisation and local infection. (See Section 5).

For advice contact Infection Control.

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Wound infections

5 WOUND INFECTIONS Jo Dale and Jo Hood The skin is home to a wide variety of bacteria. The normal flora, as is it known, generally causes the host no problems when the skin is intact. However, many bacteria can become pathogenic, multiply and invade if conditions are favourable. When the skins barrier is disrupted with a wound, it provides an ideal point of entry for pathogenic bacteria. The presence of bacteria in a wound does not necessarily indicate that infection has occurred or leads to impairment of wound healing. However, increased bacterial load can lead to reduced or no healing [1, 2]. Wounds provide an ideal culture medium for the growth of bacteria because they have: the optimum temperature for bacterial growth; a frequent supply of nutrients in the form of organic debris ; and a moist environment 5.1 Classification Wounds can be classified depending on the amount of bacteria present and the type of pathogens likely to be present. The main types are: contaminated wounds colonised wounds infected wounds Contaminated wounds Bacteria are present in low numbers but there is no multiplication. Colonised wounds There is multiplication of bacteria but no host reaction. Infected wounds There is deposition and multiplication of bacteria in the tissue with an associated host reaction. It has been considered that a bacterial content of greater than 105//g tissue comprises clinical infection and may delay healing. Before wound infection is apparent, the bacterial burden can increase to a level where there is a covert infection which is sufficient to inhibit wound healing [3].

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Wound infections

Infected wounds (continued) Infection causes delay of healing and hospital-acquired (nosocomial) infections are associated with more virulent organisms than those indigenous to patients. Specific bacteria are usually involved in wound infection (See Appendix III).

5.2 Recognising infection Clinical infection is recognised by these well-defined criteria: local pain swelling heat redness However, the above are also signs of inflammation, part of the normal wound healing process, therefore the additional criteria below should also be considered: Bridging of soft tissue and the epithelium may occur when bacteria impede the progress of epithelialisation. Delayed healing wound not healing at the expected rate or a sudden reduction in progress. Discoloration of the wound deep red colour may indicate infection. Green staining of dressings may indicate the presence of Pseudomonas aeruginosa. Friability of granulation tissue tissue becomes friable and bleeds easily on light pressure. Odour may indicate the presence of certain types of bacteria, especially anaerobic bacteria. Pocketing at the wound base problematical in deep wounds such as pilonidal sinus wounds. Unexpected pain caused by increase in pressure; may often have a definite start point. Wound breakdown organisms weaken the newly repaired tissue. A major wound infection is characterised by: systemic toxicity (pyrexia and tachycardia) local pain wound breakdown extensive cellulites

Probability of infection = (Dose of bacteria x Virulence) Host reaction

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Wound infections

Tip: treat the patient not a bacteriological swab.

Recognising infection (continued) In some instances there may be an absence of clinical cellulitis, due to a lack of a typical immune response as the patient may be immuno-compromised due to: medication systemic disease ageing ischaemia peripheral vascular disease In these cases it is important to recognise one or more other clinical signs: presence of pus increased wetness change in pain change in appearance of granulation tissue odour 5.3 Specimen collection Treatment should be based on the signs of clinical infection. However, a swab performed in the presence of the above clinical signs may be beneficial to manage the infection by identification of the causative organism and its sensitivity to antiseptics. Best practice for specimen collection: If the wound does not have excessive amounts of pus or exudate then it should not be cleaned prior to swabbing. The swab should be moistened in the transport medium if necessary and then rotated in the fingers to ensure all sides of the swab come into contact with the wound. The swab should be zigzagged across the wound to ensure the entire wound is covered. If a deep wound is being irrigated with sodium chloride 0.9%, culture of the effluent will provide a more meaningful result than a swab. 5.4 Treating patients with infected wounds Before considering the local treatment of any wound, it is important to ensure that any risk factors associated with infection are controlled or eradicated. Correct identification of the cause of the wound will lead to a rational treatment approach and subsequent healing.

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Wound infections
Treating patients with infected wounds (continued)

Factors increasing the risk of infection include: the presence of a foreign body in the wound; pieces of discarded dressing, especially gauze and tulle, dirt, suture material, drains; the presence of dead tissue may act as a focus for infection, as fewer bacteria are needed to cause infection; contused tissue; tissue ischaemia; previous or current irradiation; presence of a haematoma; the use of vasoconstricting drugs; and pre-operative shaving. Predisposing medical conditions There are a number of medical conditions that are known to predispose patients to infection.
Predisposing medical conditions: Diabetes Cancer Rheumatoid arthritis Excessive alcohol intake Malnourishment Conditions which lead to suppressed or nonfunctioning of the immune system Systemic use of steroids or antibiotics Co-existing distant skin lesions such as exfoliative dermatitis (themselves a target for infection) (4)

5.5 Local management of infected wounds Should be considered in conjunction with the use of systemic antibiotics where required. Wounds should only be dressed using products licensed for infected wounds. Dressings should be changed more frequently to allow the removal of infected material. Surgical wounds require drainage of pus (either by surgery or by removal of stitches), prescription of systemic antibiotics and, if appropriate, bed rest and elevation of the affected limb.

5.6 Topical antiseptics to be avoided (See also Section 10) Antiseptics have been shown to be destructive to normal tissue (in vivo and in vitro). Their ability to kill bacteria is compromised in the presence of blood, wound exudate or tissue, so unlikely to be effective against bacteria established in tissue. Hypochlorite: Irritatant to skin due to high pH Often selected for Gram negative

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Topical antiseptics to be avoided (continued) Hydrogen peroxide: Desloughs for a few seconds Harms healthy tissue Proflavine:

Bacteriostatic against Gram positive only

Chlorhexidine: Gram +ve and ve effective Residual tissue toxicity Acetic acid: Low pH effective against Pseudomonas Selects out S.aureus and Proteus Povidone iodine: Broad spectrum but activity decreased in the presence of pus Cetrimide. Effective against Gram ve and +ve Detergent effect high tissue toxicity (5)

5.7. Effective antimicrobial dressings

Opinion It may be as troublesome to the patient to be treated for an infection that is not present, as it is to overlook the infection that is there. [6]

These antimicrobial products will reduce the numbers of bacteria within a wound and may subsequently eliminate any infection, however there may still be a need for antibiotics: Cadexomer iodine (slow release therefore no tissue toxicity) Silver sulphadiazine Nanocrystalline silver 5.8 Antibiotic Therapy Considerations Bacterial resistance Patient allergies Side effects Sensitivity of organism

Exception: Use of topically applied metronidazole gel for grossly malignant wounds, e.g. fungating malignant lesions, where it will reduce or prevent the odour.

References 1. Kerstein, M. A Symposium: Wound woundcare manual

Wound infections
infection and occlusion separating fact from fiction. American Journal of Surgery 1999 167: (1A) (supplement), S7- S11 2. Dow et al. Infection in Chronic Wounds; controversies in diagnosis and treatment. Ostomy Wound Management; 1999; 45(8); 23-40 3. Thompson, P et al; Wound bacterial colonisation and infection in biology and management. Mulder GD (ed) Oxford Press 1993 4. Cutting KF, Harding KG Criteria for identifying wound infection. Journal of Woundcare 1994;3(4):198-201 5. Cutting K. Factors affecting wound healing. Nursing Standard 1994; 8(50): 33-37 6. Wound Bed Preparation Presentation notes (2002): Pam Spruce. Education and research Manager, Smith and Nephew Healthcare. Miller, M. and Glover, D 1999 7. Wound Management Theory and Practice Nursing Times Books Williams N.A, Leaper DJ. Wounds Biology and Management: Oxford Medical Publications Journal of Wound Care 1998

5.8 Antibiotic therapy (continued) Actions of antibiotics Bacteriostatic stop bacteria reproducing and rely on host defences to eliminate them. Bactericidal attack and kill bacteria only when they are dividing ineffective against dormant bacteria. Combinations of antibiotics Bactericidal and bacteriostatic antibiotics do not usually mix well as the static drug may force the bacteria into a dormant non-dividing state on which the cidal drug cannot act. Bactericidal drugs used together may enhance each others action; i.e. they are synergistic. Bacteriostatic drugs when used together are usually additive, so the effect of using two together can be achieved by using more of one drug. Ideal antibiotic An ideal antibiotic is only of use if it does not harm the host significantly. The ideal antibiotic should: be selective for disease causing and not harmful to the normal flora; not be impaired by body fluids or by tissue enzymes; reach adequate levels in the appropriate part of the body; i.e. the wound - this will depend on the drugs absorption, distribution and excretion; and be bactericidal The use of topical antibacterials may lead to: local cell and tissue damage; systemic toxicity; the development of contact sensitivity and allergic reactions; disturbances in the normal skin ecology, leading to super-infection and the possibility of developing antibiotic resistance; and interactions with concurrent drug therapy, especially steroids Systemic antibiotics At present, the use of systemic antibiotics is only advocated in the presence of a host reaction, therefore it is always important to seek advice from the Infection Control Team before prescribing antibiotic therapy [5].

woundcare manual

Diabetic foot wounds

6 DIABETIC FOOT WOUNDS Jo Hood and Liz Huggins The diabetic foot is a unique entity in terms of the challenges it presents for wound management. There are multiplicities of factors that can prevent effective healing which can be slow and deterioration rapid if these factors are not recognised and managed appropriately. So diabetic foot wounds require specific assessment and treatment in addition to normal woundcare protocols.

6.1 Specific Assessment It is important that both feet are thoroughly checked in case of any further undetected wounds. Assessment of patients Specific assessment of patients with diabetic foot wounds should include: neurovascular status blood sugar control cardiac or renal disease ulcer history medical and pharmacological history Assessment and classification of wounds Wounds should be assessed in terms of: Site: plantar surface/bony prominence Dimensions: may be masked by the presence of callus/necrotic tissue Infection: causative organism, extent, e.g. soft tissue/bone Assessment of aetiology Possible aetiological factors include: foot deformity functional foot problems hosiery, footwear poor self-care trauma

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Diabetic foot wounds

6.2 Treatment Diabetic foot wounds require factors additional to normal wound management.
Input from a stateregistered podiatrist via referral to the Podiatry Department is recommended.

Pressure relief Redistribution of pressure if required via padding, insoles or footwear modification. Prevention Treatment of any other foot pathology. Education Foot care and footwear advice should be given. Other action Review glycaemic control Treatment of hypertension and hyperlipidaemia Debridement Callus, necrotic tissue, slough and bony sequestrum must be removed by a suitably qualified practitioner. Regular maintenance of such wounds is usually required. Onward referrals Onward referrals to other professionals will be needed when: there is no improvement or deterioration of the wound or medical input is required; hospital investigations or tests are required; ischaemic pain is present; and specialist footwear is required 6.3 Infection Infections must be treated according to clinical signs. NB: Infection may be masked in patients with ischaemia. Actions to consider: Take wound swab if appropriate. Refer for X-ray if bony involvement suspected. For first-line treatment use a broad spectrum antibiotic; e.g. co-amoxiclav for a minimum of 10 days for all foot infections (or erythromycin if penicillin allergy). If bony involvement suspected, minimum course is six weeks. Anaerobic infection may require the addition of metronidazole.

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Diabetic foot wounds

6.4 Dressing considerations Selection of dressings should take into account the: site of the ulcer; e.g. plantar, dorsal, interdigital appearance; e.g. necrotic, sloughy, etc. aetiology; e.g. pressure Points to consider in dressing selection: Dressings need to conform to site. Appropriate for level of exudate (greater for ulcers on the plantar surface). Shock absorbing properties; e.g. if plantar or interdigital. Adhesive dressings: consider surrounding skin quality. Method of securing: consider skin quality (to avoid trauma on removal), space in shoes, plus ensuring retention. Minimal tape should be used especially for digital dressings (constricts circulation). Protect surrounding skin. Consider potential for maceration of surrounding skin especially if wound is on a weight-bearing area or pressure point as this could potentially cause further breakdown or infection. Frequent dressing changes are required to allow continual monitoring of the wound this may have cost implications.

6.5 Advice to patients The patient should be advised to: rest the foot and lower limb whenever possible, and keep the dressings dry; and seek help as soon as possible if there is any increase in pain, swelling, odour or strike-through on dressing.

Further reading
Boulton, A., Connor, H., Cavanagh, P. (eds) (1995) The Foot in Diabetes. Wiley, Chichester Edmonds, M., Foster, A. (2000) Managing the Diabetic Foot. Blackwell Science, London

woundcare manual

The ideal wound dressing

7 THE IDEAL WOUND DRESSING Val Shaw

Exudate Wound exudate, in reasonable quantities, provides optimum conditions for wound healing and should be allowed to remain in contact with the wound surface. However, excess exudate should be removed to prevent maceration of the surrounding healthy tissue. In a chronic wound, excess exudate may delay the healing process.

7.1 General considerations The ideal wound dressing should provide the optimum environment for wound healing and protection from further injury. The properties of an ideal wound dressing do not change with the introduction of new types of dressing, but the range of effects on wound healing increases. The adoption of novel dressings into the formulary should be based on scientific evidence, but the number of double blind, placebo-controlled trials conducted are very few and make this process difficult [1]. Dressing changes should be minimised, the wound kept moist but the surrounding skin dry. The high cost of interactive dressings is a potential disadvantage of their use. However, if the wound can be dressed less frequently and if healing occurs faster, their use may be cost-effective, associated with less pain and provide a better quality of life for the patient. 7.2 Characteristics of an ideal dressing [2] Provides a moist environment at the wound/dressing interface. Provides thermal insulation as wound healing is temperature dependent. Impermeable to micro-organisms in both directions. Transparent, to allow monitoring of the wound without removing the dressing. Allows removal without trauma. Free from particulate contaminants. Safe to use: non-sensitising, non-toxic, latex-free dressings and packaging. Allows gaseous exchange of oxygen, carbon dioxide and water vapour. Absorbs excess exudate and toxic substances. Should not be flammable. Available in hospital and community in a range of sizes and forms. Requires infrequent changes: products should be left in place as long as possible. Cost-effective. Non-adherent: many products are described as this but are actually low adherent.

References 1. Hansson, C. Interactive wound dressings. A practical guide to their use in older patients. Drugs Ageing 1997; 11(4):271-84 2. Morgan, D. A. In: Formulary of Wound Management Products - A Guide for Healthcare Staff, 8th edition, 2000. Euromed Communications Ltd., Haslemere, UK

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The ideal wound dressing

7.2

Characteristics of an ideal dressing [2] (continued) Acceptable to the patient. Conformable and mouldable: especially over heels, elbows and sacrum. Provides mechanical protection.

woundcare manual

Wound algorithm
8a NON-INFECTED WOUND ASSESSMENT AND TREATMENT ALGORITHM

WOUND TYPE

DRESSING AIM

EXUDATE LEVEL H = high M = medium L = low

RECOMMENDED DRESSING See formulary for choice of dressing presentation

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

Necrotic Black or brown

Yes

Debridement or

Hydrogel plus hydrocolloid +/other 2 dressing Foam or other nonadherent dressing

No Sloughy yellow or white, slimy Yes Protection

Debridement and Absorption

Hydrofibre or alginate or foam +/2 dressing Hydrofibre or alginate or foam or hydrogel or hydrocolloid +/- 2 dressing Hydrogel or hydrocolloid +/- 2 dressing Hydrofibre or alginate or foam +/2 dressing Hydrocolloid or foam or nonadherent dressing +/- 2 dressing Hydrogel or nonadherent dressing or foam +/hydrogel +/- 2 dressing Low adherent dressing or foam

No Yes Protection and Absorption

Granulating red

L No Yes Protection -

Epitheliasing Pink

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Wound algorithm
8b INFECTED WOUND ASSESSMENT AND TREATMENT ALGORITHM
WOUND TYPE DRESSING AIM EXUDATE LEVEL H = high M = medium L = low

RECOMMENDED DRESSING See formulary for choice of dressing presentation

NB: Consult with Microbiologist and consider antibiotic therapy if appropriate Infected For clinical signs of infection see Section 5 Yes Eliminate infection, Control odour, Absorption, +/- Debridement

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

8c

FUNGATING WOUND ASSESSMENT AND TREATMENT ALGORITHM

WOUND TYPE DRESSING AIM EXUDATE LEVEL H = high M = medium L = low RECOMMENDED DRESSING See formulary for choice of dressing presentation

Fungating

Yes

Absorption, Odour Control, Protection

H M L

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

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Formulary of woundcare products

Criteria for formulary inclusion of a product 1. The underlying cause and the nature of the wound; 2. 3. 4. 5. 6. 7. 8. the stage of healing cleansing/removal of debris exudate management granulation/vascularisation epithelialisation

Sizes of dressings available Ease of dressing application/removal Frequency of dressing change Comfort and cosmetic consideration Product availability on FP10 Cost effectiveness The dressing and packaging should be latex-free whenever possible

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Formulary of woundcare products

PETERBOROUGH HEALTHCARE WOUND MANAGEMENT FORMULARY

As part of the discharge planning process, a maximum of 7 days supply of dressing(s) will be issued from the hospital. The exact quantity supplied will be based on the clinicians judgement of the wound at the time of discharge.

Disclaimer
Due to a paucity of evidence in the field of woundcare, the clinician must make a thorough assessment of the patient, wound type, and stage of healing, to make a clinical judgement of the most suitable dressing. At present, it is impossible to state that a particular dressing in one group is better than one in another for a particular wound type. The most cost-effective product with the most ideal characteristics should be selected for application.
DRESSING SIZE (all sizes in cm unless otherwise stated) NON-ADHERENT DRESSINGS Low Exudate NA-Ultra 9.5 x 9.5 19 x 9.5 Tricotex 9.5 x 9.5 Absorbs exudate into secondary dressings, for use under compression bandaging Not for routine use COMMENTS

LOW ADHERENT DRESSING Release 5x5 Podiatry only spreads exudate leading to acute wound maceration

ADHESIVE DRESSING Low Exudate Mepore +Mepore Ultra 7x8 10 x 11 11 x 15 9 x 20 9 x 25 9 x 30 6.5 x 5 9.5 x 8.5 15.5 x 8.5 20 x 10 25 x 10 30 x 10 35 x 10 If applied under tension-shearing force will cause skin damage Latex present in packaging Nil low exudate Not suitable for acrylic adhesive sensitivities Can be left in place for a week or more Post-operative dressing. Waterproof

Opsite Post-op

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Formulary of woundcare products

ADHESIVE DRESSING Low Exudate Tegaderm Plus Pad 5x7 9 x 10 9 x 15 9 x 20 9 x 25 9 x 35 For Orthopaedic surgery only

VAPOUR PERMEABLE ADHESIVE FILM DRESSING Low Exudate Tegaderm 6x7 10 x 25 12 x 12 15 x 20 20 x 30 6x7 10 x 12 12 x 25 15 x 20 Prevention of pressure sores on fragile skin only DO NOT use as a secondary retention dressing Do not leave in place longer than 7 days with hydrogel

Opsite (Hospital use if included above)

As above Theatre - Use as a drape

HYDROGEL Low to moderate exudate ActivHeal Hydrogel Purilon gel 15g 8g 15g Cheapest hydrogel first choice Avoid for 24 hours if using maggots For debridement contains alginate for wet/cavity wounds The only safe hydrogel for use prior to larval therapy

Intrasite gel Intrasite Conformable

8g 15g 10x10 10x20

Avoid for 24 hours if using maggots

ActivHeal alginate

Sorbsan

5x5 10x10 10x20 5x5 10 x 10 10 x 20

ALGINATE Not for low exudate wounds Cheapest alginate first choice

HYDROFIBRE Aquacel (hydrofibre) Sheet 5x5 10 x 10 15 x 15 Not occlusive Moderate-heavy exudate Can remain for up to 7 days

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Formulary of woundcare products

HYDROCOLLOID DRESSINGS ActivHeal Hydrocolloid 5x 7.5 10x10 15x15 15x18 sacral Granuflex 10 x 10 15 x 15 15 x 20 6x6 10 x 10 10 x 13 15 x 15 15 x 18 5 x 10 7.5 x 7.5 10 x 10 5 x 20 15 x 15 10 x 10 15 x 15 20 x 20 Low to medium exudate contains pork Waterproof can remain for maximum of seven days Low to medium exudate contains pork Waterproof can remain for maximum of seven days Cheapest hydrocolloid first choice

Bordered Granuflex

Duoderm Extra Thin

For superficial wounds and low exudate

Comfeel plus

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

POLYURETHANE / HYDROCELLULAR FOAM DRESSINGS All exudates ActivHeal Non-adhesive Foam Dressing 5x5 7.5x7.5 20 x 20 Biatain Non-adhesive Lyofoam 5cm diameter 8cm diameter 7.5 x 7.5 10 x 10 17.5 x 10 25 x 10 (hospital only) 20 x 15 9 x 6.5 10x10 12.5x12.5 15x15 20x20 Allevyn 5x5 10 x 10 10 x 20 20 x 20 7.5 x 7.5 12.5 x 12.5 12.5 x 22.5 Podiatry use only. Very expensive Podiatry only heavily exudating wounds Secure dressing with adhesive tape, do not use occlusive tape or film Light exudates Cost effective if frequent dressing changes needed; e.g. infected wounds Around tracheostomies etc Cheapest adhesive foam first choice 10 x 10 18 x 10 Cheapest non-adhesive foam first choice

Lyofoam T ActivHeal Foam Island Dressing

Allevyn Adhesive

Allevyn heel dressing

Not for pressure relief Can remain for a maximum 5 days

Tielle

7x9 11 x 11 15 x 15 18 x 18

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Formulary of woundcare products

CAVITY DRESSINGS ActivHeal alginate Sorbsan (alginate) Aquacel ribbon (hydrofibre) Allevyn Cavity (foam) Rope 2cm x 30cm Ribbon 40 cm long (1g)- with probe Packing 30cm long (2g) Ribbon 2m x 25cm Circular 5 cm 10 cm Tubular 9 x 2.5 12 x 4

Cheapest cavity dressing first choice where appropriate Moderate to heavy exudate Moderate to heavy exudate

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

OVERGRANULATION Lyofoam Silver Nitrate 75% sticks All sizes 10 Under light compression Use with extreme care. For small areas (1.5 cm) of overgranulation on suture lines only

MULTILAYER COMPRESSION K- 4 # 1 K-Soft # 2 K Lite # 3 K- Plus # 4 Ko-Flex Wound contact layer Doppler before using compression bandages and holistic assessment Correct pressure essential for good healing

SKIN PROTECTION Cavilon Barrier Film Cavilon Barrier Cream Opsite spray 1ml / 3ml single use applicators 28ml spray 2g sachets 92g tube 100 ml For post op wounds which cannot be dressed. Painful if no anaesthetic! For skin protection, including delicate skin against adhesive dressings / tapes For skin protection (incontinence etc)

BURNS/SCALDS Silver Sulphadiazine 1% Cream Mepitel 50 g Argyria can be a problem with excessive use

5 x 7.5 7.5 x 10 10 x 18 20 x 30 5x5 10 x 10

Expensive not for frequent dressing changes

Jelonet

Limited use only where daily dressings required

woundcare manual

Formulary of woundcare products

DRESSINGS FOR INFECTED / MALODOUROUS WOUNDS Aquacel Ag 10x10 15x15 2cm x 45cm ribbon 6.5 x 9.5 10.5 x 10.5 19.5 x 10.5

Has adhesive border, therefore secondary dressing not required For cavities More expensive as secondary dressing for retention required

Actisorb Silver 200

Metronidazole Gel Anabact 0.75% Metrotop 0.8% Inadine (povidone iodine) Iodoflex (cadexomer iodine) 15g, 30g 30g 5x5 9.5 x 9.5 5g sachet 10g 17g Cost-effective (Anabact) Not for use on patients with metronidazole sensitivity. Use on anaerobic wounds only (See limited use section) Maximum of 4 dressings at any one time Maximum of 150g in 1 week Single 50g in one application Maximum of three months in any single course Care in severe renal failure

HONEY Activon manuka honey Activon (manuka honey) tulle dressing Algivon (manuka honey) alginate dressing 25g tube Tulle dressing

5x5 10 x 10 5x5 10 x 10

Alginate dressing

NON-ADHERENT SILICONE (OR SIMILAR) DRESSING Atrauman (Impregnated with triglycerides) 5x 5 10x20 7.5x10 20x30 Mepitel (Impregnated with silicone) 5 x 7.5 7.5 x 10 10 x 18 20 x 30 Should be left in place for 7 to 10 days, otherwise consider alternative dressing. Changing the simple secondary dressing ( amgee) is more cost effective. Should not be considered if frequent changes will be made = expensive. Useful for burns, chronic arterial leg ulcers. Not to be used on infected wounds Wet fingers with saline before handling the new dressing Cover with simple absorbent secondary dressing MUCH cheaper alternative to mepitel. Not appropriate for burns, skin grafts etc

Mepilex (silicone plus foam dressing) Mepilex Bordered

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

Adhesive dressing

woundcare manual

Formulary of woundcare products

Activheal hydrocolloid 5 x 7.5 10 x10 15 x 15 15 x 18 5x5 10 x 10 2 x 30 5x5 7.5 x 7.5 10 x 10 20 x 20 10 x 10cm square drug tariff (wcp 5x5cm + border 2.5cm) 12.5 x 12.5cm square 15 x 15cm square drug tariff (wcp 11x11cm + border 2cm) K Two bandage kit Atrauman Size 18-25cm 5 x 5cm 7.5 x 10cm 10 x 20cm 20 x 30cm 25g tube 10cm x 10cm 5cm x 5cm 5cm x 5cm 10cm x 10cm 10cm x 6m 12cm x 6m 3.5cm (red line) 5cm (green line) 7.5com (blue line) 10.75cm (Yellow line) 6 x 75mm x 3 strips Cavity Dressing

Activheal

Activheal (Non Adhesive)

Activheal (Adhesive)

Activon manuka honey Activon (manuka honey) tulle dressing Activon (manuka honey) tulle dressing Algivon (manuka honey) alginate dressing Algivon (manuka honey) alginate dressing Actico compression bandage K4 bandages ?? Comfifast 10m

Tulle dressing Tulle dressing

Steri-strip Acti V.A.C Granufoam Dressing Packs

Dressing Packs

Dressing Packs

300ml Canister with gel Small 10 x 7.5 x 3.3 com Medium 18 x 12.5 x 3.3 cm Pack sterile wound care community specification 1 pr small accelerator free nitrile lilac gloves 1x laminate sheet 1 x white poly bag 1 x dressing towel 5x10x10cm 4 ply non woven swabs 27x52" white poly apron 1 x sterile field 1 x wound measure guide Shermond 6075AF Pack sterile wound care community specification 1 pair medium accelerator free nitrile lilac gloves 1 x laminate sheet 1 x white poly bagf 1 x dressing towel 5x10x10cm 4 ply non woven swabs 1 x 27x53" white poly apron 1 x sterile field 1 x wound measure guide Shermond 6076AF Pack sterile wound care community specification 1 pr large accelerator free nitrile lilac gloves 1 x laminate sheet 1 x white poly bag 1 x dressing towel 5x10x10cm 4 ply non woven swabs 1 x 27x53" white poly apron 1 x sterile field 1 x wound measure guide Shermond 6077AF

woundcare manual

Formulary of woundcare products

Kerrammax 10 x 10 22 x 10 22 x 20 5 x 10 10 x 10

Super absorbent dressing for heavily exuding wounds.

Meefix adhesive tape

MEDICATED BANDAGES Viscopaste (zinc paste) Ichthopaste Steripaste (zinc oxide 15%) 7.5 x 6m 7.5 x 6m 7.5 x 6m Use only if react to viscopaste. Preservative free Infected leg ulcer with varicose eczema

STERILE SECONDARY DRESSINGS Non woven gauze swab (Topper 8) Wool pad (Mesorb) 7.5 x 7.5 4-ply 10 x 10 10 x 20 20 x 30 Sterile Fluid repellent backing ideal for peri-anal wounds Specialist use wound dictates Expensive

NON-STERILE SECONDARY DRESSINGS Non woven gauze swab (Topper 8) Gamgee 10 x 10 4 ply Non-sterile

500g pink or blue label

Do not use directly against wound contains cotton wool

DRESSING RETENTION Bandages 5cm x 4 m 7cm x 4 m 10cm x 4 m 15cm x 4 m 2.5 cm x 5 m Use most cost-effective product K-Band in the community

Scanpor Tape Micropore Microfoam

Cost-effective tape Hospital only

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

Theatre Use

WOUND CLEANSING SOLUTIONS Normasol sachets (sodium chloride 0.9%) Steripod (sodium chloride 0.9%) Aquasol sachets (sterile water) 25 ml

20 ml

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

100 ml

woundcare manual

Formulary of woundcare products

Irriclens (sodium chloride 0.9%) 1 x can 240 mls x 1 can

Named patient use only in hospital, otherwise community use only

LIMITED USE ITEMS Potassium permanganate 400 mg (Permitabs) Chlorhexidine sachets 0.05% Contreet Surgicel (Theatre and Mat Unit use only) Adaptic Digit (A&E and Theatre use only) Cica-care (out patients only) Jelonet (A&E and Theatre use only) Very limited use Mupirocin (Bactroban) Silver Sulphadiazine 1% Cream Cutinova Hydro Povidone Iodine Aqueous Solution 5 x 7.5 Small, medium, large, extra large 6 x 12 12 x 15 5x5 10 x 10 1 tablet dissolved in 4 litres water provides a 0.01% (1:10,000) solution 25ml 100ml Soaking macerated leg ulcers or infected highly exuding eczema Short soak only Stains clothing/containers Limited use - see infected wounds section Used in theatre occasionally to soak specific items For Podiatry only Absorbable haemostat For fingers and toes For management of scar Named patient only very expensive Burn patients for review next day, where silver sulphadiazine not indicated Initial dressing for circumcision and haemorroidectomy do not allow to dry out For MRSA wounds less than 5cm For larger MRSA wounds ITU/SRU and HDU use only for skin protection when using CPAP Skin preparation before surgery

15g 50g 2.5 x 5 500 ml

THEATRE USE ONLY Cetrimide Solution Sachets Chlorhexidine in Spirit 0.5% in 70% DEB Hydrogen Peroxide 3% (10 volumes) Povidone Iodine Spray Cavi-Care Spongistan Kaltostat 25 ml/100 ml 600 ml 100 ml 100 ml 20 g 7cm x 5cm x 0.1cm Tampon 5x5 7.5 x 12 10 x 20 15 x 25 10 cm x 10 cm 5, 7.5, 10 & 15 cms 15 cm Vaginal pack post vaginal hysterectomy, not for longer than 24 hours post-op Not to be used as an abdominal pack N.B: Unlicensed use during hernia surgery if used internally Licensed for external use only For hypospadias repair For colorectal use For orthopaedic grafting and plastics only Wound cleansing Flammable

Collatamp G Velband Ribbon Gauze Roll

Infected deep surgical wounds; e.i. infected grafts, vascular and orthopaedic use

woundcare manual

Formulary of woundcare products

Initial Community Dressings

This initiative enables all community nurses to overcome the problem of illegal boot stock, nurse prescribing and hospital discharges without dressings by giving the capacity to offer the patient an initial dressing prior to the in-depth wound assessment.

INITIAL DRESSINGS COMMUNITY ONLY Aquacel Granuflex Sacral Biatain Heel Duoderm Extra Thin Biatain Mepitel Comfeel Plus Tegaderm Tegaderm Sorbsan Plus Inadine Intrasite Conformable Mepore Mepore NA - Dressing Cavilon Steristrips Sodium Chloride 25ml Sachets K Band bandage Scanpore 10 x 10 10 x 10 7.5 x 10 10 x 10 12 x 12 15 x 20 7.5 x 10 9.5 x 9.5 10 x 10 7x8 11 x 15 9.5 x 9.5 1 ml 6 mm x 75 mm 25 ml 10cm 2.5 cm roll 10 x 10 15 x 18

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References 1. Local application to wounds 1: cleansers, antibacterials, debriders Drug and Therapeutics Bulletin 29 (24): 93-5, 1991 2. Zaki I, Shall L, Dalziel KL (1994) Bacitracin: a significant sensitiser in leg ulcer patients? Contact Dermatitis 31: 92-4 3. British medical Journal Editorial: Topical Antibiotics. Br Med J 1:494 1977 4. Kaye ET (2000) Topical antibacterial agents. Infect Dis Clin N Am 14 (2): 321-39 5. Morison M (1990) Wound cleansing- which solution? Nurse Stand 4(52): 4-6 6. Iwamoto Y, Ferguson LR, Pearson A et al (1992) Photoenhancement of the mutagenicity of 9anilinoacridine derivatives related to the antitumour agent amsacrine. J Mutat Res 268 (1): 35-41 7. DeMarini DM, Brock KH, Doerr CL et al (1988) Mutagenicity and clastogenicity of proflavine in L5178Y/TK cells. J Mutat Res 204(2): 323-8 8. Gupta R, Foster ME, Miller E (1991) Calcium alginate in the management of acute surgical wounds and abscesses. J Tiss Viabil 1(4): 115-6 9. White RJ, Cooper R, Kingsley A (2001) Wound colonization and infection: the role of topical antimicrobials. Br J Nurs 10(9)

10 WOUNDCARE PRODUCT ASSESSMENT Val Shaw 10.1 Topical antibiotics and antiseptics The indiscriminate use of topical antibiotics is not recommended for the routine treatment of colonised or infected wounds [1]. They can provoke delayed hypersensitivity reactions [2], super infections and select for resistance [3], which is a serious problem. The use of topical antiseptics must be subject to a risk-benefit assessment of possible local cellular toxicity with beneficial antibacterial action [4]. The ideal antiseptic should [5]: have a broad spectrum of activity have low potential for resistance be non-toxic be rapid acting not be an irritant or a sensitiser be effective, even in the presence of exudate, pus, slough, etc. not cause pain on application 10.2 Woundcare products to avoid Proflavine A slow acting, mildly bacteriostatic agent. An acridine derivative reported to cause mutagenicity, both gene and chromosomal mutations in bacteria [6] and cell cultures [7] raising questions about its safety. It has been shown to be inferior to alginate dressings for wound packing [8] and there is no reliable evidence that it is effective in this use, or that it has any clinical benefits [9]. Cicatrin Contains neomycin and zinc bacitracin. Application of large amounts, treatment of large areas or chronic wounds or prolonged treatment leads to systemic absorption, which may cause irreversible ototoxicity and nephrotoxicity. Use may be harmful by encouraging the colonisation of the wound by resistant organisms [10].

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10. Huavinen S, Kotilainen P, Jarvinen H et al (1994) Comparison of ciprofloxacin or trimethoprim therapy for venous leg ulcers: results of a pilot study. J Am Acad Dermatol 31: 279 - 281

Medicated tulle dressings E.g. Sofra-Tulle, Bactigras. These are not generally recommended. Sofra-Tulle contains kaolin and the antibiotic framycetin, which can lead to skin sensitisation and absorption which can cause systemic toxicity. Bactigras contains 0.5% chlorhexidine; there is no evidence of any antibacterial efficacy [11]. Paraffin tulle dressings E.g. Jelonet, Unitulle. These dressings carry different weights of paraffin per unit area to avoid adherence of the dressing to the wound. They require frequent changes in order to avoid drying out and incorporation into granulation tissue. Removal of the dressing may lead to trauma of the wound. Secondary dressings are always required. Antiseptic solutions as cleansing agents E.g. chlorhexidine. To be effective, these would need to be in contact with the wound for extended periods [12] or in high concentration, which would cause tissue toxicity.

11. Morgan D (2002) Wounds what should a dressings formulary include? Hospital Pharmacist 9: 261 - 266 12. Thomlinson D (1997) To clean or not to clean? Nurs Times 83 (9): 71 -5 13. Harris A, Rolstad BS Hypergranulation tissue: a non-traumatic method of management. In: Harding, KG, Cherry G, Dealdey C, Turner TD, editors. Proceedings of the Second European Conference on Advances in Wound Management; October 1992, Harrogate. London. MacMillan Magazines Ltd., 1993: 35-2 14. Payne CMER, Bladin C, Colchester ACF, Bland J, Lapworth R, Lane D. Argyria from excessive use of topical silver sulphadiazine. Lancet 1992; 340: 126 (letter) 15. Mertz PM, OlivieraGandia MF, Davis S (1999). The evaluation of a cadexomer iodine wound dressing on MRSA in acute wounds. Dermatol Surg 25 (2): 89 93 16. Scott Ward R, Saffle JR (1995). Topical agents in burn wound care. Phys Ther 75 (6): 526 538

10.3 Woundcare products for limited use Overgranulation Lyofoam can be used as a non-traumatic method of reducing hypergranulation tissue [13]. Silver nitrate has an irritant effect and is used occasionally to reduce hypergranulation in small areas (<1.5 cm) along a wound area. Silver may react with environmental pollutants to form black silver sulphide, giving the skin a general grey discolouration (argyria) which is largely a cosmetic problem [14]. Prolonged use often leads to argyria. Iodine dressings E.g. Inadine, Iodosorb. Iodine is a useful bacteriostatic and bactericidal agent, active against MRSA and other pathogens [15]. Its slow release from the iodophor optimises activity and reduces toxicity. The iodinated dressings should only be used on exuding wounds for best effect. Hydrogen peroxide 3% (10 volumes) An aqueous solution used to clean necrotic, infected wounds. Acts as an antiseptic due to the release of oxygen on contact with the tissues. There are safety concerns about using hydrogen peroxide solutions on open wounds because of reports of tissue embolism [16].

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Woundcare product assessment

10

17. Roe B, Cullum N (1995). The management of leg ulcers: current nursing practice. In: Cullum N, Roe B, eds. Leg Ulcers: Nursing Management. A Researchbased Guide. Scutari Press, London 18. Goodman Gilman A (1990). Antimicrobials. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 8th ed. Pergamon Press, Oxford: 1047 1182

Potassium permanganate Weak solutions (one part in 10,000) are used as soaks to cleanse and deodorise eczematous wounds and leg ulcers. There is no evidence published to support this use [17]. Silver Bactericidal, safe, broad spectrum agent. Silver sulphadiazine cream 1% releases the silver from the oil-in-cream formulation in concentrations that are selectively toxic to bacteria, e.g. MRSA, gentamicin-resistant Pseudomonas, Enterococcus and fungi [18]. Resistance has been reported, but is rare. Used as a mainstay for burns treatment. Silver-containing dressings have been developed recently: they all have different delivery systems but the mode of action is similar. Metronidazole E.g. Metrotop (0.8%), Anabact (0.75%). Is used as a topical gel in the palliative treatment of malodorous, malignant (fungating) wounds where odour is a problem, but due to the terminal nature of the disease, antibiotic resistance is not a problem.

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Product monographs

11

References 1. British National Formulary; London: British Medical Association and the Royal Pharmaceutical Society of Great Britain 2. Morgan DA; Formulary of Wound Management Products, 8th ed. (booklet). Haslemere: Euromed Communications, Sept 2000 3. www.smtl.co.uk 4. www.emc.vhn (registration may be required) 5. Val Shaw, Pharmacy Services Manager (Tel: 01733 875436) Jane Symons, Senior Clinical Pharmacist (Tel: 01733 874009) Medicines Information Department (Tel: 01733 874468) 6. Department of Health and National Assembly for Wales. Drug Tariff. London: Stationery Office

11 PRODUCT MONOGRAPHS General information about individual products is available from the: current British National Formulary [1] Formulary of Wound Management Products [2] Surgical Materials Testing Laboratory website [3] Electronic Summary of Product Characteristics [4] Pharmacy Departments [5], and package insert inside each product Precise details of sizes, shapes and prices of products can be found in the approved list of appliances, Part 1XA of the current Drug Tariff [6].

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New therapies

12

12.1 Larval (maggot) therapy The sterile larvae of the common green bottle Lucilia sericata can be used to cleanse most types of sloughy, infected or necrotic wounds including leg ulcers (venous and arterial), pressure sores, burns and diabetic foot ulcers [1]. The larvae secrete powerful proteolytic enzymes which breakdown slough and necrotic tissue which is then ingested as a source of nutrient. When first applied to a wound the larvae are only 2-3 mm long, but under favourable conditions they increase in size rapidly, reaching 8-10 mm when fully grown. In addition to cleaning the wound, maggots reduce or eliminate odour and combat infection by ingesting and killing bacteria, including antibiotic resistant strains such as methicillin-resistant Staphylococcus aureus (MRSA). For further information please contact the Podiatry Department or the Biosurgical Research Unit website: www.stml.co.uk .

12.2 Vacuum-assisted closure system (VACS) VACS consists of a pump which applies gentle negative pressure to the wound through a tube and foam sponge which are applied to the wound over a dressing and sealed in place with a plastic film to create a vacuum. Exudate from the wound is sucked along the tube to a disposable collecting chamber. The negative pressure improves the vascularity and stimulates granulation of the wound [2]. This therapy is indicated in neuropathic, venous and decubitus ulcers but contraindicated for deep infection. For further information visit STML website: www.stml.co.uk
References: [1] Larv E. Data Card, Biosurgical Research Unit (SMTL), Bridgend [2] Edmonds, M., Foster, A. (2000) Managing the Diabetic Foot. P66. Blackwell Science, London

12.3 Low-level laser therapy (LLLT) LLLT has been developed over the last three decades. It is the application of red and near-infrared light to wounds to stimulate healing and give pain relief. It is also used by physiotherapists to aid in the management of a variety of joint and soft-tissue conditions.

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Guidance for the use of Maggot Therapy

Maggot therapy is widely used by health care practitioners throughout the UK in the management of infected or necrotic wounds. Benefits of this therapy have been published in the medical and nursing press. What should you do before ordering Maggots? Assess the patient and the wound. Suitable wounds infected, sloughy, necrotic; e.g. leg ulcer, pressure ulcer, diabetic foot wound, infected wound. Unsuitable wounds dry necrotic, fistulae, wounds that bleed easily, if insufficient blood supply to allow healing. If unsure contact Janet Small, Tissue Viability Nurse, on 01733 466642 or Dawn Purdom, Clinical Advisor 07976148609. Ensure you have a hydrocolloid dressing; e.g. granuflex or zinc paste, available for protecting surrounding skin. Sleek tape to secure the net if using free range maggots. Intrasite gel should not be used 48 hours prior to application. Ensure your patients and consultants / GP consent.

Determine the amount and type of maggots you require available free range or in new biofoam bags. (measure the wound and estimate percentage of slough). Larvae calculators are available. Order via pharmacy for hospital use. Available on prescription in community - order telephone number is 08452301810. Maggots need to be used on the day of delivery. Application should be undertaken by someone who has experience in wound management and understands the healing process. Instructions for application come with the maggots but if help is required contact Janet Small or Dawn Purdom before ordering. A care plan and further information can be obtained from www.larve.com if required.

Prepared by Janet Small Tissue Viability Specialist Nurse - August 2006

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Appendix l - Patient held communication sheet

PATIENT NAME: ______________________________ ADDRESS: ______________________________ ______________________________ ______________________________ DATE OF BIRTH: ______________________________ PRACTICE ADDRESS: __________________________ HEALTHCARE PROFESSIONAL: ________________________________________________________________ GP: _________________________________

TREATMENT CURRENTLY RECEIVED BY PATIENT DATE:

NAME: CONTACT NO:

SIGNED NEXT APPT:

TREATMENT PLAN/CHANGE FOLLOWING APPOINTMENT

SIGNED: CONTACT NO:

DATE: NEXT APPT:

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Appendix II - Wound management chart (Peterborough and Stamford Hospitals

NHS Foundation Trust)

INITIAL ASESSMENT

PATIENTS NAME:

Initial assessment date:

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

Factors that may affect the Healing process Advanced age Diabetes Blood sugar Anaemia Vascular disease Infection Decreased mobility Poor nutritional intake Incontinence Neurological disease Advanced cancer Medications Allergies Fever Smoking Non-concurrence Waterlow score Others (State :)

Present (Tick)

Results

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Appendix II - Wound management chart (Greater Peterborough Primary Care

Partnership) PATIENTS NAME: HOSPITAL NO:

POSITION AND TYPE OF WOUND

WOUND NO:

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

DATE 1 WOUND DIMENSIONS Maximum length (cm) Maximum width (cm) Maximum depth (cm) 2 NATURE OF WOUND BED Necrotic (black) Sloughy (yellow) Granulating (red) Epithelialising (pink) 3 ODOUR Y-Yes 4 N-No

SURROUNDING SKIN M-macerated O-oedematous E-erythema F-fragile X-eczema D-dry H-healthy EXUDATE / DRAINAGE H-High M-Moderate L-Low CLIPS, SUTURES Date inserted:

Date removed:

DRAIN (Date removed)

PAIN (Assessment Chart: yes / no) C-continuous D-dressing N-none O-other times Analgesia required prior to dressing change (if yes please state what)

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Appendix II - Wound management chart (Greater Peterborough Primary Care

Partnership) 9 INFECTION Granulation tissue bleeds easily P-pocketing B-bridging Wound breakdown ACTION TAKEN Swab sent for M, C&S? date

10

TREATMENT OBJECTIVE (S): Healing OR patient comfort (H or P) D-debridement A-absorption O-odour control P-protection

ASSESSED BY : PRINT NAME: SIGNATURE:

TREATMENT TO BE USED: Details of dressing used to include: Size, quantity & secondary dressing?

Irrigation solution (if needed):

DOPPLER:

A.P.I. LEFT

A.P.I. RIGHT

Wound map taken (yes / no)

DATE OF NEXT DRESSING:

RE-ASSESSMENT DATE:

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Appendix III Leg ulcer assessment form

Name: Address:

SHEET NUMBER

LEG ULCER ASSESSMENT FORM (use separate chart for other wounds)
Date of Assessment Sleeping Pattern:

DoB:
Bed Other

Number
Random Blood Sugar: mmols Hb recent test: YES / NO Bloods taken: YES / NO ?ESR Urea, Creatinine Albumin, Rheumatoid Factor Refer to Phlebotomist: YES / NO Urinalysis ULCER SITE Y Past history of Ulcer Duration of present ulcer Waterflow Score Nutritional Score Advice on Diet Relevant Medication

Family History Smoker: YES / NO Allergies Smoking Cessation Advice Occupation: Past / Present Weight: Over / Normal / Under Mobility Concordance ULCER ARTERIAL RELATED Y N VENOUS RELATED Y Diabetes Thrombophlebitis Stroke/TIA Cellulitis Hypertension Vein Surgery Cardiac Failure Sclerotherapy Ulcerative Colitis Varicose Veins Past Arterial Surgery Leg Trauma/Injury Rheumatoid Arthritis DVT Myocardial Infarction/Angina Abdominal/Orthopaedic Surgery Intermittent Claudication Pregnancy/How many Cold to touch/Loss of hair atrophic - shiny skin Warm to Touch White on elevation Varicose Staining Slow capillary filling Varicose Eczema Dusky pink/blue Atrophe blanche Pain on limb elevation / Ischaemic rest pain Pain on Standing Small with steep edges Shallow / flat Slough slow to separate Lipodermatosclerosis Deteriorates rapidly Ankle flare DOPPLER ASSESSMENT Ankle Brachial Pressure R R R R L L L L Brachial/Foot Pulses Index ABPI B DP PT P B DP PT P Date ABPI Reassessments Date ABPI Reassessments Date

Leg Foot Medial Malleolus External Malleolus Pedal pulses present Poor ankle movement

Left Right

3-6 monthly Reassessments Date Date Date

R B

R DP

R PT

R P

L B

L DP

L L PT P

FINAL DIAGNOSIS/ULCER TYPE: Leg Ulcer Assessment Chart to be used in conjunction with Guidelines on the Management and Assessment of Ulcers

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ONGOING ASSESSMENT Date of Assessment Wound Dimensions: cm/mm Max. Length Max Width Ankle Circumference Appearance of Wound Necrotic (black) Sloughy (yellow) Epithelialising (pink) Granulating (red) Exudate Levels High! Moderate Low Surrounding Skin Macerated! Oedematous Erythema! Fragile! Dry/Scaling Healthy/Intact Pain! Continuous Specific Times Dressing Change None Visual Assessment Map* Photograph * Swab taken * Results Referrals: Dietician Other Referrals SIGNATURE * Tick when done ! May indicate wound infection Transfer outcomes to Care Plan. State type of dressing to be used. Give advice to patient re. exercise, elevation, nutrition etc. woundcare manual GP Specialist

Appendix IV Organisms encountered in wound management

Organisms Microbiological characteristics Sources Examples Effects

Staphylococci

Gram-positive cocci form clumps

Nasopharynx of 15% of humans

Coagulase positive

S. aureus

Causes suppuration in wounds Causes opportunistic infection particularly prosthetic vascular and orthopaedic grafts Cellulitis through release of proteases

Coagulase negative

S. epidermidis

Streptococci

Gram-positive cocci form chains Lancefield A-G groups

Pharynx group A

S. pyogenes

Bowel group D

S. faecalis

In synergy with others in wound infections and abscesses, particularly after GI surgery Gas gangrene through release of exotoxins and proteases

Clostridia

Gram-positive bacilli anaerobic spore bearing

Faeces and soil

C. perfringens

C. tetani

Tetanus through release of exotoxin In synergy with AGNB cause wound infections, particularly after GI surgery

Bacteroides

anaerobic nonspore bearing

Large bowel, vagina, oropharynx

Aerobic Gramnegative bacilli (AGNB)

Faeces

E. coli, Klebsiella, Proteus, etc.

Synergistic with Bacteroides in wound infection

Pseudomonas

Colonise burns, tracheostomy, and catheters

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Appendix V Management of tetanus-prone wounds

Management of Tetanus-Prone Wounds
Wounds are considered to be tetanus-prone if they are sustained either more than 6 hours before surgical treatment of the wound; or at any interval after injury and are puncture-type, or show much devitalised tissue, or are septic, or are contaminated with soil or manure. All wounds should receive thorough wound toilet. For clean wounds, fully immunised individuals (those who have received a total of 5 doses of tetanus vaccine at appropriate intervals) and those whose primary immunisation is complete (with boosters up to date), do not require tetanus vaccine; individuals whose primary immunisation is incomplete or whose boosters are not up to date require a reinforcing dose of an appropriate strength of combined diphtheria and tetanus vaccine (followed by further doses as required to complete the schedule)|; nonimmunised individuals (or whose immunisation status is unknown) should be given a dose of the vaccine immediately (followed by a completion of the full course of the vaccine if records confirm the need). For tetanus-prone wounds, management is as for clean wounds with the addition of a dose of tetanus immunoglobulin of human origin (HTIG) which should be administered at a different site, in addition to wound toilet and, where appropriate, antibacterial prophylaxis with benzylpenicillin, coamoxiclav or metronidazole. In fully immunised individuals and those whose primary immunisation is complete (see above) the immunoglobulin is only needed if the risk of infection is particularly high (e.g. contamination with manure). For recommended doses see the current edition of the BNF .
1

For babies and children with a potentially tetanus-contaminated injury use of adsorbed diphtheria and tetanus vaccine (DT/Vac/Ads (Child)) is recommended. For adults and adolescents previously un-immunised against tetanus, and where booster doses of tetanus are indicated, following a tetanus-prone wound use adsorbed diphtheria (low dose) and tetanus vaccine for adults and adolescents (DT/Vac/Ads (Adult)). Tetanus immunoglobulin, together with metronidazole and wound toilet should also be used for the treatment of established cases of tetanus.
Immunisation Status Clean Wound Vaccine Tetanus Prone Wound Vaccine Human tetanus immunoglobulin Only if risk especially high (e.g. contaminated with stable manure) Only if risk especially high (see above)

Fully immunised Primary immunisation complete, boosters incomplete but up to date

None required None required (unless next dose due soon and convenient to give now) A reinforcing dose of combined tetanus/diphtheria vaccine and further doses as required to complete the recommended schedule (to ensure future immunity) An immediate dose of vaccine followed, if records confirm this is needed, by completion of a full 3-dose course of combined tetanus/diphtheria vaccine to ensure future immunity.

None required None required (unless next dose due soon and convenient to give now) A reinforcing dose of combined tetanus/diphtheria vaccine and further doses as required to complete the recommended schedule (to ensure future immunity) An immediate dose of vaccine followed, if records confirm this is needed, by completion of a full 3dose course of combined tetanus/diphtheria vaccine to ensure future immunity

Primary immunisation incomplete or boosters not up to date

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

Not immunised or immunisation status not known or uncertain

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

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

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Appendix VI Fax-back comment sheet

Section 1:

Section 2:

Section 3:

Section 4:

Section 5:

Section 6:

Section 7:

Section 8:

Section 9:

Section 10:

Section 11:

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Appendix VI Fax-back comment sheet

Section 12:

Appendices 1-10:

Contact details (optional)

Fax to: Ann Heitmann, Pharmacy Department, Edith Cavell Hospital, Tel: 01733 875617
Your feedback would be welcome on any aspect of this manual. These comments will be forwarded to the Committee and considered for inclusion in its development.

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Appendix VlI Dressing request form

Request may only be made by a member of the Tissue Viability Group or Nurse Practitioner, and will only be considered if patient benefits and expenditure implications are clearly identified and supported by relevant literature. The Tissue Viability Specialist may request further information from applicants if necessary. Name of Dressing Company Producing Dressing Size (s) Indication How will the new dressing improve wound healing? Summary of references showing the benefits the new treatment will have compared to current dressings Key references reviewed. These should included independent reports and evidence based data where available List any training implications for staff Estimated number of patients to receive treatment per month Approximate monthly cost per patient, compared with alternative treatment including any non-dressing costs/savings Is this dressing available on FP10 prescriptions? If so what is the cost per patient per month? Are there any other costs; e.g. blood tests?

The pharmacist will provide help with costing and may b able to obtain references. Please contact Val Shaw/Jane Symons for advice. Name of Applicant: ____________________________ Signature: ______________________________ Base: _______________________ Date: _______________________

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

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Appendix VIlI - Non-formulary dressing request form

Patient Name: _________________________________

Hospital No:

_________________________

Consultant:

____________________________

Ward:

_________________________

Dressing Requested: ________________________

Date:

_________________________

Company Supplying Dressing: ________________________________________________________________

Reason for Request (please tick): Continued Use on Admission/Discharge New Request

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

Reason for choosing Non-formulary Dressing: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ This request may be followed up by the pharmacist to ascertain how useful it has been. You may then be asked to submit a formal request to the Tissue Viability Group Please return this form to Linda Coultrup, Level 6, Peterborough District Hospital.

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Appendix IX - Dressing changes record form

DATE

SIGNATURE

DATE

SIGNATURE

DATE

SIGNATURE

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Appendix IX - Dressing changes record form

DATE

SIGNATURE

DATE

SIGNATURE

DATE

SIGNATURE

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Appendix IX - Dressing changes record form

DATE

SIGNATURE

DATE

SIGNATURE

DATE

SIGNATURE

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Appendix X - Glossary

TERM aetiology alginate angiogenesis autolytic bactericidal bacteriostatic bio-engineered skin bony sequestrum callus

DEFINITION Cause of a disease or condition Gel extracted from the cell walls of algae, used in swabs, dressings, etc. Process of vascularisation of a tissue involving the development of new capillary blood vessels Spontaneous lysis (rupture) of cells or organelles produced by the release of internal lysosomal hydrolytic enzymes Agent capable of killing bacteria Agent that inhibits the growth or multiplication of bacteria Living replacement for skin, manufactured in tissue culture Piece of dead bone that has become separated during the process of necrosis from sound bone 1. Mass of new bony trabeculae and cartilaginous tissue formed by osteoblasts early in the healing of a bone fracture 2. Area of hard or thick skin especially on the hand or sole of the foot caused by continual friction or pressure(may precede or mask ulceration)

cellulitis

An acute, diffuse, spreading, oedematous, suppurative inflammation of the deep subcutaneous tissues which may be associated with abscess formation Proteins and vitamins involved in the clotting of blood, e.g. thrombin, factor VIII, vitamin K Fibrous protein that gives tensile strength to connective tissues, e.g. dermis, tendons, arterial walls Invaded by micro-organisms without any host response, e.g. inflammation Loose mesodermally derived tissue, e.g. cartilage, bone, blood, dermis, rich in extracellular matrix (collagen, proteoglycan) that surrounds ordered tissues and organs

clotting factors collagen colonised

connective tissue

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Appendix X - Glossary

TERM contact sensitivity debridement dehisce

DEFINITION Allergic response to contact with irritant, usually a hypersensitivity Removal of necrotic, infected or foreign material from a wound Premature bursting open or splitting along natural or surgical suture lines. A complication of surgery that occurs secondary to poor wound healing Ultrasound technique for imaging deep tissues Fibrous protein that allows elasticity in connective tissues, e.g. dermis, arterial walls Tissue covering of internal and external surfaces of the body, including the lining of vessels and other small cavities Dry scab that forms on skin that has been burned or exposed to corrosive agents; hard plaque covering an ulcer Material such as fluid, cells or cellular debris which has escaped from blood vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation Connective-tissue cells that make collagen and elastin, involved in wound healing Healing of clean, aseptic, surgical wounds that have been closed with sterile suture Wound caused by malignant cells having penetrated into the epithelium A thick layer of absorbent cotton between two layers of absorbent gauze, used in surgical dressings Highly vascularised tissue that replaces the initial fibrin clot in a wound. Rich in leukocytes and fibroblasts that secrete connective tissue Proteins and hormones secreted by cells that have a stimulating effect on other cells, e.g. interleukins, tumour necrosis factor

Doppler elastin epithelium eschar exudate

fibroblasts first (primary) intention fungating

gamgee tissue/dressing

granulation tissue

growth factors

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Appendix X - Glossary

TERM haematoma

DEFINITION A localised collection of blood, usually clotted, in an organ, space or tissue, due to a break in the wall of a blood vessel Treating the whole symptoms/disease in a patient Infection acquired by patient as a result of admittance to hospital Gelatinous watery substance useful in dressings because of its dimensional stability under controlled conditions Condition in which the immune system is not functioning normally Localised protective response elicited by injury, infection or destruction of tissue, involving exudation of fluid and leukocytic migration. Characterised in the acute form by the classical signs of pain, heat, redness, swelling and loss of function Low oxygen state usually due to obstruction of the arterial blood supply or inadequate blood flow leading to hypoxia in the tissue Softening of a tissue by soaking until the connective tissue fibres are so dissolved that the tissue components can be teased apart. Usually caused by excess exudate Phagocytic cell derived from blood monocyte. Plays an important role in killing of micro-organisms and tumour cells, antigen presentation and releases substances that stimulate other immune cells Methicillin-resistant Staphylococcus aureus. Non-susceptibility of a microbe to the action of methicillin, a semi-synthetic penicillin derivative. Many commonly prescribed antibiotics are also not effective against MRSA bacteria Morphological changes indicative of cell death and caused by the progressive degradative action of enzymes Type of phagocytic leukocyte characterised by cytoplasmic granules and a multilobed nucleus Normally resident (non-pathogenic) microbes

holistic hospital-acquired infections hydrocolloid immunocompromised inflammation

ischaemia maceration

macrophage

MRSA

necrosis neutrophil normal flora

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Appendix X - Glossary

TERM nosocomial infections

DEFINITION Infection not present or incubating prior to admittance to the hospital, but generally occurring 72 hours after admittance, the term is usually used to refer to patient disease, but hospital personnel may also acquire nosocomial infection Ingestion (killing) of bacteria and cellular debris by white blood cells Presence of hair in a dermoid cyst or in a sinus opening on the skin Appearance or characteristics of a wound upon admission Healing of clean, aseptic, surgical wounds that have been closed with sterile suture Disease caused by vitamin C deficiency affecting collagen synthesis and the consequent failure of fibroblasts to produce mature collagen for wound healing Healing of a wound without the benefit of surgical closure. The wound is allowed to close by contraction and filling with connective tissue. These wounds are more open, more prone to infection, and take longer than primary intention healing Releasing yellow or white, slimy, viscous tissue debris Leakage of fluids through dressing Increase in the internal diameter of a blood vessel those results from relaxation of smooth muscle within the wall of the vessel. This causes an increase in blood flow, but a decrease in systemic vascular resistance World health Organisation index of the degree of pain and a guide to pain relief by analgesics Base of wound closest to healthy tissue from which healing occurs Cavity in a wound, formed as a result of new tissue growing over a space

phagocytosis pilonidal sinus presentation primary (first) intention scurvy

second (-ary) intention

sloughy strike-through vasodilation

WHO pain ladder wound bed wound sinus

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Appendix Xl - Acknowledgements

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

3M Health Care Limited Bio Diagnostics Coloplast Convatec Medlock Medical Molnlycke Healthcare Limited Parema Medical Limited Smith & Nephew Healthcare Limited Unomedical

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

Wound Management Guidelines. Necrotic wounds. (1). Aim: Debridement by providing a moist environment.

Is the wound on the heel or toe? Yes No

refer to guideline 2

Is the wound infected? - Yes

refer to Guideline 5

No Low Exudate Hydrogel (Activ heal, Intrasite, purilon) AND Hydrocolloid (Activ heal or Duoderm) Apply gel to wound bed, cover with hydrocolloid. Change when exudate 1cm from dressing edge or if leaking. Medium Exudate Hydrofibre (Aquacel) AND Hydrocolloid (Activ heal, or Duoderm or Granuflex) Cover or loosely pack wound with hydrofibre. Cover with hydrocolloid. Change when exudate 1cm from dressing edge. High Exudate Hydrofibre (Aquacel) AND Foam (Activ heal or Allevyn) Cover wound or loosely pack with hydrofibre. Cover with foam or padding.

Obtain specialist advice from TVN if required.

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Protect surrounding skin if needed Cavilon Remember to assess nutritional intake. Protein supplements if large / highly exuding wounds. Seek specialist advice (TVN ) for diabetic and arterial patients.

Black heels and Toes. (2). Aim: Protect / prevent infection.

Is wound infected? - Yes No

Refer to guideline 5

Is the patient diabetic? - Yes Keep dry No

Refer to Podiatry / Foot Clinic NA Dressing.

Is arterial disease suspected? Yes Dress as above No

Referral to vascular team.

Ensure pressure is relieved For heels If hard, dry and necrotic leave, and monitor. ( EPUAP guideline 09).
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If wound is a blister (blood or clear fluid) dressing

Leave intact and allow natural absorption, no needed.

Take care not to bandage too tightly! Seek specialist advice (TVN or Podiatry) for Diabetic and arterial patients Remember to assess nutritional intake, may need protein supplement.

Sloughy Wounds. (3) Aim: To debride by providing a moist environment.

Is the wound infected? Yes

Refer to guideline 5

No

Is the slough dry? Yes

Treat as necrotic guideline 1

No

Low Exudate Hydrogel (Activ heal or Intrasite) AND Hydrocolloid (Activ heal

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

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

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or Duoderm)

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

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

Consider topical negative therapy or wound bag. Apply Aquacel to wound bed or pack loosely. Apply foam or padding. Contact TVN re other options.

Protect surrounding skin with Cavilon barrier film If debrdement slow, consider Larvae. Remember to assess nutritional intake. May need Protein supplements for cavity or highly exudating wounds. Consider Topical Negative pressure, refer to TVN Seek specialist advice (TVN or Podiatry) for patients with diabetic or arterial problems.

Granulating Wounds. (4). Aim: Promote granulation and epithelialisation.

Is the wound infected? Yes

Refer to guideline 5

No

Is the wound over granulating? Yes

Check for infection Contact TVN for advice

No

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Low Exudate Hydrocolloid (Active heal or Duoderm) OR Foam (Activ heal / Allevyn) Apply hydrocolloid / foam to wound bed. Change when exudate 1cm from edge of dressing. Can stay in place for 5-7days.

Moderate Exudate Hydrofibre (Aquacel) AND Hydrocolloid (Activ heal or granuflex) Apply aquacel to wound bed. Cover with hydrocolloid. Change when exudate 1cm from dressing edge.

High Exudate Hydrofibre (Aquacel) AND Foam or padding.

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

Protect the surrounding skin with cavilon if wound exuding. Assess nutritional status, may need protein supplements. Seek specialist advice (TVN or Podiatry) for patients with diabetic or arterial problems.

Infected Wounds (5) Aim: To treat infection systemically and decrease the bacterial burden at the wound site.

Is the wound infected? Yes

Swab / treat infection with systemic Antibiotics.

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Low Exudate Inadine OR Actisorb silver

Moderate Exudate Iodoflex OR Aquacel Ag OR Activon Tulle

High Exudate Iodoflex OR AquacelAg OR Biatain Ag OR Algivon

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

Apply iodoflex into the Apply iodoflex OR wound cover with foam Aquacel Ag OR Biatain or padding change 2- 3 ag OR Algivon. days or when yellow Change as necessary colour disappears.OR according to odour or Apply Aquacel Ag and exudate. foam and padding These dressings can leave aquacel ag insitu stay insitu for up to 7 for 3 days outer days but in wounds padding can be with high exudate will changed. OR Activon need changing more tulle cut to size of often depending on wound redress 1-2 clinical judgement. days depending on exudate. Consider Topical negative pressure Review after 2 weeks if no change contact TVN for advice. Remember nutritional assessment, may need protein supplements. Seek specialist advice for patients with diabetic or arterial problems.

Epithelialising Wound. (6). Aim: To provide a moist environment and protection to allow healing.
Epithelial Regeneration: Pink wound

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Is the wound reducing in size ? No

Refer to TVN

Yes

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

Moderate Exudate Reasses unlikely to be epithelialising

High Exudate Reassess unlikely to be epithelialising.

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

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

Is the wound a large area or deep tissue exposed?

Yes
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Apply a non- adherent dressing and Refer to A&E immediately.

Is the wound bleeding? - Yes padding

Apply non adherent dressings and Elevate the area refer to A&E if persists.

Can the wound edges be brought together without force?

Yes

Steri strip , apply atrauman or Mepitel and foam or padding.

No

Is there partial or Complete skin loss?

do not steri strip Apply low adherent dressing. Consider Mepilex border if fragile skin. Elevate and apply light bandage toe to knee.

Refer to TVN after 2 weeks if not healing. Remember nutritional assessment. Seek specialist advice (TVN) if patient diabetic or has arterial problems.

Non complex burns for management in Primary Care. Superficial burn. Skin is dry / intact. Minimal tissue damage Painful Moisturise Aqueous cream OR Non adherent dressing (Atrauman)
woundcare manual

Or

Superficial partial thickness? Blisters Red, moist and exuding Painful

Low adherent dressing (Mepitel) Padding Check after 48hours mepitel can be left insitu for up to 7 days. Consider Flamazine if antibacterial needed.

All other burns apply non- adherent dressing and refer to A&E. Seek specialist advice (TV) for patients with diabetic or arterial problems.

woundcare manual