Wound Formulary. Supported by Kingston NHS Trust

Transcription

1 Supported by Kingston NHS Trust Wound Formulary All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of NHS Kingston. Approved by: Kingston CCG Medicines Committee March 201. Review Date: March 2017

2 PRIMARY & COMMUNITY CARE WOUND FMULARY 1 This formulary has been written in response to an identified need within the health care community. It includes recommended dressings and products for the management of wounds in Kingston. The choice of product is based upon manufacturer s instructions and research based evidence and approved by Kingston Medicines Committee. It describes indications for usage for all named products, but it does not include all items available on Prescription. The process of dressing selection is complex and influenced by many factors not least of these the process of wound healing and the use of the correct dressing for the appropriate wound type. Attention should be paid to assessment and underlying disease. Aim To provide a wound formulary, based on current research, patient safety and recommendations of the Wound Formulary Working Group. This will enhance clinical practice and achieve improved management of wounds in an informed and cost effective manner. Objectives 1. For all healthcare professionals in Primary & Community Care to follow a holistic approach towards wound assessment, thereby enabling appropriate selection of dressings in accordance with wound type. 2. To encourage good clinical practice that is research and evidence based. 3. To provide Healthcare Professionals with an up to date reference tool. 4. To promote a rational approach towards prescribing wound care products in Primary & Community Care.. To highlight cost-effective and safe practice in the treatment for a wide variety of wounds. 6. To provide a rationale for choosing wound care products. 7. Formulary to be used in conjunction with local approved guidelines.

3 GUIDANCE NOTES ON USING THIS FMULARY 2 All wound care products included in this formulary are available on FP prescription, unless otherwise stated. Sterile Dressing Packs Sterile dressing packs have not been included in the wound formulary as the complete contents are rarely required. The cotton wool and pad are usually not used. If gauze is required, packs of sterile gauze swabs (7.cm²) and packs of 0 non-sterile gauze swabs (cm²) are available on the Drug Tariff. NB. Gauze is not a primary or secondary dressing and must not be used in this way or laid on patients skin. It can cause maceration and trauma on removal. Prescribing Quantities The exact number of dressings required should be prescribed. Confusion arises when the prescriber orders 1 OP. Please note that for such prescriptions, only one piece (i.e. a single dressing) can be dispensed. Dressings on Discharge and Admission A minimum of five days supply of dressings and appliances should be given when transferring a patient to the community on discharge, following an outpatient appointment, or planned admission to hospital. It is advised that community and hospital staff liaise with each other to ensure continunity of wound care for each individual patient. Advanced Woundcare Techniques and Other Products Advanced wound care techniques and products are not included in the formulary and should only be used after consultation with the Tissue Viability Nurse Specialist, Podiatrist or Leg Ulcer Nurse Specialist. Patients may be admitted or discharged from hospital with dressing products that may not be in the formulary. Contact the Tissue Viability Nurse Specialist or Leg Ulcer Specialist Nurse as appropriate for further advice for continuing supply or alternative products. These dressings can include: Protease Modulator dressings, Topical Negative Pressure, Larvae.

4 GUIDELINE STATEMENTS 3 Hand Washing Hand washing is the single most important measure in the prevention of cross infection. Before hand washing remove cardigans/pullovers, wrist jewellery (watches, bangles etc.) and rings other than wedding rings. Please refer to your Infection Prevention Policy and Guidelines for more information. Gloves Wash hands before applying gloves. Gloves must be worn for wound care at all times and must be changed after contact with each patient and at the end of each procedure. Wash hands after removing gloves. Gloves must be clean, disposable, of good quality and well fitting. They should comply with your local policy. Plastic Aprons Plastic aprons must be worn for every dressing procedure and should be discarded after each individual use. Dressing Tools Dressing scissors Bandage scissors Forceps Probes These must be sterile and once only use equipment. Disposable paper tape measures do not have to be sterile but are for single use only. Manufacturer s Instructions Before applying any woundcare product, the manufacturer s instructions should be read and carried out implicitly. Adherence to the manufacturer s storage instructions for individual products is very important. Do not use products past the expiry date. Training and Competencies Any staff undertaking wound care management should have received suitable training and be assessed competent to practice.

5 WOUND CLEANSING 4 The aim of wound cleansing is to create optimum local conditions for uncomplicated wound healing. Therefore all solutions should be warmed to body temperature before applying to the wound bed. Key Points on Wound Cleansing Gloves should be worn in the presence of bodily fluids. Irrigation is the preferred method of cleansing a deep wound or sinus. Gently wash chronic wounds in warm tap water. Do not irrigate bleeding wounds or wounds with exposed nerve endings. Do not use gauze, paper towels or cotton wool on the wound bed. This is best left untouched. Clean surrounding skin with gauze to remove dried on exudate. Dry, ischaemic wounds should not be cleansed but kept dry. Routine cleansing of clean, granulating wounds is not required and can traumatise fragile new skin. Solutions for Wound Cleansing Tap water. Sodium Chloride 0.9% solution, single use pods/sterile aerosol can. Use a sterile irrigation solution for acute wounds, burns, immuno-compromised patients, patients with renal failure and wounds exposing bone or ligaments, toe nail removal and diabetic foot ulcers. Do not use antiseptics or topical antibiotics to cleanse the wound.

6 WOUND HEALING Dressings Do Not Heal Wounds The wound healing process is a physiological response to a wound which is affected by a patient s overall health. A holistic assessment should be performed to identify underlying conditions to determine the cause of the wound. The cause then needs to be investigated, treated and managed appropriately. Dressings are chosen according to the wound presentation and for specific actions such as to hydrate or debride. Appropriate Dressing Changes Most dressings in this formulary are designed to remain on the wound for 3 to 7 days. Infected, necrotic and sloughy wounds may need to be changed more frequently. Where a dressing has to be changed more frequently for a long period of time, it is likely that it is an inappropriate dressing for that particular wound or there is an underlying factor that has not been taken into consideration. If a dressing adheres to the wound bed there is not enough moisture for healing to take place and a more suitable dressing needs to be applied. Diabetic foot wounds need to be monitored closely and the care of these patients should be managed by a multidisciplinary team. Dressings may need to be changed more frequently than non-diabetic wounds. s Secondary dressings referred to in this formulary are used to hold the primary dressing in place and should not compromise the status of the surrounding skin. Secondary dressings should compliment the primary dressing, e.g. Aquacel and Foam. Cavity Wounds All cavity wounds should be carefully probed using a sterile probe to establish the depth of the wound bed. If unable to find the wound bed then the wound may require further investigation to exclude a sinus or involvement with deep tissue and bone. Refer to a general surgeon for investigation. Over Granulation May be caused by infection, friction or occlusive dressings. Stop occlusive dressings if in use and apply a smooth foam dressing firmly, directly over the over granulation for two weeks. If not resolved contact the Tissue Viability Nurse for advice. Wounds that are complex and/or non healing at 6 weeks must be referred to the Tissue Viability Service.

7 Primary & Community Care Wound Formulary Algorithm 6 Vascular status MUST be assessed with every leg or foot wound prior to dressing selection Necrotic / Eschar (Black) Sloughy (Yellow) Granulating (Red) Epithelising (Pink) Infected Wounds (Green) Fungating Wounds (Brown)

8 NECROTIC WOUNDS 7 Tissue death caused by ischaemia. Appearance is often black or brown and has a dry leathery surface texture. Necrotic / Eschar (Black) If necrotic tissue is on the foot/lower limb and the patient has PVD or Diabetes mellitus then KEEP IT DRY and refer to Tissue Viability Nurse Specialist/Leg Ulcer Nurse Specialist/Podiatry. Check vascular status with Doppler ABPI. Necrotic Debride Remove eschar Dry / Low Exudate Moderate Exudate High Exudate CAUTIONS: Not to be used on diabetic patients unless advised by specialist. If clinical signs of infection present with raised temperature, treat with antibiotics. Seek advice from the Tissue Viability Nurse Specialist or Specialist Podiatrist. Shallow Cavity Shallow Cavity Shallow Cavity Actiform Cool Comfeel + Ulcer (no secondary dressing required) Intrasite Conformable Actiform Cool Comfeel + Ulcer (no secondary dressing required) Aquacel Ribbon Aquacel Extra Aquacel Ribbon NOTES: Exudate is likely to increase when necrosis breaks down. Ensure surrounding skin is protected from exudate. Tegaderm Tegaderm Comfeel + Ulcer Comfeel + Ulcer Eclypse Eclypse

9 NECROTIC WOUND DRESSINGS 8 Dressing description and sizes Aquacel Extra Primary dressing: A hydrofibre dressing to aid autolytic debridement and absorb exudate. x cm x cm 4 x cm Ribbon 2 x 4cm Ribbon 1 x 4cm Actiform Cool Primary dressing: A hydrogel dressing to hydrate necrotic and sloughy tissue. x 6cm x cm Comfeel Plus Ulcer A hydrocolloid dressing to aid autolytic debridement. 4 x 6cm x cm Sacral dressing: 18 x 20cm Intrasite Conformable Primary dressing: A hydrogel sheet dressing to aid autolytic debridement. x cm x 20cm (non adhesive) 7. x 7.cm x cm 12. x 12.cm x 20cm 20 x 20cm Heel dressing: 17 x 21cm Advazorb Border (adhesive) A foam dressing with soft silicone wound contact layer to manage 7. x 7.cm x cm 12. x 12.cm x 20cm x 30cm Non Adhesive x 7cm x cm 20 x 20cm Adhesive x cm 18 x 18cm Sacral dressing: 23 x 23cm Heel dressing: 19 x 20cm Contour dressing: 17cm Eclypse A superabsorbent dressing for very heavily exuding wounds. 20 x 30cm 60 x 40cm Eclypse Adherent A superabsorbent dressing for very heavily exuding wounds. x cm x 20cm Sacral dressing: 17 x 19cm Sacral dressing: 23 x 23cm Tegaderm Film A transparent thin polyurethane membrane coated with acrylic adhesive. 6 x 7cm 12 x 12cm 1 x 20cm

10 SLOUGHY WOUNDS 9 Devitalised tissue that is often moist, and yellow, white or grey in appearance. Often malodorous. SLOUGHY (YELLOW) Sloughy Remove slough Provide clean base for granulation tissue Dry / Low Exudate Moderate Exudate High Exudate Shallow Cavity Shallow Cavity Shallow Cavity CAUTIONS: Do not mistake tendons for slough if unsure seek advice. If clinical signs of infection present with raised temperature, treat with antibiotics. Can be used for Diabetic patients with caution, following Specialist advice. NOTES: Ensure surrounding skin is protected from exudate. Actiform Cool Comfeel + Ulcer (no secondary dressing required) Intrasite Conformable Comfeel + Ulcer Tegaderm Actiform Cool Intrasite Conformable Iodoflex Aquacel Ribbon Iodoflex Aquacel Extra Iodoflex Eclypse Aquacel Ribbon Iodoflex Eclypse

11 SLOUGHY WOUND DRESSINGS Dressing description and sizes Aquacel Extra Primary dressing: A hydrofibre dressing to aid autolytic debridement and absorb exudate. x cm x cm 4 x cm Ribbon 2 x 4cm, 1 x 4cm Comfeel Plus Ulcer Primary dressing: A hydrocolloid dressing to aid autolytic debridement. No secondary dressing required. 4 x 6cm x cm Sacral dressing: 18 x 20cm Intrasite Conformable Primary dressing: A hydrogel sheet dressing to aid autolytic debridement. x cm x 20cm Actiform Cool Primary dressing: A hydrogel dressing to hydrate necrotic and sloughy tissue. x 6cm x cm Iodoflex A Cadexemer Iodine paste in a gauze carrier, that needs to be removed on application. Maximum application - 0gms per single use. A maximum of 10gms - weekly. Stop using after three months. Used for debriding thick slough where a hydrogel is contraindicated. gm sachet gm sachet (non adhesive) 7. x 7.cm x cm 12. x 12.cm x 20cm 20 x 20cm Heel dressing: 17 x 21cm Advazorb Border (adhesive) A foam dressing with soft silicone wound contact layer to manage 7. x 7.cm x cm 12. x 12.cm x 20cm x 30cm Non Adhesive x 7cm x cm 20 x 20cm Adhesive x cm 18 x 18cm Sacral dressing: 23 x 23cm Heel dressing: 19 x 20cm Contour dressing: 17cm Tegaderm Film Transparent thin polyurethane membrane coated with acrylic adhesive. 6 x 7cm 12 x 12cm 1 x 20cm Eclypse A superabsorbent dressing for very heavily exuding wounds. 20 x 30cm 60 x 40cm Eclypse Adherent A superabsorbent dressing for very heavily exuding wounds. x cm x 20cm Sacral dressing: 17 x 19cm Sacral dressing: 23 x 23cm

12 GRANULATING WOUNDS 11 Wound bed is red with a granular appearance due to the capillary budding. GRANULATING Granulating Promote granulation Provide healthy base for epithelialisation Dry / Low Exudate Moderate Exudate High Exudate Shallow Cavity Shallow Cavity Shallow Cavity CAUTIONS: Advice may be sought from the Tissue Viability Nurse Specialist for over granulating wounds. If clinical signs of infection present with raised temperature, treat with antibiotics. Can be used for Diabetic patients with caution, following Specialist advice. NOTES: Ensure surrounding skin is protected from exudate. Comfeel + Ulcer Duoderm Extra Thin Intrasite Conformable lite Comfeel + Ulcer Aquacel Ribbon Duoderm extra thin Comfeel + Ulcer Aquacel Extra Eclypse Aquacel Ribbon Eclypse

13 GRANULATING WOUND DRESSINGS 12 Dressing description and sizes Aquacel Extra Primary dressing: A hydrofibre dressing to absorb exudate. x cm x cm 4 x cm Ribbon 2 x 4cm, 1 x 4cm Intrasite Conformable Primary dressing: A hydrogel sheet dressing to aid autolytic debridement. x cm x 20cm Comfeel Plus Ulcer A hydrocolloid dressing to promote granulation. No secondary dressing required. 4 x 6cm x cm Sacral: 18 x 20cm (non adhesive) 7. x 7.cm x cm 12. x 12.cm x 20cm 1cm x 1cm 20 x 20cm Heel dressing: 17 x 21cm Advazorb Border (adhesive) A foam dressing with soft silicone wound contact layer to manage 7. x 7.cm x cm 12. x 12.cm x 20cm x 30cm Lite For less exuding wounds. 7. x 7.cm x cm 12. x 12.cm 20 x 20cm Advazorb Border Lite (adhesive) A foam dressing with soft silicone wound contact layer to manage For less exuding wounds. 7. x 7.cm x cm 12. x 12.cm x 20cm Non Adhesive x 7cm x cm 20 x 20cm Adhesive x cm 18 x 18cm Sacral dressing: 23 x 23cm Heel dressing: 19 x 20cm Contour dressing: 17cm Duoderm extra thin Thin hydrocolloid dressing to promote granulation and epithelialisation. 7. x 7.cm x cm 9 x 2cm Eclypse A superabsorbent dressing for very heavily exuding wounds. 20 x 30cm 60 x 40cm Eclypse Adherent A superabsorbent dressing for very heavily exuding wounds. x cm x 20cm Sacral dressing: 17 x 19cm Sacral dressing: 23 x 23cm

14 EPITHELIALISING WOUNDS 13 Wound bed is shallow with pink tissue which migrates from wound edges. EPITHELIALISING Epithelialising Promote epithelialisation and wound maturation CAUTIONS: If clinical signs of infection present with raised temperature, treat with antibiotics. It is unusual for epithelialising wounds to present with high exudate. Assess for underlying causes and treat. NOTES: Ensure surrounding skin is protected from exudate/trauma. Dry / Low Exudate Moderate Exudate High Exudate Mepore Duoderm Extra Thin Tegaderm Comfeel + Ulcer

15 EPITHELIALISING WOUND DRESSINGS 14 Dressing description and sizes Non Adhesive (non adhesive) Comfeel Plus Tegaderm Film x 7cm x cm 20 x 20cm Adhesive x cm 18 x 18cm Sacral dressing: 23 x 23cm Heel dressing: 19 x 20cm Contour dressing: 17cm 7. x 7.cm x cm 12. x 12.cm x 20cm 20 x 20cm Heel dressing: 17 x 21cm Advazorb Border (adhesive) A foam dressing with soft silicone wound contact layer to manage 7. x 7.cm x cm 12. x 12.cm x 20cm x 30cm Primary dressing: A hydrocolloid dressing to promote epithelialisation. 4 x 6cm x cm Sacral dressing: 18 x 20cm Duoderm Extra Thin Thin hydrocolloid dressing to promote epithelialisation. 7. x 7.cm x cm 9 x 2cm Transparent thin polyurethane membrane coated with acrylic adhesive. 6 x 7cm 12 x 12cm 1 x 20cm Mepore A perforated Island dressing. 7 x 8cm x 11cm 11 x 1cm 9 x 20cm

16 INFECTED WOUNDS 1 All chronic wounds will be colonised with bacteria without necessarily having a detrimental effect on wound healing. Infection occurs when the bacterial burden overwhelms the host immune response. Treatment with Silver or Iodine products must be monitored at each dressing change and reviewed after 2 weeks. If the wound is not responding after 2 weeks seek Specialist advice. Infected Reduce bacterial load on wound bed Resolve signs of infection Low Exudate Moderate Exudate High Exudate Shallow Cavity Shallow Cavity Shallow Cavity SIGNS OF INFECTION: Localised erythema Pain, oedema, heat Increased exudate Delayed healing Dull/dark red wound bed Friable granulation tissue that bleeds easily Pocketing at base of wound Unexpected pain Bridging of soft tissue/epithelium Malodour Wound breakdown Inadine Iodosorb Iodoflex Aquacel Ag Extra Ag Iodoflex Aquacel Ag Extra Iodosorb Aquacel Ag Extra Ag Iodoflex Advazorb Foam or Foam or Eclypse if secondary dressing required. NB: Secondary dressings MUST NOT be silver. Aquacel Ag Extra Iodosorb Diagnosis of a wound infection should be made on a basis of clinical signs/symptoms NOT wound swab result. If the patient is presenting with clinical signs of infection including pyrexia, antibiotics should be commenced as soon as possible.

17 INFECTED WOUND DRESSINGS 16 Dressing description and sizes Inadine Iodosorb A Cadexemer Iodine ointment. Maximum application - 0gms per single use. A maximum of 10gms - weekly. Maximum duration up to three months. g Ag Adhesive Non adherent polyurethane foam with vapour permeable film backing impregnated with silver. x cm 20 x 20cm x 7cm x 20cm Adhesive x cm 18 x 18cm Sacral dressing: 23 x 23cm Heel dressing: 19 x 20cm Contour dressing: 17cm A Povidone Iodine fabric non-adhesive dressing. It is a non-absorbent primary dressing with wide spectrum antimicrobial activity. It is rapidly deactivated by wound exudate and is not for prolonged use, i.e. review every 2 weeks and use no longer than 6 weeks. x cm 9. x 9.cm Iodoflex A Cadexemer Iodine paste in a gauze carrier, that needs to be removed on application. Maximum application - 0gms per single use. A maximum of 10gms - weekly. Maximum duration up to three months. gm sachet gm sachet Aquacel Ag Extra Silver impregnated absorbent, soft, non woven pad or ribbon composed of hydrofibre and ionic silver. x cm x cm 4 x cm Ribbon: 2 x 4cm Ag Non adherent polyurethane foam with vapour permeable film backing impregnated with silver. 12. x 12.cm 7. x 7.cm x cm 12. x 12.cm x 20cm 20 x 20cm Heel dressing: 17 x 21cm Non Adhesive x 7cm x cm 20 x 20cm Eclypse A superabsorbent dressing for very heavily exuding wounds. 20 x 30cm 60 x 40cm Eclypse Adherent A superabsorbent dressing for very heavily exuding wounds. x cm x 20cm Sacral dressing: 17 x 19cm Sacral dressing: 23 x 23cm

18 FUNGATING WOUNDS 17 A malignancy that has progressed to cause a necrotic, exuding, cauliflower in appearance skin lesion causing odour, bleeding and pain. Fungating wounds are unlikely to heal or make significant progress due to the progression of malignancy. Therefore the aim is to manage the symptoms i.e. exudate, odour, bleeding and pain. Fungating FUNGATING WOUNDS Dry / Low Exudate Moderate / High Exudate - bleeding Primary dressing: Silflex Primary dressing: Silflex / Sorbsan Secondary dressing: / / Clinisorb (if odorous) Secondary dressing: / / Clinisorb (if odorous) Caution: Fungating wounds can bleed easily when disturbed, care should be taken when removing dressing. If this occurs use a non adherent dressing.

19 FUNGATING WOUND DRESSINGS 18 Dressing description and sizes Silflex Adhesive Clinisorb A non-adhesive silicone wound contact dressing. x 7cm 8 x cm 12 x 1cm Sorbsan Flat Primary dressing: An alginate dressing to aid autolytic debridement and absorb exudate. It is also a haemostat. x cm xcm x 20cm 7. x 7.cm x cm 12. x 12.cm x 20cm 20 x 20cm Heel dressing: 17 x 21cm Non Adhesive x 7cm x cm 20 x 20cm x cm 18 x 18cm Sacral dressing: 23 x 23cm Heel Dressing: 19 x 20cm Sacral dressing: 17cm Sterile activated charcoal cloth sandwiched between layers of nylon/viscose rayon cloth. Use for malodorous wounds. x cm x 20cm

20 BANDAGES 19 Caution: Many of these bandages have similar appearances. Great care must be taken to ensure the correct bandage is applied. Retention Bandages These are mixed fibre bandages with a degree of elasticity used to reduce oedema and to retain some dressings. No bandage should be applied to dressing area only, because of the risk of bandage and circulatory damage. Paste Bandages These are cotton bandages that are impregnated with a paste, of which there are various types. Suitable for skin conditions such as varicose eczema. They help to hydrate and remove dead scales of skin around the ulcer. Compression Bandages These bandages are designed to apply graduated compression to reverse venous hypertension for patients presenting with diagnosed venous leg ulcers.

21 RETENTION BANDAGES 20 K-Lite Bandage Description: K-Lite consists of a white knitted conformable fabric containing 93% viscose, 4% nylon and 3% elastomeric yarn. Indications for use Reduction of oedema, when it is impossible to perform a Doppler examination. In care of leg ulcers, it can be used in conjunction with a paste bandage. As a holding/retention bandage for any dressing applied to any area of the body. Contra-indications Apply with caution to an ischaemic leg, or to a patient with a Doppler reading less than 0.8mmHg. Apply with caution to the leg of a Diabetic. How to use Use over a primary dressing or paste bandage. If possible apply in the morning, when oedema has reduced overnight. Apply from toe to knee over a padding i.e. Softban. Use over a primary and secondary dressing, if required. If using on a leg, apply from toe to knee. Secure around the foot using a figure of eight around the ankle with a 0% overlap in a spiral up the leg. If using on an arm, secure around the hand and apply up the arm with a 0% overlap in a spiral. When to change the bandage Can be changed daily when reducing oedema. Can be left up to 7 days when using with a paste bandage. Change on breakthrough of exudate. K-Lite Bandage size cm x 4.m K-Band Bandage sizes (for retention of dressings where adhesive dressings are not indicated) cm x 4m cm x 4m 1cm x m

22 PASTE BANDAGES 21 Ichthopaste Description: Open weave bleached cotton bandage with zinc oxide 6% and ichthammol 2%. Indications for use Leg ulcers. In conjunction with compression bandaging for venous leg ulcers. Eczema. Chronic dermatitis. Viscopaste (PB7) Description: Open-weave bleached cotton bandage impregnated with a paste containing % zinc oxide but it also contains a propyl parabens preservative. Indications for use Leg ulcers. Chronic dermatitis. Dry skin conditions. Reduction of oedema. Contra-indications Known allergy to the constituents of the bandage, or a positive patch test. Do not apply to acute eczematous lesions, grossly macerated areas or acute infection. Use with caution on an ischaemic limb, as it could impede blood flow and increase risk of infection.

23 HOW TO USE PASTE BANDAGES 22 How to use Paste Bandages Remove outer packaging. Apply in a series of folds rather than a continuous spiral. In cases of reducing oedema can be used with padding and single k-lite application. For venous leg ulcers, use in conjunction with a compression bandage, which gives graduated compression of 40mmHg at the ankle reducing to 17mmHg at the knee. Remove the paste by unfolding the bandage from the leg. Wash leg in a lined bucket of warm water to remove the paste. When to change the bandage Change on breakthrough of exudate. Can be left on for up to 7 days, especially if using compression therapy. When using to reduce oedema, leave paste bandage on, but change the retention bandage daily, preferably first thing in the morning. Notes on use of paste bandages Requires a secondary dressing to hold it in place. Can cause allergic reactions. May increase absorption of topical corticosteroid preparations. Often used in multi-layer compression systems. Can leave in place for up to one week. Even if a patient does not have an allergic reaction to a paste bandage straight away, some patients following a course of treatment can have an allergic reaction. In these cases the bandage should be removed and an alternative treatment used.

24 COMPRESSION BANDAGES 23 Cautions: Many of these bandages have similar appearances. Great care must be taken to ensure the correct bandage is applied. Compression should only be applied to patients with venous leg ulcers, on whom a full assessment and Doppler examination has been carried out by nurses who are fully trained and competent in leg ulcer management. Any bandage if applied incorrectly can cause a breach in skin integrity with a possible tourniquet effect. Where possible, compression bandages should preferably be applied first thing in the morning to prevent any oedema worsening. When appropriately applied, compression bandages will exert 40mmHg pressure at the ankle, graduating to 17mmHg at the knee. There are several methods of attaining this pressure i.e. Short stretch bandage. Multi-layer systems. Bandages included in the formulary: Actico (short stretch bandage). K-Four (multi-layer compression bandage). Compression bandages must be prescribed according to the patient s ankle size.

25 COMPRESSION BANDAGES 24 Short Stretch Compression Bandage: Actico Description: A short stretch brown cohesive bandage Indications for use Venous ulcer, following full assessment and a Doppler reading of greater than 0.8mmHg and less than 1.3mmHg. Venous disease with no mixed aetiology. On the advice of the Vascular Surgeon, Tissue Viability Nurse Specialist or Leg Ulcer Nurse Specialist. More effective on mobile patients. Follow the manufacturers instructions. Should always be applied over full leg padding from toe to knee. If ankle is under 18cm then extra padding must be applied to achieve at least 18cm circumference. If ankle is over 2cm then a second layer of Actico bandage is required, from ankle to knee, applied at 0% overlap, 0% stretch but in the opposite direction to the first layer. Secure bandage around the flexed foot and with a figure of eight around the ankle ensuring that the bandage is not applied at full stretch over the tibialis anterior tendon. Once past the ankle apply at full stretch with a 0% overlap in a spiral action, thus producing a compression of 40mmHg at the ankle and automatically graduating to 17mmHg at the knee. Check for any extra pain, discolouration, numbness and tingling of the foot and toes, and instruct the patient to remove the bandage immediately should this occur at any time. Ensure the patient understands this. Contact the patient the same day and again the next day and rebandage if there has been any slippage due to the reduction of oedema. Always remove the bandage if there is any doubt. Seek specialist advice for the following Doppler reading less than 0.8mmHg and greater than1.3mmhg. Ischaemia. Kidney disease. Diabetes. Heart disease. Known arterial disease. Anyone who has refused Doppler examination. When a full assessment has not been carried out. Bandage sizes 8cm x 6m, cm x 6m, 12cm x 6m This bandage must not be used without padding.

26 COMPRESSION BANDAGES 2 Multi-Layer Compression Bandages: K-Four Description: Four layer bandage system which includes padding, crepe, light compression layer and cohesive compression layer. Dependant on ankle measurements for correct combination. Indications for use Venous ulcer, diagnosed following full assessment and a Doppler Ankle Brachial Pressure Index more than 0.8mmHg and less than1.3mmhg. Venous disease with no mixed aetiology. On the advice of the Vascular Surgeon, Tissue Viability Nurse Specialist or Leg Ulcer Nurse Specialist. Apply bandages in layers as given below in the standard kit for an 18-2cm ankle. 1st layer 2nd layer 3rd layer 4th layer Apply wound contact layer/dressing Padding applied from base of toes to the knee in a spiral with 0% overlap. Crepe applied from base of toes to knee in a spiral technique with 0% overlap with no tension. Use tape to secure. Light compression bandage. Apply from the base of the toes to the knee using a figure of eight technique at 0% extension and a 0% overlap. Use tape to secure. Cohesive bandage. Apply from toe to knee using a spiral technique with 0% extension and 0% overlap. Press lightly on bandage to ensure that bandage adheres to itself. If bandaging both legs, use a tubular bandage to prevent one leg adhering to the other. CAUTION When applying the four layer bandage, care must be taken to ensure that there is sufficient padding over the tibialis anterior tendon.

27 COMPRESSION BANDAGES 26 Seek specialist advice for the following Doppler reading less than 0.8mmHg and greater than 1.3mmHg. Heart disease. Ischaemia. Kidney disease. Diabetes. Known arterial disease. Anyone who has refused Doppler examination. When a full assessment has not been carried out. How to use Use the system pack to suit the ankle circumference or the compression required. Always check box and manufacturer s instructions prior to use. Check for any extra pain, discolouration, numbness and tingling of the foot and toes. Instruct the patient to remove the bandage immediately, should this occur at any time. Ensure the patient understands this. Check the patient the next day, and re-bandage if there has been any slippage. Always remove the bandage if there is any doubt. Bandage has to be removed by cutting off with appropriate bandage scissors and disposed of in a safe way. If ankle is under 18cm then extra padding must be applied to achieve at least 18cm circumference. If ankle is over 2cm then the K-plus layer should be substituted for a K-three C bandage. Prescribing Notes Prescribe the individual bandages, not the kit, to reduce waste. Bandages in K-Four Kit K - Soft cm x 3.m K - Lite cm x 3.m K - Plus cm x 8.7m Ko - Flex cm x 6m

28 PRODUCT LIST 27 Restricted Use The nominated representatives can request the alternative dressings listed below. Products Prices quoted are a guide based on March 201 Drug Tariff. For the most up to date prices please check the most current Drug Tariff. Podiatry Use Only Allevyn (Smith & Nephew) Kaltostat (ConvaTec ) Melolin (Smith & Nephew ) Bactigras (Smith & Nephew) Opsite / Betadine spray (Smith Nephew / Molnlycke) Tissue Viability Nurse (TVN)/Leg Ulcer Nurse Specialist (LUNS) Access Only Aderma (Smith & Nephew) Larvae (Bio Monde) Debrisoft (Activa) Eclypse Boot (Advancis Medical) Renasys Go NPWT (Smith & Nephew) Urgo Start Contact (Urgo) The wound algorithms suggest recommended dressings for specific wound types in Primary Care. The product list shows the recommended dressings for specific indications using a colour coded key as below. Necrotic wounds Sloughy wounds Granulating wounds Epithelialising wounds Infected wounds Fungating wounds

29 PRODUCT LIST 28 Product Size Cost per item ( ) Sorbsan Flat Aspen Medical Tegaderm Film 3M Health Care IV 3000 (For IV/ epidural sites) Smith & Nephew Advazorb Border (Bordered Silicone) Advancis Medical Advazorb Border Lite (Bordered Silicone) Advazorb Silfix (Non-Bordered Silicone) Advazorb Silfix Lite (Non-Bordered Silicone) xcm xcm x20cm 6x7cm 12x12cm 1x20cm 6x7cm 9x12cm x12cm 7.x7.cm xcm 12.x12.cm 1x1cm x20cm x30cm 7.x7.cm xcm 12.x12.cm 1x1cm x20cm 7.x7.cm xcm 12.x12.cm 1x1cm 7.x7.cm xcm 12.x12.cm Pack size ALGINATES FILMS FOAMS First line Prescribing Notes For minor bleeding Irrigate to remove Can be left for up to 7 days depending on exudate May be left for up to 7 days For hand cannulae For PICC lines For central lines May be left on for up to 7 days Can be used as primary or secondary dressings Indicated for all exuding wounds Can be left in place for up to 7 days or when reaches absorbency capacity Product Size Cost per item ( ) Advazorb (Non-Adhesive) Advazorb Lite (Non-Adhesive) Adhesive Coloplast (Non-Adhesive) Silicone (Bordered) Soft-Hold (Non-Bordered Silicone) 7.x7.cm xcm 12.x12.cm x20cm 1x1cm 20x20cm 17x21cm (heel) 7.x7.cm xcm 12.x12.cm 1x1cm 20x20cm 18x18cm xcm 23x23cm (sacral) 17cm (contour) 19x20cm (heel) x7cm xcm 1x1cm 20x20cm 7.x7.cm xcm 12.x12.cm 1x1cm x7cm xcm 1x1cm Pack size FOAMS First line cont FOAMS Second Line Prescribing Notes Can be used as primary or secondary dressings Indicated for all exuding wounds Can be left in place for up to 7 days or when reaches absorbency capacity Can be used as primary or secondary dressings Indicated for all exuding wounds Can be left in place for up to 7 days or when reaches absorbency capacity Prices quoted are based on the March 201 Drug Tariff. For the most up to date prices please check the most current Drug Tariff.

30 PRODUCT LIST 29 Product Size Cost per item ( ) Pack size Prescribing Notes Product Size Cost per item ( ) Pack size Prescribing Notes HYDROCOLLOIDS LOW/NON-ADHESIVE Comfeel Plus Ulcer Coloplast Duoderm Extra Thin ConvaTec ActiForm Cool Activa Intrasite Conformable Smith & Nephew 4x6cm xcm 1x1cm 18x20cm (sacral) 7.x7.cm xcm 1x1cm 9x2cm x6.cm xcm xcm x20cm HYDROGELS Can produce a mild odour Not suitable if anaerobic infections due to occlusive nature Can be left up to 7 days depending on exudate Change when dressing opaque/ discoloured Odour may be noticeable on dressing change Change at least every 3 days N A Ultra Systagenix Mepore Molnlycke Systagenix Opsite Post Op Smith & Nephew Silflex Advancis Medical Clinisorb CliniMed 9.x9.cm st choice for venous leg ulcers under compression (depending on wound bed) 7x8cm x11cm 11x 1cm 9x20cm 8.x9.cm 8.x1.cm x12cm x20cm x7cm 8xcm 12x1cm xcm x20cm ODOUR CONTROL For lightly exuding superficial & post-op wounds For post-op wounds, minor cuts & lacerations Can remain in place for up to 14 days (change outer dressing prn) Only effective whilst dry Aquacel ribbon Aquacel Extra ConvaTec 2x4cm 1x4cm xcm xcm 1x1cm 4xcm HYDROFIBRE Can remain in place for up to 7 days. Change when absorbency reached Eclypse Advancis Medical Eclypse Adherent xcm 1x1cm 20x30cm 60x40cm xcm x20cm 1x1cm 17x19cm (sacral) 22x23cm (sacral) SUPERABSBENTS Change when maximum absorbency reached Prices quoted are based on the March 201 Drug Tariff. For the most up to date prices please check the most current Drug Tariff.

31 PRODUCT LIST 30 Product Size Cost per item ( ) K Band cm x 4m 1cm x 4m cm x 4m Pack size BANDAGES/STOCKINETTES/TAPES Prescribing Notes For retention K Lite cm x 4.m For retention Mollelast 4cm x 4m For toe bandaging in lymphoedema K Four Kit: K Soft cm x 3.m For compression Prescribe as individual bandages K Lite K Plus Ko-Flex Urgo cm x 4.m cm x 8.7m cm x 6m Actico 8cm x 6m For compression in venous leg ulcers and chronic oedema Activa cm x 6m 12cm x 6m Viscopaste PB7 Medicated Bandage Smith & Nephew Ichthopaste Medicated Bandage Smith & Nephew Clinifast Tubular Bandages Clinisupplies Blue Line Yellow Line Beige Line Clinipore Tape Clinisupplies Mefix Molnlycke 7.cm x 6m Use in chronic dermatitis where occlusion is indicated 7.cm x 6m Use in chronic dermatitis/eczema where occlusion is indicated 7. cm x1m 7.cm x m.7cm x1m.7cm x m 17.cm x 1m 1.2cm x m 2.cmx m cm x m 2.cm x m cm x m cm x cm For securing dressings or beneath wool bandages to reduce irritancy Basic tape for securing bandages For securing bulky dressings Product Size Cost per item ( ) Inadine Systagenix Iodoflex Smith & Nephew Iodosorb Ointment Aquacel Ag Extra ConvaTec Aquacel Ag Ribbon Ag (Adhesive) Coloplast Ag (Non-Adhesive) Pack size Prescribing Notes ANTIMICROBIALS ONLY prescribe in critically colonised or infected wounds Reassess the wound at each dressing change and STOP once signs of infection have resolved Review at maximum 14 days xcm 9.x9.cm g g g xcm xcm 1x1cm 4xcm 2x4cm 1x4cm Use for minor traumatic skin injuries Change when colour changes to white Use in chronic exuding wounds Change when colour changes to white usually 2-3 times per week Change when dressing is saturated with exudate Maximum wear time of 7 days 12.x12.cm 9.20 Use in medium-heavy exuding wounds Change depending on level of exudate Maximum wear time of 7 days xcm 1x1cm 20x20cm x7cm x20cm FOAMS First line Prices quoted are based on the March 201 Drug Tariff. For the most up to date prices please check the most current Drug Tariff.

32 ACKNOWLEDGEMENTS 31 With acknowledgement to Croydon Health Services NHS Trust Formulary reviewed and approved by: Kingston CCG Medicines Committee March 201 With thanks to the Wound Formulary Working Group, Your Healthcare Tissue Viability Nurse Specialist, Your Healthcare Leg Ulcer Nurse Specialist and Kingston Practice Nurses that contributed to the development of this formulary. Printed MONTH