A Practical Guide to the Management and Treatment of Wounds in Primary Care

Transcription

1 Policy Number LCH-143 This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form. Part A Information about this Document Policy Name A Practical Guide to the Management and Treatment of Wounds in Primary Care Policy Type Board Approved (Trust-wide) Trust-wide Divisional / Team / Locality Action No Change Minor Change Major Change New Policy No Longer Needed Approval As Mersey Care s Executive Director / Lead for this document, I confirm that this document: a) complies with the latest statutory / regulatory requirements, b) complies with the latest national guidance, c) has been updated to reflect the requirements of clinicians and officers, and d) has been updated to reflect any local contractual requirements Signature: Date: Part B Changes in Terminology (used with Minor Change, Major Changes & New Policy only) Terminology used in this Document New terminology when reading this Document Part C Additional Information Added (to be used with Major Changes only) Section / Paragraph No Outline of the information that has been added to this document especially where it may change what staff need to do Part D Rationale (to be used with New Policy & Policy No Longer Required only) Please explain why this new document needs to be adopted or why this document is no longer required Part E Oversight Arrangements (to be used with New Policy only) Accountable Director Recommending Committee Approving Committee Next Review Date LCH Policy Alignment Process Form 1

2 SUPPORTING STATEMENTS This document should be read in conjunction with the following statements: SAFEGUARDING IS EVERYBODY S BUSINESS All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or by professional judgement made as a result of information gathered about the child / adult; knowing how to deal with a disclosure or allegation of child / adult abuse; undertaking training as appropriate for their role and keeping themselves updated; being aware of and following the local policies and procedures they need to follow if they have a child / adult concern; ensuring appropriate advice and support is accessed either from managers, Safeguarding Ambassadors or the trust s safeguarding team; participating in multi-agency working to safeguard the child or adult (if appropriate to your role); ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation; ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session EQUALITY AND HUMAN RIGHTS Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership. The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices. Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act. Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy

3 A Practical Guide to the Management and Treatment of Wounds in Primary Care

4 Section 1 Introduction Amendments Section 2 Principles of Practice Wound Assessment Factors That Can Adversely Affect Healing Cleansing Of Wounds Contact Sensitivities: Common Allergens Debridement In Wound Care Exudate Management Infected Wound Management Algorithm Criteria For Diagnosis Of Clinical Wound Infection Recommended Technique For Taking A Wound Swab The Infection Continuum Nutrition in Wound Care Skin Care Emollients In Dry Skin Conditions Section 3 - Wound Management Burns Classification Of Wounds Cellulitis Dehisced Wound Diabetic Foot Ulcers Neuroischaemic Ulcers Neuropathic Ulcers Fungating Wound Hypergranulated Wound IV Therapy Site Leg Ulcer Venous Ulcer Arterial Ulcer Leg Ulcer Management Lymphoedema Classification Of Bandages Compression Therapy Systems Compression Hosiery

5 Malodorous Wound PEG Site Care Pressure Ulcer Prevention And Management Sinus Wound Skin Laceration Sutured/Stapled Wound Section 4 - Wound Care Product Descriptions Properties Of An Ideal Wound Dressing Absorbent Alginate Antimicrobial Capillary Action Emollients Foam Honey Hydrocolloid Hydrofibre Hydrogel Larval Therapy (Maggots) Low Adherent Odour Absorbent Protease-Modulating Matrix Topical Skin Barriers Vacuum Assisted Closure Vapour Permeable Film Section 5 Wound Product Formulary Section 6 - Linked Information Guidelines Further Information Useful Websites Section 7 References

6 Purpose This guide provides an information source outlining the general principles of wound management. It is designed to assist clinicians base their decisions upon the best evidence available and offer a structured approach to the assessment and management of patients with wounds (Section 2 & 3). The guide also contains a formulary of wound products that are considered by the authors to be clinically evidence based and cost effective. Whilst it is acknowledged that there will be occasions when clinicians need to prescribe products that are not recommended, the products listed are to be the first line of treatment (Section 4 & 5). However, if clinicians need to prescribe outside the formulary then a clear rationale should be documented. Aim To promote cost effective, evidence based wound care practice to optimise patient care To promote rational prescribing To provide a resource and practical guide to support wound management in primary care Scope The resources within this guide are applicable to registered health professionals employed by NHS Liverpool Community Health with a responsibility for patient wound management. Authors This guide has been produced by the Skin Care Service and Medicines Management Team with contributions from NHS Liverpool Community Health Wound Management Group. The authors are grateful to all the clinical staff that participated in conducting clinical evaluations of dressings and provided support in the development of this guide. Evidence Whilst the lack of controlled studies in support of effective wound management has been noted (Dealey 1998), the authors of this guide have examined the current evidence available and a list of the references that support the authors decisions are available in Section 7. Introduction

7 Implementation, Monitoring and Review The Director of Patient Services is responsible for the implementation of the guide, with the Skin Care Service being accountable for co-ordinating the update of the guide to reflect current practice and new wound care products that become available. The monitoring of this guide will be in accordance with NHS Liverpool Community Health Clinical Effectiveness and Audit strategy, and clinical audit forward plan. Education and Training All employees of NHS Liverpool Community Health will be required to have the knowledge and skills to deliver appropriate patient care. The Learning and Development Bureau can be contacted for details of available programmes. This guide remains a resource that supports such a process. Linked Information Within the body of the text any related wound care guidelines produced by the Skin Care Service or allied health professionals have been highlighted and such guidelines are available via the NHS Liverpool Community Health intranet and updated according to clinical policies guidance (Section 6). Disclaimer The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with standards accepted at time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor NHS Liverpool Community Health will be responsible for misuse, misinterpretation, errors or omissions that may arise from utilizing information held in the resource guide. NHS Liverpool Community Health has undertaken to make this guide available to registered clinical staff and independent contractors not employed by the organisation. The purpose of this is to provide information as to the resources that are being used within NHS Liverpool Community Health. NHS Liverpool Community Health does not accept responsibility for any actions taken by independent contractors who choose to utilise the information in this guide. NHS Liverpool Community Health expects employees to comply with the guidance contained within the Policy for dealing with the pharmaceutical industry in Liverpool Primary Care Trust (2009). Introduction

8 NHS Liverpool Community Health employees should promote equality and value diversity. Within the context of wound management, for example; consider a patient s religion or beliefs when considering using a wound product that contains animal derivatives. Contact Details NHS Liverpool Community Health Wilkinson Place Stephenson Way Wavertree Technology Park Liverpool L13 1FB Review Dates First produced October 2006 Updated October 2009 Linked Information Policy for dealing with the pharmaceutical industry in Liverpool Primary Care Trust (2009) Introduction

9 This resource guide has been updated and amended on October 2009, to reflect changes in best practice, wound product availability and price changes. Section 1 Introduction changes in line with renaming of Liverpool PCT to NHS Liverpool Community Health Section 2 Infected / Critically Colonised Wound Management Algorithm has been updated to reflect guidance contained within; NICE (2008) Surgical Site Infection: Prevention and treatment of surgical site infection. Clinical guideline 74 Infection Continuum Treatment options for critically colonized and infected wound section has been updated in line with best practice guidance Nutrition and Wound Healing title changed (from nutrition in wound care) and content updated Section 3 Burns Other considerations sentence included establish mechanism of injury Diabetic Foot Ulcers Linked Information addition of best practice guidance web site Hypergranulated wound - linked information to Hypergranulated wound guideline PEG Site Care Treatment and other considerations updated Sinus Wound Other considerations information updated in line with NICE (2008) Surgical Site Infection: Prevention and treatment of surgical site infection. Clinical guideline 74 Skin Lacerations Dressings and other considerations information updated Sutured / Stapled Wounds - Other considerations information updated in line with NICE (2008) Surgical Site Infection: Prevention and treatment of surgical site infection. Clinical guideline 74 Section 4 Absorbent additional product: Sorbion Sachet S Antimicrobial Contreet - has been renamed Biatain Ag Silvercel manufacturer change to Systagenix Wound Management Capillary Action product dressing selection changed from Vacutex to Sumar Emollients Additional products Foams Addition of Biatain Soft-Hold to Biatain range Product dressing selection changed Allevyn Gentle replaces Mepilex Honey amended to reflect changes in product formulations of Activon Range including method of application Hydrocolliod Tegasorb has been renamed Tegaderrm hydrocolliod Granuflex Contraindications updated as not suitable for infected wounds Hydrofibre method of application amended in line new formulation of Aquacel ribbon Larval Therapy Amended to include changes in formulation of product Low Adherent NA Ultra: manufacturer change to Systagenix Wound Management Product dressing selection changed from Mepore Ultra to Softpore Protease modulating matrix Promogran manufacturer change to Systagenix Wound Management. Linked information removed. Section 5 Wound Product Formulary - updated Section 6 Linked Information Updated Section 7 References - Updated Amendments

10 A wound is defined as a disruption of the integrity and function of the tissues in the body (Baharestani 2004). In order to plan and implement appropriate management, a full holistic patient assessment must be undertaken. Referral to the multidisciplinary team should be promoted to improve patient outcomes. The process of wound healing is a normal response by the body to injury, which results in tissue repair or regeneration. In normal wound healing, the application of a dressing to a wound provides an optimal environment to wound healing. The key to effective wound management lies in the identification and optimisation of factors that could potentially delay the normal wound healing process and is therefore not just the act of applying a dressing. Key objectives of wound assessment Thorough, holistic and systematic patient assessment Identification of factors that could delay wound healing (see overleaf), any allergies or sensitivities identified Type of wound Identify underlying cause of wound e.g. pressure ulcer, surgical, traumatic wound, leg ulcer To complete documentation of assessment, treatment plan and rationale, reassessment, regular review and evaluation of effectiveness of treatment given Specific assessment of the wound Wound location and number of wounds Size longest, widest and deepest points, any undermining, tracking recorded. May be supported by tracings Wound duration Grade if pressure ulcer Nature of wound fluid amount, colour, odour, and consistency Indications of infection Pain Assessment of surrounding skin Tissue type and percentage (%) - i.e. black necrotic, yellow slough, red granulating, pink epithelialising Accurate assessment ensures continuity of care, improves communication between health professionals, promotes evaluation of the wound and provides supporting evidence to promote effective clinical decisions. Linked Information Wound assessment guideline Wound Assessment

11 Adapted from Morison (2004) Negative psychological factors Altered body image resulting in actual or perceived problems with social relationships and roles Social isolation Additional life stresses e.g. bereavement Patients lack of belief in treatment Negative attitudes of staff towards treatment and healing Inappropriate wound management Failure to identify and correct where possible the underlying cause of the wound Application of inappropriate topical agents and primary wound dressings Poor wound dressing technique Adverse effects of other therapies Radiotherapy Cytotoxic drugs Prolonged high-dose steroids Miscellaneous drugs including anticoagulants, local anaesthetics, alcohol and nicotine Adverse Healing Factors

12 The overriding goal of cleansing is to remove any hindrance to the maintenance or restoration of healing, achieved with the minimum of physical discomfort and psychological distress to the patient. Only cleanse those wounds that have debris to be removed necrosis/slough is often firmly attached and therefore debridement may be indicated. The routine use of antiseptics in wound cleansing is not recommended as it may be detrimental to wound healing, the bacteria may develop a resistance, and there may be a potential toxic effect on viable tissue. Cotton wool not recommended as it can redistribute bacteria within wounds. It can also drive cotton fibres into the tissues and act as a foci for infection. Warm tap water is an acceptable alternative method of cleansing chronic wounds. Short periods of soaking in lined buckets with warm tap water is particularly beneficial for lower leg wounds as it has a psychological benefit. However, prolonged soaking can produce an osmotic effect causing cells to swell. Sterile saline solution 0.9%. This is an isotonic solution compatible with and has a similar osmotic pressure to living cells so should not cause cell damage during wound irrigation. Therefore it is considered a safe cleansing agent. However, as a vital part of wound healing is maintaining surface temperature, the solution should be used warmed to body temperature at the wound surface. Although not proven, it is generally accepted that the optimum pressure to exert when cleansing wounds is 8-15 pounds per square inch (psi), plastic pod ampoules of sterile saline potentially exert 8psi. Pressures below this level may be ineffective at removing bacteria, but sufficient in removing remnants of dressing products (hydrogels, alginates) and excess exudate. Higher pressures conversely may remove bacteria - however it may also redistribute bacteria and result in splash back, which increases the risk of cross infection. Clinicians must consider the reasons for cleansing as noted above and ensure that the appropriate technique is adopted. Cleansing Of Wounds

13 Royal College of Nursing contact sensitivity recommendations state: Products which commonly cause skin sensitivity such as those containing lanolin and antibiotics should not be used on any patient. The following list of products containing allergens is not exhaustive - please check excipients listed beneath individual products in the British National Formulary (BNF) for product details. Allergen Type Products containing allergen Wool alcohols, amerchol 101, eucerin Wool fat / lanolin Many creams including Hydrous ointment, E45 cream (hypoallergenic lanolin), Vaseline Derma care Topical antibiotics: neomycin, framycetin, bacitracin, gentamicin. Parabens (hydroxybenzoates), phenosept, chloroxynenol, quinoline mix. Sorbic acid Antibiotics Preservatives/ antimicrobials Arachis (peanut) oil Oil Hewlett's cream Benzyl alcohol, Cetostearyl alcohol, Phenoxyethanol Vehicle Disodium edetate Antoxident synergist Ultrabase cream Cicatrin cream and powder, gentamycin cream and ointment, graneodin ointment, medicated tulle dressings Cetraben cream, E45 cream, Hydromol cream, Lipobase, Ultrabase cream, Paste bandages: Icthaband, Quinaband, Viscopaste, Calaband dressings, Unguentum Merck Present in most creams including corticosteroids, Oilatum emollient, Aqueous cream, Aveeno cream, E45 cream, emulsifying ointment, Cetraben cream, Diprobase cream, Epaderm ointment, Fucidin cream, Hydromol cream, Hydrous ointment, Oilatum cream, Ultrabase cream, Unguentum M cream Chlorocresol Biocide Diprobase cream, Corticosteroid creams eg Propaderm cream Quinolone mix Antiseptic and antifungal creams and Chlorhexidine ointments Disodium edetate Isopropyl palmitate Polysorbates Emulsifying agents Antiseptics, tulle dressings eg. chlorhexidine gauze dressing Diprosalic Aveeno cream Propylene glycol Solvent/Vehicle Unguentum M cream Unguentum M cream, Steripaste, E45 cream Balsam of Peru/Fragrance mix Fragrances Hewlett's cream, Ultrabase, Some bath oils and additives, over the counter moisturisers and bay products. Mercapto/carba/thiuram mix, latex Rubber Mix Elastic tubular bandages e.g. Tubigrip, Elastic supports, elastic stockings, latex gloves worn by carer Colophony, Ester gum, Resin Adhesives Adhesive tapes, adhesive bandages and dressings, cohesive bandages Common Allergens

14 o Debridement is the procedure of removing devitalised (necrotic) or infected tissue, fibrin or foreign material from a wound (NICE 2001). Unhealthy tissue impedes the natural healing process. Rationale for Debridement (Leaper 2002) To enable assessment of the wound bed Dead or devitalised tissue acts as a medium for bacterial growth Dead or devitalised tissue within the wound bed leads to prolonged inflammatory response delaying the wound healing process Dead or devitalised tissue retards wound contraction In some instances debridement is not an option. When there is evidence of peripheral arterial disease associated with gangrene, it is not appropriate to remove the necrotic tissue by creating a moist environment (autolytic debridement) as this may precipitate wet infected gangrene, which is potentially limb and/or life threatening. Factors to Consider in Choosing a Debridement Option The timescale in which debridement should take place The risks and benefits of each method in the context of individual patient assessment Level of pain experienced by the patient Presence or absence of infection The patient s attitude to debridement option Available skills, products and resources Methods of Debridement Autolytic Debridement probably the most common method of wound debridement, but traditionally time consuming, it relies on enhancing the natural process of selective liquefaction, separation and digestion of necrotic tissue. It is enhanced by the use of moisture-retentive dressings such as hydrogels and hydrocolloids that promote rehydration of necrotic tissue by creating a moist wound healing environment. The accumulating wound exudate contains white blood cells and enzymes that break down necrotic tissue. Surgical Debridement if extensive debridement is required, this is performed by a surgeon in an operating theatre. Converts a chronic into an acute wound therefore reinitiating the wound healing process. Sharp Debridement performed at the patient s bedside or home, this is the removal of dead tissue or foreign material just above the level of viable tissue (Poston 1996) by an appropriately trained health professional. Enzymatic Debridement not recommended. It is costly and there is no evidence to support its use (NICE 2001). Mechanical - usually involves the use of wet to dry gauze dressings. It is the general consensus of expert opinion that this procedure damages healthy, granulating tissue, is extremely painful for the patient and leads to wound desiccation (Bradley et al 1999). Biological the use of maggots (larvae). Maggots have been shown to rapidly remove devitalised tissue from all wound types irrespective of their underlying aetiology. Linked information: Debridement guideline Debridement

15 All open wounds will produce exudate. This is a combination of the fluid normally found bathing the cells in the extra cellular space and additional fluid that leaves the blood supply. It migrates to the wound site under the influence of the body s inflammatory response to wounding (Thomas 1997). Fluid type Fluid from acute wounds may have a beneficial effect on wound healing, as it is rich with growth factors and the necessary inflammatory components to promote healing. However, chronic wound fluid contains high levels of proteases (tissue-destructive enzymes) associated with delayed wound healing (Thomas 1997). Acceptable levels of fluid in a wound It is acknowledged that keeping wounds moist, that is, the presence of exudate is essential for wound healing. However, the correct moisture balance is difficult to define as it is suggested that wounds that are too dry will not heal optimally and wounds that are too wet will deteriorate (Bishop et al 2003). Many factors influence the production and nature of exudate including the type of dressing used, pressure, wound type, depth and surface area. Maceration Large volumes of fluid can, if poorly managed, lead to saturation of the wound bed and peri-wound area, resulting in their maceration i.e. the softening of tissue that has remained moist or wet for a long period. It appears as white soggy tissue, or excoriation (inflammation of the epidermis caused by an irritant such as chemical, bacteria or body fluid), which may lead to the breakdown of the peri-wound area and enlargement of the wound. Dressing leakage, wound pain, and prolonged healing times can also have a detrimental effect on a patient s quality of life (Vowden and Vowden 2004). Other causes of skin maceration such as perspiration or incontinence should be excluded. Assessment Exudate production can affect patient s nutritional status - a holistic patient assessment is required; consider if venous blood sample for haemoglobin, urea and electrolytes or serum albumin is indicated Identify and treat any underlying cause e.g. infection or critical colonisation, consider the use of an antimicrobial dressing Correct any underlying pathological causes i.e. venous hypertension with compression or treat cardiac failure Exudate Management

16 Assessment of exudate There is no precise validated way of measuring the level of exudate, but it will provide a benchmark for further assessments and may indicate potential cause (Scanlon 2004). The following should be recorded: Amount - high, moderate, small or none Colour - normal exudate is described as straw coloured with a watery consistency, any change in consistency, colour (opaque or purulent) or malodour may indicate the presence of infection (Hampton, Stephen Haynes 2005). Aim of treatment To achieve a balance between retaining moisture at the wound bed and preventing maceration of the peri-wound skin. Ideally a dressing should be able to absorb fluid rapidly, have a large fluid retaining capacity and control lateral wicking. Dressing choice should be made dependant upon the amount of exudate, wound size and body position in consultation with the patient. Frequency of dressing change - a realistic wear time should be estimated at dressing change to avoid wound becoming saturated according to manufacturer s instructions. Care of the surrounding skin Protect the surrounding skin from maceration using an emollient, although care should be taken to ensure it does not compromise the functions of the dressing selected such as absorption or adhesion. Topical skin barrier films provide a moisture repellent film on the skin that does not interfere with the function or adhesion of dressings (Williams 2001). Exudate Management

17 t iti i t it Adapted from Scanlon (2005) with kind permission *Refer to local antibiotic formulary ** NB For Surgical wounds with a prosthetic implant or deep metal work showing classic / additional signs of infection refer urgently back to Consultant; for any other form of implant urgently discuss with GP I I r r r I r r r Is the patient displaying symptoms of an acute systemic illness? r R r r r r r r r N I r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r Infected / Critically Colonised Wound Management Algorithm

18 Classic criteria Localised erythema Localised pain Localised heat Cellulitis Oedema Abscess formation Viscous, purulent and discoloured discharge r r r r r r r r r r r Criteria For Diagnosis

19 Action The wound should be irrigated with warm saline or tap water prior to swabbing The tip of the wound swab should be moistened with normal saline or tap water prior to sampling Only areas of viable tissue should be sampled Swabs should be taken in a zig-zag motion, covering the whole wound whilst rotating the swab (see below) The swab should be clearly labelled with all relevant patient details The microbiology request form should be accurately completed to include the following clinical information: Patient details Location of wound Size of the wound What signs of infection are present Wound aetiology Recent or current antibiotic therapy Any underlying pathologies such as peripheral vascular disease, diabetes and immunosuppression Recent increase in pain, exudate or malodour Ideally swabs should be cultured within 4 hours of collection from the patient. For community practitioners: swabs should be cultured as soon as is reasonably possible from the point of patient sampling, but should certainly reach the laboratory on the same day Swabs should be stored at ambient temperatures whilst awaiting processing Any practitioner taking a wound swab is individually responsible for ensuring the results are reviewed and acted upon appropriately Rationale To remove dressing residue and surface contaminants therefore improving accuracy in sampling of invasive causative organisms This increases the absorbency of the swab and increases the survival of bacteria prior to microbiological culture If slough or necrotic tissue is sampled only surface contaminants will be cultured This ensures that an accurate microbial sample is collected To allow for accurate patient identification This will provide the microbiologist with an accurate clinical picture and will allow more appropriate interpretation of microbial growth It will reduce the risk of false positive and false negative results The skin supports the growth of different natural flora in different body locations This reduces the risk of microbes being missed possibly due to death on route to being processed. Microbes vary in their sensitivity to oxygen and nutritional availability once removed from their natural environment Microbes vary in their sensitivity to temperature changes when removed from their natural environment This ensures that swab results are reviewed in a timely manner, antibiotic therapy adjusted if necessary and wound infection treated effectively 4 3 Swab wound in a zig-zag and rolling motion points 1 to 8 5 as shown 6 Taking A Wound Swab

20 The Infection Continuum The Infection Continuum Type STERILE CONTAMINATED COLONISED Increasing bacterial burden Description Absence of organisms for a very brief period following initial surgical incision or thermal trauma. This situation is only normal in aseptically created clean surgical wounds Presence of microbes but little active growth. Contamination is reached soon after initial wounding even with clean surgical wounds and particularly with surgical wounds that are in close proximity to dirty areas e.g. the bowel, and progresses quickly to colonisation Management Aim To promote a healing environment and minimise risk of infection To promote a healing environment and minimise risk of infection Treatment Option Undertake full, holistic assessment and manage wound according to local guidelines. Underlying pathology and tissue type should be considered Undertake full, holistic assessment and manage wound according to local guidelines. Underlying pathology and tissue type should be considered Growth and death of organisms kept at a safe level by host immune response resulting in a healthy balance. Colonisation is a normal situation for chronic wounds To promote a healing environment and minimise risk of infection particularly in high risk patient groups e.g. burns, diabetics, immunocompromised patients, patients with acute traumatic wounds Undertake full, holistic assessment and manage wound according to local guidelines. For high risk patients, consider using an antimicrobial dressing. The choice of dressing will be determined by other wound and patient characteristics e.g. exudate, tissue type, location, known sensitivities

21 The Infection Continuum The Infection Continuum Type CRITICALLY COLONISED INFECTED Increasing bacterial burden Description Host defences unable to maintain healthy balance; either too many microbes or too many species in wound base or a compromised immunity. This results in an indolent wound that does not respond to appropriate therapy and is at increased risk of becoming clinically infected Management Aim To reduce the bacterial load in the wound bed to prevent clinical infection and promote wound healing Treatment Option Undertake full, holistic assessment. (Refer to Infected / Critically Colonised Wound Management Algorithm) Consider using an antimicrobial dressing. The choice of dressing will be determined by other wound and patient characteristics e.g. exudate, tissue type, location, known sensitivities. Host defences overwhelmed resulting in local cellulitis, which may lead to bacteraemia, septicaemia and death. Clinical signs of infection will be present (see criteria for diagnosis of clinical wound infection) and the patient will feel systemically unwell Undertake full, holistic assessment.(refer to Infected / Critically Colonised Wound Management Algorithm) Consider using an antimicrobial dressing. The choice of dressing will be determined by other wound and patient characteristics e.g. exudate, tissue type, location, known sensitivities. Linked Information Infected wound guideline

22 t iti i Studies show a link between nutritional status, healing and the development of wounds (Xakellis and Frantz 1997). Early detection of wounds and identification of malnutrition are vital. Dehydration and vascular disease will compromise healing of wounds. Hyperglycaemia will also delay wound healing and increase the likelihood of both localised and systemic infections. The elderly population are the most at risk since a reduced appetite, reduced fluid intake, taste sensitivities and eating foods that are of poor nutritional quality and therefore poor wound healing. Energy and protein It is necessary to ensure adequate protein and energy are provided to meet daily requirements but protein is required for wound healing. Inadequate energy intake will affect the wound healing as the wound requires energy to heal. Exuding wounds can lose protein and if the wound becomes infected these protein losses can increase significantly; up to 100g protein per day. Malnourished patients with a compromised intake will have delayed wound healing but wound healing does not stop. An involuntary weight loss of as little as 4% is an independent factor in increased morbidity and mortality (Wallace et al 1995, Albina 1994, Breslow 1991) since it suppresses the immune response, decreases muscle mass and strength, in response to stress. Micronutrients Vitamin A, C, E, zinc selenium and magnesium have the ability to prevent or attenuate oxidative damage and can potentially enhance wound healing (Schwartz et al 2005). There is no clear evidence that supplementation of vitamin C is justified. Assessing the risk for malnutrition The Malnutrition Universal Screening Tool (MUST) is recommended by NICE (2006), as a validated method of screening for malnutrition in hospital and community settings. It requires accurate weight and height measurement, but the MUST tool does provide you with alternative ways to measure height and weight. The single assessment process (SAP), includes some observation criteria, such as loose fitting clothes or rings, and if necessary a prompt referral for a complete assessment to the community dietetic nutritional support team. Until the dietetic assessment is completed the care plan in the MUST tool should be followed. A multivitamin and mineral tablet could be prescribed if you feel it necessary prior to dietetic assessment. Nutrition In Wound Care

23 t iti Dietetic Assessment Once the patient has been referred to the dietetic team, further data will be collected to enable an individualised nutrition care plan to be developed. This will include: Anthropometric measurements such as height, weight, weight history BMI, and mid-arm circumference as measure of muscle wasting. Biochemical indices such as full blood count, serum ferritin, U and E s and C- reactive protein. A full dietary assessment including estimation of current protein, calorie, zinc, and vitamin C intake. As a result of these factors, in combination with the clinical condition, the individual s nutritional requirements are calculated and nutrition care plan will be developed to meet these requirements. Nutrition as a treatment These treatment methods can be used in combination, depending on the individual taking, into account their taste preferences, needs and ability. Food fortification advice would include increasing the intake of foods that are high in calories and protein, as well as an improvement in the nutrient density of foods eaten. Supplementation of oral intake with commercially prepared oral supplements, some of which are nutritionally complete. Providing enteral nutrition support, of which the preferred route is percutaneous endoscopy gastrostomy (PEG), either to completely replace oral intake or to supplement to oral intake. Written materials are provided to help clients, carers and other health care professionals to support the nutrition care plan. The nutrition care plan is monitored and re-evaluated on a regular basis to ensure it continues to meet the individual s needs and will be amended as necessary. All decisions are made in collaboration with all members of the primary and secondary care teams, using locally agreed care pathways. When the client is assessed as being nutritional stable, they will be discharged from the dietetic team. Linked Information Oral nutrition supplement formulary and MUST care plan NHS Liverpool Community Health Nutrition In Wound Care

24 ki i t ki iti Dry skin is characterised by decreased ability of the stratum corneum to retain water. Clinical signs of dry skin can vary in severity, itching, soreness, inflammation and cracking. Because the normal barrier function of the skin may be lost due to fissuring and cracking, the skin may also be prone to infection. Emollients work by increasing the amount of water held in the stratum corneum by either trapping (occluding) or drawing moisture from the dermis. Greasy products such as petroleum effectively achieve occlusion. Humectants are comprised of substances such as urea and glycols. Because of their low molecular weight they attract water into the stratum corneum. Generally emollients are safe, occasionally stinging may be experienced on application, generally related to one component of the emollient. This is usually a transient effect, true sensitivity or allergy is actually rare. Different emollient formulations Soap substitutes - Used to cleanse the skin in replacement for normal soap that has a drying effect on the skin Bath oils - Moisturise by leaving a thin layer of oil over the skin Creams - Are emulsions of oil and water, less greasy so cosmetically acceptable Lotions - Higher water content than creams so easier to spread but not as effective Ointments - Products consisting of substances such as paraffins, vegetable oils and animal fats, often more difficult to spread and not as cosmetically pleasing but most effective Individuals may develop favourite brands, but find it more effective to use different products for different times of the day e.g. cream after a bath, lotion during the day and ointment at night. For an emollient to be effective, it must be used appropriately in sufficient quantities, refer to British National Formulary (BNF) for charts. It is important to establish an emollient that the patient is happy to use, as this will encourage concordance with emollient treatment and maintenance regimes. A combination of products may be the solution to concordance, cosmetic acceptability by the patient is essential. Preparations containing an antibacterial should be avoided unless infection is present or is considered a frequent complication of the condition. Emollients are a first-line therapy for atopic eczema and aim to retain the skin's barrier function (keeping water in and irritants or pathogens out) and to prevent painful cracking. Frequent and continuous use is recommended even in the absence of symptoms. Preparations available include bath oils, soap substitutes and moisturisers. Generally, the greasier the preparation the better the effect, although people using very greasy products may not consider them acceptable. (NICE 2005) The Cochrane review states that the correct emollient is the one the patient will use. (Hoare et al, 2000) We are now starting to understand why emollients are such an effective therapy. However, despite their efficacy, emollients remain a very under-used therapy in the community. (Cork 1997) Linked information: The treatment of a patient with eczema Skin Care

25 Burns Burns Picture Description Aims Dressing Regime Other Considerations SUPERFICIAL BURN 1 (1st Degree) Heat injury to the skin resulting in damage to the epidermis and possibly part of but not completely the dermis Usually reddened, dry, painful, may have minor blister Lund & Browder Surface Area Calculator (guide only) Adults only Establish how burn occurred, cause, extent and depth of burn Maintain moist environment and manage exudate Minimise risk of infection Blister management Blisters have a protective function If they are not large and will not obstruct dressing or patient s movement - leave intact Large bullous blisters: it may be necessary to drain fluid to facilitate movement, but deroofing is generally not recommended as it may increase the risk of infection Low adherent Vapour permeable film Foam Antimicrobial 1 Any wound above first degree and/or bigger than 5% of total body surface area should be referred for specialist assessment in A&E or burns unit First aid in all burns: Apply cold water to localised superficial burn, cover with cling film or clean plastic bag until treatment obtained Establish mechanism of injury Refer to Walk-in-Centre/ A&E Review a new burn after hours to reassess the condition of burn Pain management Assess need for Tetanus immunisation* Superficial burns usually heal in 7-14 days if healing is delayed consider: Infection may be present. Referral to secondary care - as burn depth can be underestimated Once healed advise patient: To protect newly healed tissue The use of an emollient may soothe and ease itching Sun exposure use of sunblock for the first year while new skin matures Linked Information *Patient Group Direction for immunisations

26 Burns Burns Picture Description Aims Dressings Other Considerations PARTIAL THICKNESS BURN (2nd Degree) Affecting dermis and epidermis Usually red wet and painful, may be mottled with increased depth Minimise risk of infection Manage exudate Promote healing Management subsequent to assessment in Secondary Care: Low adherent Refer to A&E/ Burns unit if: Chemical/electrical/ hand and face burns Fully circumferential burns due to possibility of causing constricture Patients with concomitant illnesses e.g. diabetes, immunosuppressed may warrant referral Consider dietician referral for nutritional support FULL THICKNESS BURN (3rd Degree) Heat injury extending to all skin layers and possibly subcutaneous tissue of muscle and bone Dry, charred leathery Specialist treatment in burns unit may include removal of dead tissue in preparation for grafting or surgery Foam Antimicrobial Consider need for psychological support Donor site Usually dressing left in place for upto 10 days with Low adherent/ absorbent dressing Monitor for: Strike through Dressing slippage Indications of infection

27 Classification Of Wounds Classification Of Wounds Wound Type Treatment Aim Treatment choice with a cavity Treatment choice without a cavity GRANULATING Primary dressing Secondary dressing Primary dressing Secondary dressing Promote granulation Low Exudate Low Exudate Provide healthy base for Low adherent Foam or hydrocolloid Low adherent epithelialisation Hydrocolloid Hydrofibre Foam Foam Moderate / High Exudate Moderate / High Exudate Pink tissue containing new connective tissue and capillaries Alginate Foam Alginate Foam Capillary action Foam Capillary action Foam Hydrofibre Foam Hydrofibre Foam Foam EPITHELIALISING Epithelialisation is the regrowth of epithelial cells across the wound surface occurring in the end stages of wound healing. It is pink in appearance with fragile tissue Low Exudate Low Exudate To protect and promote new Low adherent Film or hydrocolloid Low adherent tissue growth by maintaining a Hydrofibre Foam Film Hydrocolloid moist environment Moderate / High Exudate Moderate / High Exudate Alginate Foam Hydrofibre Foam Foam

28 Classification Of Wounds Classification Of Wounds Wound Type Treatment Aim Treatment choice with a cavity Treatment choice without a cavity NECROTIC Debride eschar Primary dressing Secondary dressing Primary dressing Secondary dressing Low Exudate Hydrogel Low adherent Film or Hydrocolloid Film or Hydrocolloid Low Exudate Hydrogel Hydrocolloid Capillary action dressing Film or Hydrocolloid Film Dead devitalised tissue, normally black or brownish appearance Capillary action dressing Film Moderate / High Exudate Alginate Foam Capillary Action Foam Hydrofibre Foam Larval Therapy Moderate / High Exudate Alginate Capillary Action Foam Hydrofibre Larval Therapy Foam Foam Foam SLOUGHY Debride slough to provide base for granulating tissue Low Exudate Low adherent Hydrogel Hydrofibre Foam or Hydrocolloid Film or Hydrocolloid Foam Low Exudate Hydrocolloid Hydrogel Film or Hydrocolloid Moderate / High Exudate Moderate / High Exudate Moist predominantly yellow in appearance, a mixture of rehydrated necrotic tissue dead bacteria, leucocytes often with fibrous tissue Alginate Capillary action Hydrofibre Foam Foam Foam Alginate Capillary action Foam Hydrofibre Foam Foam Foam

29 Cellulitis Wound Type Description Aims Dressings Cellulitis Other considerations Cellulitis is an infection of the skin and subcutaneous tissues Usually requires antibiotic therapy to prevent infection spreading systemically, may be oral or IV Clinical signs may include: Red (erythema), hot, skin which spreads to adjacent tissue, local oedema, blistering, exudate varying levels, pyrexia, pain Preceded by minor skin breaks (e.g. trauma, abrasion, ulceration insect bite), build up of dry scaly skin, venous hypertension, lymphoedema, obesity Treat infection Pain control Manage any local skin conditions i.e. exudate, maceration Identify original cause to reduce further episodes of cellulitis Emollients to any dry skin Exudate management Low Exudate Low adherent dressings Moderate/High Exudate Foam, absorbent cellulose dressing Swab any exudate for culture and sensitivity Exclude differential diagnosis such as eczema, DVT Monitor effectiveness of analgesia Rest and elevation for lower leg cellulitis to be encouraged Liase with GP/hospital re: prescribed antibiotics Trace around marked area of erythema and monitor for any increasing cellulitis, refer to GP or hospital Monitor for pyrexia or symptoms of systemic infection developing Once initial episode has resolved consider compression therapy if cellulitis recurrent as precursor to lymphoedema Linked information Intravenous Antibiotic Policy including Cellulitis guideline

30 Dehisced Wound Dehisced Wound Wound Type Description Aims Dressings Other Considerations Dehiscence occurs following surgery when the sutures/staples are unable to hold the wound together Manage exudate Promote granulation Reduce risk of infection Dependant on size and level of exudate Moderate Exudate Alginate Hydrofibre Foam Topical negative pressure Pain control Patient support re: body image High Exudate Hydrofibre Alginate Foam Capillary action dressing Absorbent cellulose dressing Wound management pouch Nutritional / fluid intake may need review depending on fluid loss May need surgical review

31 The diabetic foot may be described as "a group of syndromes in which neuropathy, ischaemia and infection lead to tissue breakdown resulting in morbidity and possible amputation" (World Health Organisation 1995). The NICE (2004) publication, "Prevention and management of foot problems", addresses the evidence that improved outcomes are achievable through appropriate monitoring and intervention. Assessment of the Ulcerated Foot Both feet should be examined even if only one presents with an ulcer. Holistic assessment should be completed to include such factors as: Identification of aetiology (neuropatic or neuroischaemic) Peripheral neuropathy status Peripheral vascular status Medical and surgical history Ulcer cause e.g. trauma Diabetes status - latest Hba1c Lifestyle factors e.g. ability to self-care, smoking Wound assessment Effective care involves partnership between patient and professionals in developing an acceptable management plan and all decision making should be shared. Collaboration between professionals in Primary and Secondary care is essential to ensure continuity in patient care. Before commencing a dressing regime, assessment of aetiology is essential to initiate the appropriate treatment. Diabetic foot ulcers are generally divided into two categories: 1- NEUROPATHIC sensation is altered 2- NEUROISCHAEMIC sensation and circulation is altered Linked information: Wound assessment guideline Infected wound guideline Refer to Liverpool and South Sefton Podiatry Service: Diabetes foot care advice leaflets Diabetic Foot Ulcers

32 Identifying Ulcer Aetiology Below are some indicators that may assist in identifying if an ulcer is neuropathic or neuroischaemic Neuropathic Ulcer Foot warm and dry Foot pulses palpable Often painless/numb Surrounding callus/hard skin Weight bearing surface sole of foot beneath metatarsal or at other bony prominences (top of toes, sole of 1st toe) Punched out appearance, often involving deep tissues and bone Neuroischaemic Ulcer Foot may be cold Foot pulses absent Painful Callus absent Margins of the foot - side of toe, outer edge of 5th toe Area of necrosis, often surrounded by rim of erythema Acute sensation usually present Patient may be totally unaware of numbness or presence of wound Diabetic Foot Ulcers

33 Referral Pathway For a new foot ulcer, arrange urgent (within 24 hours) assessment by an appropriately trained health professional (NICE 2004). All people living with diabetes who develop a new foot ulcer should be referred to a multidisciplinary diabetes team (MDT) for assessment. Referral should be made locally to the Diabetes Centres in: The Royal Liverpool and Broadgreen University Hospital or The University Hospital Aintree The multidisciplinary team at the Diabetes Centre comprises of Diabetologist, Podiatrist, Nurse, Orthotist and diagnostic and advisory services (e.g. Diabetic Nurse Specialist, Dietician). Vascular referral Patients who may benefit from re-vascularisation should be identified and referred promptly (NICE 2004). Vascular calcification may be present in patients with diabetic foot ulcers therefore caution should be taken when interpreting Doppler APBI s as the readings may be falsely elevated. However, if a patient develops signs and symptoms of ischaemia (atrophy of skin, absence of hair, pallor/abnormal colour, absent pulses/monophasic, claudication, cool/cold limb, ischaemic rest pain, lowering of Doppler APBI) they should have rapid vascular referral. Management of the Ulcerated Foot The concept of warm moist healing has never been shown to improve outcomes for the diabetic foot ulcer (Foster 1994). Abnormal wound healing in people with diabetes is well recognised. Although the exact mechanism by which abnormal healing occurs is not known the following elements need to be considered in combination with each other depending on the assessment Sharp debridement and wound bed preparation Infection management Offloading the ulcer area Health education (behaviour management e.g. stop smoking) Diabetic Foot Ulcers

34 Wound infection Signs and symptoms of infection may be reduced in patients with diabetic foot ulcers; therefore wounds should be monitored closely and regularly redressed. Do a wound swab from the deepest part of the wound bed, if there are clinical signs of infection (refer to wound infection - Section 2). Antibiotics are to be prescribed according to sensitivity, although in consultation with GP/Microbiologist, broad-spectrum antibiotics may be commenced until sensitivity available. Osteomyelitis Infection that affects the bone and its marrow Establish whether ulcer affects soft tissue or extends to bone i.e. ulcer present or history of ulcer and: Cellulitis Probing to bone Positive bacterial culture from deep tissue Radiological indications Charcots Foot A progressive neuroarthropathic condition, characterised by osteoporosis, fractures, acute inflammation and disorganisation of bone and joint structures. Clinical diagnosis of Charcots foot is based on the appearance of a red, swollen and oedematous and possibly painful foot in the absence of infection (Jeffcote et al 2000). If osteomyelitis or Charcots foot is suspected the patient should be reviewed by the Diabetic MDT or A&E for the appropriate investigations and management. Diabetic Foot Ulcers

35 Neuroischaemic Ulcers Neuroischaemic Ulcers Wound Type Description Treatment Aim Dressings Other Considerations Dry gangrenous ischaemic wound Reduce risk of infection developing /spreading Keep wound dry, if toe is affected isolate from touching adjacent digit Low adherent dressing If dry gangrene leave exposed if appropriate Typical signs: Pulse absent Foot may be cold History of intermittent claudication Painful Minimum or no callus Area of necrosis, often surrounded by erythema Evidence of gangrene Refer to vascular surgeon Wet gangrenous wound Control moisture level Reduce risk of infection developing /spreading Low adherent May need charcoal dressing to control odour Manage in conjunction with Diabetes team Debridement may be considered by a competent practitioner i.e. have completed an accredited course in sharp debridement Minimise pressure on affected area Monitor for infection (remember these signs may be reduced or absent in DFU) Patient support where amputation may be considered

36 Neuropathic Ulcers Wound Type Treatment Aim Allow free drainage of exudate *Debridement Dressings Low Exudate Low adherent Moderate/ High Exudate Hydrofibre Alginate Foam Neuropathic Ulcers Other Considerations The principles of moist wound healing have not been shown to be effective in healing diabetic foot ulcers (DFU). Such is the high risk of infection that the wound exudate level must be carefully managed All DFU must be referred to the Multi-disciplinary Diabetes Team for holistic assessment, nurses must work in collaboration and reinforce individual health education (Refer to Liverpool and South Sefton Podiatry Service: Diabetes foot care advice leaflets) Maintain monitoring of blood glucose. Hba1c should be at optimum level Diabetic foot ulcers should be redressed frequently to enable close monitoring for indications of infection. Note clinical signs of infection may be reduced or absent in DFU Functions required of a dressing are: Low adherent Not bulky or take up too much space in shoe Able to withstand the pressures and shear forces of walking Able to absorb large quantities of wound exudate *Debridement Debridement of wound bed allows a deep swab to be taken and show the true dimensions of the wound. Debridement of the surrounding skin may be performed to minimise pressure and reduce the bacterial load by removing devitalised tissue Such debridement must be performed by a competent practitioner i.e. have completed an accredited course in sharp debridement

37 Fungating Wound Fungating Wound Wound Type Aims Dressings Other Considerations Description Malignant wounds are caused by malignant infiltration of the skin by a primary tumour or a metastasis to the skin. These lesions can grow rapidly, and commonly present with both ulcerative and fungating features (Collier 2000) Manage exudate Reduce odour Useful combinations include low adherent dressing and secondary absorbent dressing or alginate / hydrofibre and foam dressing Charcoal / odour absorbent dressing Other methods of odour control include the use of deodorising products as used in stoma care The overall aim is to improve the patient s quality of life and manage symptoms of the wound. Dressings should be comfortable and acceptable to the patient. It is important to ensure that a holistic patient assessment includes psychological assessment of the impact of the wound for the patient. Main symptoms include: Altered body image Excessive exudate Malodour Bleeding* Pain Itching *Dressings should be low adherent to minimise the risk of trauma induced bleeding. The use of haemostatic Alginates may be of use to control minor bleeds. Linked information: Fungating wound guideline

38 Hypergranulating Wound Hypergranulated Wound Wound Type Description Treatment Aim Dressings Other Considerations Appearance - red raised granulating tissue above the level of the surrounding epidermal skin layer Reduce further hypergranulation Promote epithelialisation Manage exudate Provide comfortable dressing Low adherent dressing Polyurethane foam or silver impregnated foam If the hypergranulation is around a foreign body e.g. PEG site, the overgranulation may continue until the foreign body is removed Constant movement of suprapubic catheters, gastroscopy tubes etc should be avoided as it may create friction and prolong inflammation Note: also known as overgranulation Stop any interactive dressings that may be promoting further granulation Ensure possibility of malignancy has been excluded Following wound assessment consider the use of antimicrobial to treat possible critical colonisation of bacteria or infection Linked Information Hypergranulating wound guideline

39 IV Therapy Site IV Therapy Site Type/Description Management Aim Dressings Other Consideration Central line Secure long term placement Maintain a dry site Avoid complications including local/systemic infection Highly permeable IV vapour permeable film The dressing should be transparent (for visibility of site) Waterproof and bacteria proof Have a high water vapour permeability NB: remove from the lower end of the dressing upwards using pull and stretch method Peripheral sites Maintain a dry site Secure cannula Avoid complications including local/systemic infection Highly permeable IV vapour permeable film Linked information: Intravenous Access Care and Maintenance guideline

40 L Definition: A loss of skin on the leg or the foot, which takes longer than 6 weeks to heal (Dale et al 1983). Before commencing a management plan it is essential that a holistic assessment is undertaken, this also includes a Doppler Assessment, a simple non-invasive procedure to exclude arterial disease. The Doppler assessment measurement of Ankle Brachial Pressure Index (ABPI) should not be taken in isolation and must always be used in conjunction with a holistic assessment. Without an accurate diagnosis it is impossible to formulate an effective care plan. Patients should be assessed by a health care professional with training in leg ulcer management (RCN guidelines 1998). The main causes of ulceration are: Underlying venous disease - a venous ulcer (70%) Underlying arterial disease - an arterial ulcer (10%) Underlying arterial disease and venous hypertension a mixed aetiology ulcer (10-15%) The remaining 5-10% of leg ulcers can be attributed to other disorders such as: Rheumatoid arthritis / connective tissue disorders (vasculitic ulcers) Diabetes and other endocrine disorders Malignancy Blood disorders NB: The patient should expect a full leg assessment, effective treatment and an appropriate referral. A timely assessment is essential as a delay may affect positive outcomes. Linked information: Leg ulcer guideline Leg Ulcer

41 Most venous leg ulcers occur because the valves connecting the superficial and deep veins are not functioning properly. Damage to valves within the veins results in reflux in venous blood and consequently high pressure to smaller vessels leads to oedema. Leakage of blood cells and fibrin into the tissues causing discolouration and hardening to tissue (lipodermatosclerosis) and therefore the skin is at risk of ulceration. Undertake a full leg assessment to include: Medical History Family history of venous disease History of deep vein thrombosis Varicose veins in the affected leg Previous varicose vein surgery History of abdominal surgery Surgery, fracture or trauma to the affected leg Pregnancy Obesity Clinical signs and symptoms Varicose veins Ankle flare / varicosities Skin staining / pigmentation Atrophe Blanche Lipodermatosclerosis Varicose eczema Leg oedema Doppler assessment / Clinical investigations / Ulcer history ABPI: Ankle Brachial Pressure Index - refer to leg ulcer management plan ABPI between 0.8 and 1.3 indicates safe to apply compression providing that no contraindications have been identified. ABPI greater than 1.3 if no history or clinical signs of arterial disease this may be suitable for compression. If any doubts refer to Vascular Surgeon or the Skin Care Service for additional assessment. From the history and positive clinical signs and symptoms a high reading could indicate arterial calcification - treat as arterial pathway. Venous Ulcer

42 Definition: A loss of skin on the leg or the foot due to vascular disease. Arterial leg ulcers are caused by poor blood circulation as result of narrowed arteries or damage to the small blood vessels. Disease often results from arteriosclerosis of vessel walls and atherosclerotic plaque accumulation causing vessel occlusion. Undertake a full leg assessment to include: Medical History Family history of arterial disease Previous myocardial infarction Known coronary heart disease or congestive cardiac failure Previous cerebro-vascular accident (CVA) or Transient Ischaemic Attack (TIA) Diabetes mellitus Known peripheral arterial disease, intermittent claudication/ ischaemic rest pain Smoking Clinical signs and symptoms Pain particularly when resting or on leg elevation Poor capillary refill (longer than 3 seconds) Pale shiny hairless legs Cold legs / feet in a warm environment Dependent redness Dystrophic nails Doppler assessment / Clinical investigations / Ulcer history ABPI; Ankle Brachial Pressure Index refer to leg ulcer management plan ABPI between 0.5 and 0.8 indicates not safe to apply full compression ABPI less than 0.5 significant arterial disease - no compression ABPI greater than 1.3 if history, clinical signs and symptoms indicate arterial insufficiency, a high reading could indicate arterial calcification - treat as arterial pathway. The patient with an arterial ulcer may be suitable for surgery and therefore needs to be referred to a vascular surgeon for further assessment. Arterial Ulcer

43 Leg Ulcer Management Leg Ulcer Management Only follow if full leg assessment and Doppler have been done to establish the aetiology Leg Ulcer Type Indicator/Descriptor Management Aims Treatment Options Other Considerations VENOUS MIXED AETIOLOGY ARTERIAL Usually gaiter area Shallow sloping edges, usually with higher levels of exudate ABPI greater than 0.8 Aid venous return by increasing velocity flow in deep veins Reduce oedema Reduce pressure in the superficial venous system Never attempt compression bandaging unless aetiology assured and competent in application Mixture of both venous and arterial and therefore signs from both aetiologies Doppler assessment; ABPI between 0.6 and 0.8 Any part of the leg or foot Usually small punched out defined edge ABPI less than 0.6 Increase venous return Reduce oedema Reduce pain Prevent infection Reduce pain Prevent infection Vascular investigation Prevent maceration Full compression therapy, 40mmHg pressure; refer to formulary for choice of systems Dressing selection; e.g. low adherent or foam Usually requiring redressing weekly Apply reduced compression therapy at 15-25mmHg Dressing selection; keep it simple e.g. low adherent or foam No compression Wound management as indicated within formulary Management of pain Refer to vascular surgeon It is important to note that the ulcer is a symptom of the underlying condition. In order for successful healing to occur it is necessary to treat the underlying cause (i.e. venous or arterial problems) Pain control is an important factor in obtaining patient concordance. Careful consideration should be given to managing pain and an appropriate prescription of analgesia. The aim should be to maximise patient comfort and adherence to treatment Good nutritional status is essential for wound healing to take place Patient education For appropriate dressing selection according to assessment of the wound and surrounding skin characteristics refer to Classification of Wounds Keep it simple; patients with history of leg ulceration have high incidence of sensitivities For venous ulceration; when the ulcer has healed wearing compression hosiery reduces recurrence rates Refer to Classification Of Bandages for optimum compression levels and choice of therapy Linked information: Leg ulcer guideline

44 L Definition: Lymphoedema is a swelling that develops as a result of an impaired lymphatic system. This may be as a result of the lymphatic system not developing properly or through damage or trauma. It can affect any part of the body but is most commonly seen in an arm or a leg. Clinical Signs and Symptoms Oedema Swelling that does not go down after elevation of the affected limb Non pitting oedema Heaviness Reduced function of the affected limb Skin Changes The thickness of the skin increases Build up horny scale on the surface (hyperkeratosis) Skin creases deepen Treatment There is no cure for lymphoedema but can be managed effectively by conservative therapy. The aims of Skin Care are: to keep the skin and tissues in good condition to reduce the risk of infection Daily care of the affected limb should include: Wash skin daily and dry thoroughly paying particular attention to skin folds Moisturise; aqueous cream or white soft paraffin / liquid paraffin 50/50 For hyperkeratotic tissue moisturise OR apply a hydrocolloid and leave in position for a few days as it softens the hyperkeratosis and enables the scales to lift off without damage to underlying skin Compression Therapy: to help prevent the swelling from building up in the limb. For a lower limb follow a leg ulcer pathway and initiate compression if appropriate. Lymphoedema

45 i i ti B Bandages are classified into 6 categories - they are measured against the bandage performance to determine the category. The performance is measured by: Tension The tension of a bandage is determined by the amount of force applied to the bandage during application and the ability of the bandage to sustain the tension. This is determined by its elastomeric qualities Extensibility - the ability to stretch the bandage Elasticity - of a bandage to return to its original length as the tension is reduced The categories are: Classification Type of Bandages Level of Compression Examples Type 1 Retention, lightweight elastic bandage No compression Slinky K-Band Easifix Acti-Wrap Type 2 Type 3a Type 3b Support bandages Inelastic short stretch Light compression bandages Light compression bandages No compression for crepe Some bandages used as compression therapy Crepe K-Lite Profore 2 Comprilan Actiban Actico Rosidal K Up to 20mmHg Profore 3 Litepress K-Plus Elset 21-30mmHg Profore 4 Coban Ko-Flex Type 3c Moderate compression bandages 31-40mmHg Setopress Tensopress Surepress Type 3d High compression bandages 41-60mmHg Blue line webbing (not available on FP10) Classification Of Bandages

46 i t NB: some systems contain latex - always read the manufacturers instructions. Whenever possible always choose a latex-free system System Components Pressure British Standard (mmhg) Considerations Full compression Four layer system For ankle measurement of 18cm - 25cm Wound contact layer Orthopaedic wool layer Light support crepe Light compression class 3a applied in a figure of 8 Light /moderate compression Class 3b Applied spiral No compression 17-20mmHg 20-23mmHg Use the wool and extra if necessary to shape the limb, pay particular attention to bony prominences Bandage too loose can cause slippage Bandage too tight can cause pressure necrosis Both can delay healing Apply all bandages at 50% stretch Full compression Remeasure limb after for ankle As above but add an application of wool measurement extra wool layer Particular attention to below 18cm tibial crest Wound contact layer Orthopaedic wool layer For ankle measurement 25-30cm For ankle measurement above 30cm Light support crepe Moderate compression class 3c applied in a spiral Light /moderate compression Class 3b Applied spiral Wound contact layer Orthopaedic wool layer Light compression class 3a applied in a figure of 8 Moderate compression class 3c applied in a spiral Light /moderate compression Class 3b Applied spiral This combination gives approximate pressure levels of 40mmHg This combination with greater ankle circumference gives full compression at approximately 40mmHg An increase in the ankle circumference reduces the sub bandage pressure therefore the level of compression should be increased Compression Therapy

47 i t System Components Pessure British Standard (mmhg) Considerations Long stretch bandage Orthopaedic wool No compression Long stretch exerts high compression during rest and exercise Class 3c compression bandage applied at 50% extension and 50% overlap in a spiral Gives 30-40mmHg pressure Full Wool contact layer No compression Patient choice compression Alternative to four layer Proguide bandage vari-stretch systems. Sustained pressure applied 50% stretch 50% 40mmHg two layer system for 1 week overlap in a spiral Compression Hosiery Ulcer Kit Liner Hosiery 10mmHg 30mmHg Patient choice alternative to four layer systems. Self caring - useful when applying treatments e.g. regular steroid application Reduced compression Pressure less than 25mmHg Wound contact layer Orthopaedic wool layer Light support crepe Light compression class 3a applied in a figure of 8 No compression 17-20mmHg Criteria for application of reduced compression Mixed aetiology ABPI when there is evidence of clinical signs of venous hypertension N.B. the rationale for OR Light compression class 3b applied spiral 50% stretch 50% overlap 20-23mmHg compression therapy is to optimise venous return and reverse hypertension within the veins Reduced compression Pressure less than 25mmHg Compression hosiery systems Class1 Class mmHg 15-24mmHg Alternative choice N.B. if ulcer does not show signs of healing consider reverting to bandaging system which will increase pressure level Short stretch Orthopaedic wool layer No compression Indication for venous hypertension and reduction 18-25cm Short stretch bandage of oedema and Applied full stretch 50% Applied at full lymphoedema. overlap stretch this will Initially the patient will give pressures of require more frequent Apply second bandage in 35-40mmHg rebandaging as bandage will Above 25cm the opposite direction be prone to slippage Compression Therapy

48 i i Compression hosiery should be considered when a leg ulcer has healed or as a preventative measure when a patient presents with clinical signs of venous hypertension, varicose eczema or for lymphoedema management. Prior to prescription, a complete leg assessment should be undertaken to assess the appropriateness. Classification Compression Levels Indication for use Class mmHg Mild varicosities, leg oedema Prevention of ulceration Class mmhg Varicose veins leg oedema Prevention of ulceration Class mmHg History of ulceration and many clinical signs of venous hypertension NB: high levels of compression may not be tolerated and may also reduce in concordance because of difficulty in application. Consider: Reducing the level of hosiery classification The use of aids to apply hosiery Measurement For all stockings Measure the ankle at the narrowest point Measure the calf at the widest point Measure the length of the leg below the knee (on a longer limb this may restrict choice) For closed toe Measure the foot length N.B.: if length of foot does not correspond with the girth measurement of the leg consider open toe For thigh length hosiery Measure the width of the thigh at widest point Measure the length of the leg When the patient does not fit the standard sizes measure and request madeto-measure hosiery Linked information: Leg ulcer guideline Compression Hosiery

49 Malodorous Wound Malodorous Wound Wound Type Description Aims Dressings Other Considerations Wound which has an offensive change in odour may indicate infection or colonisation of bacteria May be fungating carcinoma Reduce bacterial burden Treat infection Debride devitalised tissue Promote dignity and patient comfort Charcoal dressings only contain the odour Choice of product depends on characteristics of wound If infection is present use an antimicrobial The odour from wounds is most commonly caused by the presence of infection and devitalised tissue, therefore it is important to treat cause Reduce/contain odour Review frequency of dressing change Swab and identify organism and treat with antibiotics where appropriate Consider: Patient support Surgical/Sharp debridement Autolytic debridement Larval therapy Linked information: Wound assessment guideline Fungating wound guideline Debridement guideline

50 PEG Site Care PEG Site Care Description Aims Skin Care Other Considerations Percutaneous Endoscopic Gastrostomy Tube (PEG), which enters directly into the stomach. 2 types: those that can be removed by traction without endoscopy (CORFLO - Merck) those that can be removed only by endoscopy (FREKA - Fresenius) Maintain skin integrity around PEG site and minimise risk of infection For the first two weeks following placement: The gastrostomy site should not be touched for the first 8-12 hours after placement. After 24 hours clean around the Gastrostomy site twice daily using sterile gauze and 0.9% sodium chloride (or cooled boiled water), paying attention to meticulous hygiene. Dry site thoroughly after cleaning. Do not release fixator for the first week. Two Weeks following insertion: A clean technique using tap water may be used to cleanse PEG site. Slide fixator away from stoma and clean stoma site with tap water and a disposable cloth / clean towel ensuring the skin is dry. Ensure the tube moves freely in and out of the stoma (2-3 cm) The tube should be turned 360 degree (or as per manufacturer guidelines) once daily to help formation of stoma and make cleaning easier. This will help to prevent the bumper becoming buried. Ensure the correct point on the measuring guide on the tube is placed closest to the end of the fixation device. Remove any debris and crusting around stoma site and fixator. The stoma site should not usually need a dressing; Cavilon may be applied to prevent excoriation of the surrounding skin. If the exudate is excessive apply a foam dressing. Gently pull the tube towards until you feel resistance before putting the fixator back into place (there should be a 1cm gap between the skin surface and the fixator). Always ensure that the tube is replaced to the correct position in relation to the fixation device when cleaning is completed. Return the fixator snug to the skin. If it is applied too tight, skin necrosis may result, too loose hypergranulation may develop. Patients are advised to shower while stoma is healing (2-3 weeks) after that the patient may bathe as normal (ensuring both ends of tube are closed) the area must be thoroughly dried afterwards Observe daily for any indications of infection: pain, erythema, pus or skin breakdown. Refer to the management of infected wounds, Section 2 Linked information: Royal Liverpool and Broadgreen University Hospitals NHS Trust, PEG care guidelines Infected Wound Guideline

51 ti t A pressure ulcer is an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction and/or a combination of these (European Pressure Ulcer Advisory Panel 1998). Patients should receive an initial and ongoing risk assessment in the first episode of care. Perform holistic assessment of patient s risk factors of pressure damage including use of Waterlow tool and develop care plan accordingly. The pressure ulcer grade should be recorded using the European Pressure Ulcer Advisory Panel Classification System (see overleaf). Document the assessment of risk, noting all relevant factors including: Pressure, shear, friction Level of mobility Sensory impairment Continence Level of consciousness Acute/chronic or terminal illness Co-morbidity Systemic signs of infection Blood supply Pain Medication Posture Psychosocial status Previous pressure damage Extremes of age Nutrition and hydration status NICE (2005) Assess pressure ulcer: Cause Site/location Dimensions Stage or grade Exudate amount and type Local signs of infection Pain - including cause, level, location and management interventions Wound appearance Surrounding skin Undermining/tracking Sinus or fistula Odour NICE (2005) Pressure Ulcers

52 ti t General principles of prevention and management: Patients should receive an initial and ongoing pressure ulcer assessment This should be supported by photography and/or tracings (wound mapping) All those who are vulnerable to pressure ulcers should as a minimum be placed on a high specification foam mattress Ensure regular repositioning schedule is maintained dependant on skin inspection and health status Educate patient/carer re risk of tissue damage from friction/shear forces and importance of pressure ulcer prevention and management strategies Complete wound assessment chart reassess regularly Ensure adequate dietary intake to prevent malnutrition to the extent that this is compatible with the individual's wishes or condition Assess and manage pain related to the pressure ulcer or its treatment Assess and manage for signs of wound infection Ensure manual handling practices limit risk of friction and shearing Consider Manual Handling and Equipment Specialist Nurse referral Consider Occupational Therapy and/or Physiotherapy referral Reverse grading Pressure ulcer grading is only appropriate for defining the maximum depth of tissue involvement. Using pressure ulcer grading systems to describe healing must assume that full thickness pressure ulcers heal by replacing the same structural layers of body tissue that were lost. Clinical studies indicate that as grade 4 pressure ulcers heal to progressively more shallow depth, they do not replace lost muscle, subcutaneous fat, and dermis before they re-epithelialise. A grade 4 pressure ulcer cannot therefore become a grade 3, grade 2, and/or subsequently a grade 1 ulcer. All pressure ulcers of grade 2 and above must be recorded as a clinical incident Linked information: Pressure ulcer guideline Wound assessment guideline Pressure Ulcers

53 Pressure Ulcers Pressure Ulcers Pressure Ulcer Grade Description Other Considerations GRADE ONE GRADE TWO Definition: Non-blanching erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin (EPUAP 1998) Identification: Apply light finger pressure to area of discolouration, upon removal peripheral flush should appear. If not and area remains discoloured treat as grade one pressure ulcer. This is non-blanching erythema, suggests damage to microcirculation Definition: Partial-thickness skin loss involving epidermis and/or dermis; the pressure ulcer is superficial and presents clinically as an abrasion, blister or shallow crater (EPUAP 1998) Cover and protect with film dressing to reduce risk if caused by friction and shearing Occlude/protect and promote epithelisation (see wound classification) Patients with a grade 1 2 pressure ulcer should as a minimum provision be placed on a high specification foam mattress/cushion with pressure-reducing properties and be closely observed for skin changes

54 Pressure Ulcers Pressure Ulcers Pressure Ulcer Grade Description Additional Management GRADE THREE Definition: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia: the pressure ulcer presents clinically as a deep crater with or without undermining of adjacent tissue (EPUAP 1998) Patients with a grade 3 4 pressure ulcer should, as a minimum provision, be placed on a high specification foam mattress or an alternating pressure overlay, or a dynamic replacement mattress. (A low air loss or other specialist mattress may be required) GRADE FOUR Definition: Extensive destruction tissue necrosis, or damage to muscle, bone or supporting structure with or without full thickness skin loss (EPUAP 1998) If you can probe to bone, this is suggestive of concomitant osteomyelitis Consult GP re relevant course of action including x-ray of area if osteomyelitis is suspected and possible surgical intervention Refer to appropriate member of Multidisciplinary Team (e.g. Dietician, Equipment Specialist Nurse, Manual Handling Adviser, OT, Physiotherapist, Skin Care Service) Ensure patient is aware of extent of wound and supported appropriately Perform nutritional assessment, supplements should be given to patients with identified nutritional deficits

55 Sinus Wound Sinus Wound Wound Type Description Aims Dressings Other Considerations A narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation Free drainage of exudate Protect surrounding skin Prevent infection Remove necrotic or sloughy material Promote granulation from the base of the wound Primary Dressing Hydrofibre Alginate Secondary Dressing Occlusive low adherent or Foam If premature closure occurs the sinus may reoccur and then it may need surgical intervention All dressings put into and removed from sinus must be recorded at every dressing change and dimensions regularly reassessed Any dressing used in a sinus must be removable Caution should be taken when inserting dressing - DO NOT PACK - loosely fill Moist cotton gauze should not be used to manage surgical wounds that are healing by secondary intention An appropriate interactive occlusive dressing should be used to manage surgical wounds that are healing by secondary intention Other considerations: Nutrition Pain analgesia may be required prior to dressing change Surgical intervention Pilonidal sinuses meticulous attention to hygiene Linked information: Cavity wound guideline Surgical wound guideline

56 Skin Laceration Skin Laceration Wound Type and Description Management Aims Dressings Other Considerations Superficial Skin Laceration Skin Laceration Description: breach or split in the skin caused by blunt instrument or force (e.g. result of fall) Initial aims include: debridement of any foreign material loosely align skin edges with wound closure strips leaving gaps to allow exudate drainage, promote healing; provide optimal environment for healing General aims include: manage characteristics of wound prevent infection manage exudate acceptable cosmetic outcome Description: partial or full thickness wound involving loss of some or all affected tissue. Depending on mechanism of injury, refer to A&E e.g. crush injuries need to be observed for signs of compartment syndrome; where an impact causes bleeding within a closed anatomical space causing swelling with subsequent compromise of circulation and tissue function, which can lead to irreversible nerve damage or tissue necrosis within hours of injury. Particularly common in the compartment of lower leg and forearm. Signs include: pain, swelling, numbness, loss of peripheral pulse, contracture. Also refer to A&E if: Indications of bone involvement Indications of full thickness laceration exposing deeper lying structures Lower limb looks discoloured and capillary refill is reduced Indication of change in sensation to lower limb Treatment Choice: Low Exudate: Tissue adhesive Wound closure strips Low adherent dressing Moderate Exudate: Alginate / Hydrofibre Foam High Exudate: Foam Secure with light retention bandage, bandage toe to knee (if lower leg wound) Dressings will depend on skin fragility. Superficial lacerations to face / scalp may be inappropriate to apply dressings Pain management Note: pre-tibial lacerations often result in haematoma formation. Haematomas can cause tissue necrosis and may need assessment in Walk-In-Centre/A&E for evacuation of haematoma formation If lower limb laceration does not heal within 6 weeks perform leg ulcer assessment After care advice: Elevate legs, rest, steristrip management (keep dry, leave in situ until wound review)

57 Sutured/Stapled Wound Sutured/Stapled Wound Wound Type Description Aims Dressings Other Considerations A surgically created wound, or laceration with no skin loss whose edges can be brought together and held in place with sutures or staples The aims of treatment are to disturb the wound as little as possible to allow healing and prevent bacterial invasion. An aseptic non-touch technique should be used for changing or removing surgical wound dressings. Protect against trauma of clothing etc Low Exudate Vapour permeable film Vapour permeable film with central pad Moderate / High Exudate Foam dressing Post operative wound management Whilst the routine cleansing of wounds is not advocated, if required sterile saline should be used for the cleansing of sutured / stapled surgical wounds. Dependant upon the nature of the surgical wound, patients should be advised that they may shower (rather than bathe) 48 hours after surgery. The use of topical antimicrobial agents for surgical wounds that are healing by primary intention should not be used to reduce the risk of surgical site infection. Monitor for indications of infection (refer to infected wound section and algorithm) Provide optimal wound healing environment Manage serous fluid exudate from wound Surgical wounds that do not appear to be healing within the expected time frame should be treated as chronic wounds. Moist cotton gauze should not be used to manage surgical wounds that are healing by secondary intention An appropriate interactive occlusive dressing should be used to manage surgical wounds that are healing by secondary intention. Linked information: Surgical wound guideline Aseptic and clean dressing techniques for clinical practice

58 When considering the process of dressing selection a number of factors may be taken into consideration: Wound type superficial, full thickness, cavity Wound base necrotic, sloughy, granulating, epithelialising Wound characteristics exudate level, malodour, liability to bleed Bacterial profile sterile, colonised, infected Dressing Requirements Moisture Winter (1962) found that epithelial cells migrate over viable tissue and wounds heal three times faster in a moist environment Thermal insulation any drop in temperature below 37 degrees delays mitotic activity for up to four hours (Torrance 1986). Leucocytes will not function in a low temperature wound increasing the potential for clinical infection Highly absorbtive exudate can be harmful to good skin. Chronic wound exudate can delay healing (Phillips et al 1998) Bacterial impermeability - for protection of the wound against bacterial contamination. Strike through of exudate allows the passage for bacteria into, and out of, the wound Free of contaminants cotton wool, remains of dressings, necrotic tissue are foreign bodies and are foci for infection Low-adherent adherent dressings may tear dried exudate off the wound bed, causing trauma to newly forming tissues. Newly forming capillaries can grow through gauze loops and will be torn when the gauze is removed Non-toxic/harmful many antiseptics have been found to damage healthy tissue Patient factors acceptable to the patient and the need to bathe or shower for example. Taking into consideration known sensitivities, fragile tissue type or ethical considerations The health professional have evidence to support a dressing s effectiveness and be available in Primary and Secondary care to aid continuity of care (Adapted from Hampton and Collins 2004) NOTE: No single dressing is appropriate for all wound types and all stages of healing Properties Of Ideal Dressing

59 Product: Eclypse (Advancis) DESCRIPTION A highly absorbent exudate management product. MODE OF ACTION The use of a highly absorbent dressing comprises of rapidly wicking polyester and viscose spun woven face combined with a high capacity sheet of absorbent crystals and mechanically bonded cellulose pad. The blue backing is a polyester fluid repellent film designed to prevent strike through. INDICATIONS FOR USE For use on medium to heavily exuding wounds such as: Leg ulcers Pressure ulcers Sloughy or granulating wounds Dehisced wounds Fungating wounds CONTRAINDICATIONS Arterial bleeds and heavily bleeding wounds METHOD OF APPLICATION Eclypse is to be placed face down on wound surface with blue backing uppermost; for larger wounds several dressings can be placed side-by-side and secured with an appropriate tape Because of the fluid handling capacity of the dressing, it may become heavy and cause sagging when saturated. Once the crystals are swollen and full of exudate it is necessary to change Eclypse Frequency of dressing change - depends on level of exudate but Eclypse can be left in place for up to 7 days Absorbent

60 Product: Sorbion Sachet S (H & R Healthcare Ltd) DESCRIPTION Sorbion Sachet S has an inner layer with strongly water retaining polymers (Superabsorber). The outer layer is made of ultrasonically sealed polypropylene fleece. The product does not contain any drug substances. MODE OF ACTION Sorbion Sachet S is a hypoallergenic, hydration responsive wound dressing. The hydration responsive technology utilises the osmotic gradient to create an osmotic pull, allowing Sorbion Sachet S to modulate the wound bed and underlying tissues without drying out the wound. Sorbion Sachet S actively regulates the wound environment through removal of exudate, toxins and bacterial load, while also stimulating blood flow and supply of nutrients to the base of the wound, which in turn promotes wound healing. INDICATIONS FOR USE Management of mediumly or highly exuding wounds healing by secondary intent. For example diabetic foot ulcers, secreting laparotomy wounds, secreting burn areas, purulent skin fistulae, drainages, gall bladder, pancreas, coecal fistulae, ulcerating carcinoma and similar exuding wounds. May be used in conjunction with compression therapy where high exudate levels are particularly problematic. CONTRAINDICATIONS No contraindications known, however not suitable for low exuding wounds due to risk of drying and adhering to wound surface. METHOD OF APPLICATION The dressing may be used as a primary layer with no other products necessary or over a wound contact layer. The product should not be cut or folded (this reduces the absorbability of the dressing). The product should be applied to the wound and a suitable secondary dressing applied. The product may be used under compression. Frequency of dressing change: The dressing should be examined regularly and changed before it becomes saturated. It may be possible to leave the dressing in position for four days. Can be used on infected wounds with appropriate adjunct therapy. Absorbent

61 i t Product: Sorbsan (Unomedical) DESCRIPTION Sorbsan - An absorbent alginate dressing made from the calcium salt of alginic acid found in seaweed, prepared as a textile fibre. Sorbsan Plus - A layer of alginate bonded onto an absorbent viscose pad which is backed with a blue viscose /polyester layer to indicate the outer surface of the dressing, suitable for more heavily exuding wounds. Sorbsan Plus SA Sorbsan Plus covered with a microporous thin foam backing. This membrane extends to provide the dressing with a hypoallergenic acrylic adhesive border MODE OF ACTION When in contact with fluid a hydrophilic gel is formed as the calcium ions from the calcium alginate are replaced by sodium ions from the exudate thus provides a moist wound-healing environment Prevents lateral wicking negating the need to cut the dressing to the size of the wound Any fibres trapped in the wound are bio-degradable Has reported haemostatic properties as the release of calcium ions activates the platelets and assists in haemostasis INDICATIONS FOR USE Primary dressing for medium to highly exuding wounds: Leg ulcers can be used under compression therapy Pressure ulcers Diabetic ulcers Fungating lesions Donor sites CONTRAINDICATIONS Not to be used on patients with known sensitivity to Sorbsan or its components Not suitable for use on necrotic / dry wounds Alginate

62 i t Product: Sorbsan (Unomedical) METHOD OF APPLICATION Sorbsan flat sheet should be placed on the surface of the wound and requires an appropriate secondary dressing Ensure a 5mm overlap of Sorbsan around the wound edge to allow for dressing conformability Sorbsan does not need to be cut to the size of the wound The wound may be wet with a small amount of saline (0.9%) prior to application if the patient complains of a drawing sensation, however if the wound is not producing high enough exudate levels to gel the alginate, it may be appropriate to change to a different type of dressing The dressing may be removed by irrigation with sterile saline Frequency of dressing change - can be left in place for up to 7 days; determined by wound characteristics such as exudate levels Alginate

63 ti i i Both silver and iodine demonstrate many of the key attributes of the ideal antiseptic: Broad spectrum of activity (including activity against MRSA) Low potential for resistance Non-toxic to white blood cells in the early inflammatory stage and later to fibroblasts in proliferation and keratinocytes in epithelialisation Rapid acting Neither an irritant or a sensitizer Effective even in the presence of exudate, pus, slough etc. (Morison 1990) SECTION 1 Silver-based dressings: Hydrofibre: Alginate: Foam: Low Adherent containing hydrocolloid: Aquacel Ag Silvercel Biatain Ag Foam Urgotul SSD SECTION 2 Cadexomer Iodine Dressing: Iodoflex Antimicrobial

64 ti i i SECTION 1 - SILVER-BASED PRODUCTS HYDROFIBRE WITH SILVER: Aquacel Ag (ConvaTec) DESCRIPTION Aquacel Ag is a primary wound dressing made from sodium carboymethylcellulose (NaCMC) containing 1.2% ionic silver. MODE OF ACTION The dressing absorbs and interacts with wound exudate causing the fibres to form a soft, hydrophilic, gas permeable gel that conforms to the wound contours, providing an optimum wound healing micro-environment and trapping bacteria Sodium ions in wound exudate bind to the dressing fibres resulting in release of silver ions into the wound bed The fibres swell as they lock bacterial exudate away from the wound by vertical wicking therefore the dressing is highly absorbent The dressing retains fluid effectively and has been shown to be effective under compression INDICATIONS FOR USE The dressing is designed for use on acute and chronic wounds in the following categories: Leg ulceration Pressure ulceration Diabetic foot ulceration (neuropathic, ischaemic and neuroischaemic) Partial-thickness burns Post-operative wounds Cavity wounds and sinuses CONTRAINDICATIONS Sensitivity to the product or any of its components. Aquacel Ag does not contain latex. Antimicrobial

65 ti i i METHOD OF APPLICATION Apply the dressing directly on to the wound leaving an adequate overlap on to the surrounding skin of at least 1cm If using Aquacel Ag Ribbon, loosely fill the cavity to approximately 80% of its capacity leaving at least 2.5cm outside the wound for easy retrieval. Do NOT pack the wound tightly as this will prevent growth of new granulation tissue Aquacel Ag has been recently recommended by the manufacturer for use on dry, sloughy/necrotic wounds to facilitate debridement (this supersedes information provided on the SMTL Dressings Datacard, updated on ). In this instance is should be cut to exact size leaving no overlap on the surrounding skin. Subsequently it should be placed on the wound, moistened with normal saline solution and an appropriate secondary dressing applied Aquacel Ag can remain in situ for up to 7 days. However, the patient s condition and the level of exudate should determine frequency of dressing changes Secondary dressing required Antimicrobial

66 ti i i ALGINATE WITH SILVER: Silvercel (Systagenix Wound Management) DESCRIPTION Silvercel is a sterile non-woven pad composed of high tensile strength G-type calcium alginate, carboxymethylcellulose (CMC) and silver coated nylon fibres. It contains 8% elemental silver in a sustained release formulation. MODE OF ACTION The alginate and CMC technologies in the dressing provide high absorbency and enhanced exudate management whilst maintaining an optimal healing environment (see section on alginates) G-type alginates increase their tensile strength and maintain their structure, therefore, do not break down in the presence of sodium ions contained in the wound exudate. This facilitates easier removal from the wound bed Silvercel contains elemental silver, which is virtually insoluble until it is exposed to wound exudate and becomes ionic silver. Silver is therefore released from Silvercel in a controlled manner as it interacts with the exudate. This allows sustained silver release over a prolonged period of time, thus enhancing antimicrobial activity Slower release of silver also reduces the risk of toxicity and sensitivity reactions INDICATIONS FOR USE Silvercel is a primary dressing that provides an effective barrier to bacterial penetration. It may assist in the reduction of infection when used on medium to heavily exuding partial and full thickness wounds such as: Pressure ulcers Venous ulcers Diabetic ulcers Donor sites Traumatic wounds Surgical wounds Precautions The dressing may adhere if used on very lightly exuding wounds. If it cannot be easily removed then it should be moistened with normal saline Dressing performance may be impaired with excessive use of petroleumbased products Antimicrobial

67 ti i i CONTRAINDICATIONS Silvercel is not indicated for use in the following situations: Third degree burns Patients with a known sensitivity to alginates or silver The control of heavy bleeding METHOD OF APPLICATION Silvercel can be applied either side down onto the wound bed, ensuring that there is no overlap onto the surrounding skin If the dressing appears dry on removal then it can be moistened with an appropriate wound cleansing fluid (saline/tap water) to aid removal If the Silvercel is consistently too dry on removal it is likely that the wound is only exuding lightly therefore an alternative product should be considered Silvercel is available as a rope to be used when dressing cavity wounds. It is important that the wound is only filled to approximately 80% of its capacity to allow for swelling of the dressing and the formation of new granulation tissue Biodegradable It provides sustained release of silver up to 7 days, however, the patient s condition and the level of exudate should determine frequency of dressing changes Secondary dressing required Antimicrobial

68 ti i i FOAM WITH SILVER: Biatain Ag (Coloplast) DESCRIPTION Biatain Ag Foam dressing consists of soft, absorbent polyurethane foam bonded to a semipermeable film that regulates moisture vapour loss, prevents strike through and provides a barrier to bacteria. The silver component is dispersed throughout the foam. Biatain Ag Foam is available with or without an adhesive border. The adhesive border is hydrocolloid based. MODE OF ACTION In the presence of wound exudate, ionic silver is released into the wound to exert an antibacterial effect within the wound bed, therefore reducing the risk of wound infection. Biatain Ag Foam provides enhanced exudate management whilst maintaining a moist wound environment to facilitate healing. INDICATIONS FOR USE Indicated for the management of medium to highly exuding wounds that are potentially critically colonised or clinically infected including: Venous leg ulcers Pressure ulcers Superficial burns Partial thickness burns Donor sites Post-operative wounds Skin abrasions Diabetic foot ulcers CONTRAINDICATIONS Biatain Ag Foam is not recommended for use with hypochlorite solutions or hydrogen peroxide (these products are no longer recommended for use in wound care) It is not recommended for use on exposed muscle or bone It should not be used on patients with a known sensitivity to silver or any other ingredient of the dressing Antimicrobial

69 ti i i METHOD OF APPLICATION The correct size dressing should be applied that allows for a 1-2cm overlap onto the surrounding skin The dressing should be applied with the plain side in contact with the wound Biatain Ag Foam can be used under compression therapy Biatain Ag Foam offers sustained release of silver for up to 7 days. Frequency of redressing should be determined by the patient and wound characteristics and the level of exudate Biatain Ag Foam Adhesive does not require a secondary dressing Antimicrobial

70 ti i i LOW ADHERENT DRESSING WITH HYDROCOLLOID AND SILVER: Urgotul SSD (Urgo Ltd) DESCRIPTION Urgotul SSD is a non-occlusive antibacterial lipido-colloid dressing containing a mixture of carboxymethylcellulose (CMC)-sodium dispersed in a lipophilic network of petroleum jelly combined with silver sulphadiazine (SSD) 3.75%. It presents as a hydrocolloid-coated textile net made of 100% polyester, with continuous and non-deformable yarns. MODE OF ACTION On contact with the wound, Urgotul SSD forms a moist lipido-colloid gel, optimising the wound healing environment The non-deformable mesh ensures that the mesh remains open in all situations to allow free drainage of exudate onto the secondary dressing, therefore reducing maceration. In addition, this prevents the new granulation tissue growing into the dressing SSD dissociates slowly and continuously following interaction with the wound exudate, thus acting as a reservoir of silver in the wound bed and prolonging antibacterial activity SSD prevents the replication of bacteria and also kills bacteria INDICATIONS FOR USE Urgotul SSD is indicated for use in the following situations where wounds are infected, critically colonised or at increased risk of infection: Acute wounds Superficial, intermediate or deep second degree burns at increased risk of infection Abrasions Traumatic wounds Chronic granulating/epithelialising wounds Pressure ulcers Leg ulcers Wound dehiscence Wounds where pain on dressing removal and adherence are problematic Antimicrobial

71 ti i i CONTRAINDICATIONS It is contraindicated in the absence of specific clinical information for use on patients with renal or hepatic insufficiency, pregnant women and neonates It is not recommended that Urgotul SSD be used in conjunction with any other topical products METHOD OF APPLICATION The wound should be cleansed with an appropriate wound cleansing solution as necessary Urgotul SSD should be applied directly onto the wound and shaped to any anatomical contours If the dressing is to be used on a large surface area and/or for a prolonged period of time, it should be closely monitored for any potential systemic effects of SSD The patient/wound should be reassessed regularly to ascertain the appropriateness of continued use Urgotul SSD can be left in situ for up to 7 days however, dressing frequency must be determined by other characteristics of the wound such as exudate levels It should then be covered and secured in place with an appropriate secondary dressing dependent upon the patient/wound characteristics and levels of exudate Antimicrobial

72 ti i i SECTION 2 CADEXOMER IODINE BASED PRODUCTS Iodoflex (Smith & Nephew) DESCRIPTION Iodoflex is a cadexomer iodine flat paste consisting of a macrogol ointment base with cadexomer (a chemically modified starch). The cadexomer beads contain elemental iodine at a concentration of 0.9% within their structure. MODE OF ACTION Iodoflex acts as a desloughing agent in that wound fluid, bacteria and cellular debris are readily drawn up into the cadexomer matrix It manages excess exudate by its ability to absorb up to 6 times its own weight. The risk of maceration and leakage is therefore reduced It provides a sustained broad spectrum antibacterial effect by the controlled release of iodine into the wound environment In reducing the bacterial burden within the wound bed and removing devitalised tissue, Iodoflex also manages wound malodour INDICATIONS FOR USE Iodoflex is used to treat chronic exuding wounds where clinical infection or critical colonisation is suspected or present including: Pressure ulcers Leg ulcers Diabetic foot ulcers CONTRAINDICATIONS Patients with a known or suspected iodine sensitivity Patients with Hashimoto s Thyroiditis and non-toxic nodular goitre Patients with severely impaired renal function Patients who have demonstrated alterations in thyroid metabolism with past use of Iodoflex Pregnant women or lactating mothers as iodine can cross the placental barrier and is secreted into the breast milk Iodoflex should be avoided in patients who are taking lithium due to potential interactions and should not be used at the same time as mercurial antiseptics Antimicrobial

73 ti i i METHOD OF APPLICATION The wound should be cleansed with an appropriate wound cleansing solution if necessary One of the carrier layers should be removed and the paste placed directly in contact with the wound The second carrier layer may then be removed; however, it may be left in situ if preferred The frequency of dressing changes should be determined by the nature of the wound, particularly the amount of exudate. Dressing change is indicated when the brown/orange colour of Iodoflex becomes clear as this means the iodine content has been exhausted and the paste is saturated with exudate Iodoflex is able to provide sustained release of iodine for up to 72 hours. A single application of Iodoflex should not exceed 50 grams and no more than 150 grams should be applied over the course of one week A single course of Iodoflex should not exceed three months. At this point it should be discontinued for a short period of time i.e. one week and an alternative dressing applied Iodoflex should be covered with an appropriate secondary dressing that meets the needs of the wound Antimicrobial

74 i ti Product: Sumar (Lantor) DESCRIPTION Sumar is a low adherent absorbent dressing that has the capacity to draw interstitial fluid away from the wound, resulting in an effective rapid capillary action. Available as: Sumar Max Sumar Lite MODE OF ACTION The one-way capillary action removes exudate, slough and necrotic debris away from the wound bed. It is comprised of three layers. The outer low adherent layer transports and lifts the exudate from the wound bed. The fluid is distributed within a central layer wicking laterally until saturated. The third layer remains dry until saturation occurs within the second layer. Can be layered to increase absorbance capacity. INDICATIONS FOR USE Effective in the management of acute and chronic wounds with low, medium and high levels of wound exudate. Diabetic wounds, pressure ulcers, leg ulcers, dehisced surgical wounds, burns, stagnant and cavity wounds. Effective for debridement of slough and necrotic tissue (if used in conjunction with a vapour permeable film). CONTRAINDICATIONS Not to be used on patients with arterial bleeds, dynamic vascular fungating wounds, heavily bleeding wound. Use with caution where bone and/or tendon is exposed and a non-adherent contact layer METHOD OF APPLICATION The dressing can be placed either side down. Place dressing either in direct contact with the wound or above a wound contact layer cutting to shape and cover with secondary dressing (e.g. film dressing, foam dressing). Ensure maximum wound bed contact for flat wounds. Dressing can be used to pack/drain wounds such as cavities or sinuses if required. The dressing can be layered for heavily exuding wounds. Capillary Action

75 i t Emollient Efficacy level Product Indications for use Contraindications The cosmetic acceptability of emollients must be considered on an individual basis to ensure concordance with treatment. Rational for use of other moisturisers can be due to patient choice. Bath emollient Very little effect used in isolation Hydromol bath emollient Can be applied directly onto wet skin or diluted in water. Product should not be used were patients are know to have sensitivities or allergies to excipients or preservatives. Excipients, non listed Cream Less effective as moisturiser than ointment Epaderm Can also be used as a soap as dissolves in water and is more cosmetically acceptable than ointment. Product should not be used were patients are know to have sensitivities or allergies to excipients or preservatives. Excipients include chlorocresol Ointment Most effective as moisturiser Hydromol ointment Can also be used as a soap as dissolves in water and effective as moisturiser. It is gold standard practice to use ointment as moisturiser under compression bandaging Product should not be used were patients are know to have sensitivities or allergies to excipients or preservatives. Excipients include cetostearyl alcohol Emollients

76 Product: Biatain (Coloplast) DESCRIPTION An absorbent hydrophilic polyurethane foam. Available in a non-adhesive and an adhesive form, which has a border of a hydrocolloid adhesive making it less likely to cause any sensitivity. Biatian Soft-Hold has an open pattern of thin skin friendly adherent loops applied to 50% of the wound dressing surface, which allows exudate to drain through into the foam structure, to aid ease of application and keep in place on awkward body contours and on patient movement (will require a secondary retention dressing / bandage). Biatain Soft-Hold is not suitable for use under compression as it doesn t have bevelled edges and may cause indentation. MODE OF ACTION When applied to an exuding wound, the polyurethane foam pad absorbs and retains excessive exudate vertically across its structure, whilst the film backing permits evaporation of moisture vapour, but provides a barrier to wound exudate and microrganisms, maintaining a warm moist environment at the wound bed. INDICATIONS FOR USE Suitable for medium to heavily exuding wounds such as: Leg ulcers Pressure ulcers Superficial and partial thickness burns Donor sites Postoperative wounds Skin abrasions Can be used on infected wounds, but dressings should be renewed more frequently May be applied under compression bandages CONTRAINDICATIONS Known sensitivity to any of the components of Biatain Foams are not recommended on dry superficial wounds or those covered with dry necrotic eschar Foam

77 METHOD OF APPLICATION Ensure the correct side of the foam dressing is applied to the wound i.e. on the non-adhesive Biatain, the manufacturers name should be uppermost Foams with adhesive borders should be avoided on those patients with fragile skin. A dressing should be selected that provides 1-2cm overlap around the wound margin Biatain adhesive is waterproof therefore the patient may bathe or shower with it in place Foam dressings should not be secured with a film dressing as this affects the water vapour loss and the dressings effectiveness; secondary dressing is required for non adhesive Biatain Frequency of dressing change is dependant upon the level of exudate but can be left in place for up to 7 days. It is recommended that the dressing be changed when the exudate approaches 2cm from the margin Foam

78 Product: Allevyn Gentle Bordered (Smith & Nephew) DESCRIPTION Polyurethane foam dressing with silicone adhesive wound contact layer. MODE OF ACTION Hydrocellular foam pad is sandwiched between contact layer and highly permeable waterproof outer layer to absorb and retain exudate to provide optimal moist wound environment. INDICATIONS FOR USE For use only where there is an identified fragile tissue type. For use on shallow granulating wounds healing by secondary intent. CONTRAINDICATIONS Known sensitivity to any of the components of Allevyn Allevyn Gentle Bordered should not be used in conjunction with other medicated preparations. METHOD OF APPLICATION Dressing should be selected that provides 2-3 cm overlap around the wound margin May be left in position for up to 7 days, but more frequent changes will be required on infected or heavily exuding wounds Foam

79 Product: Allevyn Compression (Smith & Nephew) DESCRIPTION Hydrophilic polyurethane conformable foam that is 4mm thick bonded onto a semi-permeable polyurethane film. Suitable for under compression bandaging. MODE OF ACTION When applied to an exuding wound, the polyurethane foam pad absorbs and retains excessive exudate vertically across its structure even when subjected to pressure Waterproof and bacteria proof Absorbs and retains fluid even under compression Permeable to oxygen and water vapour INDICATIONS FOR USE Suitable for moderate to heavily exuding wounds such as leg ulcers under compression bandaging system Can be used on infected wounds, but dressings should be renewed more frequently It is lightly coated with an adhesive, which is de-activated on contact with moisture CONTRAINDICATIONS Known sensitivity to any of the components of Allevyn Foams are not recommended on dry superficial wounds or those covered with dry necrotic eschar METHOD OF APPLICATION Foams with adhesive should be avoided on those patients with fragile skin. A dressing should be selected that provides 2-3cm overlap around the wound margin May be left in position for up to 7 days, but more frequent changes will be required on infected or heavily exuding wounds Foam

80 Product: Activon Range (Advancis Medical) DESCRIPTION Available as: Activon Tulle low adherent knitted primary dressing impregnated with manuka honey Activon Tube Manuka honey in a gel like consistency Algivon - An absorbent, sterile, non-adherent calcium alginate dressing impregnated with Activon manuka honey. The exudate, honey and alginate form a honey gel complex which has been demonstrated to prolong the retention of honey at a wound site. MODE OF ACTION Honey is reputed to benefit wounds; however, only medical grade honey with potency above an equivalent of 10% (w/v) phenol is licensed for use in wound care i.e. it has a CE mark. The antimicrobial properties of honey are based upon its chemical composition i.e. it has a high sugar, low water, slightly acidic content that inhibits microbial growth. It has an osmotic action when applied topically to a wound that creates a moist wound healing environment facilitating autolytic debridement. Additionally hydrogen peroxide, a broad spectrum antiseptic, is produced during the process. There is some evidence that it may reduce wound malodour and have a role in enhancing cellular activity involved in the production of new tissue. INDICATIONS FOR USE Dry, sloughy or necrotic wounds including: Leg ulcers Pressure ulcers Burns Graft sites Malodorous wounds CONTRAINDICATIONS Allergy to honey/bee venom Although there has been no reported incidence of increased blood glucose levels due to the use of honey in wounds, it is advisable to monitor the blood glucose levels of patients with diabetes Patients may find an initial stinging or drawing effect which is thought to be due to the osmotic process Honey

81 METHOD OF APPLICATION Activon and Algivon should be cut to wound size and can be placed either side down on the wound bed. When the area that covers the wound appears white/opaque then the dressing needs to be replaced Can be left in place for up to 7 days, the frequency of dressing change will depend upon the amount of exudate. Secondary dressing required. Activon tube may be applied directly to a wound or used with other Activon dressings. To apply, twist off the cap and squeeze tube, ensuring coverage of the wound area, replace cap and dispose of tube. To increase the loading of other Activon dressings apply to the dressing before applying the dressing to wound. Cover with a secondary dressing of choice. Honey

82 i Product: Tegaderm Hydrocolloid (3M Health Care Ltd) DESCRIPTION Occlusive hydrocolloid dressing. MODE OF ACTION Tegaderm hydrocolloid consists of a polyurethane film, coated with a layer of an acrylic adhesive. The film, which is impermeable to exudate and microorganisms, extends past the border of a hydrocolloid mass in which are dispersed hydrophilic polysaccharide particles. When they come into contact with fluid they swell to form a gel, which provides a moist warm environment to promote autolysis. INDICATIONS FOR USE Use on low to medium exuding wounds If applied to wounds containing dry slough or necrosis, the dressing prevents the loss of water vapour from the surface of the skin, and this effectively rehydrates the dead tissue, which is then removed by autolysis Tegaderm hydrocolloid is intended for use with partial and full thickness wounds, including pressure ulcers, leg ulcers and superficial burns CONTRAINDICATIONS Not recommended for clinically infected wounds Not for use on heavily exuding wounds as too frequent dressing changes may result in skin irritation/stripping Patients with known sensitivity to Tegaderm hydrocolloid components Wounds with depth greater than 1.5cm or undermining greater than 1cm - 1.5cm. The dressing is also not indicated for the management of full thickness burns or wounds with muscle, bone or tendon exposed or with eschar covering more than 50% of the wound METHOD OF APPLICATION Prior to application the skin around the wound should be thoroughly dried and a dressing size should be chosen that provides a margin of 2.5cm around the wound to ensure an adequate seal Patient can shower with dressing in place The backing card should be removed prior to wound application and then the delivery film removed by lifting and pulling the white centre tabs towards both ends Can be left in place for up to 7 days, but should be changed before the exudate reaches the edge of the dressing to avoid leakage Hydrocolloid

83 i Product: Granuflex (ConvaTec) DESCRIPTION Granuflex Occlusive - suitable for low to medium exuding wounds Duoderm Extra Thin - part of the Granuflex range, thin hydrocolloid suitable for low exuding wounds MODE OF ACTION Granuflex consists of a thin polyurethane foam sheet bonded onto a semipermeable polyurethane film, which is impermeable to exudate and microorganisms The surface of the dressing to be placed in contact with the wound is coated with a cross-linked adhesive mass containing a dispersion of gelatin, pectin and carboxy-methylcellulose together with other polymers and adhesives forming a flexible wafer When the dressing comes into contact with wound exudate, the polysaccharides and other polymers absorb water and swell, forming a gel If applied to wounds containing dry slough or necrosis, the dressing prevents the loss of water vapour from the surface of the skin, and this effectively rehydrates the dead tissue, which is then removed by autolysis INDICATIONS FOR USE Suitable for leg ulcers, pressure ulcers, minor burns and donor sites Due to its flexible and conformable nature it is particularly useful in bordering wounds in the application of larval (maggot) therapy CONTRAINDICATIONS Not suitable for infected wounds Not suitable for heavily exuding wounds as too frequent dressing changes may result in skin irritation/stripping Patients with known sensitivity to Granuflex components NOTE: Granuflex is composed of an animal derived ingredient METHOD OF APPLICATION Dressing size should be chosen that provides a 1 2cm margin around the wound. The central portion of the backing paper is removed and the dressing should be applied with a rolling motion and pressed firmly in place for 1-2 minutes Patient can shower with dressing in place Can be left in place for up to 7 days, but should be changed before the exudate reaches the edge of the dressing to avoid leakage Hydrocolloid

84 i Product: Aquacel (ConvaTec) DESCRIPTION Hydrofibre dressings are made up of hydrocolloid fibres. These dressings have a hydrophilic action which allows the absorption of fluid directly and rapidly into the fibrous structure were it is retained. They are available in a ribbon and flat sheet form. MODE OF ACTION The dressing absorbs and interacts with wound exudate causing the fibres to form a soft, hydrophilic, gas permeable gel that conforms to the wound contours, providing an optimum wound healing micro-environment and trapping bacteria The fibres swell as they lock bacterial exudate away from the wound by vertical wicking therefore the dressing is highly absorbent and aims to prevent maceration of surrounding tissue The dressing retains fluid effectively and has been shown to be effective under compression Aquacel also has a protease-modulating function in its ability to manage wound exudate, removing excess proteases that are commonly found in chronic and infected wound fluid that can have a detrimental effect on wound healing INDICATIONS FOR USE The dressing is designed for use on acute and chronic wounds: Leg ulcers Pressure ulcers Diabetic foot ulcers Partial-thickness burns Post-operative wounds Cavity wounds and sinuses CONTRAINDICATIONS Any previous allergic reactions noted to hydrofibre dressings Caution - proliferation of new blood vessels can result in some bleeding and burning sensation Hydrofibre

85 i Product: Aquacel (ConvaTec) METHOD OF APPLICATION Deeper cavities or sinuses should be gently filled and not tightly packed. It is recommended that only about 80% of the cavity should be filled with the dressing to accommodate swelling Aquacel has been recently recommended by the manufacturer for use on dry, sloughy/necrotic wounds to facilitate debridement. In this instance is should be cut to exact size leaving no overlap on the surrounding skin. Subsequently it should be placed on the wound, moistened with normal saline solution and an appropriate secondary dressing applied The components of Aquacel ribbon now have additional stitch bonding to improve strength and reduce the risk of breakage and shrinkage. However the ribbon may only be cut horizontally to reduce its length and not vertically (ie its width should not be cut) to maintain its properties. Frequency of dressing changes will depend on the wound status, but the dressing can be left in place for up to 7 days Requires secondary dressing Hydrofibre

86 Product: Purilon (Coloplast) DESCRIPTION Hydrogels are used to promote wound debridement by re-hydrating the wound bed and encouraging separation of non-viable (sloughy/necrotic) tissue. MODE OF ACTION Hydrogels are three-dimensional cross-linked structures made up of hydrophilic homopolymers and co-polymers Hydrogels have a water content of over 95% which enables it to transmit water vapour and oxygen. This allows donation of water molecules to the wound surface, re-hydrating non viable tissue and maintaining a moist wound environment Has limited fluid absorption ability NOTE: Purilon does not contain propylene glycol, a preservative found in some dressings and other hydrogels, which is known to inhibit maggot development and their effectiveness. Therefore, Purilon can be used for patients prior to maggot therapy INDICATIONS FOR USE Hydrogels are primarily indicated for dry and moist necrotic wounds, as well as wounds with a mix of necrotic and granulated tissue, such as: Leg ulcers Pressure ulcers CONTRAINDICATIONS Not recommended for use on infected wounds Not to be used on highly exuding wounds METHOD OF APPLICATION Hydrogels are applied directly to the wound; requires a secondary dressing such as a vapour permeable film or hydrocolloid Frequency of dressing change - every 2-3 days depending on level of exudate Hydrogel

87 DESCRIPTION Maggots of the greenbottle fly, Lucilia sericata, have been shown to rapidly remove devitalised tissue from all wound types, irrespective of their underlying aetiology. They are effective against infections caused by a variety of micro-organisms, including the resistant bacterium methicillin resistant Staphylococcus aureus (MRSA). LarvE is the brand name for sterile larvae produced by Zoobiotic Ltd. INDICATIONS FOR USE Used in the treatment of necrotic, infected and sloughy chronic wounds Wounds in which sharp debridement may expose bone, joint or tendon A wound in which autolytic debridement has failed or is contraindicated A secondary debridement method after sharp debridement or prior to skin grafting Wounds where the demarcation between devitalised and healthy tissue is difficult to define as maggots will only eat dead tissue. Any nurse applying maggots should be competent in the procedure Consent should be obtained from the patient prior to consideration to maggot therapy and its use carefully explained as to why this method of treatment would be beneficial, supported by patient information leaflet Larval therapy must be prescribed by a registered medical practitioner as an unlicensed medical product. CONTRAINDICATIONS Caution should be taken when applying near exposed blood vessels Not to be used for wounds that contain fistulae or wounds that bleed easily such as some fungating wounds, dry necrosis. Patients on anticoagulation therapy need to be monitored closely, and treatment is therefore inappropriate in patient s home environment. INSTRUCTIONS FOR USE LarvE are available in 2 formats free range or enclosed in a net pouch. All of the necessary procedure components required are contained within the supplied packs, however additional equipment required: Sterile dressing pack Additional sterile saline 0.9% pods Perforated dressing eg Release Sterile gauze Lightweight retention dressing / bandage t Larval Therapy

88 t LarvE BioFOAM consists of maggots that are enclosed in net pouches. The dressings contain pieces of hydrophilic polyurethane foam and this encourages activity in the LarvE by providing a favourable environment. These are for wounds of a more specific size or more cosmetically acceptable to the patient. Order Code BFD 20C BFD 25C BFD 50C BFD 70C BFD 100C BFD 120C BFD 150C Dressing Size 2 x 2cm 2.5 x 4cm 5 x 5cm 7 x 7cm 10 x 10cm 7 x 12cm 2.5 x 15cm The Free Range LarvE allows the larvae to be applied directly to the wound, (concealed within a net dressing) where they can roam freely over the surface seeking out areas of slough or necrotic tissues, particularly suitable where cavities or undermining are present. The number of pots and net size is calculated using the LarvE calculator and ordering guide provided by Zoobiotic to aid clinical judgement (see below) The LarvE Calculator Larval Therapy