2012 - 2014
BARNSLEY WOUND CARE POLICY
FOR THE
PREVENTION AND MANAGEMENT
OF
PRESSURE DAMAGE &
TREATMENT & MANAGEMENT
OF
ALL WOUNDS
CONTROLLED
DOCUMENT
1
LEAD: LYNNE HEPWORTH
DATE: Sept 2012
TISSUE VIABILITY NURSE SPECIALIST
SWYPFT
REVIEW DATE: Sept 2014
INTRODUCTION - Why Have A District Policy?
PART I - Prevention of Pressure Damage
1.1
Multi-Disciplinary Approach
1.1.1
1.1.2
1.1.3
1.1.4
1.1.5
1.1.6
1.1.7
Role of the Nurse
Role of the Hospital Doctor
Role of the General Practitioner
Role of the Physiotherapist
Role of the Occupational Therapist
Role of the Pharmacist
Role to the Dietician
1.2
Education and Training
1.3
Mattress Replacement
1.4
Linen for Patient Use
1.5
Equipment
1.6
Assessment of the Patient’s Risk
1.7
Risk Assessment Tools in use in Barnsley
1.7.1 Norton Score
1.7.2 Waterlow Risk Assessment
1.7.3 Modified Andersen Score
1.8
2
Action for “At Risk” Patients
PART 2 - Management of Pressure Damage
2.1
Wound Assessment and Management
2.1.1
2.1.2
2.1.3
2.1.4
2.1.5
2.1.6
2.1.7
2.1.8
2.2
Patient Assessment
General Assessment of the Patient
Assessment and Routine Investigations
Wound Assessment
Dressing Assessment
Fluid filled blisters
Completing incident reports (Datrix)
Wound Assessment Flow Chart
Treatment Protocols and Formulary
2.2.1 Using the Formulary
2.2.2 Wound Management Formulary
Protocols 1 & 2
Protocols 3 & 4
Protocols 5 & 6
Protocols 7 & 8
Protocol 9
2.3
Factors affecting Healing
2.3.1 Systemic Infection
2.3.2 Diabetes
2.3.3 Carcinoma
2.3.4 Anaemia
2.3.5 Poor Nutritional State
2.3.6 Reduce Immunity
2.3.7 Poor Circulation
2.3.8 Wound Contaminated by Impacted Material
2.3.9 Position of the Wound
2.3.10 Local Infection of Wound
2.4
3
Medical and Surgical Measures
2.5
Transporting Patients
2.5.1
2.5.2
2.5.3
2.5.4
2.5.5
2.5.6
2.5.7
Internal Transportation of Patients
Mode of Transport
Minimising Delays
External Transportation of Patients
Patients requiring Stretcher Overlays
Action by Ambulance Crew
Handover – Continuity of Care
2.6
Medical & Surgical Measures
2.7
Transporting Patients
2.7.1
2.7.2
2.7.3
2.7.4
2.7.5
2.7.6
2.7.7
Internal transportation of patients
Mode of transport
Minimising delays
External transport of patients
Patients requiring stretcher overlays
Action by ambulance crew
Handing over continuity of care
2.8
Discharge and Transfer
2.9
Monitoring Information
2.9.1 Prevalence Monitoring Information
2.9.2 Incidence Monitoring Information
2.9.3 Prevalence and Incident Monitoring Returns
4
PART 3 - Policies For Specialist Areas
3.1
Ambulance Services
3.1.1
3.1.2
3.1.3
3.1.4
3.1.5
3.2
Accident and Emergency Department
3.2.1
3.2.2
3.2.3
3.2.4
3.2.5
3.2.6
3.2.7
3.2.8
3.2.9
5
Education and Training
Equipment
Assessment of the Patient’s Risk
Transferring Patients
General Prevention Measures
Assessment
Equipment
Trolley Patients
Incontinence
Specific Nursing Action
Transfer/Liaison with Other Departments
Wards
Transfer to Other Hospitals / Nursing Homes
Staff Training / Induction
3.3
Operating Theatres
3.4
X-ray and Departments
3.5
Patients with Spinal Injuries
PART 4 - Leg Ulcer Guidelines
4.1
Treatment for Venous Leg Ulcers
4.1.1
4.1.2
4.1.3
4.1.4
4.1.5
4.1.6
4.2
Medical History
Limb Assessment
Doppler
Pain Control
After Care
Leg Ulcer Assessment Form
Compression Therapy
4.2.1
4.2.2
4.2.3
4.2.4
4-Layer Bandage System
Reduced Compression
Bandage Types
Compression Hosiery
4.3
Leg Ulcer Referral Route
4.4
Differential Diagnosis
4.5
General Advice Leaflet
4.6
Advice for Healed Leg Ulcers
PART 5 – Skin Tears
5.1
Definition
5.2
Risk Factors
5.3
Common Precipitating Causes
5.4
Dressings
APPENDICES
Appendix 1
30° Tilt – A Pressure Relieving Position
Appendix 2
Basic Care Guide for Patients Undergoing Long
Ambulance Journeys
Appendix 3
Pain Control Charts
Appendix 4
Guide to Equipment Selection Flow Charts
Appendix 5
Nutrition and Pressure Damage
Appendix 6
Wound Assessment Chart
6
INTRODUCTION
7
INTRODUCTION
WHY HAVE A DISTRICT POLICY?
The purpose of this manual is to set out, in one document, a policy for the prevention and
prevention of pressure damage and management of all wounds that is based on evidence
based practice and draws together the expertise and best practice from the health services
and care homes within Barnsley.
One of the first steps in the implementation of the policy was the formation of a Wound
Care Advisory Group. This continuing group consists of representation from primary and
secondary care providing health services within Barnsley and the private sector.
The Wound Care Advisory Group is responsible for ensuring that a co-ordinated and
systematic approach exists across the district to wound care and for developing,
monitoring and evaluating the policy.
Group members will act as a resource person for their Trust, speciality or sphere of work.
They are responsible for ensuring that all the information is disseminated throughout their
organisation.
It will be necessary for each unit that delivers patient care, to form a multi-disciplinary subgroup or other appropriate mechanism that will take responsibility for the following areas:

Ensuring the necessary structures are in place to implement the policy

Developing local procedures, training packages and standards, within the
framework of the District Policy

Implementation of the policy

Monitoring and evaluating local performance against the standards set

Evaluating the proposals of the advisory group for implementation within their unit

Providing, to their unit, a network of information, education, support and advice
The effective development and implementation of the Wound Care Policy is a catalyst for
change, raising standards, developing practice and optimising patient care.
Throughout this manual and the policies within them, the term unit refers to a Trust,
Care Home, Ambulance Service or other deliverer of health care services.
PART I
PREVENTION OF PRESSURE DAMAGE
1.1.
Multi-Disciplinary Approach
1.1.1
1.1.2
1.1.3
1.1.4
1.1.5
1.1.6
1.1.7
Role of the Nurse
Role of the Hospital Doctor
Role of the General Practitioner
Role of the Physiotherapist
Role of the Occupational Therapist
Role of the Pharmacist
Role of the Dietician
1.2.
Education and Training
1.3.
Mattress Replacement
1.4.
Linen for Patient Use
1.5.
Equipment
1.6.
Assessment of the Patient’s Risk
1.7.
Risk Assessment Tools in use in Barnsley
1.7.1
1.7.2
1.7.3
1.8.
Norton Score
Waterlow Risk Assessment
Modified Andersen Score
Action for “At Risk” Patients
PREVENTION OF PRESSURE DAMAGE
1.1
Multi-Disciplinary Approach
The prevention and management of pressure damage requires a multi-disciplinary
and holistic approach to patient care. Though in the past, pressure ulcers have
been seen as the domain (and responsibility when they develop) of the nursing
profession, today it is increasingly acknowledged that the many factors involved in
the development of a pressure ulcer cannot be addressed by good nursing care
alone. The contribution of all disciplines is mentioned frequently throughout this
policy.
A multi-disciplinary approach to pressure damage requires three things if it is going
to work:

Firstly, multi-disciplinary team members need to acknowledge that pressure
ulcers cannot be prevented or treated by nursing care alone; it is a shared
problem with a shared solution. This is a perception that is becoming
increasingly uncommon as demonstrated by the sections that follow later,
each written by the relevant health care professional about their role.

Secondly, nurses traditionally involved to the exclusion of all others, need to
recognise the valuable contributions to be made by their non-nursing
colleagues by bringing appropriate patients to their attention.

And thirdly, a co-ordinator is required, who can ensure continuity of care and
can monitor the effect of the prevention and/or treatment plan.
1.1.1 Role of the Nurse
The nurse has a focal role in co-ordinating the care required to prevent and/or treat
pressure damage. Aspects of this care are covered in detail throughout this Policy,
from the initial assessment of risk to discharge, and it is not intended to list them all
again here. It is, however, worthwhile to emphasise here, the importance of the
nurse’s role as co-ordinator, particularly for patients in the community – own home
or nursing/residential home – who do not have the same access to non-nursing
care, as do patients in hospital.
10
1.1.2 Role of the Hospital Doctor
The role of a doctor in prevention of pressure ulcers is mainly two fold:

Identification of all the “at risk” groups of patients, for example people with
neurological disease, e.g. CVA, cord-injury, motor neurone disease, very ill
patients, patients with symptomatic disease and with poor mobility,
incontinent patients. These should have anti-pressure protection started
immediately (high risk foam mattress and 30 degree tilt).

To identify and treat underlying medical problems vigorously that affect the
wound healing process:
-
Prescribing appropriate treatments e.g. Vitamin supplements,
Vasodilators, Recommended wound treatments (per policy document)
-
Maintain good nutritional status, fluid balance
-
Pain relief to enhance early mobility and to prevent depression
-
Consideration should be given to the catheterisation of incontinent
patients
-
Early referral for surgical opinion for deep sores which are not healing
rapidly avoiding months of slow medical treatment
-
Participate in a planned hospital discharge for those in “at risk” groups
to ensure continuity of care in the community
1.1.3 Role of the General Practitioner
As soon as a patient is identified as having pressure damage or at risk of
developing pressure damage, the patient’s general practitioner should be promptly
informed.
Where pressure damage already exists the GP will need to know:
 The size and quantity of dressings to be prescribed
 If any wound swabs have been taken and what organisms, if any, have been
grown and subsequent sensitivities
 If no wound swabs have been taken, but there are clinical signs of wound
infection, an antibiotic may still be prescribed blindly in line with existing
guidelines
 The degree of discomfort experienced by the patient to enable the GP to
prescribe appropriate analgesia
11
Where the wound does not respond to treatment and persists longer than 3 months
or is recurrent, the nurse or GP may wish to consider arranging a referral to a tissue
viability nurse or hospital consultant.
General practitioners can play a primary role in the prevention of pressure damage
by educating “at risk” patients and their carers in prevention strategies during home
visits and routine surgery consultations. This can be of particular value for those
patients or carers that, through choice, do not have day-to-day assistance from
other health care professionals.
General practitioners also, like the hospital doctor, play a key role in the
management of underlying conditions that increase the risk of pressure damage or
delay healing e.g. cerebral vascular accidents, diabetes, obesity etc.
1.1.4 Role of the Physiotherapist
The most important preventive measure offered by the physiotherapists is that of
educating carers in positioning of the patient, to avoid exposure of the tissues to
excessive concentrations of pressure. One method of achieving this is the 30° tilt.
(See appendix 1)
In addition to good positioning, it is vital when maintaining skin integrity to use safe
transfers when moving a patient; to encourage mobility – stimulating efficient
systemic function and to promote continence through exercise, education and
electrotherapy, if necessary.
1.1.5 Role of the Occupational Therapist
Occupational therapists can, by assessment, offer methods and equipment for the
prevention and management of pressure sores. Intervention is particularly valuable
for those who are wheelchair dependent, or spend a large proportion of their time
sitting.
The areas in which such people are particularly at risk are in the seating equipment,
bed and bath and during transfers.
Correct wheelchairs, cushioning and special seating can be provided by liaison with
the Disablement Services Centre.
Occupational therapists work as part of a multi-disciplinary team, and in liaison with
nursing staff, can assess for the provision of the correct mattresses and, because a
percentage of pressure sores are caused by shearing, Easi-glide sheets can make
it safer to move people in bed.
Hoists with the correct slings, or transfer boards for the more able, can be provided,
after assessment.
12
Bathrooms are a particular hazard and the provision of the correct equipment for
getting into and out of the bath, and cushioning in the bath is important.
During home assessments it is necessary to identify any risks within the home.
If people are at risk from pressure damage, advice on suitable clothing is also
necessary.
1.1.6 Role of the Pharmacist
The pharmacist’s role in a multi-disciplinary wound management team is to provide
information about the physical properties of dressings, their usage and cost.
As dressings and wound management products have become more sophisticated,
they have also become more wound specific. No single dressing is suitable for the
management of all wound types and few are ideally suited for the treatment of a
single wound during all the stages of the healing cycle.
The pharmacist can advise on the most appropriate product for use in any given
situation and can help in the development of wound management policies.
The pharmacist can also help in the assessment of new products as and when they
become available.
The aims of good care and management of a wound should include individualised
therapy for each patient and for each wound. The patient should be treated
holistically and any co-existing condition that could affect wound healing treated.
The pharmacist can give advice on medication that may affect wound healing, and
also give advice on pain relief for painful wounds.
The pharmacist can also liaise with community colleagues to ensure continuity of
treatment when patients are discharged from hospital, especially when products are
not available on FP10 prescriptions.
1.1.7 Role of the Dietician
Dieticians play a role in both the prevention and management of pressure damage.
The dietician will assess the patient’s current and previous nutritional intake and
make appropriate recommendations. This may require the prescription of nutritional
supplements.
In assessing the diet, external factors such as a physical and mental state, dentition
and social circumstances need to be taken in to account. The multi-disciplinary
team can help in determining these factors.
13
It is important that an appropriate follow-up system is available to community
patients.
The dietician can provide ongoing training to all staff in how to assess a patient’s
nutritional state using a Body Mass Index score (BMI) and the role of dietary
supplements.
1.2 Education and Training
It is the responsibility of each practitioner to ensure that their knowledge and
practice is up-to-date, reflecting the outcome of current research and known best
practice.
Each unit will ensure that there are education and training programmes, including
refresher training, available for relevant staff that cover the following, as appropriate
to their area and sphere of work:

Moving and handling and positioning (to meet the requirements of current
Health and Safety legislation)

Assessment of the patient and their risk of developing pressure damage

Prevention of pressure damage

Management of pressure damage
It is each individual’s responsibility to ensure that they use the correct techniques
and selects the appropriate equipment when moving and handling and positioning a
patient, to minimise harm to the patient, themselves and their colleagues.
The appropriate moving and handling equipmant will be readily available and staff
should know where to obtain these aids and be trained in their safe operation.
1.3 Mattress Replacement
Each unit has a continuing, effective replacement programme for mattresses,
mattress covers and trolley overlays that is co-ordinated by a designated individual.
Each unit will follow the manufacturer’s recommendations for care and maintenance
of the mattress/cover/overlay.
Manufacturers of the standard NHS contract 150mm mattress, recommend that it
have a life span of 5 years. Each unit using these mattresses will have, therefore, a
mattress replacement programme over a 5-year period. This programme then
becoming a perpetual programme every 5 years.
14
Units utilising types of mattress/cover/overlay other than standard NHS contract
150mm mattress, will have a replacement programme specific to the manufacturer’s
recommendations of life expectancy of the mattress.
Each unit will follow the manufacturer’s recommendations of care of the
mattress/cover/overlay whist in use that may include:

Date stamping of the mattress/cover/overlay on receipt and use

Turning/rotation of the mattress whist in use (following manufacturers
guidance)

Routine inspection of the mattress/overlay (including internal inspection of
the inner foam, inbetween patients)

Mattress covers not to be cleansed with phenol-based solutions

Any cracked/torn/worn mattress covers to be replaced
All new beds should be supplied with a new mattress.
Each unit will be aware of the methods for evaluating the effectiveness, comfort and
appearance of the mattress (see mattress turning program files):

Testing of mattress foam for indentation – Hand Compression Assessment

Recovery of the foam indentation after a 24 hours rest period

Contamination of the foam with body fluids, condensations – Water
Penetration Test
Units utilising other mattresses/overlays will follow the manufacturer’s
recommendations for assessment of effectiveness, comfort and appearance.
1.4 Linen for Patient Use
All linen – sheets, pillow slips, stretcher and trolley overlays, etc should be free from
creases, darns, patches and roughened areas within the area in contact with the
patient. Linen that is unsatisfactory should be returned to the laundry for relaundering or disposal where appropriate.
15
1.5 Equipment
Each unit will have a system for storing and managing the distribution of pressure
relieving equipment, ensuring equipment is used appropriately.
Pressure relieving equipment and aids should be of proven effectiveness. The
Department of Health Medical Devices Directorate evaluates pressure-relieving
equipment and produces reports available free to the NHS. Trials of new
equipment must be ratified by the Medical Devices Group.
Written criteria will be available to enable the patient’s key worker to select the most
appropriate pressure relieving aid.
The appropriateness of the pressure relieving aid will be re-assessed following
changes in the patient’s condition, level of risk or grade of existing pressure
damage. Where indicated, the pressure relieving aid will be promptly changed for
one providing a higher or lower degree of relief from pressure as appropriate.
1.6 Assessment of the Patient’s Risk
The multi-disciplinary team should undertake assessment of the patient’s risk of
developing new or further pressure damage as soon as practical. Part II, section
2.1 shows some of the factors to be considered when assessing risk. Any risk
assessment tool used, should be seen as an aid to deciding the level of risk and to
provide guidance when selecting the most appropriate pressure relieving
equipment. The tool should not be viewed as an acceptable alternative to a proper
multi-disciplinary assessment.
Each ward/home or unit will identify a risk assessment tool that is appropriate for his
or her patients.
Patients will have their risk of developing pressure damage assessed within one
hour of admission/transfer/first contact.
For patients in the community, the community nurse will assess their risk of
developing pressure damage on the first visit.
Each patient will be re-assessed for their risk of developing pressure damage
following a change in their condition.
The result of such assessments will be documented in the patient’s personal
records. The result of the most recent assessment will be communicated to other
health care professionals when responsibility for the patient’s care is transferred
from one individual/team to another.
16
1.7
Risk Assessment Tools in Barnsley
1.7.1 Norton Score
Score
Mental State
Activity
Mobility
Incontinence
4
General
Condition
Good
Alert
Ambulant
Full
Not
3
Fair
Apathetic
Poor
Confused
Slightly
limited
Very limited
Occasional
2
Walks with
help
Chair-bound
Usually/urine
1
Very bad
Stuporous
Bed-fast
Immobile
Doubly
At risk = score of 14 or less
1.7.2 Waterlow Risk Assessment
BUILD – WEIGHT FOR
HEIGHT
Average
Above average
Obese
Below average
0
1
2
3
SKIN TYPE
VISUAL RISK AREAS
Healthy
Tissue paper
Dry
Oedematous
Clammy/pyrexia
Discoloured
Broken/split
0
1
1
1
1
2
3
SEX/AGE
Male
Female
14-49
50-64
65-75
75-80
81+
1
2
1
2
3
4
5
SPECIAL RISKS
TISSUE
MALNUTRITION
Terminal Cachexic 8
Cardiac failure
5
Peripheral vascular
disease
5
Anaemia
2
Smoking
1
NEUROLOGICAL
DEFICIT
Diabetes
4
CVA
6
MS
6
Paraplegia
6
Motor/sensory 6
MAJOR
SURGERY
Orthopaedic – 5
Below waist/
spinal cord
On table
> 2 hours
MEDICATION
Steroids
Cytotoxics
High dose antiinflammatory
5
Ring scores in table, add total. Several scores per category can be used.
Score: 10+ = at risk
15+ = high risk
20+ = very high risk
17
4
1.7.3
Modified Andersen Score
Absolute (Score 2)
Relative (Score 1)
Not conscious
Limb mobility restricted
Orthopaedic trauma/surgery (major)
Incontinent
Requires fluid/rehydration
Nutritionally deficient/emaciated
Tetraplegia/paralysis
Coloured red over bony area
Hasn’t to/can’t/won’t move
70 years old or more
Total Score =
Score of 2 or more = “At Risk”
1.8
Action for “At Risk” Patients
Patients will have an individual documented plan of care of their identified risk
factors and this will be implemented within a maximum of 2 hours from admission.
The management of “at risk” patients should involve all members of the multidisciplinary team as appropriate. (See Section 1.1)
The care plan will be communicated to all other health care workers contributing to
the patient’s care.
Evaluation of care will be continuous, however, the patient’s care will be evaluated
and reviewed following any change in their condition or treatment.
The patient’s plan of care will be communicated to other health care professionals
when responsibility for the patient’s care is transferred from one individual/team to
another.
18
PART 2
MANAGEMENT OF PRESSURE DAMAGE
2.1
Wound Assessment and Management
2.1.1
2.1.2
2.1.3
2.1.4
2.1.5
2.1.6
2.1.7
2.1.8
2.2
Patient Assessment
General Assessment of the Patient
Assessment and Routine Investigations
Wound Assessment
Dressing Assessment
Fluid filled blisters
Completing Datrix Reports
Wound Assessment Flow Chart
Treatment Protocols and Formulary (Barnsley Business Unit Only)
2.2.1 Using the Formulary
2.2.2 Wound Management Formulary
Protocols 1 and 2
Protocols 3 and 4
Protocols 5 and 6
Protocols 7 and 8
Protocol 9
2.3
Pain and Wound Management
2.4
Guidelines to Selection of Equipment
2.4.1
2.4.2
2.4.3
2.4.4
2.4.5
2.4.6
2.4.7
2.4.8
DHSS Standard Issue Mattress
Vaperm, Soft Foam, Key 2 Care, Pentaflex
Cairwave Therapy very high risk mattressess
Sheepskins
Chair Cushions and Devises
User Guide – Pressure Reducing Equipment – Seating Systems
User Guide – Pressure Reducing Equipment – Lying Systems
User Guide – Pressure Reducing Equipment – Specialist Beds
2.5
Factors affecting Healing
2.5.1 Systemic Infection
2.5.2 Diabetes
2.5.3 Carcinoma
2.5.4 Anaemia
2.5.5 Poor Nutritional State
2.5.6 Reduce Immunity
2.5.7 Poor Circulation
2.5.8 Wound Contaminated by Impacted Material
2.5.9 Position of the Wound
2.5.10 Local Infection of Wound
2.6
Medical and Surgical Measures
2.7
Transporting Patients
2.7.1
2.7.2
2.7.3
2.7.4
2.7.5
2.7.6
2.7.7
Internal Transportation of Patients
Mode of Transport
Minimising Delays
External Transportation of Patients
Patients requiring Stretcher Overlays
Action by Ambulance Crew
Handover – Continuity of Care
2.8
Discharge and Transfer
2.9
Monitoring Information
2.9.1 Prevalence Monitoring Information
2.9.2 Incidence Monitoring Information
2.9.3 Prevalence and Incident Monitoring Returns
20
MANAGEMENT OF PRESSURE DAMAGE
2.1
Wound Assessment and Management
2.1.1 Patient Assessment
A holistic approach to the management of patients with pressure damage is vital
and requires input from the multi-disciplinary team. On the following pages is a list
of factors to consider when undertaking a comprehensive assessment of the patient
followed by guidance on routine investigations.
2.1.2 General Assessment of the Patient
FACTORS TO DOCUMENT
Age
IMPORTANCE
Age related changes affect the elasticity and
healing properties in the skin. Nutritional
status may be affected in relation to income.
People over the age of 70 have the highest
prevalence of mixed arterial and venous
disease.
Skin Inspection
An inspection of the skin/vulnerable areas
should be done within 1 hour of admission in
patient areas and on first contact in other
areas (Local Policy)
Specific Illness:
All of these diseases may delay healing or
Diabetes,
cardiac
failure, cause particularly severe wounds.
rheumatoid arthritis and other
collagen diseases and cancer
21
Known Allergy
The prevention
essential.
of
allergic
reactions
is
Nutritional Status
Obesity and malnourishment can delay wound
healing. Lack of protein, vitamin C and zinc
reduces collagen synthesis. Lack of iron
reduces the oxygen carrying capacity of the
blood cells.
Degree of Mobility
Pain and stiffness will reduce mobility and
exercise. This will contribute to poor blood
circulation and muscle wasting.
Sleep Patterns
Sleeping more comfortably in a chair or
having a history of hanging a leg over the side
of the bed may indicated the presence of
arterial disease.
Smoking Habits
Smoking is an important factor in the
development of peripheral vascular disease.
Daily Living Activities
Poor hygiene and/or the inability to wash can
exacerbate wounds and delay healing.
Incontinence may cause skin excoriation.
There is a need to be aware of the limitations
placed on individuals where particular
dressings or sutures are used. The mental
health status and ability to understand wound
causes and treatment need to be considered
as well as the home environment.
Medicines
Some drugs delay healing and/or affect
surrounding skin, such as prolonged treatment
with steroids, antibiotics and chemotherapy.
History of the Wound
The date of onset of the wound, previous
treatment and family history may provide
useful clues to planning effective treatment.
2.1.3 Assessment and Routine Investigations
INVESTIGATIONS
IMPORTANCE
Urinalysis
To exclude the possibility of diabetes or a
case of incontinence or urinary tract infection.
Blood Pressure
To detect hypertension that may influence
circulation and oxygen reaching the tissue.
Peripheral Pulses
Reduction or absence of these pulses may
indicate the presence of ischaemia.
Wound swabs in the presence of To identify pathogenic organisms, which
obvious pain, oedema and would delay the healing process.
cellulitis associated with infection.
Blood Tests:
Immune status. Detection of anaemia,
Erythrocyte Sedimentation Rate diabetes, vitamin deficiency, low white cell
(ESR),
rheumatoid
factor, count and electrolyte imbalance.
syphilis.
Haemaglobin
22
Other Factors:
Temperature, type of tissue
involvement, pH of wounds,
fibrosis of wound margin, foreign
bodies, haematoma, malignant
disease and mechanical stress on
tissue.
Temperature of wounds less that 37oc will
heal more slowly.
An acid environment
improved wound healing.
Fibrosing rings
around a wound margin will cause bridging.
Continued trauma to a wound will prevent
tissue repair.
2.1.4 Wound Assessment
Grading of pressure damage for documentation and monitoring will be according to
the four-point Clinitron Grading System, as shown below.
Clinitron Grading System for Pressure Damage
All pressure sores should be graded.
Do not use unclassified, ungradeable or unstageable.
If you are unsure regarding pressure sores grade 3 or 4, the pressure sore should
be graded 3.
An RCA completed with documentation to support your decision and note the
possibility that the pressure sore could deteriorate.
23
Grade 1
Non-blanching, persistent erythema
Damage to the micro-circulation
Reversible
Grade 2
Partial thickness skin loss involving epidermis
and/or dermis
Superficial and presents clinically as an
abrasion, blister or shallow crater
Grade 3
Full thickness skin loss
Damaged to sub-cutaneous tissue
Eschar or slough may be present
Look for undermining
Grade 4
Full thickness wound with extensive damage to
muscle, bone or supporting structures
High risk of sepsis
Life threatening
The site(s) of all pressure damage will be documented using the Wound
Assessment Chart (See Appendix 6). The size and shape of all areas of pressure
damage will be recorded. Where pressure damage is particularly irregular,
consideration should be given to measuring and sketching the area in the patient’s
record. Also consider taking a photograph using a measure/tape on the skin to
show size of wound (with signed consent)
All visible areas should be re-assessed at each change of the patient’s position,
areas occluded by dressings will be reassessed at each dressing change. Any
improvement or deterioration of the site(s) of pressure damage will be documented.
On Discharge/transfer the site(s), grade and size of pressure damage will be
notified to the person taking over the responsibility for the patient’s care.
Wherever possible a photocopy of the Wound Assessment Chart and RCA (Root
Cause Analysis) form if applicable, should be sent out with the discharge letter.
24
2.1.5 Dressing Assessment
The flow chart on the following page should be used as guidance to determine the
appropriate treatment protocol for the type of pressure ulcer in consultation with the
patient’s doctor.
The treatment protocols, in Part II, Section 2.2, describe the range of products most
suitable for a particular pressure ulcer/wound.
The selected product should be altered to meet the changing nature of the pressure
ulcer/wound, but it should be give a minimum of 5 to 7 days to take effect unless
there is an adverse reaction.
Dressings should be changed in accordance with the manufacturer’s instructions
and the protocol for the type of wound, and to meet the requirements of the
individual patient. The number of dressings inserted into the wound should be
documented in the care plan. When dressing a deep wound, ensure all dressings
are removable, tie together or use and alternative longer product.
On discharge/transfer to another team’s care, the dressings currently used and
when last changed should be documented in the discharge/transfer letter and 2
dressing changes should be sent home with the patient if discharged from a
hospital site.
2.1.6 Fluid Filled Blisters
Fluid filled blisters of lower legs Associated with cellulitis
Protect the blister with jelonet, if they are distended, aspirate the fluid using a
fine needle and syringe to prevent the tissue tearing, then protect with jelonet.
2.1.7 Incident Reports
If a patient develops pressure damage of grade ΙΙ or above, then a clinical incident
report (Datrix) should be made. This will highlight the plan of intervention to
prevent further pressure damage and ensure appropriate support surfaces are
provided.
If a patient is transferred to your care with existing pressure damage Grade ΙΙ or
above, then a clinical incident report (Datrix) should be made. Identifying numbers
of ulcer sites, grades etc. and where the patient has come from.
SEE FLOW CHART FOR REPORTING PRESSURE DAMAGE (Appendix 8)
25
2.1.8 Root Cause Analysis (R.C.A)
If a patient has a Grade ΙΙΙ or above pressure ulcer, then a root cause analysis form
should be completed with action plan attached (see Appendix 7). A copy of this
should be attached to the Datrix report.
When the patient is transferred or discharged from your care, send a copy of the
RCA with discharge papers. SEE FLOW CHART REPORTING PRESSURE DAMAGE (Appendix 8)
26
2.1.7.
Wound Assessment Flow Chart
Skin Intact
Superficial Wound
Wound not improving
Open Wound
Flat Moist
Infected
Clean
Necrotic
Flat Dry
No treatment
required
Implement
prevention plan
as necessary
27
Shallow
Deep
Shallow
Deep
Shallow
Deep
Protocol
Protocol
Protocol
Protocol
Protocol
Protocol
Protocol
9
2
3
4
5
6
7
8
Seek
specialist
advice
Protocol
Protocol
1
SECTION 2.2
TREATMENTS PROTOCOLS
AND FORMULARY
APPLIES TO
BARNSLEY BUSINESS UNIT
ONLY
2.2
Treatment Protocols and Formulary
The treatment protocols and formulary on this section describe the range of
products most suitable for a particular pressure ulcer/wound.
The flow chart should be used as a guide to determine the appropriate
treatment protocol.
2.2.1 Using the Formulary
Selecting Products
All dressings and treatments within the formulary have been reviewed and
approved for the treatment of wounds by the Wound Care Advisory Group. Advice
on this can be obtained from the tissue viability nurse. Where a product cannot be
obtained outside the hospital, advice should be sought from the tissue viability
nurse on an appropriate alternative that will be available on prescription.
Additions to the Formulary
No products can be added to this formulary without the approval of Wound Care
Advisory Group. Staff wishing to have a product included should contact their areas
representative to the Wound Care Advisory Group, the District Tissue Viability
Nurse or a Pharmaceutical Advisor.
2.2.2 Wound Management Formulary
-
-
29
Protocols 1 and 2
Protocols 3 and 4
Protocols 5 and 6
Protocols 7 and 8
Protocol 9
TREATMENT PROTOCOLS AND FORMULARY
Wound Management Formulary
Protocols 1 & 2
Lilac
Protocols 3 & 4
Yellow
Protocols 5 & 6
Blue
Protocols 7 & 8
Pink
Protocol 9
Green
30
WOUND MANAGEMENT FORMULARY
Non or Low Adherent Dressing
a. Suitable for dry wounds or lightly
exuding wounds
- Melolin (Smith & Nephew)
- Telfa (Tyco)
b. Knitted Viscose Primary Dressing
- N-A Ultra (Systagenix))
- N-A Dressing (Systagenix))
c. Silicone Wound Contact Dressing
d. Knitted polyester contact dressing
Impregnated with triglycerides
- Mepitel (Molnlycke)
- Silflex (Advancis
- Adaptic Touch (Systagenix)
- Utrgotul (Urgo)
e. Foam dressing with low adherence
suitable for skin tears etc.
- Atrauman (Hartmann)
- Transorbent (Aspen)
Semi-Permeable Films
Suitable for relatively shallow wounds - Clearfilm (Richardson HC)
e.g. dermabrasion or partial thickness - Hydrofilm (Hartmann)
burn or secondary dressing to e.g.
Kaltostat or Intrasite Gel
Island Dressings
Suitable for relatively shallow wounds
e.g. dermabrasion or partial thickness
burn or secondary dressing to e.g.
Kaltostat or Intrasite Gel
- Clearpore (Richardson HC)
- Opsite Post-op (Smith & Nephew)
- Cosmopore-E (Hartmann)
- Softpore (Richardson Healthcare)
Hydrogels
Suitable for desloughing and for light to
medium exuding wounds, but not if
anaerobic infection is present
- Activeheal hydrogel (Medlogic)
- Actiform Cool (Activa)
- Intrasite Conformable (Smith & Nephew)
Hydrocolloids
a. Semi Permeable
Suitable for desloughing and for light to
medium exuding wounds, but not if
anaerobic infection is present
b.
31
Fibrous
-
Comfeel Ulcer (Coloplast)
Granuflex (Convatec)
Duoderm Extra Thin (Convatec)
Comfeel Transparent (Coloplast)
Comfeel Paste (Coloplast)
- Aquacel (Convatec)
- Versiva XC (Convatec)
Alginate Dressings
a. Suitable for exuding wounds only
- Sorbsan (Aspen)
b. Alginate dressings with absorbent
backing
- Sorbsan Plus (Aspen)
Polyurethane Foam Dressings
a. Adhesive margin
Suitable for exuding wounds
- Activheal Foam (Medlogic)
- Allevyn (Smith & Nephew)
- Tegaderm foam Adhesive (3M Healthcare)
b. Non-adhesive
Suitable for exuding wounds
Flat Wound
- Activheal Foam (Medlogic)
- Allevyn (Smith & Nephew)
Wound with Cavity
- Allevyn Cavity Wound Dressing (S&N)
c. Silicone Adhesive
Suitable for fragile skin
- Allevyn Gentle border (Smith & Nephew)
- Mepilex border (Molnlycke)
Odour Absorbing Dressing
- Actisorb Silver 220 (Systagenix)
- Carboflex (Convatec)
- Sorbsan Plus Carbon (Aspen)
Paste Bandages
Suitable for treating skin conditions
associated with leg ulcers e.g. eczema,
inflammation
-
Icthopaste (Smith & Nephew)
Viscopaste (Smith & Nephew)
Coltapaste (Smith & Nephew)
Zipzoc (Smith & Nephew)
Paraffin Tulle (Non-Medicated) Dressing
Suitable for clean, superficial wounds
e.g. dermabrasion or partial thickness - Jelonet – normal loaded product (S&N)
burns, skin tears
32
Desloghers
Used to deslough wounds
Antibacterials
-
a. For infected or colonised wounds -
Activheal hydrogel (Medlogic)
Actiform Cool (Activa)
Granuflex (Convatec)
Comfeel (Coloplast)
Aquacel (Convatec)
Sorbsan (Aspen)
Acticoat Range (S&N)
Flaminal (Crawford)
Urgotul SSD (Urgo)
Silver Sulphadiazine 1% cream (S&N)
Activon (Advancis)
Actilite (Advancis)
Algivon (Advancis)
Aquacel AG (Convatec)
Sivercel Non Adherent (Systagenix)
Cutimed Sorbact (BSN)
ASkina Calgitrol Ag (B Braun)
b. For malodorous fungating wounds - Metrotop
Metronidazole gel
- Anabact
Antiseptics
a. Cleansers
b. Dressings
- 10% Povidone Iodine Solution
- Octenalin (MRSA only)
- Inadine (Systagenix)
- Cadexomer Iodine/Iodoflex/Iodosorb (Smith &
Nephew)
Wound Irrigation
- Sterile Sodium Chloride 0.9% Solution
- Tap Water
Protease Modulating
- Promogram (Systagenix)
- Promogram Prisma (Systagenix)
- Aquacel (Convatec)
Highly Absorbent
- Eclypse (Advancis)
- Kerramax (Ark)
- Drymax (Aspen)
Silicone Dressings
-
33
Mepitel (Molnlycke)
Silflex (Advancis)
Urgotul (Urgo)
Adaptic Touch (Systagenix)
Allevyn Gentle border
Mepilex border
Protocols
1&2
PROTOCOLS 1 AND 2
SUPERFICIAL WOUNDS
FLAT DRY WOUNDS
FLAT MOIST WOUNDS
Telfa (first choice)
Atrauman
Melolin
Jelonet
N-A Dressing
Silflex (first choice)
Softpore
Mepitel (second choice)
Clearpore
Comfeel Transparent
Opsite post-op
Duoderm Range
CosmoporE
Urgotul
Hydrofilm
Clear film
Adaptic touch
35
PROTOCOL 1 - FLAT DRY WOUNDS
Flat dry wounds require a simple dressing, such as a low adherent dressing.
NB: These dressings are low adherent rather than non-adherent.
Low adherent dressings are the modern alternative to traditional dressings such as
cotton wool, gauze, lint and gamgee.
NB: Secondary dressings may be needed e.g. bandages or adhesive tape.
MELOLIN
Consists of a film of polyethylene , onto which is bonded an absorbent layer,
consisting of a mixture of cotton, viscose and polyacrylonitrile fibres, backed with a
layer of an apertured non-woven cellulose fabric. The plastic film is present to
prevent the dressing adhering to the wound surface and is perforated to allow the
passage of exudate from the wound into the body of the pad.
Indications
Melolin may be used on its own to dress dry sutured wounds, superficial cuts and
abrasions, and other lightly exuding lesions. It may also be used as a primary
wound contact layer for more heavily exuding wounds, if backed by a secondary
absorbent dressing.
Contra-Indications
In common with other perforated film dressings, Melolin should be used with
caution in the treatment of leg ulcers that produce copious quantities of very
viscous exudate. Under these circumstances, the exudate may become trapped
under the dressing, leading to maceration and inflammation of the surrounding
skin.
Application
Melolin has a relatively low absorbent capacity and is, therefore, intended for use
on lightly exuding wounds. In these situations, a single dressing may be secured
in position by surgical tape. On more heavily exuding wounds, Melolin may be
used as a wound contact layer, beneath a secondary absorbent pad, held in
position with tape or bandage.
Removal
The frequency with which the dressing should be changed depends entirely upon
the nature and condition of the wound.
36
TELFA
Telfa consists of an absorbent perforated plastic film faced dressing, open at two
ends surrounding an absorbent core. The perforated plastic film is present to
prevent the dressing adhering to the wound surface and is perforated to allow the
exudate to pass through it into the absorbent pad.
Indications
Telfa may be used on its own to dress dry sutured wounds, superficial cuts and
abrasions and other lightly exuding lesions. It can be held in place with tape or
bandages.
For more heavily exuding wounds, it may be used as the wound contact dressing
with a secondary absorbent dressing.
Contra-Indications
In common with other perforated film dressings, Telfa should be used with caution
in the treatment of leg ulcers that produce copious quantities of very viscous
exudate. Under these circumstances, the exudate may become trapped under the
dressing, leading to maceration and inflammation of the surrounding skin.
Application
Telfa has a low absorbent capacity and is therefore, intended for use on lightly
exuding wounds.
Unless used as a wound contact layer with a secondary
dressing.
Removal
If the dressing is adhered to the wound, irrigate with tap water or saline to ease
the dressing from the tissue without disturbing granulation of new epithelialisation.
N-A DRESSING
N-A Dressing comprises of a warp knitted fabric manufactured from a viscose
monofilament.
Indications
Low adhesive wound contact on ulcerative or granulating wounds. Ideal to use
with Vacuum Assisted Closure treatment.
37
SOFTPORE and COSMOPORE
Softpore and Cosmopore are island dressings, with an adhesive border. This
island pad has a low adherent wound contact layer and is perforated to allow
exudate to pass in to the absorbent padding.
Indications
To be used on dry to low exuding wounds and to cover sutures lines, cuts, grazes
and small ulcers.
Contra-Indications
Not to be used on frail skin, where the adhesive can be harsh and cause tearing of
the tissues.
Application
Softpore and Mepore have a low absorbent capacity and should be used on lightly
exuding wounds.
Removal
To remove, carefully ease one corner from the skin and ease gently by supporting
the skin as you remove the adhesive border. If the absorbent pad is stuck to the
wound, irrigate with normal sterile saline, to prevent any tissue damage
PROTOCOL 2 - FLAT MOIST WOUNDS
Flat moist superficial wounds require dressings, which will promote moist wound
healing and epithelisation.
Semi-permeable film

Clearfilm

Hydrofilm
Permeable to gases and moisture vapour – impermeable to water and microorganisms – consists of a thin polyurethane layer, coated with a vinyl adhesive.
These dressings are only suitable for shallow pressure sores/wounds, producing a
small amount of exudate.
NB: Exudate may be aspirated using a syringe and needle, employing aseptic
techniques – a small patch of film dressing must be placed over the
puncture to prevent leakage or contamination occurring.
38
CLEARFILM
Clean the wound and surrounding skin with sterile sodium chloride 0.9% solution
or tap water and allow the skin to dry completely. As with all adhesive products,
the skin must be dry and free of detergent residue to assist good adhesion.
Application
-
Peel open the pack and remove the sterile dressing.
Remove and discard the centre cut-out piece, exposing the window.
Peel the paper backing from the dressing to expose the adhesive surface.
View the site through the transparent dressing window and centre the dressing
over the wound. Press in place, smooth from the centre towards the edges.
- Remove the paper ‘frame’ as you smooth down the dressing edge.
Removal
Observe the site without removing the dressing. The dressing may remain in place for as
long as it is needed for up to 7 days, provided it remains intact. Frequent removal is
unnecessary and may cause irritation.
Gently grasp the edge of the dressing and slowly pull the dressing from the skin in the
direction of hair growth, by stretching the dressing to break the adhesive.
Observe the site without removing the dressing. The dressing may remain in
place for as long as it is needed for up to 7 days, provided it remains intact.
Frequent removal is unnecessary and may cause irritation.
Gently grasp the edge of the dressing and slowly pull the dressing from the skin in the
direction of hair growth, by stretching the dressing to break the adhesive.
HYDROFILM
Clean the wound and surrounding skin with sterile sodium chloride 0.9% solution
or tap water. Dry /or allow skin to dry completely.
As with all adhesive products the skin must be free of grease/cream/detergent
residue to allow good adherence.
Application
Peel open the sterile pack. The backing papers are numbered (1,2,3 & 4).
Remove number 1, take hold of the clean edge of exposed dressing, then remove
backing paper 2. Place the adhesive side of the dressing over she wound,
smooth down to ensure adhesion.
Remove paper 3 then paper 4. Finally smooth down the dressing.
39
Peel open the sterile pack. The backing papers are numbered (1,2,3 & 4).
Remove number 1, take hold of the clean edge of exposed dressing, then remove
backing paper 2. Place the adhesive side of the dressing over she wound,
smooth down to ensure adhesion.
Remove paper 3 then paper 4. Finally smooth down the dressing.
Removal
The dressing can stay in place for up to 7 days.
To remove the dressing see instructions for removal of Tegaderm dressing
(stretching technique).
NB: Do not apply film dressings under tension. Skin shearing or blistering
may result if excessive tension is present.
OPSITE POST OP / CLEARPORE
Opsite post op and Clearpore are vapour permeable adhesive film dressings with
an island absorbent pad. The island pad is
a low adherent dressing.
Indications
To be used on dry to low exuding wounds and to cover suture lines, cuts, grazes
and small ulcers.
Contra-indications
Not to be used on patients with a known sensitivity to films.
Application
Expose the central section of the dressing by lifting the two covering sheets on the
adhesive side of the dressing, gentle press on the film border to enable adhesion to
the per-wound skin. Slowly remove each side of the backing paper smoothing down
the dressing to ensure adhesion.
Removal
To remove, place flat hand over the dressing, lift one corner of the film, gently
stretch the film laterally moving the flat hand across the dressing whilst stretch short
sections until all the dressing is loose. This method will break the adhesive, thereby
reducing pain at dressing change.
40
PARAFFIN GAUZE – JELONET
Jelonet is a paraffin gauze dressing with not less than 175g of paraffin per m2 of
cloth.
Indications
Use as a primary wound contact layer in the treatment of burns, ulcers, skin grafts
(both donor and receptor sites) and a variety of traumatic injuries. The material is
also used as a transfer medium for skin during grafting.
Contra-Indications
Although there are no absolute contra-indications to the use of paraffin gauze, if the
dressing is placed upon a heavily exuding wound, its semi-occlusive nature may
cause tissue maceration, by preventing free movement of exudate away from the
surface of the wound.
Application
Apply directly to the surface of the wound and cover with an absorbent pad, held in
place with tape or bandage, as appropriate.
Removal
The frequency of dressing change will depend entirely upon the nature of the
wound.
NB: If paraffin gauze is left in position for prolonged periods of time it can
become adherent and cause damage upon removal.
41
MEPITEL, SILFLEX & ADAPTIC TOUCH
Mepitel, Silflex AND Adaptic touch are soft silicone wound contact dressings,
which do not adhere to the moist wound surface, but gently to the dry surrounding
skin. This significantly reduces pain and trauma during dressing change.
Indications
They are indicated for painful or macerated wounds, weak or sensitive skin, leg
and foot ulcers, abrasions, skin tears, pressure ulcers, traumatic wounds, burns,
blisters, fixation of skin grafts and dermatological conditions such as epidermolysis
bullosa.
They also reduce the need for frequent primary dressing changes in moderate to
heavily exuding wounds.
As the wound can be irrigated through the
Mepitel/Silflex/Adaptic touch and the outer dressing only can be changed.
Contra-Indications
In the treatment of heavily bleeding wounds, Mepitel/Silflex/Adaptic touch should
be covered with a sterile saline moistened pad until bleeding has stopped.
When Mepitel/Silflex/Adaptic touch is used on blisters, or for the fixation of skin
grafts, the dressing should not be changed before the fifth day post application.
If the wound is infected, consult a healthcare professional for the appropriate
medical treatment.
Application
Clean the wound carefully, if needed, and dry the surrounding skin.
Choose a size of dressing that will overlap dry surrounding skin by at least 1cm.
Mepitel/Silflex/Adaptic touch can be cut to size, if needed, before removing the
protective films. If more than one piece of Mepitel/Silflex/Adaptic touch is
required, overlap the dressings by at least 1cm. If an overlap is necessary over
the wound surface, ensure that the pores of the dressing are not blocked.
While holding the larger protective film, remove the smaller one.
adherence to gloved hands, moisten gloves in sterile saline.
To avoid
Apply Mepitel/Silflex/Adaptive touch over the wound. Smooth dressing in place on
to the surrounding skin, ensuring a good seal.
Remove the remaining protective film. Where clinically indicated, treatments such
as topical steroids, topical antimicrobials or Hydrogels can be applied over the top
of, or under, Mepitel/Silflex/Adaptic touch.
42
Apply an inexpensive secondary absorbent dressing pad (e.g. Mesorb or Eclypse)
on top of Mepitel/Silflex/Adaptic touch. In contoured or jointed areas, ensure
sufficient padding is applied to keep the Mepitel/Silflex/Adaptic touch held flat
against the surface of the wound.
Fix in place with a suitable fixation device.
Mepitel/Silflex/Adaptic touch can be used under compression bandages.
Removal
Mepitel/Silflex/Adaptic touch can be left in place up to 14 days, depending on the
clinical condition of the wound.
The secondary absorbent dressing pad (e.g. Xupad/Eclypse/Kerramax/Drymax)
can be changed as required.
Exudate should pass freely through the dressing and the pores should not be
blocked.
If the pores do become blocked, gently irrigate with sterile saline, ensuring that
any excess saline is removed carefully with clean absorbent material.
Alternatively, a new dressing should be applied.
Mepitel/Silflex/Adaptic touch are single use dressings and should not be re-used.
If the condition of the wound deteriorates unexpectedly, discontinue use and
consult a healthcare professional for the appropriate medical treatment.
COMFEEL PLUS TRANSPARENT
Comfeel Plus Transparent is a thin transparent hydrocolloid dressing made of
sodium carboxymethylcellulose, artificial elastomer, tackifier and plasticiser with a
top layer made from semi-permeable polyurethane film.
Indication
Comfeel Plus Transparent is indicated for superficial, acute wounds, e.g. superficial
burns, superficial partial thickness burns, donor sites, minor traumatic wounds,
post-operative wounds, minor chronic ulcers i.e. pressure sores and leg ulcers in
the final stages of healing.
Contra-Indications
Comfeel Plus Transparent provides an optimal moist-wound healing environment
locally.
43
Wounds which are solely or mainly caused by an arterial insufficiency or
complicated diabetic wounds (primarily lower leg and foot) should be inspected by
a physician or nurse regularly.
Wounds with signs of clinical infection, fever and local symptoms, such as pain,
erythema (redness) or pus should have a bacterial swab examination.
The use of Comfeel Plus Transparent may be continued at the discretion of a
physician, together with the appropriate medical treatment.
NB:
Not to be used on patients with systemic infections such as tuberculosis,
syphilis or leprosy until the infection is under medical control.
Not for use on deep partial thickness or full thickness burns.
Not for use on patients allergic to one or more of the components declared.
Application
To apply Comfeel Plus Transparent dressing, use the handles to ensure aseptic
application. Remove the protective paper. Place the adhesive side to the wound,
ensuring the dressing extends over the edges of the wound by at least 1.5cms, to
ensure good adhesion. Remove the handles.
Removal
Comfeel Plus Transparent dressing should remain in place for the longest possible
period time, but no more than 7 days. When the Comfeel Plus Transparent
dressing absorbs wound exudates, a whitish gel is formed in the wound bed. When
the gel reaches the upper film surface of the dressing, the appearance becomes
‘marbled’ or transparent. When transparency has been reached the dressing
should be changed.
In the case of leakage, the dressing should be changed immediately.
To remove Comfeel Plus Transparent dressing, press down on the skin, lift 2
corners of the dressing and stretch the dressing to break the adhesive, this will aid
the ease of removal and reduce any pain caused by the removal of the dressing.
44
DUODERM EXTRA THIN
Duoderm Extra Thin is a sterile hydrocolloid dressing, consisting of an inner layer
of hydrocolloids (gelatine, pectin, sodium carboxymethylcellulose) contained within
an adhesive polymer matrix and an outer layer of polyurethane film. The outer
film is impermeable to exudate and micro-organisms.
The hydrocolloid
component of the dressing interacts with wound exudate to produce a soft mass,
which enables removal with little or no damage to newly formed tissue.
Indications
The dressing is indicated in the management of lightly exuding acute wounds,
such as minor burns, abrasions and lacerations, post-operative wounds and lightly
exuding chronic wounds.
Contra-Indications
In the presence of anaerobic infection, occlusive therapy is not recommended.
Inappropriate use, or too frequent dressing changes may result in skin irritation or
stripping.
Application
Carefully irrigate and clean the wound with sterile sodium chloride 0.9% solution.
Dry the surrounding skin, making sure that any ointments, creams or other oily
substances are removed.
Choose a dressing to allow a minimum of 2cm overlap onto intact skin.
Remove from backing paper and apply dressing using a rolling motion and gently,
but firmly, smooth and mould the dressing into place, concentrating on wound
margins.
Removal
Frequency of dressing changes will depend on the state of the wound. Duoderm
Extra Thin should be changed just before the softened area reaches the edge of
the dressing, or when leakage occurs. The dressing should not be left in place for
longer than 7 days.
To remove the dressing, press down on the skin, lift the edge of the dressing all
round the wound margin then carefully remove. Sterile saline will aid removal of
gel from wound bed.
Irrigate the wound with sterile sodium chloride 0.9% solution; remove any gel on
the wound bed and dry surrounding skin.
45
ATRAUMAN
Atrauman ais a non-medicated impregnated dressing for atraumatic wound
treatment. The support fabric is made of hydrophobic polyester tulle, impregnated
with a non-medicated ointment based on triglycerides (neutral fats).
The water repellent polyester filaments and the smooth surface structure of the tulle
counteract adhesion to the wound by preventing new tissue from penetrating the
dressing. The non adherent properties are enhanced by the ointment base. It has
no occlusive effects and does not cause maceration of the surrounding skin.
Exudate can drain freely into an absorbent secondary dressing. By keeping the
edges of the wound soft and supple it is thought that it may enhance
epithelialisation.
Indications
For the treatment of wounds, especially for exuding wounds. May be useful for
patients with sensitive skin. May be applied in combination with a topical
medication of choice.
Contra-indications
None known.
Application
Remove from sterile peel pack and cut to size if necessary. After removal of one of
the cover papers, place this side of the dressing to wound and remove second
cover. Will require a secondary dressing to absorb exudate.
Removal
Can be removed painlessly without causing any new damage. The ointment base
may be absorbed when left in place for an extended period in this case wound
adhesion which may occur, this can be eliminated by placing a secondary Atrauman
dressing over the first one.
46
URGOTUL
Non-adherent soft polymer wound contact dressing.
Indications
For treatment of moist wounds where adherence would be an issue.
Ideal for fragile skin conditions e.g. Skin tears, blistering skin etc.
Contra-indications
Known allergy to the product.
Application
Remove the dressing from its sterile pack (aseptic technique). Moistened glove
finger tips to prevent the dressing sticking to item – remove one backing sheet,
place the dressing onto the wound overlapping good skin by at least 1 cm.
Remove the second backing sheet – Place secondary dressing over the top to
hold dressing in place.
Removal
Can be left in place for up to 7 days.
Can be removed by gently easing the dressing from the wound, saline
or warm tap water can be used for any stubborn areas where adherence
occurs.
47
Protocols
3&4
PROTOCOLS 3 AND 4
INFECTED WOUNDS
NB: Where infection is diagnosed, systemic antibiotics should be prescribed
after checking wound swab result.
SHALLOW INFECTED WOUND
DEEP INFECTED WOUNDS
Inadine
Povidone iodine 10% solution
Actisorb Silver 220
Cadexomer iodine – Iodoflex/Iodosorb
Urgotul SSD
Aquacel Ag
Cadexomer iodine – Iodoflex/Iodosorb
Activon Tube (paste)
Silvercel non-adherent
Actisorb silver 220
Aquacel Ag
Silvercel
Activon Tulle / Tube
Algivon
Actilite
Cutimed Sorbact
Algivon
Silver Sulphadiazine 1% cream
(Flamazine)
Cutimed Sorbact
Askina Calgitrol Ag
Flaminal Hydro / Forte
Metronidazole gel
Excillon AMD (drain sponge)
HEAVILY EXUDING
Aquacel Ag
Allevyn Ag
Silvercel non-adherent
Algivon
49
HEAVILY EXUDING
Aquacel Ag
Silvercel
Algivon
MALODOROUS WOUNDS
(Due to anaerobic infection)
1. Metronidazole Gel
2. Actisorb Silver 220
3. Sorbsan Plus Carbon
4. Carboflex
NB: Clinical infected wounds will not heal, however, it is usually not necessary
to sterilise wounds.
50
PROTOCOL 3 – INFECTED WOUNDS
NB: Where infection is diagnosed, systemic antibiotics should be prescribed,
NEVER topical.
POVIDONE IODINE DRESSING (Inadine)
Inadine consists of a knitted viscose fabric, impregnated with a polyethylene glycol
(PEG) base, containing 10% povidone-iodine, equivalent to 1% available iodine.
In the presence of wound fluid, the povidone-iodine, a potent bactericidal agent
with a broad spectrum of activity, is readily released from the PEG base. The
dressing, which is designed as a low adherent wound contact material, is yellowbrown in colour and superficially resembles paraffin gauze. Unlike paraffin or
lanolin, the base used in the production of Inadine is water-soluble and easily
removed from the skin or wound surface.
Indications
Inadine is indicated for the prophylaxis and treatment of infection in minor burns,
superficial skin-loss injuries and as a dressing for adjunctive therapy in the
treatment of infected ulcerative wounds.
Contra-Indications
Inadine should not be used on patients who are sensitive to iodine or povidoneiodine.
Warnings and Precautions
Inadine is for topical uses only and not more than four dressings should be applied
at any one time.
The product should be used with caution in pregnant or lactating mothers,
because of the possible effects of elevated serum iodine levels on the foetus or
neonate.
Povidone-iodine may be absorbed through the unbroken skin of the neonate and
young child. Monitoring serum iodine levels and thyroid function tests are
advisable in these patients.
Application
Inadine is applied directly to the surface of the wound and covered with a sterile
secondary dressing held in position with tape or bandage, as appropriate.
51
Removal
Adherence to the surface of the wound is unlikely with Inadine, but if it does
become a problem, the dressing may be removed following irrigation with sterile
sodium chloride 0.9% solution or tap water.
The frequency of dressing changes depends primarily upon the condition of the
wound. If large quantities of exudate are produced, daily changes will probably be
required, but if the wound is relatively dry the interval between changes may be
extended. For most applications, however, it is unlikely that the dressing will
retain significant levels of antibacterial activity if left in position longer than two
days.
POVIDONE IODINE SOLUTION
Povidone iodine solution has the broadest spectrum of actions of any antiseptic
commonly available. The antibacterial effect is reduced by contact with pus and
exudate.
Active iodine is brown; on inactivation iodine is converted to colourless iodides.
NB:
Povidone iodine must be applied at intervals sufficiently short for
brown coloration to persist.
METRONIDAZOLE GEL / TABLETS
Metronidazole tablets can be given systemically to remove odour (200mg –
400mg tds).
Topical gel indicated for de-odourisation of fungating, malodorous wounds /
tumours. Metronidazole is active against the anaerobic bacteria associated with
the pungent odour. Use once or twice daily, as necessary.
Metronidazole is now available for use as a topical application in a commercially
available gel, Metrotop 0.8%.
CADEXOMER IODINE (Iodoflex/Iodosorb)
Iodoflex/Iodosorb is an antibacterial agent, which cleans the wound, reduces pain
and speeds up the healing process.
Indications
Iodoflex/Iodosorb is indicated for the topical treatment of leg ulcers. When applied
to the wound Iodoflex/Iodosorb cleans and reduces bacteria at the wound surface.
In long-term (chronic) ulcers, it speeds up the healing process and reduces pain.
52
Contra-Indications
Iodoflex/Iodosorb should not be used on patients who are sensitive to iodine.
Pre-cautions
Patient with thyroid problems should have their thyroid profile monitored whilst on
iodine preparations as their medication dose may need adjusting.
Application
Clean the wound and the surrounding area with either a gentle stream of sterile
water or saline, or using a sterile wet swab, if necessary.
For Iodoflex Paste - remove the carrier gauze on both sides of the paste, mould
the paste to the shape of the wound and apply to the wound surface/cavity.
For Iodosorb Ointment - apply Iodosorb ointment to a dry sterile dressing,
ensuring sufficient to cover all parts of the wound to a depth of 3mm.
Position the prepared dressing onto the wound. Lightly smooth a gloved finger
over the dressing to spread the ointment underneath to the shape of the ulcer and
to a minimum depth of 3mm.
Apply compression bandaging, where appropriate
Discard any remaining Iodoflex/Iodosorb
Removal
Iodoflex/Iodosorb should be change three times a week or when it has become
saturated and lost its colour.
If necessary, soak the dressing for a few minutes and then remove.
Remove the remaining Iodoflex/Iodosorb with a gentle stream of sterile water or
saline, using a sterile wet swab if necessary. Tap water should be used when
treating leg ulcers. Use warm water in a socially clean bowl, emollient can be
used as a soap substitute, to give the foot and leg a thorough clean.
Gently blot any excess fluid, leaving the wound surface slightly moist, before reapplying Iodoflex/Iodosorb.
53
Warnings and Precautions
A single course of treatment should not exceed 3 months.
The product should be used with caution in pregnant or lactating mothers because
of possible effects of elevated serum iodine levels on the foetus or neonate.
Does the patient have Thyroid disease?
Is the patient is taking any other medicines, which include lithium and certain
sulphonamide drugs, which are anti-diabetic or anti-infective.
M.R.S.A. (Methicillin Resistant Staphylococcus Aureus) IN WOUNDS
M.R.S.A. can colonise wounds without causing an infection.
therefore, not always necessary.
Treatment is,
When treatment is deemed in the best interest of the patient, de-colonisation of
the wound may be required.
The following solutions/preparations are recommended for wound cleansing in
M.R.S.A. colonised wounds
Povidone Iodine 10% Solution
Clean the wound daily for 7 days with Povidone Iodine 10% solution. Ensure that
no contra-indications are presents for treatment e.g. pregnancy, thyroid disease
etc.
OCTENILIN
Irrigate the wound thoroughly with Octenilin wound cleanser.
Rinse thoroughly with sterile water or sterile sodium chloride 0.9% solution.
Dress the wound according to the agreed procedure.
NB:
54
Keep out of eyes – Rinse thoroughly with tap water and
consult the doctor if splash into the eyes.
Silver Sulphadiazine 1% Cream (Flamazine)
Clean the wound thoroughly with sterile sodium chloride 0.9% solution.
Apply the cream to the affected area daily with a sterile gloved hand and/or
spatula.
NB: As Silver Sulphadiazine Cream can cause maceration of normal skin
on prolonged contact; care should be taken to prevent spread onto
non-affected areas.
An absorbent pad, Jelonet or gauze dressing should be applied on top of the
layer of Silver Sulphadiazine Cream.
Contra-Indications / Warnings
Silver Sulphadiazine should not be used in pregnancy or in neonates or in infants
during the first few month of life.
Silver Sulphadiazine Cream is contra-indicated in patients with a known sensitivity
to Silver Sulphadiazine or other components of the preparation, such as cetyl
alcohol or propylene glycol.
Once opened the tube must be discarded after 7 days and new tube used.
AQUACEL AG
Aquacel Ag – silver impregnated antimicrobial absorbent dressing is a soft, sterile,
non-woven ribbon dressing composed of Hydrofiber and ionic silver.
The silver in the dressing kills a broad spectrum of wound bacteria and aids in
creating an antimicrobial environment.
The dressing absorbs high amounts of wound fluid and bacteria and creates a soft
cohesive gel that intimately conforms to the wound surface, maintains a moist
environment and aids in the removal of non-viable tissue from the wound (autolytic
debridement). A moist wound environment and control of wound bacteria
supports the body’s healing process and helps the risk of wound infection.
Indications
Aquacel Ag may be use for the management of:

Wounds where there is an infection or an increased risk of infection

Wounds that are prone to bleeding, such as wound that have been mechanical or
surgically debrided

Surgical wounds
55

Traumatic wounds

Oncology wounds with exudates, such as fungoides – cutaneous tumours,
fungating carcinoma
Contra-Indications
Aquacel Ag should not be used on individuals who are sensitive to, or who have
had an allergic reaction to silver or sodium carboxymethylcellulose.
Aquacel Ag is not compatible with oil-based products such as petroleum.
Application
Aquacel Ag is sterile and should be handled appropriately. Prior to application the
wound may be debrided, if necessary, and then cleansed with an effective
cleansing agent, to be determined by the healthcare professional.
Aquacel Ag ribbon should be introduced into the wound cavity, leave at least
2.5cm outside the wound for easy retrieval.
For dry wounds – introduce the Aquacel Ag into the wound and wet with sterile
saline. Cover the dressing with a moisture retentive dressing to avoid drying out
of the dressing.
Removal
Aquacel Ag should be changed when the dressing becomes saturated with
exudates or when good clinical practice dictates that the dressing should be
changed.
Gently remove the secondary dressing according to the instructions of that
product.
Remove the Aquacel Ag and discard in clinic waste.
Irrigation of the wound with normal saline may be necessary to remove the
residual gel.
Re-dress the wound site with a new Aquacel Ag and cover with a secondary
dressing.
56
ACTIVON RANGE (HONEY)
Activon is a medical grade Manuka honey, which can be used as a topical
treatment for infected wounds. It can also be used for the treatment of
malodorous wounds.
The anti-bacterial effects of the Manuka honey are also assisted by the presence
of hydrogen peroxide in a very low concentration (an oxidising agent released by
the action of the enzyme peroxidase, which is added by bees to the nectar they
collect).
ACTIVON TULLE
Activon Tulle is low adherent gauze dressing loaded with Manuka honey, held in
place by an appropriate secondary dressing.
The honey is donated to the wound and will debride sloughy tissue, whist dealing
with bacteria in the wound, thus de-odourising the exudate
ACTIVON TUBE
Activon Tube is a single use tube of Manuka honey; this can be used in
combination with the Activon Tulle to give an increased loading of honey to the
wound, or with other secondary dressings.
Indications
Activon may be use for the management of infected wounds, malodorous wounds,
fungating malodours tumours, sloughy wounds and colonised wounds
Activon is safe for use with diabetic patients.
Removal of dressing
Carefully remove the Tulle from the wound and irrigate remaining honey from the
wound, using sterile saline, or in the case of leg ulcers, wash the foot and leg in a
bowl of warm tap water.
Contra-Indications
Not to be used where honey allergies exist.
Precautions: Honey can be painful for some patients because of the
osmotic effect it has on the wound.
57
ACTILITE
Actilite is a non-adherent knitted viscose dressing impregnated with a combination
of pure medical grade Manuka honey with Manuka oil. It is an effective antibacterial for preventing or reducing bacterial colonisation in a wound whilst
maintaining a moist healing environment.
Indications
The manufacturers state Actilite can be used on all wound types e.g. cuts and
abrasions, pressure ulcers, leg ulcers, surgical wounds, bums, graft sites.
Contra-indications
Do not use if the patient is allergic to bee venom, bee products or essential oils, e.g.
tea tree oil or any materials used in the dressing.
Application
Place Actilite directly onto wound bed, either side down. To cover larger wounds
place additional dressing side by side or for smaller wounds, cut to size (the viscose
material does not fray). Cover with an appropriate secondary dressing depending
on levels of exudate e.g. a film dressing or absorbent pad. Actilite may be left in
place for up to 7 days. To maintain the level of efficacy, change the dressing when
the colour fades significantly.
Removal
Occasionally it may be necessary to facilitate the removal of Actilite by irrigating the
wound bed with saline (0.9%) solution.
ALGIVON
Algivon is an absorbent, sterile, non-adherent wound contact dressing comprising of
calcium alginate mechanically bonded fibres, impregnated with medical grade
Manuka honey.
When wet the fibres swell and form a sodium calcium gel when in contact with
wound exudate.
The Manuka honey used in the dressing is produced to the highest standards for
medical use, having a minimum ant-bacterial efficiency equivalent to 12% phenol.
Indications
All acute and chronic infected wounds. sloughy wounds, leg ulcers, pressure
ulcers, fungating lessions, abrasions, malodourous wounds.
58
Contra-Indications
Arterial bleeds or hevily bleeding wounds. Patients with a known sensitivity to
calcium alginate or bee venom. Some patients may experience a drawing
sensation, this can be painful.
Application
Algivon is placed either side down onto the wound surface or can be placed side by
side to cover large wound areas or cut to size ensuring the dressing does not touch
the periwound as this may cause breakdown of good tissue.
Depending on levels of exudate an appropriate secondary dressing should be
selected. Wounds with low exudate use film or bandage, wounds with high levels
of exudate should be covered with a more absorbent secondary dressing.
Frequency of changes depends on levels of exudate, but Algivon can be left in
place for up to 7 days if exudate allows.
Removal of Dressing
Algivon will need changing as the honey is highly diluted by exudate of which the
calcium fibres have substantially gelled. In some cases it may be necessary to
irrigate the wound bed with saline solution (0.9%) before removal.
SILVERCEL / SILVERCEL NON-ADHERENT
Silvercel is a hydro-alginate antimicrobial dressing with silver in a sterile woven
pad, composed of high alginate, carboxymethylcellulose (CMC) and silver coated
fibres. The unique composition of the dressing manages exudate in moderate to
heavily exuding wounds. The silver fibres kill a broad spectrum of microorganisms associated with the bacterial colonisation and infection of wounds. The
non-adherent version has a perforated film coating on both sides of the dressing.
Indications
Silvercel is intended for use in the management of moderate to heavily exuding
partial and full thickness chronic wounds, including pressure ulcers, venous
ulcers, diabetic ulcers, donor sites, traumatic ulcers and surgical wounds.
Contra-Indications
Silvercel should not be used on surgical implantations or on patients with known
sensitivities to silver.
Precautions
Silvercel dressing is not intended to stop bleeding, nor for use on dry wounds, as
the dressing relies on exudate to enable the release of the silver.
59
Application
Cut or fold the dressing to fit the wound, loosely pack in to deep cavities, ensuring
the dressing does not overlap the wound margins.
Cover and secure the Silvercel with a non-occlusive secondary dressing.
Removal
The frequency of the dressing change will depend on the patient’s condition and
the level of exudate. The dressing should be changed when the secondary
dressing has reached its absorbency capacity or up to 7 days.
Gently remove the secondary dressing as per manufacturers instruction.
If the wound appears dry, saturate the Sivercel dressing with normal saline 0.9%
prior to removal, or tap water if dealing with leg ulcers.
Gently remove the dressing from the wound bed.
Irrigate the wound with normal saline 0.9%, or tap water, prior to applying the new
dressing.
URGOTUL S.S.D
Urgotul S.S.D is a hydrocolloid dressing which is non-adhesive, non-occlusive and
does not adhere to the wound bed.
The dressing consists of a polyester mesh, impregnated with hydrocolloid particles
(carboxymethylcellulose) Vaseline and silver sulphadiazine.
The presence of silver sulphadiazine, which is an antibacterial agent, confers on
the Urgotul S.S.D dressing the ability to act on the organisms, which are most
frequently responsible for infecting wounds. Silver sulphadiazine has a broad
spectrum of antimicrobial activity covering the Gram +ve and Gram –ve bacteria
and certain moulds and yeasts. It is particularly effective against staphylococcus
aureus and pseudomonas aeruginosa. It is pliable and comfortable for the patient.
Directions for Use
Clean the wound as per policy. If an antiseptic cleanser is used first, rinse the
wound thoroughly with normal saline.
Remove the protective wings from the dressing.
Apply Urgotul S.S.D directly onto the wound.
Urgotul S.S.D will adhere to surgical gloves, consequently it is recommended that
the gloves be moistened with normal saline 0.9% to aid with ease of handling.
Cover with a secondary dressing.
60
NB: The silver sulphadiazine is active for up to 2 days, so dressing changes
should be planned with this guidance.
Side effects
The silver sulphadiazine can give rise to erythemas, contact eczemas and in rare
cases photosensitivity and leucopenias.
The passage of Sulphadiazine into the systemic blood stream exposes the patient
to a risk of systemic sulphonamide complications e.g. haematological. renal,
intestinal and skin complaints.
Contra-Indications
Do not use if the patient has any known sensitivity to sulphonamides and other
ingredients.
Not to be used in patients with renal impairment, pregnant or breast feeding
women, newborn and premature babies.
Removal
Gently remove the secondary dressing, following the manufacturers instructions.
Urgotul S.S.D dressing can be peeled away from the wound gently, which will not
cause trauma or pain.
CUTIMED SORBACT
An antimicrobial product – bacteria binding gauze, Green in colour.
By the principles of hydrophobic interaction, bacterial and fungi become physically
and irreversible bound to the dressing.
The dressing is coated with a fatty acid derivative (DACC) which gives the dressing
its water repellent properties (Hydrophobic)
Removing the dressing removes the bound bacteria which cannot multiply or
escape once bound to the dressing fibres.
Indications
All types of colonised or infected wounds.
61
Contra-indications
Dry wounds.
Application
Swabs – Open out the swab, can overlap onto good skin.
The dressing can be cut if needed.
Removal
If dressing has adhered use saline or tap water to ease removal.
MALODOUROUS WOUNDS
SORBSAN PLUS CARBON
Sorbsan Plus Carbon is a highly absorbent alginate dressing with a layer of
activated carbon to trap and absorb wound odour.
See Protocols 7 & 8 – Sorbsan range.
Indications
Sorbsan Plus Carbon is intended for use in the management of flat shallow
wounds, wounds with moderate to high exudates, infected wounds, fungating
wounds and malodorous wet wounds.
ACTIVATED CHARCOAL DRESSINGS
Used to help in the management of discharging, purulent and contaminated
wounds by bacterial infection and offensive odour.
The dressings are intended to be applied directly to the wound surface and
covered with appropriate secondary dressings.
ACTISORB SILVER 220
Incorporates a woven cloth consisting of 95-98% carbon. The charcoal cloth is
enclosed in a sleeve of spun-bonded non-woven nylon fabric, which is sealed
along all found edges to facilitate handling and reduce particle and fibre loss.
Activated charcoal has the property of absorbing odour and noxious materials,
such as toxins and degradation products from the wound.
62
The charcoal cloth contains silver residue, chemically and physically bound onto
carbon. These impart antimicrobial properties to the fabric, in addition to the
absorptive characteristics described above.
Application
Actisorb Silver 220 is intended for use as a primary wound dressing. In use, the
product is applied directly to the surface of the wound and covered with a
secondary dressing held in place with tape or bandage, as appropriate.
The secondary dressing chosen will depend upon the nature of the wound, but in
general, a simple absorbent pad will be sufficient.
NB: There may be circumstances where it is not considered appropriate to
place Actisorb Silver 220 directly onto the surface of a malodorous
wound. In these instances, the dressing may be placed between the
selected wound contact material and secondary dressing.
On wounds, which tend to dry out, care is needed if Actisorb Silver 220 is used as a
primary dressing because adherence may be a problem.
Frequency of dressing Change
Depends entirely upon the nature and condition of the wound.
NB:
Actisorb Silver 220 should be used in the intact state and not cut to
shape prior to application to the wound.
CARBOFLEX
Carboflex is a sterile non-adhesive dressing with an absorbent wound contact
layer (containing alginate and hydrocolloid), an active charcoal central pad and a
smooth water resistant top layer.
Indications
Carboflex is indicated for the management of malodours acute and chronic
wounds. It may be used as a primary dressing for shallow wounds or with
deeper wounds as a secondary dressing over wound fillers.
Carboflex may be used on infected malodorous wounds under medical
supervision, together with appropriate antibiotic therapy and frequent monitoring
of the wound.
63
Contra-Indications
Do not use on individuals with a known sensitivity to the dressing or its
components.
Application
These dressings are sterile and should be handled appropriately. If required, the
wound should be debrided and necrotic tissue removed. Cleanse the wound
site, rinse well and dry the surrounding skin.
NB: Do not cut the dressing.
Choose a dressing, sized so that it is larger than the wound area to ensure that
the dressing overlaps the wound edge by at least 3.2cm. For shallow wounds the
dressing may be placed directly onto the wound as a primary dressing, and for
cavity wounds, Carboflex can be laid over a wound filler/gel as a secondary
dressing.
Place the fibrous (non-shiny) surface on to the wound or cavity filler.
Secure Carboflex in place over the wound with tape of other appropriate material.
The absorbent wound contact layer will take up exudate and form a soft gel.
Change the dressing when clinically indicated or if there is exudate strike-through
to the top layer or if the odour is no longer being absorbed. With non-infected
malodorous wounds, the dressing may be left undisturbed for up to 3 days. If the
wound is infected, then the dressing should be changed more frequently.
Removal
Carefully lift away from the wound by grasping one corner of the dressing.
FLAMINAL (FORTE / HYDRO)
Flaminal Hydrogel – For light or moderately exuding
Flaminal is an enzymatic alginogel for use in infected wounds.
There are two types:


Flaminal Hydro – Indicated for low to moderately exuding wounds
Flaminal Forte – Indicated for moderate to high exuding wounds
Flaminal debrides and desloughs, it contains natural occurring enzymes glucose
oxidase and lactoperoxidase for antimicrobial activity with damaging healing cells. It
contains alginate to balance moisture levels and protect wound edges. It is safe to use
on all types of wounds at any stage of the healing process.
64
It provides a biodegradable, soft and soothing wound interface whilst reducing pain and
trauma. It kills bacterial without damaging key healing cells. Flaminal can be re-capped
and re-used for the same patient providing and aseptic technique is followed
Application - Follow aspesis throughout the procedure
Flaminal can be applied directly to a secondary dressing of applied to a piece of sterile
gauze and introduced to the wound bed.
Syringe method – Flaminal can be precision applied using a syringe. Remove the
plunges from a sterile syringe, squeeze the desired amount of Flaminal into the barrel of
the syringe, replace the plunger then apply the Flaminal to the wound.
Ideal for narrowed wounds.
Removal
Flaminal is biodegradable, irrigate the wound with saline / tap waer to remove the
excess gel.
EXCILON AMD (drain sponge)
A primary dressing embedded with PHMB 0.2% (polytexamethylene biguanide),
a bacterial killing polymer. PHMB attacks bacteria on and within the dressing
fabric, helping keep infection out of the wound and limiting cross contamination.
Indications
The Excilon AMD drain sponge is a pack of 2 pre-cut gauze swabs embedded
with PHMB ideal for around tracheostomy sites, chest drain sites, external
fixation sites, suprapubic sites. P.E.G / feeding tubes, IV lines / central lines,
post surgery drains, pin-sites / external orthopaedic castings etc.
Two sizes available 5 x 5cm and 10 x 10 cms. Dressing changes cost pennies 15p
for pack of 5 x 5cm (Sept 2012 NHS Supplies).
Application
Secondary dressings are not necessary, can be held in place by simple tape.
Each pack has 2 sponge/swabs. Provides total coverage and conceals the exit
Site. Place one sponge around the site then place the other on top, in the
opposite direction to ensure total coverage – can be taped in place.
65
ASKINA CALGITROL Ag
A highly absorbent non-adherent dressing with a wound contact of silver alginate
matrix which has a strong antimicrobial protective action, which has a slow
extended release of silver ions, whilst providing a moist environment. In contact
with wound exudate, the alginate matrix forms a soft gel allowing the immediate
liberation of silver ions. The release of silver is maintained for up to 7 days.
Indications
Infected wounds, moderate to highly exuding wounds of partial and full thickness.
Pressure ulcers, venous leg ulcers, second degree burns and donor sites.
Active against a broad spectrum of microorganisms including M.R.S.A.
Application
Thoroughly clean the wound with saline, tap water or Octenalin. Select an appropriate
size dressing that will completely cover the wound surface, ensluring2 – 3 cms margin
beyond the wound.
Apply the dressing with the silver matrix (dark grey surface) touching the wound.
Secure in place with an appropriate fixation dressing.
Removal
Remove fixation and /or secondary dressings, gently remove the Askina Calgitrol
Ag. Thoroughly cleanse the wound to remove any residue left from the Askina
Calgitrol Ag (dark staining may occur).
Contra Indications
Not to be used on patients with known silver allergies, or allergies to any other
component of the dressing.
66
Protocols
5&6
PROTOCOLS 5 AND 6
BLACK NECROTIC
SHALLOW WOUNDS
YELLOW BROWN SLOUGHY
SHALLOW WOUNDS
Granuflex
Intrasite Conformable
Activheal hydrogel and
Clearfilm /Hydrofilm
Granuflex
Activheal hydrogel and
Clearfilm / Hydrofilm
Comfeel Paste
Comfeel Plus
Comfeel Plus
Actiform Cool (Backing film on)
Actiform Cool (Backing film on)
YELLOW BROWN SLOUGHY
SHALLOW MOIST WOUNDS
Granuflex
YELLOW / BROWN SLOUGHY
SHALLOW WOUNDS (WET)
Aquacel
Actiform Cool (Backing film off)
Sorbsan flat
Intrasite conformable
Sorbsan plus
Activheal hydrogel
Comfeel Plus
Aquacel
Sorbsan flat
BLACK NECROTIC
DEEP WOUNDS
68
YELLOW BROWN SLOUGHY
DEEP WOUNDS
Activheal gel and Aquacel
Aquacel
Comfeel Paste
Comfeel Paste / Granugel
Sorbsan flat / packing
Sorbsan packing
DEBRIDEMENT AND DESLOUGHING
SLOUGHY/NECROTIC WOUNDS
NB:
These wounds will not heal until the slough is removed.
Depending on the type and condition of the wound, the slough may be composed of
necrotic tissue or a mixture of fibrin and pus, which contains bacteria, leukocytes and
significant quantities of DNA protein. Inflammatory mediators may also be present,
which can cause inflammation of the skin surrounding the wound. The presence of
slough and devitalised tissue will predispose a wound to infection, by acting as a
bacteriological culture medium and inhibiting the action of leukocytes in controlling
invading organisms. It follows, therefore, that effective wound cleansing is essential if
infection is to be avoided and healing is to take place at the optimum rate.
Surgical debridement / Versajet therapy are by far the most rapid method, but this
may not always be appropriate and alternative techniques are required.
COMFEEL PLUS
Comfeel Plus hydrocolloid has a range of dressings:

Comfeel Plus Ulcer Dressing

Comfeel Plus Contour Dressing

Comfeel Plus Sacral Dressing
Comfeel Plus is made of calcium alginate sodium carboxymethylcellulose, artificial
elastomer, tackifier and plasticiser and a top layer made from semi-permeable
polyurethane film.
Indications
Comfeel Plus Ulcer Dressing is indicated for the treatment of leg ulcers and
pressure sores, also for superficial burns, superficial partial thickness burns, donor
sites and skin abrasions.
Comfeel Plus Contour Dressing is indicated for use in treatment of wounds in
difficult to dress sites.
Comfeel Plus Sacral Dressing is indicated for low to medium exudating sacral
wounds.
69
Application

Comfeel Plus Ulcer Dressing
Use the ‘handles’ to ensure aseptic application. Remove the protective
paper. Place the adhesive side to the wound. Ensure that the dressing
extends over the edges of the wound by at least 1.5cm to ensure good
adhesion. Remove the handle.

Comfeel Plus Contour Dressing
Remove the protective paper from the centre of the dressing and place the
dressing on the wound. Remove the protective paper from the wings without
stretching the thin hydrocolloid and gently press, one at a time, to ensure the
dressing adheres to the skin.
The frame of the dressing acts as a suitable border ensuring good adhesion,
providing that the wound edges do not extend beyond the central island.
Removal
To remove the dressing, press down on the skin. Lift the edge of the dressing all
round the wound margin until the edges are free from the skin surface, then
remove carefully from the wound, by stretching the dressing to break the
adhesive.
COMFEEL PASTE
Comfeel Paste is composed of sodium carboxymethylcellulose, guar gum,
cetostearyl alcohol, white soft paraffin and artificial elastomer.
Indications
Comfeel Paste is primarily indicated for the management of pressure sores and
leg ulcers. It can also be use for filling other cavity wounds to provide added
absorption and may be used to enhance debridement to moderate necrosis.
Contra-Indications
Not to be used on patient allergic to one of more of the components declared.
Not to be used on patients with systemic infections such as tuberculosis, syphilis
or leprosy until the infection is under medical control.
70
Application
Fill the cavity to approximately one third of the wound depth. Then cover with a
Comfeel Plus dressing.
Removal
Irrigate the wound with sterile sodium chloride 0.9% solution to remove any gel left
on the wound bed.
GRANUFLEX
Granuflex consists of a thin polyurethane sheet bonded on to a semi-permeable
polyurethane film, which is impermeable to exudate and micro-organisms. 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 gelatine, pectin and
carboxymethylcellulose together with other polymers and adhesives.
Indications
Granuflex may be used in the treatment of leg ulcers, pressure sores, minor
burns, donor sites (after haemostasis has been achieved) and many types of
granulating wounds. If applied to small 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.
Contra-Indications
Granuflex should not be used on patients who have a known sensitivity to
Granuflex or its components.
Strict vegetarians may not wish to use the dressing, because of the gelatine
content.
Colonisation of chronic wounds is common and is not a contra-indication to the
use of Granuflex. Where systemic or local infection develops during the use of the
dressing, appropriate adjunctive therapy should be initiated. The use of Granuflex
may be continued, but the progress of the wound should be monitored carefully
and all treatment should be under medical supervision.
NB: The use of Granuflex in the presence of anaerobic infection is not
recommended.
71
Application
An appropriately sized dressing is removed from its paper backing and lightly
pressed into position over the wound. In order to ensure good adhesion to the
surrounding skin, a minimum overlap of 2-3cm from the margin of the wound
should be allowed.
The dressing should be applied with a rolling motion – the dressing must not be
stretched. The dressing should be smoothed gently but firmly into place with
particular attention being paid to the wound margins.
NB: Do not hurry this procedure as initial adhesion improves as the
dressing warms up.
Removal
The frequency of dressing change will be governed by the state of the wound. If
large volumes of exudate are produced, daily changes may be required, but on
some wounds the dressing may be left in place for 4-5 days before it is changed.
It is generally recognised, however, that the dressing is not left in place for longer
than 7 days.
To remove the dressing, press down on the skin. Lift the edge of the dressing all
round the wound margin until the edges are free from the skin surface, and then
remove carefully from the wound.
Irrigate the wound with sterile sodium chloride 0.9% solution to remove any gel on
the wound bed, and then dry the surrounding skin.
72
GRANUGEL
Granugel is a sterile gel composed of hydrocolloids (pectin, sodium
carboxymethylcellulose) in a clear, viscous vehicle. Granugel has the capacity to
donate water, as may be required to hydrate a dry wound, or to absorb fluid as
would be required in a lightly exuding wound.
Indications
Granugel is indicted for the management of dry, necrotic, sloughy and granulating
wounds, either superficial or cavity wounds.
Contra-Indications
Do not use if the patient has a known sensitivity to the gel or other ingredients.
When a wound is clinically infected, Granugel may be used together with an
appropriate antibiotic therapy and the progress of the wound monitored carefully
under medical supervision. Do not use in the presence of anaerobic infection.
Application
Apply Granugel directly into the wound. Do not fill the wound beyond the level of
the surrounding skin. Cover with an appropriate secondary dressing e.g.
Granuflex.
Granugel should be changed when the cover dressing leaks or for routine
dressing changes. On necrotic and sloughy wounds, Granugel should be
changed every 3 days. For clean granulating wounds, Granugel can be left on for
up to 7 days, depending on the level of exudate.
If necessary, the gel can be irrigated with sterile saline.
NB: Product – Drug interaction with Povidone Iodine
preparations, due to the starch content of the dressing.
or
iodine
AQUACEL
Aquacel Hydrofibre Wound Dressing is a soft, sterile non-woven pad of ribbon
dressing, composed of hydrocolloid fibres (sodium carboxymethylcellulose). This
conformable and highly absorbent dressing interacts with wound exudate and
forms a soft gel, which maintains a moist environment for optimal wound healing,
debridement and easy removal, with little or no damage to healing tissue.
Aquacel has been re-catogorised as a protease modulating dressing. Aquacel
locks away harmful proteases that are responsible for delaying wound healing.
73
The dressing may be left in place for up to 7 days. However, when used on
heavily exuding wounds or for other clinical reasons, the dressing may have to be
changed more frequently.
Indications
Aquacel is indicated for the management of exuding wounds. These include
chronic wounds such as pressure sores and leg ulcers and acute wounds such as
abrasions, lacerations, incisions, donor sites and first and second degree burns.
This dressing is further intended for use in the management of surgical or
traumatic wounds that have been left to heal by secondary intent.
For local management of wounds that are prone to bleeding, such as wounds that
have been mechanically or surgically debrided, donor sites and traumatic wounds.
Aquacel facilitates the control of minor bleeding.
Contra-Indications
Aquacel should not be used on patients with a known sensitivity to this dressing or
its components.
Application
Aquacel is sterile and should be handled appropriately. Prior to application, the
wound may be debrided, if necessary, and then cleansed with an effective
cleaning agent, to be determined by the health care professional.
Apply Aquacel to the wound site and cover with a moisture retentive secondary
dressing.
Removal
Aquacel should be changed when the dressing becomes saturated with exudate,
or when a good clinical practice dictates that the dressing should be changed.
This dressing can remain in place for up to 7 days.
Gently remove the secondary dressing, according to the package insert of that
product.
Remove the Aquacel and discard in clinical waste.
74
Occasionally, irrigation of the wound, with normal sterile, is necessary to remove
the residual gel without disrupting the delicate granulation tissue.
Redress the wound site with a new Aquacel dressing and cover with a secondary
dressing as previously described.
ACTIFORM COOL
Actiform Cool is a hydrogel sheet wound dressing. The dressing is blue in colour
with a protective wing to the wound contact side, and a top liner to be left in place,
for drier wounds.
Indications
Actiform Cool is indicted for use on leg ulcers, burns, scalds and radiation therapy.
It can be used as a method of relieving pain in the wound bed and under
compression for moderate to highly exuding wounds.
Contra-Indications
Actiform Cool should not be used as a covering for deep, narrow cavities or
sinuses.
Haemostasis must be achieved before applying the dressing.
Application

Lightly Exuding Wounds
Remove the sterile dressing from the package.
First remove one of the overlaid white plastic liners. Position and smooth into
place, whist removing the second folded white plastic liner.
Take care not to remove the clear top-liner from the back of the dressing, as
this is required to position the dressing and maintain hydration.
Leave the film top-liner in place and secure with a suitable cover dressing or
bandage.

Moderate to Heavily Exuding Wounds
Remove the sterile dressing from the package and if necessary, cut the
dressing to fit the wound.
75
Remove one of the overlaid white plastic liners. Position and smooth into
place, whist removing the second folded white plastic liner.
Once in place, the top-liner should be removed to allow exudate to pass
though into a secondary absorbent dressing or pad and bandage.
Removal
Actiform Cool should be changed as often as the condition of the wound dictates.
The time between dressing changes could be up to 7 days, but in the initial
stages, frequent monitoring is recommended.
The dressing should be changed at the first sign of strike-through of fluid.
Remove the dressing by lifting gently from one corner and peeling back the
dressing.
If necessary, removal may be facilitated by soaking the dressing with water or
normal saline 0.9% to rehydrate any part of the dressing that is dry.
As exudate is absorbed into the dressing, a soft gel is formed and the dressing will
appear cloudy, swollen and the colour of the exudate. This is normal.
ACTIVHEAL HYDROGEL
Activheal Hydrogel is an amorphous hydrogel in 15grm tubes.
Under an occlusive dressing the aqueous gel protects the wound and aids
autolytic debinderment of necrotic tissue therefore facilitating wound healing.
Indication for use
Hydrogel is designed to maintain a moist wound healing on wounds such as
pressure ulcers, leg ulcers, skin graft donor sites and diabetic foot ulcers.
Contra – indications
Activheal Hydrogel should not be used on third degree burns or surgical
implantations.
76
Directions for use
Remove the cap from the tube; turn the tube over and allow the plastic collar to
drop off.
Replace the cap and screw fully to the bottom to pierce the cap.
Apply gel to the wound to a depth of 5mm. Do not apply the gel to the healthy skin.
Cover the wound with an occlusive dressing i.e. Felm/Hydrogel.
This is a single use product discard any left over gel.
Removal
Change the dressing every two – three days. Clean the wound with normal saline
to remove necrotic debris or excess gel.
Storage
Store at room temperature.
Avoid freezing or excessive heat.
INTRASITE CONFORMABLE
A soft non-woven dressing with a light load of intrasite gel.
Indications
Hydrogel dressings are most commonly to donate liquid to dry sloughy wounds and
facilitates autolytic debridement of necrotic tissue.
Ideal on areas of the body where it would be difficult to place hydrogel. Secondary
dressings would be required.
Removal
Remove the secondary dressings, then carefully remove the intrasite conformable
dressing, if stuck apply saline to soak the dressing.
Contra-indications
Not to be used on patients where known allergy / reaction to the hydrogel.
77
SORBSAN
Sorbsan is a highly conformable sterile non-woven primary dressing made of
calcium alginate BP and is available as flat dressing, packing and ribbon.
Sorbsan Plus is hydrophilic, so wound exudate is drawn into the dressing along
with contaminating bacteria.
Indications
There are no known contra-indications to the use of Sorbsan. However, the
dressing will be of little value if applied to wounds, which are very dry or
completely covered with hard, black necrotic tissue.
Lightly exuding wounds are normally considered less appropriate for treatment.
The simultaneous use of topical agents, such as antiseptics and antibiotics with
alginates may be inappropriate as some of these agents alone may induce
reactions. Therefore, their use with Sorbsan may reduce or negate its beneficial
effects.
Application
Sorbsan Plus has a blue backing, which indicated the outside of the dressing.

First Sorbsan Application
Cleanse the wound with sterile chloride 0.9% solution. (If the site has a
completely dry necrotic cover then remove this by an acceptable debriding
technique.)
Dry the skin around the wound.
Select the appropriate size dressing (see presentation table) that will
completely cover the wound surface.
NB: Apply Sorbsan dressing directly to the wound surface, leaving a
margin of at least 2mm around the wound. Cut the dressing to fit
the wound.
Cover with secondary dressing pad. Secure with surgical tape or bandage as
appropriate.

78
Subsequent Dressing Changes
Remove the tape or bandage.
Lift the dressing and irrigate away any gelled alginate with sterile sodium
chloride 0.9% solution, removing the dressing in one piece.
Dry the skin around the wound.
Select the appropriate size Sorbsan dressing (see presentation table,
overleaf) that will completely cover the wound surface.
NB: Apply Sorbsan dressing directly to the wound surface, leaving a
margin of at least 2mm around the wound. Cut the dressing to fit
the wound.
Cover with secondary dressing.
Secure with surgical tape or bandage as appropriate.
Frequency of Dressing Change
Dressing changes should normally occur when the area of alginate covering the
wound is completely gelled. Therefore, the interval between dressing changes will
depend entirely upon the state of the wound.
On heavily exuding and sloughy wounds, daily changes may be required at the
beginning of treatment, but this may be reduced to twice a week as the healing
progresses.
Wound Progress
The wound may initially appear to increase in size in the early stages of alginate
treatment. This is normal, as sloughy tissue is removed from the edges of the
wound. This is necessary to promote the healing process.
NB:
79
When the wound reaches little or nor exudate levels, it may be more
suitable to consider other suitable wound care products.
PRESENTATION TABLE
TYPE OF DRESSING
80
INDICATIONS FOR USE
Flat Dressing
Shallow wet wounds and ulcers
Packing
Large deep open wet wounds
Ribbon
Small deep open wet wounds
Large wet wounds
Sinuses
Wet wounds in awkward locations e.g. toes
and breasts
Sorbsan Plus
Large shallow, very wet wounds and ulcers
Protocols
7&8
PROTOCOLS 7 AND 8
SHALLOW CLEAN WOUNDS
HEAVILY EXUDATING
MEDIUM EXUDATING
Activheal Foam Range
Activheal Foam Range
Allevyn
Allevyn , Allevyn Gentle (1st choice silicone border)
Tegaderm Foam Adhesive
Mepilex border (2nd choice silicone border)
Tegaderm Foam Adhesive
Sorbsan Plus
Aquacel
Xupad – (1st choice)
Sorbsan Range
Eclypse – (2nd choice)
Versiva XC
Superabsorbers
Kerramax – (1st choice)
Drymax – (2nd choice)
Aquacel
Alione
Advadraw
The aim is to stimulate epidermal regeneration as quickly as possible.
DEEP CLEAN WOUNDS
HEAVILY EXUDATING
Allevyn Cavity Wound Dressing
Sorbsan Packing/Rope
Sorbsan
Aquacel
Aquacel
Activheal Foam – island (Adhesive)
82
MEDIUM EXUDATING
Activheal foam is a sterile wound dressing consisting of a pink polyurethane
membrane coated with pressure sensitive adhesive with a centrally located
hydrophilic absorbent polyurethane island.
The dressing is self-adhesive, soft and highly absorbent, comfortable and creates
the ideal environment for moist wound healing.
Application
The dressing is applied to the skin with the central part of the dressing in contact
with the wound.
The dressing has a self-adhesive border; therefore no other secondary dressings
are required. Apply the dressing with the pink side up.
Activheal Foam – (non-adhesive)
The same as the foam island but without the polyurethane membrane and adhesive
border.
Application
The dressing is applied to the skin with the central part of the dressing in contact
with the wound.
A secondary product is needed to hold the foam in place i.e. bandages, tapes etc.
Indication for use
Activheal foam dressings may be used on wounds where there is moderate to high
exudate.
ALLEVYN FOAM
Allevyn consists of a layer of soft, hydrophilic polyurethane foam, 4mm thick,
bonded onto a polyurethane film. The film, which is permeable to moisture
vapour, provides a barrier to the passage of water or wound exudate, and also
prevents the passage of micro-organisms into or out of the dressing.
The surface of the dressing to be place in contact with the wound is covered with
an apertured three-dimensional plastic net, which is claimed to reduce adherence
to granulating tissue.
The dressing has a high absorbency strike through is prevented by the semipermeable backing.
83
By virtue of these characteristics, the dressing provides a micro-environment at
the surface of the wound, which is conducive to moist wound healing, and within
limits, independent of the rate of exudate formation.
Presentation of the Dressings:




Non-adhesive version
Adhesive version
Shaped dressing – i.e. sacral, heel, etc
Sillicone adhesive
Indications
Allevyn may be applied to a variety of heavily exudating wounds and may be
used as a secondary dressing. The silicone adhesive version should be used on
patients with fragile skin.
Contra-Indications
No absolute contra-indication to the use of Allevyn have been reported, but the
dressing will be of limited use if applied to a wound covered by a dry scab of
black necrotic tissue. This should first be removed surgically or by some other
means.
The Allevyn heel dressing should not be used as a pressurerelieving device.
Application
A size of Allevyn should be chosen that would overlap the edges of the wound by
2-3 cm. This is placed with the white side next to the skin.
The non-adhesive dressing may be secured with tape or a piece of dressing
retention sheet, e.g. Mefix or held in position with a suitable bandage, as
appropriate. If necessary, Allevyn may be cut to shape with a pair of sterile
scissors.
The Allevyn Adhesive should be applied by peeling back the proactive wings and
applying the dressing centrally over the wound. Smooth down the edges of the
border, to ensure good adhesion.
84
Frequency of Dressing Changes
The frequency at which the dressing should be changed depends upon the
nature of the wound. On a clean, non-infected wound, it is possible to leave
Allevyn in position for up to 4 days, although this will depend upon the amount of
exudate produced. Removal
The Allevyn Adhesive has a low-tac adhesive, which is dissolved in contact with
exudate. To remove the dressing, peel the adhesive border away from the skin,
by stretching the dressing to break the adhesive. Irrigate the stuck foam with
saline to release it from the skin.
AQUACEL
Aquacel Hydrofibre Wound Dressing is a soft, sterile non-woven pad of ribbon
dressing, composed of hydrocolloid fibres interacts with wound exudate and forms
a soft gel, which maintains a moist environment for optimal wound healing,
debridement and easy removal, with little or no damage to the healing tissue.
Also Aquacel has been re-categorised as a protease modulating dressings,
Aquacel locks away the harmful proteases that are responsible for delaying wound
healing.
The dressing may be left in place up to 7 days. However, when used on heavily
exuding wounds, or for other clinical reasons, the dressing may have to be
changed more frequently.
Indication
Aquacel is indicated for the management of exuding wounds. These include
chronic wounds, such as pressure sores and leg ulcers and acute wounds such as
abrasions, lacerations, incisions, donor sites and first and second degree burns.
This dressing is further intended for the use in the management of surgical or
traumatic wounds that have been left to heal by secondary intent.
For the management of wounds, which are prone to bleeding, such as wounds
that have been mechanically or surgically debrided, donor sites and traumatic
wounds.
Aquacel facilitates the control of minor bleeding.
Contra-Indications
Aquacel should not be used on patients with a known sensitivity or allergy to any of
its components.
85
Application
Aquacel is sterile and should be handled appropriately. Prior to application, the
wound may be debrided, if necessary and then cleansed with an effective
cleansing agent, to be determined by the health care professional.
Apply Aquacel to the wound site and cover with a moisture retentive appropriate
secondary dressing.
Removal
Aquacel should be changed when the dressing becomes saturated with exudate,
or when good clinical practice dictates that the dressing should be changed. This
dressing can remain in place for up to 7 days.
Gently remove the secondary dressing, according to the package insert of that
product.
Remove the Aquacel and discard in clinical waste.
Occasionally irrigation of the wound with normal saline or tap water is necessary,
to remove the residual gel without disrupting the delicate granulation tissue.
Redress the wound site with a new Aquacel dressing and cover with a secondary
dressing as previously described.
ALLEVYN CAVITY WOUND DRESSING
Allevyn Cavity Wound Dressing is a highly comfortable, absorbent dressing
consisting of a soft, polymeric outer membrane with a three-dimensional
honeycomb like structure containing a mass of hydrophilic polyurethane foam
chips. The outer membrane, which provides an effective low adherent wound
contact layer is perforated to allow exudate to be drawn into the interior of the
dressing where it is absorbed and retained by the polyurethane foam chips. The
dressings are available in a range of shapes and sizes for the management of
cavity wounds.
Indications
Allevyn Cavity Wound Dressing is indicated for the extended management of full
thickness cavity wounds healing be secondary intention, or for the temporary
treatment of wounds prior to delayed primary closure.
Contra-Indications
There are no absolute contra-indications to the use of Allevyn Cavity Wound
Dressing, but the dressing is not appropriate for the management of very dry or
relatively superficial wounds.
86
Application
An appropriate size dressing should be gently inserted into the wound and held in
place with tape, a semi-permeable film dressing or a bandage, as appropriate. If
necessary, depending upon the condition and location of the wound, an absorbent
secondary dressing may be applied.
Removal
The interval between dressing changes will depend mainly on the condition of the
wound and the amount of exudate produced. Heavily exudating or sloughy
wounds may require that the dressing is changed daily, but in clean lightly
exudating wounds the dressing may be left undisturbed for 2-3 days or sometimes
even longer. If the wound is infected however, frequent changes are advisable.
NB:
Allevyn Cavity Wound Dressing must not be cut open.
TEGADERM FOAM ADHESIVE
A polyurethane foam dressing with a film adhesive border. The dressing is highly
absorbent and the film backing / border allows moisture vapour transfer.
INDICATIONS
Tegaderm foam adhesive dressing can be used as a primary or secondary dressing
On moderate to highly exudating wounds.
APPLICATION
Select a dressing large enough to ensure the foam overlaps the wound by 2 – 3 cms.
Remove the backing paper and place the dressing onto the wound, smooth down the
film border. Remove the individual ‘spider like’ backing papers from the centre of the
dressing to the outside, smoothing down the film to the contours of the body.
REMOVAL
Gently lift one edge of the film border, place a hand on to the dressing, pull the film
laterally to break the adhesive, thereby reducing the pain at dressing changes that
some adhesive dressings can cause. Lift the hand supporting the dressing, move
over and repeat the lateral stretching of the film until the dressing can be lifted off the
wound.
CONTRA INDICATIONS
Not to be used on patients with known sensitivity to film dressings
87
SORBSAN
Sorbsan is a highly conformable sterile non-woven primary dressing made of
calcium alginate BP and is available as flat dressing, packing and ribbon.
Sorbsan Plus is hydrophilic, so wound exudate is drawn into the dressing along
with contaminating bacteria.
Indications
There are no known contra-indications to the use of Sorbsan. However, the
dressing will be of little value if applied to wounds, which are very dry or
completely covered with hard, black necrotic tissue.
Lightly exuding wounds are normally considered less appropriate for treatment.
The simultaneous use of topical agents, such as antiseptics and antibiotics with
alginates may be inappropriate as some of these agents alone may induce
reactions. Therefore, their use with Sorbsan may reduce or negate its beneficial
effects.
Application
Sorbsan Plus has a blue backing, which indicated the outside of the dressing.

First Sorbsan Application
Cleanse the wound with sterile chloride 0.9% solution. (If the site has a
completely dry necrotic cover then remove this by an acceptable debriding
technique.)
Dry the skin around the wound.
Select the appropriate size dressing (see presentation table) that will
completely cover the wound surface.
NB: Apply Sorbsan dressing directly to the wound surface, leaving a
margin of at least 2mm around the wound. Cut the dressing to fit
the wound
Cover with secondary dressing pad.
Secure with surgical tape or bandage as appropriate.
88

Subsequent Dressing Changes
Remove the tape or bandage.
Lift the dressing and irrigate away any gelled alginate with sterile sodium
chloride 0.9% solution, removing the dressing in one piece.
Dry the skin around the wound.
Select the appropriate size Sorbsan dressing (see presentation table,
overleaf) that will completely cover the wound surface.
NB: Apply Sorbsan dressing directly to the wound surface, leaving a
margin of at least 2mm around the wound. Cut the dressing to fit
the wound.
Cover with secondary dressing.
Secure with surgical tape or bandage as appropriate.
Frequency of Dressing Change
Dressing changes should normally occur when the area of alginate covering the
wound is completely gelled. Therefore, the interval between dressing changes will
depend entirely upon the state of the wound.
On heavily exuding and sloughy wounds, daily changes may be required at the
beginning of treatment, but this may be reduced to twice a week as the healing
progresses.
Wound Progress
The wound may initially appear to increase in size in the early stages of alginate
treatment. This is normal, as sloughy tissue is removed from the edges of the
wound. This is necessary to promote the healing process.
NB:
89
When the wound reaches little or nor exudate levels, it may be more
suitable to consider other suitable wound care products.
PRESENTATION TABLE
TYPE OF DRESSING
INDICATIONS FOR USE
Flat Dressing
Shallow wet wounds and ulcers
Packing
Large deep open wet wounds
Ribbon
Small deep open wet wounds
Large wet wounds
Sinuses
Wet wounds in awkward locations e.g. toes
and breasts
Sorbsan Plus
Large shallow, very wet wounds and ulcers
ECLYPSE
Eclypse is an absorbent cellulose-dressing pad, with a fluid repellent backing.
Indications
Eclypse can be used as a primary or secondary dressing for medium to heavily
exuding wounds.
XUPAD
Xupad is an absorbent dressing pa.
Indications for use
Can be used on all types of wet wounds as primary or secondary dressing.
Can be secured in place by using surgical tape or bandages.
90
KERRAMAX / DRYMAX
A super absorbent polyacrylate primary or secondary dressing. locks in fluid swelling
to more than 10 times its thickness.
INDICATIONS
All types of wet / moderate to highly exudating wounds. Can be used
under compression bandages. Locks fluid in the dressing.
Locks away bacteria.
APPLICATION
Either side of dressing can be placed on the wound.
VERSIVA XC
Versiva XC is a non-adhesive gelling foam dressing. It is a sterile wound dressing
consisting of: a top polyurethane foam/film layer, an absorptive non-woven fibrous
layer and a thin, non adhesive wound contact layer.
The outer foam/film layer protects the wound from external contaminants and
manages the moisture vapour transmission of the exudate absorbed by the
dressing. The non-woven fibrous layer absorbs and retains exudate by forming a
cohesive gel.
The dressing absorbs wound fluid and creates a moist environment to aid autolytic
debridement without damaging new tissue.
Indications
Versiva X may be used on a wide variety of wound types as a primary or secondary
dressing. It may be used alone or in combination with other wound care products.
Contraindications
It should not be used on individuals who are sensitive to or have had an allergic
reaction to any of the components.
Application
Choose a dressing size and shape to ensure that the central absorbent pad is
larger than the wound area. Line up the centre of the dressing with the centre of
the wound. It may be cut to size for convenience. Maximum recommended wear
time is up to 7 days.
91
Removal
Press down gently on the skin and lift one corner of the dressing. Continue until all
edges are free. Carefully lift away the dressing and discard according to local
protocol.
ADVADRAW
A rapid capillary action dressing.
A three layer dressing designed to rapidly absorb exudates and intestinal fluids and
optimize conditions for healing at the wound interface.
Rapid capillary action dressings have a central wicking layer that quickly distributes
absorbed fluid throughout the dressing and creates sustained movement of fluid
away from the wound bed.
It is made from a triple layer of polyester and viscose fibres with a perforated wound
contact polymer film on either side to prevent adhesion of the newly formed tissue to
the dressing. The non-adherent film readily allows passage of fluid but prevents
granulation tissue adhering to the dressing.
Indications
Wet wounds, sloughy wounds, deep or shallow wounds, wounds with a deep cavity
or sinus where previously topical negative pressure therapy has been problematic
for the patient.
Application
Advadraw is available in a range of rectangular sizes as well as a spiral.
It can be cut to size or a narrow ribbon to fit into larger sinus / channelled wound.
The dressing can be left in place for up to 7 days. Advadraw can be used under
compression bandages. It can be held in place by a film, surgical tape or a
secondary dressing.
CONTRA-INDICATIONS
Advadraw must not be used on wounds that are actively bleeding
92
MEPILEX BORDER
An absorbent soft silicone dressing with polyurethane foam with an adhesive border.
The dressing has 5 layers:
1. Safetac technology wound contact layer to minimise pain and trauma.
2. The absorption layer attracts moisture / exudate rapidly and prevents it returning to the
wound.
3. The spreading layer distributes exudate evenly to maximise the full surface area of the
retention layer above.
4. The highly absorbent retention layer stores exudate and ‘locks’ it safely from the wound
and surrounding skin.
5. Shower-proof barrier and viral barrier backing film, with high permeability to allow
effective vapour transmission
Indications
For use on patients with fragile skin on all types of wounds.
Application
Pull back the backing papers to expose the central region of the dressing, place over
the wound, gently remove each backing paper, smoothing down the dressing at the
same time.
The dressing can be lifted and adjusted to ensure a good fit around shapes of the body
the silicone adhesive will remain effective.
Removal
Lift one corner of the dressing, gently pull back the dressing from the wound. The
safe-tac technology ensures that no epidermal cells are removed, therefore there is no
skin stripping at removal of a dressing.
93
ALIONE
Alione is a hydrocapilliary dressing, which is highly absorbent, which provides an
optimal moist wound-healing environment. It is an all-in-one dressing. The wound
contact layer is a non-adherent material; the inner layer is a highly absorbent
material that works similar to the principles of a disposable nappy, locking the
moisture in the hydrocapilliary fibres. The outer layer is a semi-permeable water
resistant, bacteria proof film, which allows moisture vapour transfer. It comes in
two presentations:


Alione Adhesive (with a hydrocolloid adhesive)
Alione Non-adhesive
Indications
For use on pressure ulcers, leg ulcers, leaking surgical wounds and very wet
wounds.
Contra-Indications
Not to be used on dry wounds.
Application

Alione Adhesive
Use the handles on the films of the dressing to ensure aseptic application, remove
the larger paper covering and apply the dressing over the wound. Then
remove the remaining plastic film ensuring the dressing is smoothed down to
achieve good adhesion.

Alione Non-adhesive
Apply directly over the wound and secure in place with bandages
Removal

Alione Adhesive
To remove the dressing, lift a corner of the adhesive border. Place the flat of
one hand over the dressing; with the other hand stretch the hydrocolloid
border to break the adhesive, work around the border until the entire adhesive
is loose. Gently remove the dressing. If any part of the dressing is stuck to
the wound, irrigate it with normal sterile saline 0.9%.

Alione Non-adhesive
Remove by gently lifting the dressing from the wound. If any part of the
dressing is stuck to the wound, irrigate with normal saline 0.9% or tap water.
94
Protocol
9
95
PLEASE NOTE
Products on
Protocol 9
Are to be
prescribed by a
Doctor or Extended
Prescriber
ONLY
96
PROTOCOLS 9
Dressing and Therapies Under Specialist Advice Only
THERAPY
Maggot Therapy (Larvae)
Topical Negative Pressure Therapy (VAC, Venturi, PICO)
Flowtron Therapy
Versajet Therapy
DRESSINGS
Acticoat
Acticoat Absorbent
Promogran / Prisma
97
SPECIALIST THERAPIES
MAGGOT THERAPY (Larvae)
Maggots can be used as a bio-surgical debridement method of preparing the wound
bed, by removing sloughy tissue and exposing clean healthy tissue.
Available on prescription – Contact TV Team.
TOPICAL NEGATIVE PRESSURE (TNP)
Topical Negative Pressure therapy creates a sealed environment to remove
bacteria a exudate from wounds. This promotes a wound bed which
will granulate much quicker than with conventional dressings. The three
systems available in Barnsley are:
debris,
Vacuum Assisted Closure (V.A.C) therapy - using foam and a track pad.
VAC therapy units deliver controlled negative pressure to the wound and monitor
accurate therapy delivery to ensure fast and effective wound healing.
The VAC system has Sensa T.R.A.C. technology which enables the monitoring
of the negative pressure at the wound site and adjusts accordingly.
There are several models of VAC units:
VAC ATS – A large non-portable unit ideal for bedfast/immobile patients. Has a
short battery back up of 2 – 4 hours which enables transfer of patients to other area.
Canister capacity 500 or 1000 mls.
VAC Freedom – A small portable unit, battery powered which requires a daily
Recharge of the batteries (ideally overnight), leaving the freedom of full mobility whilst
carrying the pump in a shoulder bag and having the ability to leave home without
compromising the therapy. Canister capacity 300mls.
ACTIVAC – The update to the battery powered Freedom unit.
A small portable unit with a 14 hour battery life. Having all the benefits of the Freedom
pump. Canister capacity 300mls.
INFOVAC – the update to the VAC ATS pump. A non portable unit ideal for
bedfast immobile patients. Canister capacity 500mls.
Application of VAC therapy
Follow the procedure in the Royal Marsden clinical procedure manual.
98
Pressures of a VAC therapies are measured in millimetres of mercury (mmHg) in 25
mmHg units.
Black foam (granufoam) normal pressure should be 125 mmHg.
White foam (versafoam) normal pressure should be 150 mmHg.
Contact the Tissue Viability team for guidance on application and prescribing pressures
and where necessary reduce the pressure by 25mmHg to prevent complications of
bleeding
VAC therapy should be used with caution on patients on anticoagulant therapy (Warfarin)
VENTURI TNP therapy - using moist gauze and a drain (channel or Flat)
There are tow types of Venturi pumps in use in Barnsley. Both are portable and battery
powered.
Venturi Advanti
The larger of the two pumps – with a 600ml capacity canister. The unit is battery
powered and requires charging at least 4 hours in 24 hours (ideally over night), leaving
the patient fully mobile and able to leave the home during the day.
Venturi Compact
A small version of the Avanti which is a third of the size bsattery powered with a 300ml
capacity canister.
The Venturi has a gauze and drain method of delivering the negative pressure to the
wound.
There are two drain choices:
Flat Drain - cut to fit inside the wound
Indications:
- Shallow or deep wounds
- Minimal to heavy exudate
- The wound should always be lined with gauze before placing the drain inside
- Rationale – tissue will granulate into the drain holes causing pain and bleeding on
removal.
99
Channel Drain - can be coiled inside the wound or cut to fit inside the wound
Indications:
- Shallow or deep wounds
- Minimal to heavy exudates
- Wounds with tunnelling or undermined areas
- Sinus wounds
- Requires a layer of moistened gauze between the drain and the wound bed unless
managing a sinus or tunnelled area when it can be placed directly down the sinus/tunnel
tract
- Rationale – Tissue will granulate into the drain holes causing pain and bleeding
on removal.
Application of Venturi dressings
Follow the procedure in the Royal Marsden clinical procedure manual.
Pressure for both the Venturi systems are measured in millimetres of mercury 80 mmHg
being the standard automatic setting. Pressure can adjust up or down in 5 mmHg unit.
Contact the Tissue Viability team for guidance on application or pressure setting.
Consumables for the above systems are available on prescription and via the
supplies department.
When NOT to use Topical Negative Pressure therapy pump
 Should not be used on patient with actively bleeding wound.
 Should not be used on wounds with untreated oestemylitis
 Should not be used on cancerous wounds
IF IN ANY DOUBT PLEASE CONTACT THE TISSUE VIABILITY TEAM
Consumables for TNP systems are all available on prescription with an exception of the
VAC ATS canisters which can be obtained via supplies.
100
PICO – A single use TNP system.
Pico consists of a small discrete pump, powered by two ‘AA’ lithium batteries.
The pump is coupled to an advanced foam’ dressing which negates the need
for a canister.
The dressing consists of:
* A silicone adhesive wound contact which helps establish and effective seal
yet is gentle to the peri-wound
* An airlock layer that distributes the negative pressure across the dressing
* A superabsorbent layer which holds the wound exudate away from the skin.
* A high rate moisture vapour transmission (MVTR) film which allows a one
way transpiration of the collected exudate vapour and makes the canister
redundant.
Pico is supplied in a single pack. It contains one pump and two dressings. The pump life
is 7 days. The dressing can be changed once during the 7 days treatment if needed.
Additional fixation strips are also supplied allowing the wound to be inspected if required
during the 7 days. There are several dressing sizes available.
The pressure is set at 80mmHg.
Indications
Trauma wounds that have been sutured, skin graft sites and post surgical wounds.
Application
Clean the peri-wound skin to ensure it is free of creams/ointments etc. Each Pico system
has a set of application instructions (laminated). Follow the manufacturers guidance.
A wound with a slight depth more that 0.5cm can be filled with a AMD gauze (moistened)
Kerlix - as used in Talley systems.
Pico may be used over the top of a non-adherent layer if required (Silflex/Mepitel/Adaptic
touch), for example skin grafts.
NB: Keep the laminated Quick Reference guide in the patients home as there are
instructions regarding the pump status, alarms and errors (trouble shooting).
Removal / Dressing Change
To change the dressing within the 7 day period, press the orange button on the pump to
stop the Pico therapy. Disconnect the dressing from the pump. Apply the 2 nd dressing to
the wound, connect it to the pump. Press the orange button to reinitiate the therapy.
101
The pump will automatically stop functioning after 7 days of use. All the lights will turn off
at this point.
The dressing should be gently removed and disconnected from the pump, then discarded
in clinical waste. Another system may be applied if appropriate. The batteries should be
removed from the pump and disposed of as per local policy (battery recycling).
The empty pump should be disposed of as clinical waste.
102
FLOWTRON THERAPY
Flowtron therapy can be used in the treatment of venous leg ulcers. Flowtron
therapy is the use of intermittent pneumatic compression (IPC) to reduce swelling
and aid venous return.
The first line treatment for venous leg ulcers is by sustained compression, using
bandages. Flowtron therapy using the sequential garments has been shown to
improve the healing rates in venous leg ulcers.
Flowtron Therapy consists of a pump with a variable pressure setting and garments
of varying size and lengths for the leg. The therapy is used for 30-60 minutes twice
a day, over the top of the bandages. One leg or both legs can be treated at the
same time. The patient can use this independently at home, in the community.
The garment, which may be knee or thigh high, is attached to the pump and works
by gently inflating and deflating, stimulating venous return.
VERSAJET – Hydrosurgery System
The Versajet II system enables the practitioner to precisely select, excise and
evacuate non-viable tissue bacteria and contaminants from wound burns and soft
tissue injuries using a jet of saline under controlled pressure.
It consists of the Versajet II unit, a hand piece delivering normal saline under high
pressure and a collection canister unit.
The hand piece is slowly moved over the soft tissue surface, it creates a smooth
wound bed while maximising good tissue preservation.
The tissue preservation technique reduces time in the wound healing rates by
preparing the wound bed for healing.
Outcomes
Reduces bacterial burden
Preserves viable tissue
Removes slough, necrosis and debris
Minimises peripheral damage
Benefits
Reduced number of debridements Reduced healing time (compare to conventional
methods)
Minimises cross infection
Reduces treatment costs
Versajet II therapy is available in Barnsley via the Tissue Viabilty team and within the
diabetes podiatry service.
103
ACTICOAT – This dressing should only be used on wounds that
have a confirmed infection following wound swab.
TWO WEEK ONLY
Acticoat is an absorbent wound dressing that helps to maintain a moist
environment at the wound bed. It is an antimicrobial barrier dressing that
contains nanocrystalline silver.
It contains three layers; an absorbent rayon/polyester inner core sandwiched
between outer layers of nanocrystalline silver-coated, low adherent polyethylene
net.
The low adherent wound contact layer helps minimise trauma at dressing
changes.
The nanocrystalline silver provides an effective anti-microbial barrier to microbial
contamination protecting the wound from invasive pathogen and microorganisms.
The nanocrystalline silver is effective against micro-organisms in the wound,
helping reduce the risk of cross infection.
There are two presentations of Acticoat:


Acticoat – effective for 3 days
Acticoat 7 – effective for 7 days
Indications
For use on infected partial and full thickness wounds, pressure ulcers, venous
ulcers, diabetic ulcers, burns, donor and recipient graft sites and infected
wounds.
Contra-Indications
Not to be used on patients with a known sensitivity to silver.
Not to be used on patients undergoing MRI (Magnetic Resonance Imaging)
examinations.
104
Precautions
Do not use if the dressing colour is not uniform.
For external use only – DO NOT PUT INTO CAVITIES.
Not compatible with oil based products i.e. petroleum – DO NOT USE 50/50
OINTMENT.
Avoid contact with electrodes or conductive gels during electronic measurements
e.g. EEG and ECG.
Application
Remove the dressing from the packaging using an aseptic technique. Moisten
the dressing with water (tap or sterile). DO NOT USE SALINE.
Squeeze out any excess water or leave the dressing on the sterile field for
approximately 2 minutes.
Cut the dressing to the desired shape, using sterile scissors.
Apply the dressing to the wound with the blue surface as wound contact.
Secure in place with appropriate secondary dressing that will maintain a moist
wound-healing environment.
Change the dressing depending on the amount of exudate present and the
condition of the wound.
Frequency of Dressing Changes
Acticoat
- Every 3 days or sooner if exudate levels dictate
Acticoat 7
- Every 7 days
Removal
Remove the secondary dressing. Should the dressing be dry or adhered to the
wound, moisten or soak the dressing with sterile saline 0.9% or tap water, to
assist removal and avoid disrupting the healing process.
NB:
Acticoat may cause transient discolouration of the sounding skin.
ACTICOAT ABSORBENT -This dressing should only be used on
wounds that have a confirmed infection following wound swab.
105
Acticoat absorbent consists of an absorbent alginate coated in nanocrystalline
silver. The dressing is dark grey in appearance. The nanocrystalline silver
provides an effective antimicrobial barrier to microbial contamination protecting
the wound from invasive pathogenic micro-organisms.
In the presence of exudate, the alginate turns to a gel and will help to maintain a
moist wound-healing environment.
Indication
For use on infected full and partial thickness wounds, pressure ulcers, venous
ulcers, diabetic ulcers, burns, donor and recipient sites, cavity wounds and
infected wet wounds.
Contra-Indication
Not to be used on patients with known sensitivity to silver.
Not to be used on patients with known sensitivity to alginate dressings.
Not to be used on patients undergoing MRI (Magnetic Resonance Imaging)
examinations.
DO NOT USED ON DRY OR LOW EXUDATING WOUNDS.
Precautions
Do not use if the dressing colour is not uniform.
Not to be used in wounds, which are heavily bleeding.
Acticoat Absorbent is not compatible with oil-based products such as petroleum
(Do not use 50/50 ointment).
Avoid contact with electrode or conductive gels, during electronic measurements,
e.g. EEG or ECG.
Application
Remove the Acticoat Absorbent from the packaging using an aseptic technique.
Choose a dressing that is slightly larger than the wound. The dressing should
have intimate contact with the wound, ensuring the entire surface is covered. Do
no overlap onto good skin.
The dressing does not need to be moistened prior to application, (only use on
exuding wounds).
Cut the dressing to shape with sterile scissors or fold into the wound.
106
Secure with an appropriate secondary dressing.
Change the dressing as exudate levels dictate.
The dressing may be left in place for up to 7 days.
Removal
Remove the secondary dressing and gently ease off the Acticoat Absorbent. If
any areas of the dressing are stuck to the wound, soak thoroughly with sterile
saline 0.9% or tap water, to allow the dressing to be removed easily without
disrupting the healing wound.
NB: Acticoat Absorbent
surrounding skin.
may
cause
transient
discolouration
of
the
PROMOGRAN / PRISMA
Promogran is a dressing, which has a protease modulating matrix.
NB: Protease is an enzyme, which breaks down proteins, therefore
preventing wound healing if present in a wound.
The Promogran is a fibre dressing, which is a hexagon shape (6 sided), and it
comes in 2 sizes:
28 cm2 = Approximately 5.3 cm x 5.3 cm
123 cm2 = Approximately 11.1 cm x 11.1 cm
Promogran reduces the amount of the enzyme protease in the wound, so that the
healing process can progress.
Indications
The wound bed should be free of necrotic (black) and thick sloughy tissue
(yellow).
Promogran can be used on pressure ulcers, leg ulcers (both venous and arterial),
traumatic wounds, diabetic ulcers, non-healing skin graft donor sites and nonhealing surgical wounds.
Infection should be treated before using Promogran, with appropriate antibiotics
and anti-microbial dressings.
107
Application
Apply Promogran directly onto the wound bed, covering the whole of the wound.
Do not overlap onto the surrounding skin. (If the wound is dry, before applying,
moisten the dressing with saline.)
Sufficient Promogran should be applied to the wound, so that a small amount is
still present at the dressing change. (Depending on the size of the wound and
the levels of exudate.)
Promogran can be layered onto the wound under compression, for dressings that
are changed less frequently.
Promogran is a bio-degradable gel when in contact with moisture, that will
naturally dissolve into the wound.
Cover the Promogran with an anti-microbial dressing, such as Actisorb Silver 220
(Activate Charcoal Dressing with Silver) for patients who are susceptible to
infection. Or if using Prisma a secondary SIMPLE DRESSING SHOULD BE
USED.
Secure in place with an appropriate secondary dressing.
108
2.3
Pain and Wound Management
Pain relief is often considered to be of secondary importance, with emphasis being
placed upon wound healing rates, and the ease of dressings.
Although a certain amount of pain or discomfort will almost always occur whenever
the skin is damaged or traumatised, it is the responsibility of the nurse to ensure
that this is not made worse by subsequent treatments.
Pain associated with wound management can be subdivided into 2 categories: first,
the pain, which is experienced while the dressing is in place (or immediately
following its application); second, the more acute pain, which results when an
adherent dressing is removed.
Much of the pain experienced with partial thickness wounds is probably caused by
stimulation of nerve endings by localised dehydration of the area. The use of semipermeable films and hydrocolloid and hydrogel dressings, that retain moisture, can
help ease this situation.
Probably the most severe pain is experienced at the time of the dressing. Gauze
swabs (both woven and non-woven) and traditional non-adherent dressings, such
as paraffin gauze, often cause pain and trauma on removal, due to the granulating
tissue growing through the fibres of the dressings.
Some wound cleansing solutions containing hypochlorites and acids also cause
pain and discomfort.
NB:
2.4
Appendix 3 provides examples of pain control charts.
Guidelines to Selection of Equipment
2.4.1 DHSS Standard Issue Mattress (No longer purchased in Barnsley health services)
The standard mattress does not provide sufficient support for vulnerable patients.
The foam within this mattress wears very quickly. All such mattresses need to be
replaced every 5 years.
2.4.2 Vaperm, Soft Form, Pentaflex
These are examples of thicker and more expensive foam mattresses, but they have
a longer lifespan then the DHSS standard issue and provide some pressure
reduction.
Spenco, Permalux, Bodypillow, Propad etc
These mattresses are classed as mattress toppers or overlays and are placed on
top of the normal mattress. They provide comfort rather than protection and are
washable. The average lifespan of a Spenco is 2 years.
NB:
See the User Guide on the following pages for examples of use.
2.4.3 Alternating Mattress Therapy
This mattress can either be hired or purchased.
By completely removing pressure from all parts of the body, during its 7.5 minute
cycle, the mattress often reduces the need for frequent repositioning of the patient.
This will free valuable nursing time for other nursing care, whilst reducing pain and
discomfort for the patient and allowing undisturbed sleep. Alternating therapy
increases the supply of oxygen to the wound site, resulting in significant
improvements in the healing of pressure sores.
However the patient should be repositioning every 2–4 hours using 30 degree tilt
and the use of off-loading devises for the heels whilst on the alternating mattress.
NB:
See the User Guide on the following pages for examples of use.
2.4.4 Overlay Alternating Mattresses
These beds should be placed on top of a standard hospital or divan mattress and
not directly on the bed base.
-
Very few overlay alternating mattresses are left in Barnsley. A decision was made
to only purchase full mattresses 6 years ago.
NB:
See the User Guide on the following pages for examples of use.
2.4.5 Sheepskins
Sheepskins do not relieve pressure but can be very effective when used in
conjunction with other support systems, as they keep the skin dry and reduce
friction.
The patient states they offers some comfort as some alternating mattresses can
feel very hard.
2.4.6 Chair Cushions and Devices
Any patient confined to a wheelchair should have a chair cushion.
Alternating cushions are available for high risk patients – these should not be
placed in a wheelchair as mains supply is needed.
NB:
110
See the User Guide on the following pages for examples of use.
2.4.7 User Guide Pressure Reduction Equipment – Seating Systems
COMFORT
LOW RISK
MEDIUM RISK
HIGH RISK
VERY HIGH RISK
Care Lite II
Dunlopillo
Nester Cushion
Proactive II
Proactive II
Transoft Seat
Cushion
Transflo Seat Cushion
Supatec
Multi-Tec
Eclipse Alternating
Cushion
Eclipse Full Lumbar
Alternating Cushion
Vaperm Cushion
Alpha Trancell
Multi-Tec
Flotech Plus
AirWorks
CareChair
Propad
Fibre Cushion
Propad
Flotech
Eclipse Alternating
Cushion
STM 3
STM 4
Permaflow Cushion
Permaflow Cushion
STM2
Repose Contur
(recliner chair/inflateable
device)
Spenco
111
2.4.8 User Guide Pressure Reduction Equipment – Lying Systems
COMFORT
MEDIUM RISK
HIGH RISK
VERY HIGH RISK
Vaperm Mattress
Superdown Overlay
Pentaflex
Overture – Overlay
Viaclin – Overlay
Aircare – Overlay
Extracare Plus
Bi-Wave
Convertible II
Cairwave / Airwave
Unidown Overlay
Softform Mattress
Propad Overlay
Alpha Excell –
Overlay
AlphaTrancell
Autologic
Sidhill Trio
Softform Mattress
Propad Overlay
Permaflow Overlay
Memaflex Overlay
Memaflex Mattress
Eclypse Phase III
Quattro Prime
Permaflow Overlay
Transform Mattress
Medicus First Step
Mattress Topper
Transair PPS 2000
Spenco Overlay
Premier Mattress
Therapulse Pulsation
Bed System
Sheepskins
Sidhill
Plus 2
Carelite II
LOW RISK
Transform Mattress
112
2.4.9 User Guide Pressure Reduction Equipment – Specialist Beds
COMPANY
KCI
KCI
KCI
LYNETTE
TYPE OF MATTRESS
PEDICARE
Paediatric Critical Care System (Cot)
MONARCH
Low Air Loss Therapy (Bed)
MAGNUM
Low Air Loss Therapy (Bed)
LATERA
MOST SUITABLE USE

An air support surface providing pulsation therapy and
controlled air suspension therapy for paediatric patients.

Built-in digital scale for weighing patients.

Built-in heater.

Suitable for patients 18-25 stone in weight.

Provides complete pressure relief.

Built-in digital scale, for weighing patients.

Built-in heater.

Suitable for patients up to 57 stone in weight, can sit/stand
the patient unaided.

Built-in digital scale for weighing patients.

Built-in heater.


Lateral rotation bed to aid 30 degree tilt.
Suitable for patients up to 29 stones
113
COMPANY
TYPE OF MATTRESS
MOST SUITABLE USE
EGERTON
PARAGON 8000
Cardiac Bed

Able to provide the traditional cardiac posture, where the
patient’s legs fall naturally to the dependant position as the back
is raised.
EGERTON
PARAGON 5000
Air Fluidised Bed

Paragon 5000W – Wider, to accommodate the larger patient.
EGERTON
PARAGON 9000
Turning Bed

Paragon 5000L – for use when mobilising the patient or in
the domiciliary situation.

Provides extensive range of movements to facilitate the
repositioning of all patients, irrespective of how immobile, heavy,
seriously ill or severely injured.
The lists of equipment are not exhaustive, merely a selection of the various types of mattresses available.
The choice of mattress should be determined by the individual patient’s requirements and to the hirer’s preference.
This guide offers basic information only. The flow charts, see appendix 4, provide a quick guide to selecting the most appropriate
equipment.
Any other companies supplying these products will be more than happy to visit and arrange demonstrations for you.
114
2.5
Factors Affecting Healing
2.5.1 Systemic Infection
A severe systemic infection can lead to breakdown of healthy tissue. Control of
systemic infection is essential to obtain wound healing.
2.5.2 Diabetes
Diabetic patients not only have the primary metabolic abnormalities, but an
increased susceptibility to infection. Often associated with decreased vascular
efficiency.
2.5.3 Carcinoma
The poor healing ability of patients suffering from a malignancy is well recognised.
Cytotoxic therapy and irradiation affect the process of cell division.
2.5.4 Anaemia
Reduction in haemoglobin concentration decreased the capacity of the blood to
transport and deliver oxygen to the tissues.
2.5.5 Poor Nutritional State
Deficiency in essential vitamins, protein, calcium, vitamins C and A contributes to
slowing down the rate of healing.
2.5.6 Reduced Immunity
The wound healing process is slowed considerably when the patient’s immune
system is compromised by the use of steroids and cytotoxic drugs.
2.5.7 Poor Circulation
A good blood supply to the tissue is essential to the healing process.
2.5.8 Wound Contaminated by Impacted Material
Impacted material or foreign bodies present in the wound may affect healing, by
causing infection, irritation or becoming covered by granulating tissue.
The presence of dead tissue can cause secondary wound breakdown.
2.5.9 Position of the Wound
Wounds situated in difficult sites can be a problem to keep clean and free from
interference wounds in folds of skin i.e. the apron of the abdomen are suseptable to
fungal infections.
2.5.10 Local Infection of Wound
Acute local infection is visually evident with the wound being swollen, hot and
inflamed. Surrounding cellulitis may occur. If the infection is not treated
bacteraemia septicaemia and death can follow.
2.6
Medical and Surgical Measures
Pressure ulcers, their prevention and management, have historically been seen as
a nursing problem but as Section 1.1 shows, the multi-disciplinary team
demonstrates, every member of the health care team has a contribution to make.
For certain patients the involvement of the relevant responsible doctor is vital if a
ulcer is to be avoided or for healing to take place and examples of these are given
also in Part 2 Section 2.1 - General assessment of the patient, routine
investigations etc. This is particularly important consideration for patients who may
not routinely be seen by a doctor, for example patients in the community or in a
nursing home. Below are some further examples of where medical treatment
beyond prescribing is necessary.
2.7

Medical intervention in cases of locally infected ulcers, use of appropriate
antibiotic therapy etc can assist in the healing process.

Surgical debridement of necrotic tissue at an early stage can greatly hasten the
healing process.

Many ulcers can be rapidly and effectively be treated by plastic surgery if
referred early enough. Unfortunately this referral is usually left too late, the
pressure ulcer deteriorates, patients are cachexic and septicaemic and beyond
help. This is unsatisfactory, and any patient with serious pressure damage i.e.
Grade 3 or above, should be referred to a plastic surgeon at an early stage.
Transporting Patients
2.7.1 Internal Transportation of Patients
Where patients with or at risk of pressure damage are required to attend other
departments for tests, investigations etc this should be organised to address the
following:
2.7.2 Mode of Transport
A trolley may be more suitable for a patient with a pressure ulcer on their sacrum or
buttocks even though they might otherwise be considered fit to be moved in a
wheelchair. Where trolley overlays are available, these should be used for
vulnerable patients.
Wheelchairs without both footplates must not be used to transport patients. Where
a wheelchair cushion is available, this should be used.
Where patients are being moved from bed to trolley, attention should be given to
preventing shearing forces on the patients skin. Slide sheets and transfer boards
should be used.
116
2.7.3 Minimising Delays
Departments will have systems to fast-track patients with or at risk of developing
pressure damage. When arranging tests in other departments, the patient’s status
should be notified to the department concerned.
When a patient is escorted by a member of the nursing team they should ensure
that the patient receives appropriate pressure relieving care during the time spent
away from the ward. Where the care of the patient is temporarily transferred to
another department, the nurse responsible for the patient should inform the
department of the care provided.
2.7.4 External Transportation of Patients
When arranging ambulance transport for patients, the ambulance service will be
notified where the patient has, or is at risk of developing, pressure damage. The
ambulance service will be asked to supply a stretcher ambulance for all patients
with a pressure ulcer on their sacrum or buttocks or at high risk of developing
pressure damage.
If a patient is being taken to a hospital for tests, the relevant department should be
notified if the patient is at risk, to endeavour to minimise delays. Where a stretcher
overlay is used to transport the patient, this should be used on any trolley at the
hospital, where the patient is attending for tests, and returned with the patient on
the return journey.
Prior to transporting patients, the patient should be nursed wherever possible in a
position that they will not be travelling in, i.e. a patient who will travel laying on their
back, should be nursed on their side for two hours prior to the journey. On the
return to the ward/home, the patient should have their position altered again after
the journey.
The nurse escorting the patient will have continuing responsibility for ensuring that
any pressure area care required during the time away from the ward/home is
delivered.
Where a patient will not have a nurse escort, the nurse handing over care to the
ambulance service will detail the care required during the journey.
2.7.5 Patients Requiring Stretcher Overlays
When booking the ambulance for a patient with, or at risk of developing, pressure
damage, it is necessary to identify on the booking form the following information:


Patient at risk of or with pressure damage
Stretcher required, with or without overlay
This information can be recorded on the special instructions section on the form.
117
2.7.6 Action by Ambulance Crew
Upon receipt of the call, where a stretcher overlay is required, the ambulance crew
will collect the overlay from the nearest available point.
Propad overlays will be stored at:



Barnsley Ambulance Station
Hoyland Ambulance Station
BHNFT Ambulance Liaison Station
- I overlay available
- 1 overlay available
- 2 overlays available
2.7.7 Handover – Continuity of Care
The ambulance crew will be briefed by the nurse/carer of the patient’s special
needs during the journey.
2.8
Discharge and Transfer
When discharging a patient with, or at risk of, pressure damage the same principle
apply as with any discharge and transfer. Preparation and planning should begin
as early as possible in order that continuity of care can be achieved.
Information that should be notified in advance of the discharge/transfer within the
written document should include:
1.
2.
3.
4.
Patient’s risk assessment score
Grade of ulcer – Clinitron Grading System
Site(s) of ulcer
Present dressings and date last changed
If a patient requires nursing on a pressure relieving bed, the receiving area will
require sufficient notice of the discharge/transfer in order that they may arrange to
provide similar support. Also send photocopies of the Wound Assessment Chart,
Tissue Viability Advice sheet (if in use) and an Root Cause Analysis (if applicable).
2.9
Monitoring Information in Nursing Care Homes
The purpose of monitoring information is to ascertain the number of residents in
Barnsley nursing homeswith pressure damage and its origins, to identify problem
areas, implement prevention programmes – including staff training, and evaluate
the overall effectiveness of existing prevention programmes. It is not a tool to be
used punitively.
2.9.1 Prevalence Monitoring Information
The purpose on monitoring prevalence is to find out, at a point in time, the overall
number of patients with pressure damage currently being cared for by the hospital,
community services or the nursing or residential home. It will distinguish between
those admitted with pressure damage and those who developed damage since
admission.
118
Caution should be used in interpreting the latter information; a patient admitted as
an emergency having being found lying on the floor of their home, may arrive at
Accident and Emergency with intact skin. The damage to their skin however, will
have already begun.
Data will be collected twice yearly
2.9.2 Pressure Ulcer Reporting Process
All pressure damage grade II and above will be recording on an incident report via
Datix including patient admitted to your care with existing pressure damage and
patients who develop pressure damage whilst in your care. (follow flow chart on
next page).
2.9.3 R.C.A. (Root Cause Analysis)
All pressure ulcers grade III and above should have a R.C.A with action plan
completed including patients admitted with existing grade III or above and patients
who develop grade III or above whilst in your care (see following forms).
The incident report with an attached RCA should be sent via the Datix system to the
patient safety department.
119
PRESSURE ULCER REPORTING PROCESS
Patient admitted with pressure ulcer
Complete Incident Report via Datix
To include: Grade, where ulcer originated from
(if known i.e BHNFT, Care Home), site(s)
of wound, number of pressure ulcers.
Also complete Incidence Report via Datix
If patient develops pressure ulcer whilst in your care:
Date pressure ulcer identified & date of admission to your care
Responsible person to complete the
investigation report on Datix for
Grades II and above
(Ward/Unit Manager- District Nurse)
Community Patients:
With an RCA in place who are
admitted to BHNFT – Fax or Email a
copy to Ian Boldy - Safeguarding
Adults Fax No: 01226 435396
Email: ian.boldy@nhs.net
Residential patients:
Full Root Cause Analysis (RCA)
for
Grade III and above
(Sister/District Nurse)
Attach a copy of RCA
To Datrix Report
Patient Safety sends e-mail to
Lead Nurse or Matron for your area
& Lead TVN
and send copy to:
Leave a copy to be attached to
care home’s hospital admission
pro forma to take in case of
emergency admission
In-patients:
On discharge from the ward,
photocopy the RCA and send to
discharge destination i.e. Nursing
Home, Residential Home, District
nurse team etc.
Patient Safety Department
Email to
Lead Tissue Viability Nurse
Tissue viability Nurse Investigates
Patient Safety Department at
Kendray Hospital
Process new attachment
Patient Safety Department:
Provide monthly report for
Matron/District Nurse Lead & Tissue
Viability Nurse
120
2.94 Incidence & Prevalence Monitoring in Nursing Home
Monthly statistics are collected from nursing homes and returned to the Community Tissue
Viablity Service.
Root cause analysis forms will be completed for all pressure ulcers grade 3 and above by
a member of the tissue viability team.
Reporting forms for incidence and prevalence monitoring within Barnsley nursing homes
are on next pages.
121
Community Tissue Viability Service
Barnsley Business Unit
SWYPT
Mount Vernon Hospital
Mount Vernon Road
Barnsley
S70 4DP
Tel: 01226 433215
Fax: 01226 433359
DATE
Manager/s
Barnsley Nursing / Care Homes
Dear Manager
RE: MONTHLY INCIDENCE & PREVALENCE MONITORING FIGURES
Please find enclosed copy of the pressure ulcer Incidence & Prevalence forms (sheet 1 &
sheet 2).
Could you please familiarise yourself with the new forms and ensure they are completed
accurately. Residents with more than one pressure ulcer need all wounds documenting
and grading on the form.
It will be the responsibility of each Care Home to complete both forms on the
20th of each month and post them to Carmen Kilner, Tissue Viability Secretary (return
address labels enclosed).
Your PROMPT RETURN by the 25th is essential.
Failure to return this information could trigger a low level concern being raised with
the commissioners.
Yours sincerely
Lynne Hepworth
Lead Tissue Viability Specialist Nurse
122
NURSING / CARE HOMES
INCIDENCE & PREVALENCE MONITORING - Sheet 1
PRESSURE DAMAGE
MONTH COMPLETED: …………………………………………………………….
COMPLETED BY: …………………………………………………………………..
CARE HOME: ………………………………… Tel No: ………………………….
A
Number of nursing residents in the care home
B
Number of nursing residents AT RISK
(i.e. Norton Score 14 or below or Waterlow 10 or above)
C
Number of nursing residents at risk WITHOUT
Pressure Damage
D
Number of nursing residents at risk WITH Pressure
Damage
 Check FORMULA - Add C + D should = B
E
Number of nursing residents who developed Pressure
Damage whilst in YOUR NURSING CARE
Please complete an incidence form for grade ΙΙ and above and submit
the form to your care home manager
Please complete sheet 1 & 2 on the 20th of each month and post both sheets
to the Tissue Viability Office by the 25th of each month.
Many thanks
Lynne Hepworth
Lead Tissue Viability Nurse Specialist
Tel: 01226 4332
123
INCIDENCE & PREVALENCE MONITORING
PRESSURE DAMAGE – TISSUE VIABILITY INFORMATION - Sheet 2
Please complete and enter all patients with any pressure damage or pressure care intervention.
All pressure ulcers need documenting as some patients may have more than one pressure ulcer.
Form completed by: ……………………………
NHS Number
Residents
Initials
D.O.B
SEX
M/F

Care Home: …………….…………………..
Pressure ulcer
present on
admission to care
home
Date pressure
ulcer occurred
Site of pressure
ulcer
Grade of
pressure
ulcer
Month end: ………………
Reposition
chart in place
Y/N
Frequency
of
re-positioning
Name of mattress
in use
Y/N
Please keep a photocopy of this form for your record
124
PART 3
POLICIES FOR SPECIALIST AREAS
Ambulance Services
Education and Training
Equipment
Assessment of the Patient’s Risk
Transferring Patients
General Prevention Measures
Accident and Emergency Department
Assessment
Equipment
Trolley Patients
Incontinence
Specific Nursing Action
Transfer/Liaison with other Departments
Wards
Transfer to other Hospitals/Nursing Homes
Staff Training/Introduction
Operating Theatres
X-ray and Departments
Patients with Spinal Injuries
POLICIES FOR SPECIALIST AREAS
3.1
Ambulance Service
3.1.1 Education and Training
There will be a staff education and training programme, which covers the
following areas:
 Lifting, moving and positioning of patients to prevent damaged to their skin
 Assessment of the patient and their risk of developing pressure damage
 Prevention of pressure damage through identification of contributing factors
and action, where possible, to minimise or remove these contributing factors
3.1.2 Equipment
Pressure relieving equipment and aids should be of proven effectiveness. The
Department of Health Medical Devices Directorate evaluates pressure relieving
equipment and produces reports available free to the NHS.
Pressure relieving equipment and aids will be cleaned, maintained and replaced
in accordance with the manufacturer’s instructions.
3.1.3 Assessment of the Patient’s Risk
Patients’ whose first contact with the health services is with the ambulance
service e.g. as a result on a 999 call, will have their risk of developing pressure
damage assessed using the Modified Andersen Pressure Risk Screening system.
The ambulance staff will document the Modified Andersen score and will
communicate this to the receiving hospital staff, along with any other contributory
factors, e.g. the situation and position that the patient was found in.
3.1.4 Transferring Patients
Patients being transferred from one health care unit to another, either
permanently or for investigations, should have their risk of pressure damage
noted to the ambulance services at the time of booking the ambulance.
When arranging ambulances for at risk patients, the ambulance service will
endeavour to minimise delays in transporting these patients.
Where stretcher overlays are available, these should be used for vulnerable
patients.
127
Where a nurse is escorting a patient, the responsibility for ensuring appropriate
care for the patient to prevent further or new pressure damage will rest with the
nurse. The ambulance service will cooperate with the nurse to provide that care
and will ensure that when moving or positioning the patient, due regard is given to
preventing skin damage.
Where a patient is to be transferred without a nurse escort, particularly where the
journey time is in excess of 2 hours, it is the responsibility of the nurse handing
over care to the ambulance service to detail the care required by the patient
during the journey. This will include positioning, easing of pressure areas and
how frequently this will be required.
(See Section 2.7 – Transporting patients with pressure damage)
3.1.5 General Prevention Measures
For all patients being transferred by ambulance, certain simple measures can be
taken in order to minimise new or further pressure damage:

Remove wet clothing, where possible

Ensure the patient is not lying on creased linen or clothing. Re-position
clothing to ensure that zips etc do not lie beneath the patient. Items in
trouser pockets, such as keys, should be removed.

Ambulance stretcher covers that have ironed-in creases, darns or patches
should be rejected and returned to the laundry for re-laundering or disposal,
as appropriate.

Use pressure relieving aids where available.

When lifting or moving, always ensure that the patient is lifted clear of the
surface beneath them to prevent shearing forces on their skin.

For patients undergoing long journeys, without a nurse escort, the protocol is
a basic guide to care (See Appendix 2). The ambulance crew should,
however, always obtain advice from the nurse handing over care.
128
3.2
Accident and Emergency Department
3.2.1
Assessment
All trolley patients must be assessed for their risk of developing pressure
damage using the Anderson Score. Certain patients will always be classed at
high risk and must be attended to immediately. These patients are those who
are:




Unconscious
Paralysed
Grossly dehydrated, or
Suffering from major trauma/surgery
The assessment must be made on the Anderson scoring sheet and a report
made of the nursing action taken. Where the patient is identified as being at risk
or where existing pressure damage is found, a pressure damage prevention
programme must commence immediately.
3.2.2
Equipment
Ensure the patient is placed on a trolley with a pressure relieving mattress.
Ensure that a minimum of three pillows, are available to aid positioning.
Stretcher covers/padding should be free from creases, soiling or wrinkles.
Trolley Mattresses that are damaged must be reported and action taken
immediately. Damaged equipment or linen must not be used.
3.2.3
Trolley Patients
Remove outer clothing to prevent damaged from lying on zips, buttons etc.
Gowns must be made of soft material.
NB: Gowns should not be fastened or tucked beneath patients lying on
trolleys.
3.2.4
Incontinence
All patients who are soiled must be attended to immediately.
Patients confined to a bed/trolley should be offered bedpans or urinals as
necessary.
129
3.2.5
Specific Nursing Action
Trolley patients should have their pressure areas checked for signs of reddening
at regular intervals. Any changes should be recorded, including action taken.
Patients confined to a wheelchair due to their injury should be stood or lifted at
least every 30 minutes to relieve pressure.
3.2.6
Transfer/Liaison with other Departments
The presence of pressure damage or risk will be noted on the X-ray card and the
radiographer informed of the risk.
Patients at high risk of pressure damage should remain in the A&E Department
until the radiographer is ready for them. This will allow nursing staff to continue
pressure area care.
3.2.7
Wards
The ward will be notified by telephone of the presence of pressure damage/risk
and the relevant score.
A copy of the ‘at risk’ score and action taken will be sent to the ward.
3.2.8
Transfer to other Hospitals/Nursing Homes
When booking ambulance transport the presence/risk of pressure damage with
the relevant ‘at risk’ score will be made known. A Propad stretcher overlay will
be requested.
The ambulance crew will also be notified of the pressure damage/risk.
The receiving unit will be advised by telephone of the presence of pressure
damage/risk.
A copy of the nurse transfer form will be sent to the receiving unit or ward.
3.2.9
Staff Training/Induction
All new staff to the department will be asked to read of this policy and the system
explained to them by a registered nurse.
Staff will be expected to up-date their knowledge and attend lectures, seminars
etc when the opportunity arises.
All staff will be aware of Barnsley Hospital NHS Foundation Trust’s Moving and
Handling procedure.
130
3.3
Operating Theatres
The patient’s safety and comfort whilst in theatre is the shared responsibility of
nursing staff, operating department assistants, surgeons and anaesthetists.
Aims of the policy:

To prevent pressure damage occurring whilst the patient is in theatre

To manage the care of pressure damaged already present
131
The following guidelines will apply throughout the patient’s stay in theatre:
CRITERIA
GUIDELINES
ACTION
Waterlow Score 10+
Medium to low risk patient
Thick mattress
Heel supports
Oasis pressure pad
Waterlow Score 15+
High risk patient
Thick mattress
Heel supports
Oasis pressure pad
Other risk factors
Eczema, ulcers, dry fragile Thick mattress
skin or long-term steroid Heel supports
therapy
Oasis pressure pad
Position on theatre table
other than supine
Lateral
Thick mattress
Heel supports
Oasis pressure pad
Lithotomy/ Lloyd Davies
Thick mattress
Padding around ankles
and feet or jelly
stirrups
Oasis pressure pad
Prone/knee chest
Thick mattress
Heel supports
Pillows to support
chest
Induced hypotension
Patients at risk due
decreased vascularity
extremities
to Thick mattress
to Heel supports
Oasis pressure pad
Pressure sores present
Named nurse on ward to Check
adequate
write sites of sores on protection
before,
theatre check sheet
during
and
after
operation
Thick mattress
Heel supports
Oasis pressure pad
132
3.4
X-ray and Departments
The patient’s safety and comfort whilst in the X-ray Department is the
responsibility of the radiologists, radiographers and assistant radiographers,
nurses and portering staff.
It is the responsibility of the ward or department that is sending the patients for an
x-ray to identify patients already with pressure damage or those who are at high
risk of developing pressure damage, this will be done by marking the x-ray card
with a red dot in the top right hand corner.
For all patients, friction should be avoided when transferring patients from the
trolley, bed or chair to the x-ray table. Patients should be lifted onto the table or a
patient slide used as appropriate.
X-ray staff should ensure that patients are not left on the x-ray table for long
periods without pressure damage protection.
Patients with damage or at risk should be given priority by portering staff to
ensure a speedy return to the ward.
3.5
Patients with Spinal Injuries
The care required by patients with spinal injuries, who are being transferred to a
specialised unit is as follows:

When requesting an ambulance, request a stretcher overlay and scoop
stretcher.

Immediately it is known that the patient is to be transferred, he/she should
be nursed on their side for a period of 2 hours or until the ambulance
arrives.

Once the patient is on the ambulance stretcher, the traction cord should be
tied to the stretcher handle and removed on the scoop leaving the patient
resting on the stretcher overlay for the duration of the journey.
133
PART 4
LEG ULCER GUIDELINES
4.1
Treatment for Venous Leg Ulcers
4.1.1
4.1.2
4.1.3
4.1.4
4.1.5
4.2
Leg Ulcer Assessment
4.2.1
4.2.2
4.2.3
4.2.4
4.2.5
4.2.6
4.3
Leg Ulcer Assessment, Including Doppler
Compression Bandaging
Patient Education
Diet
Exercise
Medical History
Limb Assessment
Doppler
Pain Control
After Care
Leg Ulcer Assessment Form
Compression Therapy
4.3.1
4.3.2
4.3.3
4.3.4
4-Layer Bandage System
Reduced Compression
Bandage Types
Compression Hosiery
4.4
Leg Ulcer Referral Route
4.5
Differential Diagnosis
4.6
General Advice Leaflet
4.7
Advice for Healing Leg Ulcers
4.1
Treatment for Venous Leg Ulcers
To reduce/reverse venous hypotension by supporting the superficial venous system
and increase the flow of blood back up through the deep veins.
4.1.1 Leg Ulcer Assessment, Including Doppler
All wounds on the lower leg that remain non-healing, no later than 6 weeks should
have an initial full assessment, if not showing signs of healing after 12 weeks,
repeat.
4.1.2 Compression Bandaging
If no cellulitis in the skin, 4-layer is the first choice for achieving graduated
compression. Important to measure the leg to get correct size of bandages, and to
assist shaping the leg using wool bandages to achieve a graduated shape.
4.1.3 Patient Education
Give the patient verbal and written information.
4.1.4 Diet
Advise a healthy, well balanced diet that includes proteins, vitamins and minerals
e.g. meat, fish, fresh fruit and vegetables and milk.
If the patient is overweight advise to try and lose some weight, involve dietician via
GP if necessary.
4.1.5 Exercise
Advise against standing for long periods, walking is good exercise.
When resting advise to try and elevate legs, preferably heart level or above.
Advise not to cross legs when sitting and not to wear tight fitting shoes or socks.
Advise exercising the ankle and rotating the foot to aid the calf muscle pump action.
4.2
Leg Ulcer Assessment
(To Be Carried Out On All Lower Leg Wounds Of 6-Weeks Duration Or More)
4.2.1 Medical History
Medication, diet, family traits (if parents had ulcers), lifestyle, any underlying
disease or allergies.
135
Underling conditions such as malnourishment, anaemia, thyroid problems, obesity,
diabetes, rheumatoid arthritis, hypertension, varicose veins should be treated if
possible; if not ulcers will not heal or will be very slow to heal.
Other conditions that should be identified are coronary heart disease, stroke,
claudication and TIA as these help to identify the type of ulcer i.e. venous, arterial or
mixed.
4.2.2 Limb Assessment
Is the leg warm/cold, hairless, shiny? Is oedema present (if yes, when and type)? Is
there staining, eczema, induration or ankle flair? Is the leg painful, if so, when
day/night, resting active?
4.2.3 Doppler
Should confirm interpretation of other information. If APBI <0.8 compression
consult TV team. Refer to GP for vascular assessment. Treat the wound without
compression, until another opinion is obtained.
Listen to the arterial sounds during the assessment, Triphasic, Biphasic or
Monophasic. Triphasic sounds are healthiest, Monophasic indicate some arterial
disease.
4.2.4 Pain Control
Very important, pain can restrict movement.
Pain control is essential for
compliance. In some cases (e.g. severe arterial disease) the patient may require
regular analgesics for pain relief. Also consider other comfort actions, such as
footstool, bed cradle.
4.2.5 After Care
When the wound is healed, it is important to prevent recurrence. Verbal and written
information, on care of legs should be given. Compression hosiery should be
worn. Prescriptions should be issued for 2 pairs every 6 months.
Annual Doppler test to check ABPI. Advice on the use of emollients and skin care
to prevent tissue breakdown.
136
TISSUE VIABILITY SERVICE - LEG ULCER ASSESSMENT side 1
Patient No:
NHS No.
Date:
Surname :
Title:
Forenames:
D.o.b:
Sex: M / F
Medication:
Allergies:
Urinalysis:
Current Treatment:
MEDICAL HISTORY
HEALTH PROMOTION (tick, cross or circle)
MI
Weight Management Advice:
CVA
Height:
Weight:
TIA
Claudication
Mobility: walks freely / walks with aids / exercise
Previous Arterial Surgery
Substance misuse:
Diabetes
Alcohol units per week:
Arthritis
Leg Oedema
Pulmonary Embolism
Personal Hygiene:
Continence Issues:
Communication Issues:
Previous DVT
Pain score:
Thrombophlebitis
Where do you sleep? Bed / Chair
Lower Leg Fractures
Day …… Night ……. Resting …..
Do you Smoke? Yes / Previously / Never How Many per day?
Previous VV Surgery
Comments:
VV’s present
Lipodermatosclerosis
Number of pregnancies
DOPPLER ASSESSMENT
Blood Pressure:
Right
Leg
Left
Leg
Please record results using the
following codes:
T - Triphasic
B - Biphasic
M - Monophasic
RIGHT
Result
Ankle
(cms)
Gaiter
(cms)
Calf
(cms)
Brachial Pulse
Ankle
movement
Full
Restricted
Fixed
Ankle Brachial Pressure:
ABPI
Index:
T
LEFT
B
M
Result
T
B
M
Dorsal Pedis Pulse: DPP
Posterior Tibial Pulse:
PTP
NORMAL RANGE ABPI = 0.8 TO 1.3
137
POSITION OF ULCER (Indicate by Numbers) side 2
Ulcer Number
1
2
3
4
5
6
Ulcer Site
Duration of present ulcer
(months)
Size of Ulcer
Appearance:
Sloughy
Granulating
Epithelialising
Depth:
Superficial
Deep
Skin:
Normal
Eczema
Dry
Eczema
Wet
Maceration
Cellulitis
Summary of Causes - please circle
Venous
Arterial
Arthritic
Vasculitic
Diabetic
Obesity
Trauma
Malignancy
Frailty
Poor Mobility
Other ..................................................
RECOMMENDED TREATMENT………………………………………………………………….
ADDITIONAL INFORMATION ……………………………………………………………
138
4.3
Compression Therapy
Compression can be applied to a leg ulcer when there is no history of arterial disease.
Be aware of conditions that can indicate arterial disease, e.g. CVI, heart disease,
severe heart failure, claudication, MI, rheumatoid arthritis, diabetes, Raynaud’s disease,
sickle cell anaemia. Do not apply compression if cellulitis is present.
If applying compression for the first time, written and verbal instructions should be given
so that the patient will know how to remove the bandage if the toes should become
numb or discoloured and how to contact the nurse if needed. There should be a followup visit from the nurse within 24 hours to check for any problems.
Record wound progress every 4 weeks on Wound Assessment Chart. If not showing
signs of improvement, check for systemic infection, i.e. pain, heat, inflammation,
swelling then treat, if necessary.
If not showing signs of infection, with the GP’s permission, take blood samples for FBC,
U&E, TFT, RBS, check for compliance and continue to compress. Also check if patient
is sleeping in bed at night.
If no improvement at 12 weeks, refer to the TV Nurse for further investigation.
4.3.1 4-Layer Bandage (long stretch)
Contact layer - Non-adherent dressing
Layer 1 - Orthopaedic wool to protect the limb, spiral toe to knee. Bony prominence
padded and leg shaped with the wool to provide shape to give graduated compression.
Use a tape measure to ensure the calf circumference is 10cms greater than the ankle
circumference. 2-3 rolls of wool may be needed (or even more).
Layer 2 – Crepe, or light support equivalent bandage over the wool layer toe to knee
with 50% overlap spiral.
Layer 3 – Class 3a bandage toe to knee, 50% overlap, 50% stretch in a figure of eight.
Layer 4 – Cohesive layer, toe to knee, 50% overlap spiral.
NB:
Never apply compression before assessment.
suspected, refer as appropriate.
If arterial disease is
4.3.2 Reduced Compression
If patients are referred out of hospital on reduced compression therapy, ensure clear
instructions are given regarding bandaging techniques (i.e. 3 Layer top spiral or figure
8).
139
4.3.3 Bandage Types
Retention Bandages
Keeps dressings close to the wound without inhibiting movement or restricting blood
flow. They are available in widths of 5cm, 7.5cm, 10cm and 15cm. Some of those
commonly used are Slinky, Kband, Acti-wrap, and Easyfix.
Light Support
Used to support mild sprains and joints. There is no evidence to support the
effectiveness, however, they do provide light support without exerting undue pressure.
Available in widths of 5cm, 7.5cm, 10cm and 15cm. Bandages in this range are Crepe,
Soffcrepe, Setocrepe, Hospicrepe, Klite, Profore 2 and Clinilite.
Type 3A Compression
Used to give light compression for varicose ulcers, used for reduction of oedema.
Available in 10cm and 15cm. Bandages in this range are Elset, KPlus, and Profore 3.
Type 3B Compression
Used to provide support in sports injuries or as a secondary securing bandage e.g. over
zinc bandages in the treatment of venous ulcers. Can cause skin reactions if next to
the skin, if too tight, it can create a tourniquet effect. Not to be used with arterial ulcers.
Available in widths of 2.5cm, 5cm, 7.5cm, 10cm and 15cm. Coban, Cohfast, Co-plus,
Ko-flex, Profore 4.
Type 3C Compression
High compression used in venous insufficiency, venous leg ulcers and gross oedema in
an averaged sized person. Require skill to achieve graduated compression. Not to be
used if arterial insufficiency suspected. If applied wrongly, it can cause severe,
sometimes irreversible damage to the limb. Only available in 10cm widths. Setopress,
Tensopress, Surepress, Profore+, K-type C.
Type 3D Compression
Extra high compression, must never be used routinely, it can only be used in extreme
cases, under specialised supervision. Mostly with the largest and most oedematous
limbs. Available in 7.5cm and 10cm. Blue Line Webbing, Red Line Webbing.
Short Stretch Sustained Compression Bandage
Short stretch bandaging is used to provide sustained compression therapy in the
treatment of venous leg ulcers. More commonly used in Europe than in Britain at the
moment.
It works by maintaining a position as the calf muscle expands and because the
bandage does not give way, force is directed back to the leg where it can act more
effectively on the deep vein. It must never be used on patients who have marked
arterial problems.
140
Advantages

Easy to apply with little training – bandage is applied at full stretch.

Low resisting pressure therefore tolerated better for patients who find difficulty
coping with compression bandages.

Shoes usually fit over the bandage.

The patient can often apply the bandage themselves when shown how.

Not as hot to wear as the 4-Layer bandage.

No rubber in the bandages.

Safer in ulcers of mixed aetiology as there is little residual compression when the
leg is at rest, provides low resting pressures.
Disadvantages

Can slip down, particularly after the first 24 hours, when oedema is reduced by
the compression.

Usually requires the patient to be ambulant to achieve the massage effect of the
bandage.
Short Stretch Bandage - available on prescription





Actiban
Actico
Comprilan
Rosidal K
Silkolan
High compression cotton bandage
High compression cohesive bandage
High compression cotton bandage
High compression cotton bandage
High compression cotton bandage
Two layer bandage systems
Giving 40mmHg at the ankle



Easy to apply
Cool for the patient
Shoes usually fit over the bandages
Systems Available:



Coban 2
K-Two System
Proguide
Two-layer Bandage Systems
Systems available for reduced compression.
Coban 2 little (for ABPI as low as 0.5)
K-Two (Reduced)
141
Multi-Layer Compression Bandaging
Profore System (Smith & Nephew)





NB:
Tricotex contact layer
Profore 1
Profore 2
Profore 3
Profore 4
Softban natural
Soffcrepe 25cm – 30cm
Litepress
Coplus
Kit Sizes available
18cm – 25cm
above 30cm
(The bandages will
vary in each kit)
Profore System should be ordered by ankle circumference.
System Four (Molnlycke)





Setoprime primary dressing
4#1
Softexe
4#2
Setocrepe
4#3
Elset
4#4
Coban
Only in 18cm - 25cm
ankle circumference
Ultra Four (Robinson)





NB:
Setoprime
Ultra Four #1
Ultra Four #2
Ultra Four #3
Ultra Four #4
contact layer
Sohfast
Reduced compression
K-Lite up to 18cm
K Plus 18cm – 25cm
Cohfast
Ultra Four should be ordered by ankle circumference.
K-Four (Urgo)





Paratex contact layer
Layer #1 K-Soft
Layer #2
K-Lite
Layer #3 K-plus
Layer #4 Ko-flex
Only in 18cm – 25cm / 26 – 32 cm
ankle circumference
Proguide System (Smith & Nephew)



NB:
Foam wound contact layer
Layer #1 Proguide 1
Layer #2 Proguide 2
Kit Sizes available
18cm – 22cm
22cm – 28cm
28cm – 32cm
Ankle circumference
Proguide System should be ordered by ankle circumference.
K-Two System (Urgo)


K – Tech
K - Press
142
Coban 2 (3M)

Multilayered bandage system (One Size)
4.3.4 Compression Hosiery
TYPE
DESCRIPTION
USE
Class Light support
1
Compression at ankle 14-17 mm/hg
Available below knee or thigh length
Made to measure
Available on FP10
Superficial or early varicosities
Class Medium support
2
Ankle pressure 18-24 mm/hg
Available below knee or thigh length
Made to measure (closed heel/open
toe)
Varicosities of medium severity,
prophylaxis and treatment of ulcers
and mild oedema
Class Strong support
3
Ankle pressure 25 – 35 mm/hg
Available below knee or thigh length
Made to measure
Available on FP10
Gross varicosities, post thrombotic
venous insufficiency, gross oedema,
ulcer treatment and prophylaxis.
Two Layer Hosiery for Treating Ulceration (instead of multi-layer bandages)
NAME
Activa Leg Ulcer Kit
Jobst Ulcercare (with
MANUFACTURER
Activa
AMOUNT OF COMPRESSION
AT THE ANKLE
40 mmHg
BSN
40 mmHg
Convatec
35 mmHg
zip)
Surepress
Light Compression Hosiery (10 mmHg liner stockings)
For patients who have difficulty applying class Ι or ΙΙ stockings or who need less compression.
Activa Liner Stockings
Giving 10 mmHg at the ankle in sizes – Small, Medium, Large, X Large and XX Large.
Two of these stockings can be worn together on one leg where patients have difficulty
applying Class ΙΙ hosiery, giving 20mmHg at the ankle
143
4.4
Leg Ulcer Referral Route
Clinical assessment indicates
varicose disease. Doppler index 0.8
or above. Treat as venous for 12
weeks.
Assessment and clinical
investigations should be undertaken
by a healthcare professional, trained
in leg ulcer management.
Clinical assessment indicates
diabetic ulcer NB: ABPI may by
unreliable in this group of patients.
Review Leg Ulcer
Clinical assessment suggests arterial
disease, Doppler index below 0.8.
Routine vascular referral. No
compression. Below 0.6 requires
urgent referral
If not already been screened, then
refer to diabetes centre for foot
screening. No compression to be
used until peripheral vascular status
has been confirmed.
If definite signs
of
improvement
continue and
review monthly
Ulcer healed –
re Doppler and
arrange
compression
hosiery and
aftercare
Annual
re-assessment
and Doppler
No improvement
Full re-assessment
and Doppler to identify
reason for nonhealing. Refer to
beginning or TV Nurse
NB:
Check list for re-assessment
If ulcer is not showing definite measurable progress towards
healing consider:
1.
Bandage – is sufficient graduated compression being
achieved?
2.
Is leg being appropriately elevated?
3.
Dressing – is it appropriate?
4.
Has general health/mobility altered?
5.
Has ulcer developed arterial component?
6.
Consider dermatology referral for non-responding
ulcers/non-responding eczema cellulitis.
7.
May need to consider specialist referral in cases of
rheumatoid disease.
144
4.5
Differential Diagnosis
VENOUS
ARTERIAL
Site
Usually gaiter area
Anywhere on lower leg
Shape
Usually shallow, flat margins,
irregular shape
Often deep punched out edges
Pain
Some, often relieved by rest
Oedema
Generalised
Greater at night. Relieved by
lowering leg
Claudication on exercise
Localised
Varicosities
Sometimes
Never
Surrounding skin
Venous eczema,
Lipodermatosclerosis, atrophy
blanche, ankle flare, staining
Shiny, hairless, pale cold blue
feet, dependent rubor
Pulses
Present
Absent or diminished
ABPI
Greater than 0.8
Less than 0.8
Mixed
Mixed ulcers can be defined as being of both venous and arterial
aetiology. A mixed ulcer involves venous and arterial
insufficiency.
GENERAL ADVICE LEAFLET
LOOKING AFTER VENOUS ULCERS
DO
1.
Walk or exercise if possible as this improves the blood flow around
the body. Gentle ankle exercises when sitting help to improve
blood supply to legs and feet eg:
i) Rotate ankles in circular motion clockwise and anticlockwise
ii) Pump your calf muscle by pointing toes and then bringing foot
back to a right angle with your leg.
2.
Rest during the day for a couple of hours – raise legs so that ankles
are level or above your heart to help blood return to the heart and
to help reduce any swelling
3.
Eat a healthy balanced diet – this will help healing
4.
If overweight, try to lose weight, ask your nurse or
G.P. for advice.
5.
If you smoke, try to reduce the number per day or stop smoking
6.
Look after your skin, apply creams if prescribed
7.
Examine your legs and feet regularly, look for changes in colour or
any new sores
8.
Wear comfortable shoes
9.
Avoid extremes in temperature i.e. hot baths, hot water bottles
or extra cold things
10.
Keep bandages on. They are meant to feel firm but comfortable.
If worried about them, contact your district nurse for advice
11.
When you are healed, you will probably be prescribed and fitted
with support socks as prevention is better than cure.
BARNSLEY PCT (N
DON’T
1.
2.
3.
4.
5.
Do not wear tight shoes or socks
Do not cross your legs
Do not stand for long periods of time
Do not ignore sores or any changes to legs/feet
Do not remove dressings, contact your nurse if worried
CONTACT NUMBERS:
Tissue Viability Nurse: ……………………………………………
Your District Nurse/Practice Nurse: ……………………………..
146
PATIENT ADVICE LEAFLET
“prevention is better than cure”
COMPRESSION STOCKINGS/SOCKS
1.
It is very important that you take special care of your legs and wear the
stockings that have been prescribed for you. These will keep the circulation
working well in your legs and hopefully prevent your legs from swelling. If not, you
are at risk of skin breakdown or the start of an ulcer.
2.
The stockings should be comfortable but have to fit firmly and need to
every day.
be worn
3.
If you take them off for bed, you need to put them back on first thing in
morning before your legs have time to swell.
the
4.
Your stockings should fit smoothly along your leg and have no wrinkles
creases. Never turn them over at the top
or
5.
Renew your stockings every 3 – 6 months depending on the manufacturer’s
instructions, sooner if they no longer fit firmly and comfortably, or if they become
laddered.
6.
Wash your stockings gently as directed by the manufacturer.
Avoid detergents or fabric softeners which may irritate your skin.
Do not use direct heat or tumble dry, do not iron them.
HOW TO PUT ON STOCKINGS /SOCKS
1.
2
3.
4.
5.
Turn stocking inside out up to heel
Pull foot of stocking over your foot
Gradually ease stocking up over heal and ankle
Ease rest of stocking up the leg. Avoid pulling hard at the top
Check toe and ankle piece is in place
SKIN CARE ADVICE





Looking after the skin on your legs helps prevent infection and breakdown. Use
an emollient cream to moisturise your legs as shown in clinic. Many of these
creams can also be used instead of soap to wash your legs – check with your
nurse if you are not sure.
Apply any cream in the direction that hair grows, this prevents build up of cream
at the root of the hair.
Avoid injury – knocks, scratches, insect bites etc.
Do not sit too close to the fire.
Contact your nurse or doctor if there is any damage or irritation or if the skin
begins to break down again.
147
EXERCISE
Walking (if possible) improves the blood flow around the body. Gentle exercises when
sitting help improve the blood supply to the legs and feet eg:
i)
ii)
rotate ankles in circular motion clockwise and anticlockwise
pump your calf muscle by pointing your toes and then bringing foot
back to a right angle with your leg.
REMEMBER EVEN SMALL MOVEMENTS ARE BETTER THAN NONE
ELEVATION
Both legs should be elevated regularly.
They need to be at least level with your heart to have a good effect.



Lie down on your settee or bed with your legs raised on a pillow.
Do not wear tight garters, socks or shoes which could restrict the blood flow
Do not stand still for long periods of time or sit with legs crossed as this will
interfere with the blood flow to and from your legs.
DIET


Eat a healthy balanced diet. Ask your nurse if you need advice.
Drinking plenty of fluids, especially water each day will help to prevent skin
becoming dry.
Contact your nurse or doctor:
1.
If you notice any signs of a new ulcer developing or if you notice pain, when
walking or cramp type symptoms.
2.
To arrange a repeat doppler test in 12 months time
(telephone - 01226 433215)
CONTACT NUMBERS:
Your District Nurse: ……………………..
Your Practice Nurse: ……………………
Tissue Viability Office: 01226 433215
148
PART 5
SKIN TEARS
5.1
Definition
5.2
Risk Factors
5.3
Common Precipitating Causes
5.4
Dressings
149
5.1
Definitions
A skin tear is a traumatic wound that occurs principally on the extremities of older
adults as a result of friction alone or shearing and friction, which separates both the
epidermis and the dermis (partial thickness wound) or which separates both the
epidermis and the dermis from underlying structures (full thickness wound).
5.2
5.3
5.4
Risk Factors

Advances age

Dependence for activities of daily living, including bathing, dressing and
Transferring

Impaired mobility and confined to bed, chair or wheelchair

History of previous skin tears

Compromised nutritional status

Sensory and cognitive deficits

Visible changes in skin including serule purpura, dryness, pitting, oedema
and fragility

Drugs such as corticosteroids and anticoagulants

Agitated behaviour in the elderly

Cardiac, pulmonary and vascular disorders
Common Precipitating Causes

Knock or bump into bed rail, other furniture or equipment

Transfers from beds or charts

Falls

Use of restraint

Removal of tape or adhesive dressings and taking blood

Staff jewellery, watches, fingernails (see uniform policy)
Dressings
Skin closure strips are not always successful due to swelling, especially on
elderly skin.
Avoid where possible on the elderly
150
Appropriate dressing will vary depending on classification, exudate amount, skin
fragility and individual patient factors.

Cleanse to remove residual clot or debris

Replace and secure skin flap where present

Cover with appropriate dressing
151
APPENDICES
Appendix 1
300 Tilt – A Pressure Relieving Position
Appendix 2
Basic Care Guide for Patients undergoing Long Ambulance Journeys
Appendix 3
Pain Control Charts
Appendix 4
Guide to Equipment Selection Flow Charts
Appendix 5
Nutrition and Pressure Damage
Appendix 6
Wound Assessment Chart
Appendix 7
Pressure Ulcer grade III and IV Root Cause Analysis (RCA)
152
Appendix 1 - 300 Tilt – A Pressure Relieving Position
The most important measure for preventing pressure damage is to avoid pressure of the
tissue to excessive concentrations of pressure.
A simple and cheap method of achieving this is done by using three extra pillows in the
bed to maintain a 300 tilt of the patient’s body in relation to the surface of the bed. This
position is particularly useful for patients being nursed in the community as it can be taught
to carers.
The need for “turning” is reduced to a tilting from one side to the other, totally avoiding
weight transmission through the bony prominences, using the soft gluteal mass instead.
Turning a patient over no longer requires the carer to take the patient’s weight, as the
patient is eased from one side to the other rather than being lifted and turned.
The period between changes of position can be extended for up to 8 hours * allowing a full
night’s sleep for both patient and carer, although a 4 hour * period is more normally used,
where no special mattress is available.
(This method was developed in 1981 in a YDU in Lincoln and has since been advocated
by Ken Preston – a Nurse Specialist in Pressure Area Prevention.)
*Careful,
ongoing assessment of the patient is required to ensure that they can be safely
left in one position for extended periods without damage to the skin.
An illustration of the 300 tilt is on the next page.
153
Appendix 1 - The 300 Tilt - A Pressure Relieving Position
To be scanned
The pillows can be
positioned on either
side of the patient and,
if positioned correctly,
the patient can be
safely left up to four
hours*.
The pillows should be
positioned so that the
patient is lying 300 from
flat and weight is taken
through the fleshier
areas, such as the
buttocks, but not the
bony areas like the hips
of sacrum.
*Careful,
ongoing
assessment
of
the
patient is required to
ensure that they can be
safely left in one
position for extended
periods without damage
to the skin.
154
Appendix 2 - Basic Care for Patients Undergoing Long Ambulance
Journeys
Where a patient is to be transferred without a nurse escort and the anticipated journey
time is in excess of two hours:

Obtain specific advice from the nurse handing-over, as to the patient’s individual
needs concerning positioning and re-positioning during the journey. It is important
that this advice is strictly adhered to, and in particular the recommended time
intervals for re-positioning the patient should not be exceeded.

Remove any wet clothing, where possible.

Ensure the patient is not lying on creased linen and/or clothing. Re-position
clothing to ensure that zips etc do not lie beneath the patient. Items in trouser
pockets, such as keys, should be removed.

Ambulance stretcher covers (green sheets), that have ironed-in creased, darns or
patches, should not be used.

Use pressure relieving aids where available.

When lifting or moving the patients, ensure that the patient is always lifted clear of
the surface beneath them in order to prevent shearing forces on the skin.
155
Appendix 3 - Guidelines For Using The Pain Control Chart
Patient’s Name:_____________________________ Unit No: ______________
Allergies, if any
Type of Pain



Patient’s description of the pain, and nurse’s assessment of pain, plus site and
grading.
Indicate site(s) of pain on the body chart, using letter ‘A – E’.
Grade degree of pain, for each site, using number ‘0 – 5’ (see grading scale) e.g.
site ‘A’ graded ‘3’, site ‘B’ graded ‘1’.
Example:
Date
Time
12.7.06 09.03
5
4
3
A
2
1
B
0
Action Taken




Alternative measures, e.g. change of position, relieved by food/drink, or elimination.
Diversion therapy, physiotherapy, counselling etc.
Review requirements of analgesia given.
Additional drugs required, e.g. sedatives, hypnotics, relaxants etc.
Analgesia Given

Name of drug, route and dose.
Evaluation of Drugs Given


Patient’s own evaluation of drug effect and nurse’s assessment of effect.
Review of site and grading.
Comments/Evaluation of Actions Taken
 See ‘Action Taken’
NB:
When possible it is envisaged that the chart will accompany the patient on
admission and discharge to afford continuity of care.
156
Date
&
Time
Type of Pain:
Description of site(s):
Evaluation of Drug(s)
Given
Action Taken
Comments / Evaluation of
Action Taken
Analgesia (if given)
Route / Dose
Signature
157
Appendix 3 - Pain Control Chart
Grading
Scale
Date
Time
5
4
3
2
1
0
Date
Time
5
As much pain as I
could possibly bear
A very bad pain
5
Quite a lot of pain
3
A little pain
2
No pain at all
1
Sleeping
0
4
3
2
4
1
0
158
ACUTE PAIN SERVICE OF ________________HOSPITAL
Appendix 3
Postoperative pain assessment and observation chart
Name:
Unit No:
Address:
DoB:
Consultant:
Ward:
Patients on PCA or Epidural
infusions must have
observations completed 2
hourly
1.
Respiratory rate: While the patient is at rest count the respiratory
rate for one minute.
2.
Sedation score: Look at the patient and decide which of the following
apply:
Awake
1
Dosing intermittently
2
Mostly sleeping
3
Enter score as O in graph
Only awakens when aroused
4
(1-4 below)
3.
Pain assessment score: Ask the patient “Which of the following
words describes the pain you are experiencing at the moment?”
No pain
1
Mild pain
2
Moderate pain
3
Enter score at X in graph
Severe pain
4
(1-4 below)
Time
40
39
38
37
36
35
170
160
150
140
130
120
110
100
90
80
70
60
50
40
240
220
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
Resp
Resp
IF PAIN SCORE IS 3 OR 4 REVIEW CURRENT REGIME
4
3
2
1
Nausea
Yes/No
4
3
2
1
Nausea
Yes/No
159
Appendix 3
PCAS RECORD FORM
Date:
Name:
DoB:
AM/PM Perioperative Opiates
Procedure:
Pre-Op:
Surgeon:
Per-Op:
Anaesthetist:
Recovery:
WT:
Local Block:
WD:
Unit No:
Details of PCA Infusion
Morphine ………………………… mg in 30ml syringe
Conc………………………………. mg/ml
Loading dose given……………… mg at ……………. hrs
Lockout duration…………………. (normally 5 mins)
4hr maximum dose……………… mg
Background infusion……………. mg/hr
Date
Time
Resp
Rate
Conc
Level
Signed…………………………….
Pain
0-3
IV Site
Total
Received
to Date
Nausea &
Vomiting
Seen by
Anaesthetist
Reason for discontinuation……………………………………………………………..
Amount of drug wasted………………………… Nurse’s signature ……………..
160
Appendix 3 - Nursing Observations
Nursing observations are to be recorded:

¼ hourly in recovery

1 hourly for 4 hours on Ward

4 hourly until discontinued
Respiratory Rate:

If <12 – call anaesthetist

If <8 – switch off pump and call anaesthetist
NB: Anaesthetist on call for obstetrics is also on call for PCA
Conscious Level:
0 = Unrousable – CALL ANAESTHETIST
1 = Asleep but rousable
2 = Awake but drowsy
3 = Awake and alert
Pain:
0 = No pain at rest or moving
1 = No pain at rest, slight pain on movement
2 = Some rest pain, moderate pain on moving
3 = Continuous pain, severe pain on moving
IV Site:
Ok / Inflamed (I) / Tissued (T)
Total Tries and Number Good:
Read from PCAS by pressing history button
Nausea and Vomiting
Enter N, V or O (neither)
PLEASE RETURN FLOPPY FORM TO ANAESTHETIC DEPARTMENT FOR AUDIT THANK YOU
161
Appendix 4 - Guidance For The Use of Pressure Reducing Equipment
For patients with pressure damage
Grade 1 –2


Adopt prevention plan
Reduce risk factors
- Foam mattress and cushions
- Mattress toppers
- Turning regime
NB: Alternating system may be
required
Adopt a Prevention Plan to
Reduce Risk Factors
Grade 2-3

Adopt prevention plan
- Alternating mattress i.e.
Alpha Xcell
Alphatranscell
Overture
Viaclin
Aircare
Extracare Plus
- Cushion
Foam and gel
Turning regime

Frequent position changes

Correct handling technique

Nutritional assessment

Pain control

Consider drug therapy

Continence – skin care

Pressure reducing aids
Grade 3-4

NB:
Adopt prevention plan
- Alternating mattress i.e.
Bi-Wave
Cairwave
Autologic
Eclypse Phase III
- Cushion i.e.
STM 3/4
Roho
Proactive 2
Turning regime
Eclypse Cushion
Alternating Cushion
Heel and elbow pressure ulcers may only require accessories such as heel off
loading devices and elbow supports. Pillows or Repose Foot Protectors can be
used to raise the affected limb from the bed to remove the pressure.
162
Appendix 4 - Guidance For The Use of Pressure Relieving Equipment
Low Risk
Waterlow 10 – 14
Norton 15 – 12
Medium Risk
Waterlow 15 – 19
Norton 11 – 8
High Risk
Waterlow 20+
Norton below 8
Adopt a prevention plan to
reduce risk factors
 Frequent position changes
 Correct handling technique
 Nutritional assessment
 Pain control
 Consider drug therapy
 Continence – skin care
 Pressure reducing aids
Pressure reducing aids
(No pressure damage present)
Lying Surfaces

Foam mattress i.e.
Vaperm
Key 2 Care
SoftForm
Pentaflex

Mattress toppers i.e.
Propad
Spenco
NB:
Accessories
Dermal pads
Elbow pads
Heel off loaders
Leg troughs
Repose Foot Protectors
Totally immobile patients who cannot be moved may require an alternating
system as the best preventative choice.
163
Appendix 5 - Nutrition and Pressure Damage
It is important at any age the dietary intake of any individual fulfils the nutritional
needs of that person. A regular and varied diet is more likely to fulfil nutritional
requirements. Factors, which influence and may diminish nutritional intake include
chronic physical and/or mental illness or disability, poor dentition, reduction in the
sense of taste and smell, poverty and poor social conditions. Ageing is associated
with many of these factors as well as natural changes occurring in the physiology of
the skin, the vascular system and the body’s metabolism.
Nutrients affecting the development and healing of pressure damage include protein
to maintain and regenerated body tissues, as well as carbohydrates and fats to
provide energy, protect body mass and maintain cell membranes. Vitamin C, which
is depleted in the body during illness or infection, plays a dominant role in wound
healing, being necessary for collagen synthesis. Vitamin A and Thiamine (B1) also
plays a role in collagen synthesis. Vitamin K helps indirectly by preventing internal
bleeding problems. Deficiency in zinc inhibits wound healing, while iron deficiency
anaemia leads to reduced appetite and poor wound healing.
Nutrition and Prevention of Pressure Damage

All patients/clients should be provided with a nutritionally adequate diet.

All patients/clients should be screen to identify those as risk. This screening
should be reviewed regularly, using the nutritional screening tool to assess the
Body Mass Index (BMI).

The dietician will assess those patients/clients referred requiring nutritional
intervention.

Health promotion, to encourage sound nutrition, should be carried out.

Those patients/clients who do have pressure damage should receive a diet,
which will improve their medical condition.
GRADE
0–1
Food and fluid intake should be observed referring patient/client to a
dietician if intake is inadequate.
2 and above
Following referral, an individual nutrition plan should be advised and
communicated to those concerned. The plan should give special
consideration to:
 Energy - to cover needs
 Protein - 1.2-2 g/kg body weight
 Vitamin C – Supplementation as necessary
 Zinc – to correct deficiency
 Iron – to correct deficiency
Nutritional needs can be fulfilled in different ways:
164
Normal diet
Changed to high protein/high calorie diet where someone has the
ability and appetite to consume it. Fruit juice should be encouraged
daily.
Normal/soft diet Where a patient/client’s appetite and ability to eat is limited.
and supplement
Complete liquid
When a patient/client can only take fluids via the oral or enteral route
– an individual regime being drawn up by the dietician.
Supplements available on prescription
Indications for prescribing:

Disease related malnutrition

Intractable malabsorption

Pre-operative preparation of patients who are under-nourished

Treatment for those with proven inflammatory bowel disease

Dysphagia

Continuous ambulatory peritoneal dialysis

Short bowel syndrome

Bowel fistula

Haemodialysis

Following total gastrectomy
165
Prescribable supplements
Fresubin
A balanced 1 kcal/ml liquid in carton, various flavours. Stocked by
pharmacy.
3.8g protein, 13.8g carbohydrates per 100ml
Ensure
Plus
1.5 kcal/ml liquid in 200ml cartons, various flavours.
should be used as recommended by a dietician.
pharmacy.
6.25g protein, 20.4g carbohydrate per 100ml.
Fortimel
High protein supplement, 1 kcal/ml in 200ml carton. For use only as
recommended by a dietician. Stocked by Catering Department.
10g protein, 10.3 g carbohydrate per 100ml.
Enlive Plus
1.5 kcal/ml. Various flavours. Should be used as recommended by
dietician.
Gluten, lactose and fat free.
4.8g protein, 32.7g
carbohydrate per 100ml.
Fortisip
300 kcal/ml. Various flavours. Should be used as recommended by
dietician. 6g protein, 18.4 carbohydrate per 100ml.
Fortijuice
300 kcal/ml in 200ml. Various flavours. Should be used as
recommended by dietician. Gluten, lactose and fat free. 4g protein,
33.5g carbohydrate per 100ml.
Ensure Plus
Stocked by
166
Appendix 6 - Wound Assessment Chart
Wound Assessment Chart
NAME: _______________________UNIT NO: _______________ DOB: ___________
TYPE OF WOUND: __________________________LOCATION: __________________
DATE OF ONSET: _______________________________________________________
DATE OF ASSESSMENT: _________________________________________________
SIGNATURE OF NURSE: _________________________________________________
DATE
WOUND
MEASUREMENTS
LENGTH:
BREADTH:
DEPTH:
WOUND
DESCRIPTIO
DIAGRAM
Shade area to identify sloughy
necrosis granulation
–
percentage etc.
DATE
DATE
DESCRIPTION OF WOUND BED
PRESSURE ULCER
(ONLY) GRADING
I, II, III, IV
(if pressure ulcer)
EXUDATE AMOUNT
YES/NO
Type eg serous fluid, blood,
pus,
colour eg infected
ODOUR
NONE / SOME / OFFENSIVE
SURROUNDING
SKIN
CONDITION:
COLOUR:
OEDEMA: eg pitting, leaking,
red excoriated etc.
PAIN TREATMENT
0 = NONE
INFECTION SWAB
SENT
TREATMENT
YES/SUSPECTED/NO
NO/YES/DATE:
PRESCRIBED
DRESSING
TYPE:
SIZE:
PROTOCOL
SELECTED
1 – 9 (from wound Care Policy)
DRESSING CHANGES
FREQUENCY:
PROPOSED REVIEW
DATE
DATE:
ASSESSING NURSE
SIGNATURE:
5 = SEVERE
167
Appendix 7 (1)
PRESSURE ULCER (GRADE III + IV) ROOT CAUSE ANALYSIS TOOL
Name completing this form ………………………… Date of completion ……………………….
Name:
Unit No:
D.O.B
GP:
Patient’s Address:
Date of Admission to your service / care home:
Pressure Damage Visible on Admission:
Risk Assessment Date:
Safe Guarding issues: Yes low level concerns
Risk Tool Used:
Risk Score:
Weight/BMI:
Waterlow / Norton
Medical History / Diagnosis:
Medication:
Wound Assessment Chart in place
Last date wound was assessed and
documented:
Continence Details:
Continence products used:
Nutritional Status:
Nutritional products used:
Skin Condition:
Skin products used:
168
Appendix 7 (2)
Name:
Unit No:
DOB:
Mobility:
Turning / Movement
Regime:
Date Commenced:
Equipment Used:
Date Commenced:
Type:
Static Cushion
Alternating Cushion
Static Mattress
Alternating Mattress
Heel/Elbow Protectors
Other
Patient’s Journey / Chronology of Events (last 4 weeks):
PRESSURE ULCER/S:
Date Detected:
Site
Grade:
Treatment Used:
Completed By:
IR1 Serial No: (if applicable)
169
Appendix 7 (3)
ACTION PLAN FOLLOWING PRESSURE ULCER ROOT CAUSE ANLAYSIS (RCA)
PATENTS NAME:
RECOMMENDATIONS / SOLUTIONS
UNIT NO:
ACTIONS
LEAD PERSON
DATE:
TIMESCALE
DATE
COMPLETED