Wound Management

Wound
Management
Formulary and
Educational Resource Book
Authors: Kathryn and Peter Vowden

Index
WOUND HEALING ...................................................................................................................................... 1
I. THE STAGES OF WOUND HEALING ............................................................................................................. 1
(a) Inflammatory phase: 0-3 days........................................................................................................ 1
(b) Destructive/Migratory phase: 2-5 days........................................................................................... 1
(c) Proliferative phase: 3-24 days........................................................................................................ 2
(d) Maturation phase: 24 days - 1 year................................................................................................ 2
II. GROWTH FACTORS, CYTOKINES AND CHEMOKINES AND THEIR INFLUENCE ON WOUND HEALING ................... 2
III. WOUND TYPES AND CATEGORISATION ..................................................................................................... 2
Open and closed wounds .................................................................................................................... 3
IV. FACTORS DELAYING WOUND HEALING ..................................................................................................... 3
1. Poor Circulation ............................................................................................................................... 3
2. Poor Nutrition/Malnutrition ............................................................................................................... 3
3. Drug therapy.................................................................................................................................... 3
4. Immune Response .......................................................................................................................... 3
5. Age .................................................................................................................................................. 3
6. Obesity ............................................................................................................................................ 3
7. Psychological................................................................................................................................... 3
8. Infection ........................................................................................................................................... 4
9. Moisture........................................................................................................................................... 4
10. Temperature .................................................................................................................................. 4
11. Chemical........................................................................................................................................ 4
12. Mechanical .................................................................................................................................... 4
13. Presence of Tumour ...................................................................................................................... 4
14. Local Factors ................................................................................................................................. 4
15. Smoking......................................................................................................................................... 4
16. General Factors............................................................................................................................. 5
PATIENT AND WOUND ASSESSMENT .................................................................................................... 6
PATIENT ASSESSMENT CAN BE THOUGHT OF ON FOUR LEVELS (MORISON, 1992) ........................................... 6
WOUND ASSESSMENT................................................................................................................................. 6
Assessment should include: ................................................................................................................ 6
TREATMENT EVALUATION ............................................................................................................................ 7
WOUND GRADING AND APPEARANCE .................................................................................................. 8
EPUAP PRESSURE ULCER GRADING SYSTEM ............................................................................................ 8
PLANNING CARE: WOUND BED PREPARATION ................................................................................... 9
TISSUE MANAGEMENT - NECROSIS .............................................................................................................. 9
INFECTION AND INFLAMMATION - BACTERIAL BALANCE .................................................................................. 9
Wound Colonisation and Infection..................................................................................................... 10
The use of Antimicrobials and Antibiotics.......................................................................................... 11
MOISTURE MANAGEMENT - EXUDATE ........................................................................................................ 11
EPITHELIAL EDGE - CELLULAR FUNCTION AND BIOCHEMICAL BALANCE WITHIN A WOUND ................................ 13
OTHER FACTORS THAT ARE IMPORTANT IN WOUND CARE ............................................................ 13
HYDRATION AND NUTRITION...................................................................................................................... 13
WOUND CLEANSING ............................................................................................................................... 14
INDICATIONS ............................................................................................................................................ 14
TYPES OF CLEANSING FLUID ...................................................................................................................... 14
Tap Water.......................................................................................................................................... 14
METHODS OF CLEANSING .......................................................................................................................... 14
DEBRIDEMENT OF WOUNDS ................................................................................................................. 15
DEFINITIONS ............................................................................................................................................ 15
SHARP DEBRIDEMENT ............................................................................................................................... 15
CONTRA-INDICATIONS FOR SHARP DEBRIDEMENT BY NURSING STAFF........................................................... 15
CAUTIONS FOR CONSERVATIVE SHARP DEBRIDEMENT ................................................................................. 15
NURSING PROCEDURE- RHARP DEBRIDEMENT ........................................................................................... 16
i
Bradford Wound Healing Unit 2008
THE PROCEDURE...................................................................................................................................... 16
Equipment ......................................................................................................................................... 16
Other equipment................................................................................................................................ 16
COMPLICATIONS OF SHARP DEBRIDEMENT ................................................................................................. 16
THE IDEAL DRESSING ............................................................................................................................ 17
COST EFFECTIVE WOUND CARE ................................................................................................................. 17
CHOOSING THE IDEAL DRESSING ............................................................................................................... 17
1. Maintain high humidity................................................................................................................... 17
2. Removes excess wound exudate.................................................................................................. 17
3. Permit thermal insulation ............................................................................................................... 17
4. Impermeability ............................................................................................................................... 18
5. Gaseous exchange........................................................................................................................ 18
7. Non-adhesive, comfortable and conforming.................................................................................. 18
DRESSING SELECTION FLOW CHART.................................................................................................. 19
CHOOSING A WOUND DRESSING ......................................................................................................... 20
DRESSING COST CODE ............................................................................................................................ 20
ADVANCED WOUND CARE PRODUCTS ....................................................................................................... 20
DRESSING OPTIONS ............................................................................................................................... 21
INTRODUCTION: LOW/NON ADHERENCE DRESSINGS ...................................................................... 22
N-A ULTRA ............................................................................................................................................ 23
MEPITEL................................................................................................................................................ 24
ATRAUMAN........................................................................................................................................... 25
INTRODUCTION: FILM ............................................................................................................................. 26
TEGADERM........................................................................................................................................... 27
OPSITE FLEXIGRID & OPSITE PLUS.................................................................................................. 28
CAVILON ............................................................................................................................................... 29
INTRODUCTION: HYDROGEL ................................................................................................................. 30
INTRASITE GEL/CONFORMABLE ....................................................................................................... 31
ACTIFORM COOL ................................................................................................................................. 32
INTRODUCTION: HYDROCOLLOIDS ...................................................................................................... 33
GRANUFLEX & DUODERM .................................................................................................................. 34
COMFEEL PLUS ................................................................................................................................... 35
TEGADERM HYDROCOLLOID .................................................................................................................. 36
INTRODUCTION: HYDROFIBER.............................................................................................................. 37
AQUACEL.............................................................................................................................................. 38
INTRODUCTION: ALGINATE ................................................................................................................... 39
SORBSAN ............................................................................................................................................. 40
KALTOSTAT .......................................................................................................................................... 41
INTRODUCTION: FOAM ........................................................................................................................... 42
ALLEVYN & ALLEVYN ADHESIVE ....................................................................................................... 43
LYOFOAM ............................................................................................................................................. 44
MEPILEX & MEPILEX BOARDER......................................................................................................... 45
TIELLE ................................................................................................................................................... 46
INTRODUCTION: DEODORISERS ........................................................................................................... 47
CLINISORB............................................................................................................................................ 48
ACTISORB SILVER 220........................................................................................................................ 49
METRONIDAZOLE GEL........................................................................................................................ 50
INTRODUCTION: ANTIMICROBIALS ...................................................................................................... 51
ACTICOAT ABSORBANT / ACTICOAT 7 ............................................................................................. 52
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IODOFLEX............................................................................................................................................. 53
AQUACEL AG ........................................................................................................................................ 54
ACTISORB SILVER 220........................................................................................................................ 55
FLAMAZINE........................................................................................................................................... 56
MEDIHONEY WOUND GEL .................................................................................................................. 57
INADINE ................................................................................................................................................ 58
BETADINE OINTMENT ......................................................................................................................... 59
INTRODUCTION: ADVANCED PRODUCTS ............................................................................................ 60
PROMOGRAN & PROMOGRAN PRISMA............................................................................................ 61
VACUUM ASSISTED CLOSURE (VAC) ............................................................................................... 62
LARVE (STERILE MAGGOTS)............................................................................................................... 65
XELMA................................................................................................................................................... 66
BANDAGES USED IN WOUND CARE ..................................................................................................... 67
Orthopaedic wool bandage................................................................................................................ 68
Application of compression bandages............................................................................................... 68
Compression hosiery systems........................................................................................................... 68
GUIDELINES FOR THE MANAGEMENT OF A MALIGNANT WOUND .................................................. 70
PACE GUIDELINES .................................................................................................................................. 71
GUIDELINE FOR THE RISK ASSESSMENT AND PREVENTION OF PRESSURE ULCERS ....................................... 71
GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF LEG ULCERS .......................................................... 72
MANAGEMENT OF PATIENTS WITH DIABETES (FOOT ULCERATION)................................................................ 73
GUIDELINES, POLICIES AND OTHER SUPPORTING LITERATURE ................................................... 74
GUIDELINES AND POLICIES ....................................................................................................................... 74
SPECIALIST WOUND CARE SOCIETIES AND JOURNALS ................................................................................ 74
SPECIALIST JOURNALS ............................................................................................................................. 74
REFERENCES........................................................................................................................................... 75
APPENDIX I - WOUND CARE SERVICE PROFILE ................................................................................. 80
THE WOUND HEALING UNIT ...................................................................................................................... 80
Contact details................................................................................................................................... 80
COMMUNITY TISSUE VIABILITY SERVICE .................................................................................................... 80
Contact details................................................................................................................................... 80
APPENDIX II - EXAMPLE WOUND MANAGEMENT CHART ................................................................. 81
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Wound Healing
i. The stages of wound healing
The healing of wounds can be thought of as having several stages although it must be remembered that
the process is a continuous one. Deep wounds heal firstly, through the formation of granulation tissue and
then through epithelialisation. Shallow wounds, where only the epidermis has been damaged, heal
through epithelialisation only. There are three basic phases involved in the healing process:
(a) Inflammatory phase: 0-3 days

When tissue is disrupted blood vessels are damaged and bleeding occurs into the space created.
Platelets arrive at the wound site and initiate haemostasis forming a fibrin-platelet clot. This fibrin-platelet
clot loosely unites the wound edges and prevents further bleeding into the wound, drying to forming a
scab.
Damaged tissue and mast cells secrete histamine and other local hormones and enzymes causing
vasodilatation of the surrounding capillaries. These capillaries become more permeable and white blood
cells and serum are able to pass into the damaged area. The vasodilatation and increased capillary
permeability cause the signs of inflammation; redness, heat, swelling and pain.
An influx of polymorphs and macrophages defend against bacteria, ingest debris and begin the process
of repair. A number of local and systemic factors can slow or halt this influx of white blood cells. For
example, high doses of corticosteroids such as Prednisolone can stop or slow this inflammatory response
and subsequent wound healing.
(b) Destructive/Migratory phase: 2-5 days

Dead tissue and bacteria are removed in this stage to make way for new growth. Cells in healthy tissues
are held together by proteoglycan-fibronectin cement. Where cells die due to injury, the body acts to
dissolve this intercellular cement. The liquefaction of connective tissues in order to eliminate necrotic
matter is called autodebridement and is associated with increasing levels of metaloproteases within the
wound. Macrophages migrate into the wound and play a vital role in this stage by engulfing bacteria, any
foreign bodies and necrotic tissue. With neutrophils, the macrophages attract fibroblasts and influence the
growth of new blood vessels into the wound by chemotactic activity and the release of growth factors.
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(c) Proliferative phase: 3-24 days
A semblance of order appears on approximately the third day in a healthy person. A temporary
extracellular matrix is formed which supports cell adhesion and fibroblasts function (Schultz et al 2005).
This in turn allows the development of new blood vessels. The fibroblasts begin to produce collagen, a
process that depends on zinc, oxygen and ascorbic acid. This may be deficient in some disease states
such as diabetes. Collagen strands are deposited in a haphazard way and form a fibrous network that
supports the new capillary loops. The tissue formed is called Granulation tissue. It has a moist translucent
red appearance. Signs of inflammation disappear now and the fibroblasts contract pulling the wound
edges together. There is extensive growth of epithelial cells, migrating from the wound edge and from
islands within the wound itself that bridge the wound.
Wound contraction is an important part of wound healing as it means that the body does not have to
make as much granulation tissue to fill in the wound cavity. The tensile strength of the wound is increased
during this phase of the healing process and this process continues into the next phase, the maturation
phase.
(d) Maturation phase: 24 days - 1 year

During the maturation phase there is a decrease in vascularity, shrinkage of fibroblasts and a
reorientation of collagen fibres, this changes the appearance from red granulation tissue to a pink early
epithelialisation. Finally, a white relatively avascular tissue develops, and the epidermis is restored to
normal thickness.
Wound contraction, which starts during the proliferative phase and continues into this final phase of
healing, is extremely powerful and may, in certain instances, cause deformation (contracture). The
healing process can lead to the formation of excessive amounts of scar tissue resulting in a hypertrophic
or possibly a keloid scar.
ii. Growth factors, cytokines and chemokines and their influence on

wound healing
Three major classes of soluble protein mediators, growth factors, cytokines and chemokines, are
recognised to play an important role in wound healing, acting as cell-to-cell communicators. It is thought,
for example, that growth factors produced by the various cells involved in wound healing act to
communicate with non-immune cells as to 'what to do next'. Each growth factor has a different role, for
instance Epidermal Growth Factor promotes epithelial growth. Additional information on growth factors
and other mediators is available (Shen & Falanga, 2003; Ovington & Schultz 2004). Platelet derived and
other growth factors are available as specialist wound care products. Angiogenesis stimulating factors
initiate the growth of a new blood supply for developing granulation tissue and are an essential
component in effective wound healing. The balance and effectiveness of these growth factors is
influenced by the action of a number of proteinases in the wound bed (Hart, 2002a & b).
Cytokines regulate inflammation by regulating proliferation of white cells. They may also regulate the
production of matrix metalloproteinases (MMPs) by fibroblasts. Chemokines direct the recruitment and
activation of white cells.
iii. Wound types and categorisation

Wounds were categorised by Harding (1992) into acute and chronic wounds. Acute wounds comprise
surgical, traumatic and thermal injuries where it is expected that the healing process should be uneventful
and scarring and long-term damage minimised. The patient should return to a normal lifestyle.
Chronic wounds fail to complete the healing cycle and have an impact on the patients health status and
lifestyle. Chronic wounds include malignant fungating wounds, pressure sores, leg ulcers and diabetic
foot ulcers. These wounds are the result of systemic disease processes that often require specialist
intervention, investigation and treatment of the underlying cause in conjunction with care of an open
wound. The assessment process is the key through which wound aetiology can be defined and factors
likely to delay healing identified. The assessment process has recently been reviewed by Grey et al
(2006).
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Open and closed wounds
Sutures, clips or wound adhesives bring the opposing edges of a wound together and create the moist,
warm, clean environment necessary for healing. In this situation, dressings are of secondary importance.
However, on open wounds such as abrasion, burn or pressure sores sutures cannot be used. In such
open wounds, the choice of dressing is of critical importance as it can provide the right environment to
prevent complications and optimise healing.
iv. Factors delaying wound healing

Many factors have been recognised to reduce or delay the healing potential of a wound (Troxler et al ,
2006). Dealey (1999) relates the healing potential of a wound to the activities of daily living model of
care. Mulder et al (1998) considers the physiological and biological effects of these factors on the healing
process. Bale and Jones (1997) link these factors with the physiology of wound healing and patient
assessment. The following factors are identified as some of the main causes for delay in wound healing.
1. Poor Circulation
Delayed healing and tissue breakdown is frequently associated with poor circulation and this may be due
to local pressure, vascular disease or diabetes mellitus. Vowden and Vowden (1996) discuss the
influence of peripheral arterial disease on leg ulcer healing. Mustoe et al (2006) discuss the role of
hypoxia and ischaemia-reperfusion injury in delayed wound healing.
2. Poor Nutrition/Malnutrition
Nutrition has a significant impact on wound healing (McLaren, 1992). Lack of protein will result in
insufficient building blocks for cell regeneration. Deficiency of Vitamin C - which is essential for collagen
synthesis - will delay healing. Zinc deficiency will cause slowing down of epithelialisation and collagen
synthesis. Pinchcofski- Devin (1994) provides a review of the role of nutrients in the wound healing
process. More recent reviews have been conducted by Arnold and Barbul (2006) and Posthauer (2006),
the latter publication containing an assessment quiz. Oliver (1994) highlights aspects of continued
nutritional support in the community.
3. Drug therapy
Anti-inflammatory drugs (NSAID) suppress initial inflammatory process. Systematic and topical cortico-
steroids can suppress both multiplication of fibroblasts and the immune system. Mulder et al (1998) lists
the drug types that are known to effect wound healing in addition to those listed above these include
anticoagulants, anti-neoplastic drugs and anti-prostaglandins.
4. Immune Response
Allergy to topical applications, may delay healing. Cameron (1998) highlights common allergens
associated with wound care. Irritants and allergens include lanolin (wool alcohols), topical antibiotics,
emulsifiers (such as cetyl alcohol), rubber, and the parabens group of preservatives, colophony,
fragrance mix or balsam of Peru. Simple bland preparations are recommended for patients with known
skin allergies.
5. Age
Cell replication is slower (senescence) and the skins resistance to injury decreases with increasing age.
These skin changes are discussed by Mulder et al (1998) and Bale and Jones (1997). Sorensen (2006)
found that both old age and male gender have a negative impact on abdominal wound healing.
6. Obesity
Adipose tissue has poor vascularity. No known mechanism is responsible for increased infection and
wound breakdown in obese surgical patients but these patients are at high risk of postoperative wound
problems (Mulder et al., 1998).
7. Psychological
Increases in hormone levels, particularly glucocorticoids (occurring in stress and anxiety for example)
may suppress the inflammatory phase and effect healing in both acute and chronic wounds (Kiecolt-
Glaser et al, 1995; Cole-King and Harding, 2001). Reducing stress has been demonstrated to reduce
postoperative wound infection. Increased pain levels have also been shown to impact on surgical wound
healing (McGuire et al, 2006)
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8. Infection
Local or systemic infection inhibits healing. Resistance to infection is related to physiological ability and
the patients physical health. Bacterial toxins are potent inhibitors of healing, some toxins having more
devastating effects than others. A guide to understanding wound infection is provided by Miller and
Gilchrist (1996) and Gilchrist (1999). Williams and Leaper (1998) provide a review of the pathogenesis,
host response and clinical aspects of infection. Both the diagnosis and the management of infection have
been the subject of recent EWMA Position Papers (EWMA 2005, 2006).
9. Moisture
Based on the work of Winter (1962) a moist environment allows the optimum environment for healing
(Hermans and Bolton, 1993). Epithelial cells will migrate over living tissue and this process can be
delayed by dehydration. A wound surface that has been exposed to air for a lengthy period suffers
cellular dehydration, tissue necrosis and increase in wound depth. When a wound has to be exposed for
examination by the medical staff cling film can be used to prevent dehydration and help protect and
maintain temperature (see below). Most modern dressings have been designed to allow "moist" healing.
The use of the most appropriate dressings will maintain a moist environment at the wound surface without
causing maceration of the surrounding skin. In chronic wounds exudate can be detrimental to healing.
Cherry and Harding (1997) debate the management of wound exudate, an important element of wound
bed preparation, and Vowden and Vowden (2004) discuss the importance of exudate management in
wound healing. The role of dressings in exudate management is the subject of a World Union document
(2007).
10. Temperature
o
The optimum temperature for cellular activity and division is 37 C. Frequent dressing changes and
application of cold solution and leaving the wound exposed can decrease the local temperature (Dealey,
1999). Melling and Leaper (2006) have demonstrated the beneficial effect of warming on wound healing
in surgical patients.
11. Chemical
Inappropriate use of chemicals, for example Eusol, dyes or antiseptics, can damage the wound and
retard healing. This practice should be discouraged. A review of the hypochlorite literature is provided by
Moore (1992). Antiseptic uses in wound care are discussed by Brennan and Leaper (1985) and are
debated by Scanlon and Stubbs (2002). All conclude that long-term use of these substances should be
avoided.
12. Mechanical
Unnecessarily disturbing the wound bed can damage the developing granulating tissue. Inappropriate
dressing can also damage the granulating tissue. Mechanical cleansing of the wound is not required.
Thomlinson (1997) illustrates the ineffectiveness of wound cleansing although irrigation can remove
debris derived from dressings and exudate. The use of wet-to-dry dressings is discouraged (NICE
Guidelines).
13. Presence of Tumour

Malignancy can inhibit healing as can a range of anti-neoplastic therapies. Grocott (1995a; 1995b) and
Dealey (1999) give advice on treatment of fungating wounds that are based on symptomatic control.
Previous radiotherapy may also affect local wound healing (Bullard et al 2005)
14. Local Factors

Poor surgical technique, such as over use of diathermy or poor choice of suturing material, are among
factors that will delay healing of a surgical wound (Leaper and Gottrup, 1998).
Poor assessment or some wound care practices may predispose to delayed or non-healing. Inappropriate
choice of wound dressing, the use of fibre shedding materials like cotton wool or fragments of gauze
swabs, tight bandaging on an ischaemic or diabetic limb can all lead to deterioration of the wound.
15. Smoking
Smoking has been found to have an adverse affect on the healing of acute and chronic wounds
(Sorensen, 2005). Smoking appears to increase the risk of infection and dehiscence Sorensen (2003).
This affect can be reduced by four weeks of abstinence Sorensen (2003).
4
16. General Factors
Poor assessment of the cause of the wound can lead to inappropriate treatment and this will lead to poor
healing.
Any deterioration in the patients overall health adversely affects wound healing. Poor nutrition, for
example, due to prolonged fasting or medical conditions such as oral or dental problems will adversely
affect wound healing as can immobility following a stroke.
Other medical conditions that can delay or prevent healing include diabetes, uraemia, anaemia, liver and
renal damage and various vascular and connective tissue disorders. High levels of stress (Detillion, 2004)
and poor social conditions may also affect both the incidence of chronic wounds and wound healing
(Franks, 1995).
5
Patient and Wound Assessment
Assessment should include information from different sources. It should bring together general and
specific information on the patient, the skin, the circulation and the wound itself, only in this way can an
accurate diagnosis be made, risk factors evaluated and effective treatment commenced (Vowden and
Vowden, 1998). Grey et al (2006) emphasize the importance of accurate assessment in establishing a
diagnosis, planning and monitoring outcomes.
Patient assessment can be thought of on four levels (Morison, 1992)

1. General patient factors that could delay healing
2. Immediate causes of the wound and any underlying pathophysiology
3. Local conditions at the wound site
4. Potential consequences of the wound for the individual
This should allow you to identify and record in a care plan:
1. Factors that will help formulate a treatment plan such as the general appearance of the skin,
wound pain or allergies
2. Factors that will delay healing such as general health, nutritional status, underlying disease,
medication or incontinence
3. The cause of the wound so that further problems can be prevented, such as immobility resulting
in pressure sores, venous hypertension resulting in a venous ulcer or diabetes giving rise to a
neuropathic ulcer
4. Functional and psychological factors that will result from the wound or its treatment that may
delay healing
5. The requirement for the carer in both hospital and community
The care plan should ensure the management of all factors that could influence wound healing. This may
include referral to other members of the multi-disciplinary team such as Nurse Consultant, Clinical Nurse
Specialists, Dieticians, Physiotherapists, Podiatrist, Vascular Consultant or Dermatologist
Wound assessment
Wounds are graded according to their depth and colour. For pressure ulcers use the EPUAP scale
(http://www.epuap.org/grading.hmtl). The aim of any assessment is to allow accurate grading and
description of the wound appearance. Measurement forms an important part of documentation and can
be achieved simply by the use of a tracing map. Vowden (1995) has reviewed different wound
measurement techniques. This information will enable the carer to select the correct type of dressing and
allow the progress of the wound to be monitored.
Assessment should include:

1. The general appearance of the wound
2. The size of the wound
3. The shape of the wound
4. The depth of the wound
5. The amount, type and colour of exudate
6. Wound related pain (EWMA Position Document: Pain and WUWHS 2004)
Dressing changes and wound cleansing can be painful. If the wound is painful or pain is
anticipated, prescribed analgesics should be given prior to dressing changes. If severe pain is
anticipated, Entonox may be prescribed and/ or EMLA cream may be used topically. Always
consider potential causes of wound pain:
a) Is an agent being used which is known to provoke an irritant response?
b) Is the dressing being changed too infrequently?
c) Is the wound infected?
d) Is the dressing being changed unnecessarily?
7. The condition of the surrounding skin
8. The presence of infection and details of swab results
6
This information should be recorded on a wound care assessment chart with the size and shape recorded
as a traced diagram an example assessment chart is included (Appendix 2). It is important that a date be
set for the re-evaluation of the wound and that any changes in dressing policy following re-assessment
are recorded. At discharge or transfer, all this information must be passed on to the receiving area or
Community Nurse to allow continuity of care.
Treatment evaluation
The effectiveness of treatment should be continually evaluated, both formally and informally, and
progress documented and audited. Evidence exists that hard-to-heal wounds can be recognised from
both information gained during assessment and by measuring treatment effect in terms of reduction in
wound size (Troxler et al 2006) as shown by the leg ulcer chart below.
7
Wound Grading and Appearance
EPUAP Pressure Ulcer Grading System
Grade 1:
Non-blanchable erythaema of intact skin.

Discolouration of the skin, warmth, oedema,
induration or hardness may also be used as
indicators, particularly on individuals with
darker skin.
Grade 2:
Partial thickness skin loss involving

epidermis, dermis, or both. The ulcer is
superficial and presents clinically as an
abrasion or blister.
Grade 3:
Full thickness skin loss involving damage to

or necrosis of subcutaneous tissue that may
extend down to, but not through underlying
fascia.
Grade 4:
Extensive destruction, tissue necrosis, or

damage to muscle, bone, or supporting
structures with or without full thickness skin
loss.
Reproduced from EPUAP Guide to pressure ulcer grading: http://www.epuap.org/grading.hmtl
8
Planning Care: Wound Bed Preparation
Wound documentation and observation by skilled staff are important elements of effective wound care
and the concept of wound bed preparation is a useful model to work from.
The aim of wound bed preparation (WBP), a process described by Falanga (2000), is to create an optimal
wound-healing environment. The core precept of WBP is to focus on both the wound and the patient as a
whole. This approach will frequently require a multidisciplinary and structured approach to care delivery.
The process which has evolved into the concept of TIME (Schultz 2004, 2005) is illustrated below and
has been reviewed by EWMA in a key Position Paper (www.ewma.org) :
Application of TIME to dressing selection
Although interrelated, the relative importance of each intervention will vary in each wound. Most
therapeutic actions address several of these components together.
Tissue Management - necrosis

Necrotic material, the most obvious marker of a chronic wound, can be both a focus for bacteria and a
barrier to healing. Falanga (2001) introduced the concept of initial and maintenance debridement in the
context of WBP reflecting the need to respond to a dynamic situation within the wound. Debridement,
other than with surgical excision, is rarely completed in one treatment episode; rather a mixed wound is
created with some areas still containing necrotic material and bacteria.
Infection and Inflammation - bacterial balance

5 6
A bacterial load of 10 to 10 organisms per gram in a wound bed, irrespective of the organism, will
adversely affect wound healing (Dow et al, 1999) and this can be further influenced by the synergistic
9
interaction of microorganisms. Therapy should always reflect the clinical status of the wound and not be
based on culture results alone.
Wound Colonisation and Infection
Healthy skin provides a physical barrier to bacterial invasion of underlying structures. There are three
main routes for the acquisition of bacteria by skin wounds:
Self contamination from skin or gastrointestinal tract
Airborne contamination via dust, skin squames or water droplets
Contamination by contact with clothing, equipment or the skin or carers
The criteria for identifying wound infection in a range of different wound types is explored in the EWMA
Position Document Identifying criteria for wound infection (www.ewma.org) .
Colonisation
Many wounds, especially if chronic, are colonised by a variety of bacteria including potentially pathogenic
species. These colonising bacteria may exhibit no apparent harmful effect and although many wounds
become colonised by a diverse range of bacteria, infection is not an inevitable consequence. Usually,
colonised wounds do not require specific antimicrobial therapy.
The exception to this is where the wound is covered with slough or eschar that may harbour significant
quantities of bacteria and can act as a potential focus for microbial spread. Such eschar should be
actively debrided.
To prevent the spread of microorganisms (resistant or susceptible strains), it is important that all
healthcare professionals pay particular attention to hand hygiene.
Bacterial load is seen to rise progressively between wounds with local contamination to those with overt
infection associated with systemic signs such as pyrexia or septicaemia. This is often represented as
The bacterial load escalator:
Infection
Infection occurs when microorganisms cause damage to body tissues either by their presence or through
5
the production of poisonous substances (endo and exotoxins). A bacterial load of >10 organisms per
gram usually results in infection although lower levels of virulent organisms may cause infection. A
positive swab result does not necessarily mean that a wound is infected. The wound may simply be
colonised. If a wound shows any of the following then the presence of infection requiring intervention
should be considered:
Abscess with inflammation
Cellulitis
Wound discharge which is characterised as:
o Serous exudate with inflammation
o Seropurulent (turbid serous exudate)
o Haemopurulent
o Frank pus
Pyrexia*
Raised C-reactive protein levels*
Raised white blood cell counts*
* with no other source of infection
10
The use of Antimicrobials and Antibiotics
All wounds contain microorganisms, yet the majority are, and will not become, infected. The diagnosis of
wound infection is a clinical judgement, supported by, but not led by laboratory culture results. Many
problems associated with the emergence and increased prevalence of antibiotic resistance have arisen
by the over use and misuse of antibiotics. A progressive increase in bacterial load is deleterious to a
wound and will eventually lead to overt infection. The clinical stages that should be used to determine a
therapeutic strategy have been described by Vowden and Cooper (2006)
Algorithm for managing wound infection (From Vowden & Cooper 2006)
When systemic signs of infection are present, specific virulent microorganisms known to adversely affect
the wound are identified, or the wound fails to respond to local treatment the patient may require
treatment with antibiotics as recommended by a Doctor/Consultant Microbiologists. The choice of
antibiotic should be based on microbial sensitivity testing when ever possible and should be modified
according to any known allergy.
The presence of a biofilm (a bacterial colony, which may consist of several separate strains of bacteria,
surrounded by a protective impenetrable glycocalyx) may prevent effective treatment with antibiotics
alone (Sibbald, 2001). Similarly wounds infected with resistant strains of bacteria such as MRSA may
require additional therapy. Further information on the management of infection and the use of antibiotics
can be found in the Infection Control Policy, the Guidelines for the Selection of Antimicrobials, and from
prescribing information.
Moisture Management - exudate

Moisture balance is an important element in wound healing. Acute wound fluid having a demonstrable
beneficial effect, chronic wound fluid has, in contract, an adverse effect on healing. Exudate management
consists of two related management phases; direct management such as the use of absorbent dressings,
compression bandaging and topical negative pressure therapy (VAC) and indirect management such as
control of heart or renal failure. Frequently both methods need to be combined. The following two flow
charts taken from the World Union document (2007) illustrates the management strategy.
11
12
Epithelial Edge - cellular function and biochemical balance within a
wound
Normal wound healing is highly co-ordinated with rapid choreographed changes in specific cell
populations occurring as an acute wound progresses from injury through repair and remodelling to
healing. This process is impaired in chronic wounds where the process stalls, due to either under or over
expression of building or degradative proteins (proteases) or cells at one or more stages in the healing
process. Although still experimental, modern therapy is now beginning to address this by the introduction
of substances such as growth factors, extracellular matrix replacement and protease modulators to the
wound.
Other factors that are important in wound care

Hydration and Nutrition
Many nutrients are involved in promoting new tissue formation; suppressing oxidation of tissues, free
radical scavenging and improving wound function. Adequate nutrition helps to maintain immune
competence and decrease the risk of infection.
Malnutrition often becomes worse during hospitalisation and can result in a delay in the healing process.
Patients with adequate nutritional intake before surgery have better wound healing when compared with
patients who have poor pre-operative nutritional intake (Olde Damink 1997). Early restoration of nutrition
after surgery also improves post-operative recovery and wound healing. When the diet lacks vitamins and
minerals, physiological replacement of dietary deficiency can prevent development of a full deficiency
state. However, supplementing nutrients in patients who are not clinically deficient has yet to be shown to
be effective and may be harmful (Thomas 1997).
Local policy requires the use of the MUST nutritional assessment tool to identify and monitor those
patients who suffer from, or are at risk of, malnutrition.
It is therefore important to encourage patients to have a wide and varied food intake to provide a
balanced diet to maintain body cell mass and promote wound healing.
If dietary intake is considered inadequate, record the patients food and drink intake, and refer to the
Dietician for further assessment and advice. Patients should also be referred to the Dietician if they have
lost 10% of their initial body weight unintentionally within the last month or they have a BMI of less than
17 or an MQ of less than 80. Obesity does not equate with either appropriate nutritional balance or
hydration. The Dietician will assess the patients nutritional requirement and aim to provide this by the
most appropriate method. This may involve the use of meal shakes, dietary supplements or enteral tube
or intravenous feeds. The patients ability to meet their nutritional needs should be monitored and further
action taken if intake remains sub-optimal.
In addition to nutrition, fluid balance is important. Dehydration can result in diminished healing ability
since water is a major component of healthy cells. A large wound may exudate significant volumes of fluid
that can result in electrolyte imbalance as well as dehydration. A heavily exudating wound may also delay
healing by macerating surrounding skin. When wounds are heavily exudating a cause for this should be
sought, and if possible corrected. For example, this may include the management of peripheral oedema
by compression and/or diuretic therapy.
Nutritional status should be re-assessed regularly following an individualised assessment plan that
includes an evaluation date. The frequency of reassessment should be based upon the condition of the
individual (European Pressure Ulcer Advisory Panel, 2003). Where patients present with severe wounds
or pressure ulcers (Grade 3 or 4) the multidisciplinary team should consider the patients basal energy
expenditure and pay attention to fluid loss through their wound(s).
Where an assessment or screening of nutritional status indicates that malnutrition may be present,
nutritional intervention should be considered and discussed with the medical team and/ or dietician.
13
Wound Cleansing
Indications
Wound cleansing is NOT indicated for most wounds and should only be performed with a specific goal or
aim.
Wound:
to remove excess exudate, slough or necrotic tissue
to remove remnants of old dressing material
to remove dirt and debris from traumatic wounds which could cause wound infection
to allow inspection and assessment of dirty traumatic wound
Surrounding skin:
The skin surrounding a wound may require care including washing at dressing change to remove
wound exudate and skin debris or for patient comfort.
Wound cleansing does not, by itself, reduce the number of bacteria in a wound. Thomlinsons study
(Thomlinson, 1997) revealed that bacteria were simply redistributed.
Types of cleansing fluid

Cleansing can be achieved with either tap water or normal 0.9% saline. The chosen cleansing fluid
o
should be at a comfortable temperature and should not be below 28 C (Lock, 1979). The decision to use
isotonic saline is dependant on the type, depth and extent of the wound and the period of time that the
fluid will remain in contact with the wound. Care should be taken if the full extent of the wound is not
known.
Tap Water
Any fears regarding bacterial contamination of tap water appear to be unfounded (Angeras and Bradbard,
1992). Studies have shown no increased risk of infection if sutured wounds are washed with soap and
water (Noe and Keller, 1988) or when the patient showers (Chrintz et al, 1989). Microbiologists suggest
running the tap water for a few minutes to flush out potential bacteria accumulations prior to use as a
precautionary measure. Beam (2006) in an extensive review found tap water to be equally effective to
saline when used as a cleansing agent.
Methods of cleansing
Wound and skin cleansing is best achieved by gentle irrigation either by showering, irrigating with a jug of
warm water or saline or by irrigation with a syringe.
The patient often appreciates irrigation or short immersion of the wounded area in a bowl or bath. This
practice is useful for skin care and cleansing particularly in patients with leg ulceration (Lawrence, 1997).
Care must be taken to avoid prolonged immersion of the wound and cross infection. Lawrence (1997)
suggests using disposable plastic bags to line the bowl. Care must be taken in the cleansing of lifting
equipment and the bath if this is the chosen method of care. De Smet et al (2006) have shown that there
is little direct effect on environmental bacterial contamination by wound cleansing.
14
Debridement of Wounds
Definitions
Debridement is the removal of devitalised, infected tissue or foreign materials and debris. The body can
remove this material by natural processes but large quantities of debris can prevent adequate inspection
of a wound, delay healing and provide a focus for infection.
Debridement is complete when 100% of the wound bed consists of healthy granulation tissue (Vowden
and Vowden, 1999a; Vowden and Vowden, 1999b). To achieve this several methods of debridement may
be required and short term goals set such as the softening of eschar prior to sharp debridement. A
number of debridement methods exist and these include autolysis, mechanical debridement, biological
(larval) debridement and sharp or surgical debridement (Vowden and Vowden, 1999a; Vowden and
Vowden, 1999b).
Sharp debridement is conservative frequently leaving a thin margin of necrotic tissue.
Surgical debridement is more extensive and includes debridement to bleeding healthy tissue.
Sharp debridement
Debridement is an accepted principle of good wound care, especially when debris is acting as a focus for
infection (NICE 2001). A document of the Conservative sharp debridement of wounds is available from
the TVNA web site (www.tvna.org/). Debridement is however only one part of overall wound care and
should not be used in isolation. Appropriately trained staff in a number of clinical areas routinely performs
sharp debridement. When managing a wound and it is considered that debridement is required, consider
if it is necessary to refer for specialist debridement or treatment.
Prior to debridement all patients will have:

A documented comprehensive and holistic assessment
The underlying cause of the wound identified which may (if the wound is on the leg) include Doppler
ABPI to exclude arterial disease
A wound assessment and photograph, when possible, before and after the procedure.
An explanation of, and give informed consent for the procedure
The decision to perform sharp debridement should be multi-disciplinary and have a specific rationale and
documented aims.
Contra-indications for sharp debridement by nursing staff

Patients with clotting disorders
Fungating or malignant wounds
Wounds on the face, hands or feet (excluding the heel area)
Wounds on ischaemia digits
Wounds near the following structures:
o Arterial structure including a vascular graft
o A prosthesis
o A dialysis fistula
Cautions for conservative sharp debridement

Lower limb wounds in the presence of ischaemia *
Patients on long term anti-coagulant therapy, e.g. Warfarin, Aspirin
Patients on short term anticoagulant therapy, e.g. subcutaneous heparin
Wounds on heels**
Wounds on the achilles tendon area
Note: conservative sharp debridement in the presence of clinical infection may require systemic antibiotic
cover Referral to the podiatrist may be appropriate for multidisciplinary assessment of all foot wounds
* Decisions with regard to whether or not the debridement of ischaemic lower limbs is appropriate
should ideally be made in conjunction with the Vascular Surgical Consultant.
** Referral should be made to the podiatrist for joint assessment and management, if appropriate.
15
Nursing procedure- Sharp debridement
Within Bradford Trusts nurses carrying out sharp debridement will:
Be a registered nurse and have university accredited wound management modules.
Maintained competence by attending study days on sharp debridement.
Have undertaken supervised practice with a suitable mentor with training emphasis on competency,
anatomy and tissue types and have undergone an assessment by the Nurse Consultant in wound
care, a Consultant or a Podiatrist.
Nurses wishing to undertake Sharp debridement:

Do so in line with the recommendations outlined in NMC Code of Professional Conduct (2002)
Should know and understand the anatomy
Recognise structures and be able to distinguishing between viable and non-viable tissue
Have adequate equipment, lighting and, if appropriate, assistance
Be able to deal with complications
Recognise the limitations of the technique and their skill
The procedure
The patient should be comfortably positioned on bed or couch in such a way as to allow full view of
the wound
The patient should receive suitable analgesia for both the wound and the procedure
Suitable lighting must be available
Apron and well fitting sterile gloves should be worn
Equipment
Sterile dressing pack
Scalpel with 10 and 15 blade
Sharp scissors
Forceps capable of grasping or holding necrotic tissue
Sterile gauze
Haemostatic dressing
Other equipment
Culture swab
Biopsy pot
Camera
Doppler if appropriate
(Suture material)
Complications of sharp debridement

Stop the procedure should any concerns or uncertainties regarding the extent of the necrotic tissue or
damage to underlying structures occur.
Pain Provide adequate analgesia either systemically or topically in the form of Lignocaine or
EMLA cream. Evaluate the need to continue or delay the procedure. Continue adequate
analgesia after the debridement
Bleeding Apply pressure to the bleeding point or area and/or use a haemostatic agent such as
Kaltostat. Stop the procedure if excessive bleeding occurs. Occasionally suturing of the
bleeding vessel may be required.
Ensure that equipment is available to manage complications prior to commencing this procedure. Report
and document difficulties, liaise with doctor / multidisciplinary team and, if necessary, complete a clinical
incidence report form.
16
The Ideal Dressing
There are two different categories of dressings
1. Primary - This is in contact with the wound.

2. Secondary - This is not in contact with the wound but covers the primary dressing.
When choosing a secondary dressing ensure its compatibility with the primary wound contact layer.
Cost effective wound care

It is important, not only that a dressing performs the function it claims, but that it does it in a cost and
clinically effective way. Cost effectiveness is achieved by appropriate choice of treatment. This may not
always be achieved by using the cheapest product. Factors such as healing time, nursing costs,
frequency of dressing changes and requirements for other products such as secondary dressings,
antibiotics and analgesics all need to be considered when selecting a product. At times the use of multiple
products may be necessary but in general this should be discouraged. When necessary products from
different manufactures may be combined providing this is not contra-indicated in the product literature.
Franks and Bosanquet (2004) and Harding et al (2000) have looked at cost effectiveness, concluding that
modern wound dressings provide more cost-effective care this supported by Scanlon et al (2005)
concluded in a research analysis that dressing selection should not be based on the cost of individual
dressings alone.
Some dressings such as antimicrobial dressings potentially impact adversely on cellular function (Paddle-
Ledinek et al 2006) and so their use should be time restricted and for specific indications.
The process of dressing selection relies on careful wound assessment and is underpinned by the Trusts
educational strategy, short courses and modules run at The School of Health Studies in the University of
Bradford.
Choosing the ideal dressing

There are many hundreds of wound products available all having slightly different properties. The ideal
wound management choice is dependant on the type, depth and colour of the wound taken in conjunction
with the stage of healing and what the main objectives of treatment e.g. debridement or protection.
Dressing choice will also be influenced by the level and type of exudate. Turner (1985) described The
ideal dressing. Thomas (1990) and Morison (1992) expanded this description. Their suggestions are
discussed by Bale and Jones (1997). Some authors include criteria such as longevity of wear, shelf life,
availability and cost-effectiveness in their definition all of which are important.
For the purpose of this document the ideal dressing is considered to be one that ensures optimal healing
by:
1. Maintain high humidity

Epidermal cells require a moist (not wet) surface to permit them to migrate across the wound surface a
dry wound forces the cells to burrow deeper until they meet a moist level, delaying healing. This is based
on the initial work of George Winter (1962). Studies by Freidman and Su (1983) showed that the moist
environment enhanced natural autolytic processes by breaking down necrotic tissue.
2. Removes excess wound exudate

Exudate, microorganisms, toxins and dead cells are removed to relieve maceration, tissue oedema, and
to reduce pain and swelling. The dressing choice will allow control of the exudate, either by absorbing it
into the dressing or by passing it on to a hydrophilic absorbent secondary dressing (Cherry and Harding,
1997)
3. Permit thermal insulation

o
A constant temperature of 37 C is essential to maintain biological processes (mitosis and enzymatic
activity). Myers (1982) found that, following wound cleansing it was 3 hours after replacing the dressing
before mitotic activity was returned to normal.
17
4. Impermeability
A dressing should prevent bacteria gaining access to the wound surface. A soaked or leaking dressing
provides a pathway for bacteria in either direction. Some dressings are waterproof allowing bathing whilst
in position.
5. Gaseous exchange
At different phases of wound healing both hypoxia and normal amounts of oxygen are required. A more
rapid restoration of the microcirculation occurs in an anaerobic environment (Knighton et al, 1981). High
levels of oxygen are necessary for the development of fibroblasts and collagen. The role of oxygen and
hyperbaric therapy in wound healing has been reviewed by Heimbach (1985), Simmons (1999) and
Phillips (2005).
6. Non-fibre shedding/ non-toxic

Fibres shed into the wound causes irritation and can become a focal point for infection. Granulating tissue
can grow into the open mesh, attaching the dressing to the wound. Local irritation or sensitivity can occur
with some products used the most common is iodine.
7. Non-adhesive, comfortable and conforming

The dressing must be non-adhesive to the wound bed and protect the wound from further trauma that will
delay healing (Dealey, 1999). Patient compliance is best achieved with a comfortable, conforming, flexible
dressing causing minimal pain when changed and which does not take excessive time to redress.
18
Dressing Selection Flow Chart
19
Choosing a Wound Dressing
To help with the choice of the most appropriate dressing the flow chart (page 14) relates the wound
grade and appearance to dressing type options. By following the correct pathway you will be led to
an options box that contains a recommended dressing category. The dressing options table below
then lists the recommended products of that dressing type. A detailed description of all the
recommended products then follows in relation to the dressing type.
Dressing Cost Code

The detailed description of each dressing contains a cost code. This can be used as a guide only.
The total cost of a dressing depends on many factors including the size of the wound and the
frequency of dressing changes. Charges also vary according to purchasing conditions.
Each product listed has been given a cost code: BAND A are priced between 1p and 49p
BAND B are priced between 50p and 1.49
BAND C are priced between 1.50 and 1.99
BAND D are priced between 2.00 and 2.49
BAND E are priced between 2.50 and 4.99
BAND F are priced above 5.00
Advanced Wound Care Products
Some Products listed in this resource file are designated Advanced Wound Care Products and are
not freely available either within the Hospital or Community. These products are highlighted in red in
the formulary. Details on these products are included to provide staff, who may be managing a
patient receiving specialist wound care, with the necessary information to understand care
requirements of patients receiving treatment with these products. These products are highlighted in
the formulary.
Advanced Product Manufacturer Approximate costs

Xelma (Restricted availability) Molnlycke Healthcare 100 (tbc)
LarvaE SMTL 50/treatment
VAC KCI 39 therapy unit/day
Consumables 25
Promogran Johnson & Johnson Band E
Promogran Prisma Band F
20
DRESSING OPTIONS
Recommended
Dressing Type Band Alternatives Band
Product
Low adherence N/A ultra A Atrauman A
Non adherence Mepital E
Tegaderm B
Film Opsite Flexigrid B Opsite Plus B
Cavilon Barrier spray F**
Hydrogel Intrasite gel/conformable C Actiform Cool D
Granuflex D
Tegaderm
Hydrocolloid Duoderm B D
Hydrocolloid
Comfeel Plus D
Hydrofiber Aquacel D
Alginate Sorbsan C Kaltostat C
Allevyn D
Allevyn Adhesive C Mepilex D
Foam
Lyofoam B Mepilex Boarder D
Tielle D
Metronidazole gel E*
Deodorisers Clinisorb C (Anabact)
Actisorb Silver 220 D
Antimicrobials
Cadexomer Iodoflex E
Acticoat Absorbant F**
Silver containing Aquacel Ag E
Acticoat 7 F**
antimicrobials Actisorb Silver 220 D
Flamazine F*
Honey Medihoney wound gel E**
Antiseptics Inadine A Betidine ointment B*
Advanced Products
Protease Promogran E
modulators Promogran Prisma F
Topical Negative **
V.A.C.
Pressure Therapy
Larval therapy LarvE **
Extracellular **
Xelma
matrix
Product cost banding is based, where possible, on a 10x10cm dressing or equivalent: BNF March 2007
F* = 20 gm tube; F** = 28ml spray; F** > 10
E* = 15gm tube; E** = 10gm tube
B* = 20gm tube
** = See individual advanced product details
21
Low/Non adherence dressings
Introduction: Low/Non adherence dressings

Low or Non-adherence describes the physical characteristics of a primary dressing indicating that it does
not adhere to the wound bed or cause significant trauma to the wound. All in this range require a
secondary dressing usually an absorbent product.
There are three products in the range silicone N/A and Atrauman both provide a low adherence Mepital is
the dressing of choice for finger tip injuries and following toe nail avulsion and for patients where
dressings may adhered to the wound bed such as when using a VAC
Studies have shown the advantage of the use of Mepital in reducing wound pain at dressing change. Pain
at wound dressing change (www.ewma.org/english/english.htm) and the World Union document:
Minimising pain at wound dressing-related procedures: A consensus document (World Union of Wound
Healing Societies, 2004) details management strategies relating to wound pain.
Recommended Product(s)
N-A Ultra
Mepital
Alternative Products()
Atrauman
22
N-A ULTRA
COST CODE A
Dressing type: LOW ADHERENCE Manufacturer: Johnson & Johnson
What is it?
N-A ultra has a silicone coating. This dressing is designed to act as a low adherence primary contact
layer. Available in: 9.5x9.5cm and 19x9.5cm
How does it work?

These dressings are porous so they allow free drainage of exudate. Having low adherence they can be
removed from granulating wounds without causing significant trauma to the delicate healing tissues.
Advantages
1. Inexpensive
2. Easy to apply
3. Generally low adherence therefore less trauma at dressing changes
4. Can be used with other dressings, gels, creams etc.
5. No contra-indications have been reported
Disadvantages
1. N-A ultra is a low adherence dressing but can stick to some wounds.
2. Require a secondary dressing.
Wounds to use it on
Any sort of wound where dressing adherence may be a problem. Indications for use are therefore any
ulcerated or granulating wound such as leg ulcers, pressure sores, burns, cuts or abrasions.
How to use it
These dressings are used as a primary dressing, an absorbent secondary dressing is then generally
applied the whole being kept in place by bandage or tape.
Minimum and maximum changing times

The secondary dressing should be changed as often as required, leaving the primary N-A dressing
undisturbed. Weekly changes of N-A or N-A Ultra are required.
Bibliography:
Thomas, S. (1994) Low adherance dressings. J Wound Care 3(1): 27-30.
23
MEPITEL
Equivalent to: Mepilex foam/N/A dressing COST CODE E for 8x10cm
Dressing type: NON ADHERENT Manufacturer: Molnlycke
What is it?
Mepitel is a semi-transparent, non-adhesive wound contact layer (Safetac). It is a flexible polyamide net
coated with soft silicone. The silicone is tacky which prevents the lateral drainage of exudate. The nature
of the dressing allows minimum pain and reduced damage to tissue on removal.
How does it work?

The soft silicone layer (Safetac) is slightly tacky but not adhesive. This layer prevents skin stripping and
does not cause pain on removal. Mepitel is not absorbent but contains pores (1mm diameter) that allow
the passage of exudate into a secondary absorbent dressing.
Advantages
1. Mepitel has been demonstrated to reduce wound pain in different types of wounds
2. Where other dressings have low adherence to the wound bed Safetac is non adherent
3. Mepitel can be used with topical agents.
Disadvantages
There are no contraindications for the use of the dressing. Imprints of the mesh can be seen if pressure is
applied over the dressing this is not damaging to granulation tissue.
Wounds to use it on
Mepitel is useful where adherence of the dressing represents a particular problem such as skin tears,
abrasions, blistering diseases, burns or skin grafts. Where indicated, topical agents can be applied under
or over Mepitel.
How to use it
Mepitel is removed from the protective film and applied to the wound bed. It can be difficult to apply as the
tacky nature sticks to gloves moistening gloves can help in positioning the dressing.

The times of dressing change is dependant on the level of exudate and the type of wound. Change is
recommended to inspect the wound bed at least at weekly intervals.
Bibliography:
Gotschall, C. S., Morrison, M. I. and Eichelberger, M. R. (1998) Prospective, randomized study of the efficacy of Mepitel on children
with partial-thickness scalds. J Burn Care Rehabil 19(4): 279-283.
O'Donovan, D. A., Mehdi, S. Y. and Eadie, P. A. (1999) The role of Mepitel silicone net dressings in the management of fingertip
injuries in children. J Hand Surg [Br] 24(6): 727-730.
Platt, A. J., Phipps, A. and Judkins, K. (1996) A comparative study of silicone net dressing and paraffin gauze dressing in skin-
grafted sites. Burns 22(7): 543-545.
Schober-Flores, C. (1999) Epidermolysis bullosa: a nursing perspective. Dermatol Nurs 11(4): 243-248, 253-246.
24
ATRAUMAN
Equivalent to: N-A Ultra COST CODE A
Dressing type: LOW ADHERENCE Manufacturer: Hartmann
What is it?
A non-medicated wound contact layer dressing made of water-repellent (hydrophobic) close weaved
polyester tulle impregnated with neutral triglyceride fatty acids. The dressing contains no paraffins and is
conformable, permeable to wound exudate and non-adherent.
How does it work?

Atrauman is intended for use as a primary wound contact layer. The fatty acids are present to reduce the
adherence of the product to the wound.
Advantages
1. Cheap
2. Easy to apply
Disadvantages
1. Tulle gauze dressings can allow new granulation tissue to grow into the gauze mesh and cause
adherence and damage at dressing change. The hydrophobic properties and weave of this dressing is
said to make this less of a problem
2. If placed on heavily exudating wounds the semi-occlusive nature of the dressing may prevent free
movement of exudate and cause maceration
3. No evidence to support use of this product
Wounds to use it on
Use on red or pink wounds, traumatic injuries, burns and skin grafts.
How to use it
The dressing should be placed directly onto the surface of the wound and covered with a secondary
dressing and secured with tape or bandage. Several layers of the dressing can be used if necessary.

Daily to 7 days depending on the type of wound.
Bibliography:
25
Film
Introduction: Film
Film dressings are flexible sheets of transparent polyurethane coated with an acrylic adhesive. They can
be used as a primary or secondary dressing.
These dressings are semipermeable, vary in size and thickness, and have an adhesive that holds the
dressing on the skin. They conform easily to the patient's body but do not hold well in highfriction areas,
such as the heel or buttocks. Because films are transparent, the wound can be easily monitored.
Film dressings generally require a border of dry, intact skin for the adhesive edge of the dressing; film
dressings will not adhere to moist skin or moist wound beds because the moisture inactivates the
adhesive. Therefore, the condition of the periwound skin should be assessed before application to
determine if a film dressing is appropriate.
Because films are semiocclusive and trap moisture, they allow autolytic debridement of necrotic wounds
and create a moist healing environment for granulating wounds.
Both Tegaderm and Opsite Flexigrid have similar MVTR characteristics. Opsite Plus combines the
properties of a high MVTR dressing with an absorptive pad and is suitable minor injuries and post-
surgery.
Cavilon, a barrier film, is different and functions to protect periwound skin from damage.
Tegaderm
Opsite Flexigrid
Cavilon Barrier spray
Alternative Product(s)
Opsite Plus
26
Film
TEGADERM
Equivalent to OPSITE FLEXIGRID COST CODE B for 10x12cm dressing
Dressing type: FILM Manufacturer: 3M Health Care Ltd
What is it?
Tegaderm is a sterile and transparent dressing that consists of a thin polyurethane film with a
hypoallergenic, water resistant adhesive. The dressing is permeable to both water vapour and oxygen but
impermeable to micro-organisms. It is available in sizes: 6x7cm 10x12cm, 10x25cm, 15x20 and 20x30
cm.
How does it work?

Tegaderm produces a moist environment by reducing evaporation from the wound surface. This reduces
scab formation and encourages healing.
Advantages
1. Possesses good oxygen and moisture vapour permeability
2. Transparent and therefore allows visualisation of the wound without disturbing the dressing
3. An intact dressing is impermeable to liquids and bacteria preventing wound contamination
4. May provide some relief of pain in acute wounds (Briggs, 1996)
Disadvantages
1. May stick to some skin and it can remove healthy skin if care is not taken to stretch and release it
before removal
2. Tegaderm Plus should not be used on patients with known iodine sensitivity
Wounds to use it on
Can be used as a primary or secondary dressing or as a protective cover to area susceptible to skin
breakdown or exposed to friction. Also may be used to dress invasive sites such as IVIs, closed, clean
surgical wounds, minor abrasions and Grade 1 pressure sores. It should not be used as a primary
rd
dressing on infected wounds/sites and is not recommended for use on deep cavity wounds, 3 degree
burns or heavily exudating wounds.
How to use it
Choose a dressing size, which ensure a 4-5 cm. margin of healthy skin to ensure there is good adhesion.
Peel off the central backing and apply to the site. Seal the edges before removing the frame around the
outside of the dressing, carefully smoothing the edges. To remove: Gently grasp the edges and slowly
pull horizontally to the patient's skin to break the seal. Gently remove the dressing in the direction of hair
growth.

Varies considerably, dependent on the state of wound and level of exudate. On clean wounds may be left
undisturbed for up to 7 days.
Bibliography:
Briggs M (1996) Surgical wound pain: a trial of two treatments. J Wound Care 5(10):456-460
Ravenscroft, M. J., Harker, J. & Buch, K. A. (2006) A prospective, randomised, controlled trial comparing wound dressings used in
hip and knee surgery: Aquacel and Tegaderm versus Cutiplast. Ann R Coll Surg Engl, 88: 18-22.
27
Film
OPSITE FLEXIGRID & OPSITE PLUS

Equivalent to TEGADERM COST CODE B for 10x12cm dressing
Dressing type: FILM Manufacturer: Smith & Nephew
What is it?
Opsite Flexigrid is a sterile transparent dressing that consists of a thin polyurethane film with a
hypoallergenic, water resistant adhesive. The dressing is permeable to both water vapour and oxygen but
impermeable to microorganisms. It is available in sizes: 6x7cm, 10x12cm, 12x25cm and 15x20cm sizes.
Opsite Plus combines a high Moisture Vapour Transmission Rate (MVTR) film with the cushioning and
absorbency of a low adherent pad and is designed specifically as a postoperative dressing.
How does it work?

This product produces a moist environment by reducing evaporation from the wound surface. This in turn
reduces scab formation and encourages healing.
Advantages
1. Possesses good oxygen and moisture vapour permeability
2. Transparent, can visualise wound without disturbing it
3. An intact dressing is impermeable to liquids and bacteria
4. Can be used as a secondary dressing securing a hydrogel or alginate dressing
Disadvantages
1. It can stick to some skin and it can remove healthy skin if care is not taken
2. Mild acne has been observed on testing
Wounds to use it on
This product can be used as a primary or secondary dressing or as a protective cover to area susceptible
to skin breakdown. It may also be used to dress donor sites, closed, clean surgical wounds, minor
abrasions and Grade 1 pressure ulcers or to prevent friction. It should not be used as a primary dressing
on infected wounds/sites. Opsite Post-Op is suitable for all postoperative wounds, particularly over joints.
How to use it
To apply: Choose a dressing size which ensures a 3-4 cm. margin of healthy skin to be included to
ensure there is good adhesion. If required the outline of the wound can be traced onto the plastic grid that
is then removed and filed with the patient's case records.
To remove: Gently grasp the edges and slowly pull horizontally to the patient's skin to break the seal.
Gently remove the dressing in the direction of hair growth.

Changing times vary considerably depending on the state of wound. On clean wounds the dressing may
be left undisturbed for in excess of 14 days.
Bibliography:
Cosker, T., Elsayed, S., Gupta, S., Mendonca, A. D. & Tayton, K. J. (2005) Choice of dressing has a major impact on blistering and
healing outcomes in orthopaedic patients. J Wound Care, 14: 27-9.
Fear, M. (2001) British Journal of Community Nursing, 6(8): 421 - 425
Williams C (1995) Opsite flexigrid. British J Nursing. 4(7):411-412, 414
28
Film
CAVILON
COST Single use applicator B
Multiuse spray (28ml) F
Dressing type: BARRIER FILM Manufacturer: 3M Health Care Ltd
What is it?
Cavilon is an alcohol free, quick drying non-cytotoxic liquid film. Is available as a spray and applicator.
How does it work?

Cavilon forms a breathable transparent protective coating on the skin. It is intended to protect intact or
damaged skin from urine, faeces and wound exudate. It is also useful to protect fragile skin from adhesive
products and helps with adhesion of dressings.
Advantages
1 Alcohol free formula will not sting on application.
2 Claims 72 hours protection from urine and faeces
3 Non-cytotoxic and hypoallergenic (suitable for use on neonates)
4 Protects skin from adhesive tape complications and trauma
Disadvantages
1 Allow the product to dry as it is adhesive
2 Will not adhere to wet or weeping skin.
Wounds to use it on
Apply to pressure areas to prevent friction damage; to skin surrounding wounds to protect from either
exudate or excrement; around stomas to protect skin from adhesive stripping.
How to use it
Spray affected skin or apply using sponge applicators. Allowed to dry the film protects the skin from
exudate or incontinence damage. Dressings applied before Cavilon is dry will help dressing adhesion.

Daily application may be necessary in some cases of skin excoriation due to incontinence. In other cases,
when used for protection, apply at dressing change.
Bibliography
Baatenburg De Jong, H. & Admiraal, H. (2004) Comparing cost per use of 3M Cavilon No Sting Barrier Film with zinc oxide oil in
incontinent patients. J Wound Care, 13: 398-400.
Cameron, J., Hoffman, D., Wilson, J. & Cherry, G. (2005) Comparison of two peri-wound skin protectants in venous leg ulcers: a
randomised controlled trial. J Wound Care, 14: 233-6.
Neander, K. D. & Hesse, F. (2003) The protective effects of a new preparation on wound edges. J Wound Care, 12: 369-71.
Schuren, J., Becker, A. & Sibbald, R. G. (2005) A liquid film-forming acrylate for peri-wound protection: a systematic review and
meta-analysis (3M Cavilon no-sting barrier film). Int Wound J, 2: 230-8.
Williams, C. (1998) 3M Cavilon No Sting Barrier Film in the protection of vulnerable skin. Br J Nurs 7 (10): 613-615.
29
Hydrogel
Introduction: Hydrogel
Hydrogel dressings are water- or glycerin-based products. Because they're usually clear or translucent,
the wound can be monitored without removing the dressing.
Use hydrogels to maintain a moist wound environment on a clean, healthy, granulating wound and to
facilitate autolytic debridement in wounds with necrotic tissue such as slough or eschar. Hydrogels can be
used on pressure ulcers, skin tears, surgical wounds, and burns, including radiation oncology burns and
are safe on neonatal skin.
Hydrogels are suitable for wounds with minimal to moderate drainage.
Three forms are available: amorphous (Intrsite Gel), impregnated-gauze (Intrasite Conformable), and
sheet hydrogel (Actiform Cool) which is useful on painful wounds. Because the gel can cause maceration,
avoid applying it on the periwound skin.
Intrasite Gel
Intrasite Conformable
Actiform Cool
30
Hydrogel
INTRASITE GEL/CONFORMABLE
COST CODE C for 25g
Dressing type: HYDROGEL Manufacturer: Smith & Nephew
What is it?
Provided in an applicator, Intrasite is an aqueous gel consisting of a carboxymethyl cellulose polymer.
Sizes 8g and 15g applicators. Intrasite Conformable is an impregnated gauze with 7.5g of Intrasite on a
10x10cm gauze.
How does it work?

The gel will hydrate a wound allowing autolytic debridement; it also will absorb exudate and thus
produces a moist environment at the wound surface.
Advantages
1. Assists rehydration and autolysis of dead tissue
2. Facilitates re-epithelisation minimizing scar formation in granulating wounds
3. May reduce wound pain
Disadvantages
1. Not ideally suited for use on heavily exudating wounds
Wounds to use it on
Use on wounds requiring debridement including black, green and yellow or red wounds with low to
moderate exudate.
How to use it
Squeeze the gel into wound. On re-dressing, the gel should be removed by irrigating before re-applying.
The excess gel is removed and a secondary dressing applied.
The choice of secondary dressing depends on the state of the wound:

Dry Use an occlusive dressing to reduce fluid loss and gel drying out e.g. Opsite
Light Non-adherent less permeable i.e. N-A
Heavy Simple absorbent pad or foam e.g. Allevyn/Allevyn Adhesive.
Interval between dressing changes depends on the wound. The dressing should be changed when the
area of Intrasite Gel covering the wound is completely liquefied.

Daily/every three days
(Infected wounds - daily)
Bibliography:
Ingle, R., Levin, J. & Polinder, K. (2006) Wound healing with honey - a randomised controlled trial. S Afr Med J, 96: 831-5.
Vernon, T. (2000) Intrasite Gel and Intrasite Conformable: the hydrogel range. Br J Community Nurs 5(10): 511-516.
Williams, C. (1994) Intrasite Gel: a hydrogel dressing. Br J Nurs 3(16): 843-846.
31
Hydrogel
ACTIFORM COOL
COST CODE D for 10x10cm dressing
Dressing type: HYDROGEL Manufacturer: Activa Healthcare
What is it?
A second-generation hydrogel with high water content (70%) that donates or absorbs moisture from the
wound bed. The gel has additional properties relating to surface ionic charge, which allows higher water
content than a standard hydrogel. The dressing is available in a variety of sizes.
How does it work?

The gel is said to exert a dynamic effect on the wound bed. The gel is able to donate moisture to a dry
wound and absorb moisture from an exudating wound.
Advantages
1. Easy to apply
2. Wound pain reduction - cooling and soothing to the wound bed. Pain reduction from time of
application
3. Can both hydrate wounds and absorb moisture
4. Assists autolytic debridement
Disadvantages
1. Can dry out if clear plastic backing removed inappropriately. If this occurs rehydrate before removal.
2. Not suitable for deep cavity or sinus wounds
Wounds to use it on
Can be used for pain reduction in all types of painful wounds including leg ulcers, minor traumatic injuries
such as burns and scalds.
How to use it
The dressing can be cut to size. Remove the white plastic liner and apply the dressing to the wound. For
moderately exudating wounds the outer clear plastic cover can be removed and the dressing covered by
a film or an absorbent secondary dressing. For low exudating wounds or wounds requiring fluid donation
the outer clear plastic cover should be left in place. On an exuding wound the sheet will turn into a jelly-
like state that can be easily washed off the wound.

As ActiFormCool debrides and desloughs generally quite rapidly, when using for the first time it is a good
idea to check after 48 hours, but it can then be left up to 7 days, depending on levels of exudate.
Bibliography
Hampton, S. (2004) A small study in healing rates and symptom control using a new sheet hydrogel dressing. J Wound Care, 13:
297-300.
Young, S. & Hampton, S. (2005) Pain management in leg ulcers using ActiForm Cool. Wounds UK, 1: 94-101.
32
Hydrocolloid
Introduction: Hydrocolloids
Hydrocolloid dressings consist of absorptive ingredients (typically carboxymethylcellulose, pectin, or
gelatin). Like hydrogels, hydrocolloids can absorb minimal to moderate amounts of drainage. They can be
used for partial- or full-thickness acute and chronic wounds.
Because they are occlusive, hydrocolloid dressings do not allow water, oxygen, or bacteria into the
wound. This may help facilitate angiogenesis and granulation. Hydrocolloids also cause the pH of the
wound surface to drop; the acidic environment can inhibit bacteria growth.
Like hydrogels, hydrocolloids can help a clean wound to granulate or epithelialize and encourage autolytic
debridement in wounds with necrotic tissue. However, because of their occlusive nature, hydrocolloids
cannot be used if the wound or surrounding skin is infected.
As Hydrocolloids are conformable to the patient's body these dressings adhere well to high-friction areas,
such as the sacrum and heels. All sheet hydrocolloid dressings have a film covering to make the product
waterproof.
Hydrocolloid dressings react with wound drainage and swell or "melt out, leaving a residue in the wound.
When the dressing is removed, a gel residue may be left in the wound bed. Remove this residue by
cleaning gently with a wound cleanser before assessing the wound. A distinctive foul odor may also be
present. This may be from product breakdown, not infection.
Hydrocolloids adhere best at body temperature. To promote adherence, the clinician should place his or
her hand over the dressing after applying it to the wound. The heat from the clinician's hand will assist in
molding the dressing to the wound and facilitating adherence.
Hydrocolloid dressings with thick edges may "roll up" and adhere to the patient's clothing or bed linens,
decreasing the dressing's wear time. Dressings with thinner, tapered edges generally adhere better to the
periwound skin without rolling up.
Granuflex
Duoderm
Comfeel Plus
Tegaderm Hydrocolloid
33
Hydrocolloid
GRANUFLEX & DUODERM

Equivalent to COMFEEL PLUS & TEGASORB COST CODE D for 10x10cm dressing
Duoderm (B)
Dressing type: HYDROCOLLOID Manufacturer: ConvaTec
What is it?
Granuflex is a hydrocolloid dressing in the form of a wafer or a thinner version DUODERM. The wafer's
outer layer is semi-permeable and is bonded to an inner matrix of hydrocolloid particles and hydrophobic
polymer. Available in a variety of shapes and sizes.
How does it work?

Granuflex creates a moist environment conducive to autolytic debridement (this may lead to an initial
increase in wound size). The moist environment also increases mitosis and encourages angiogenesis
and the formation of granulation tissue. It also supports epithelialisation. Granuflex combines with
exudate to form a viscous yellow gel that can resemble pus.
Advantages
1. Can be used to debride necrotic wounds by rehydration and to deslough by autolysis
2. Reduces pain, the moist gel prevents exposed nerve endings drying out
3. Effective barrier to bacteria
4. May be used to remove dirt and small foreign bodies from wounds
Disadvantages
1. It can be difficult to apply in awkward areas
2. Unusual smell, patients should be warned of this phenomenon
3. Sensitivity can develop with prolonged use
4. Skin maceration can develop with inappropriate use
Wounds to use it on
Use on black, yellow, red or pink wounds with low to moderate exudate. It can be used on clinically
infected wounds but care should be taken and the wound monitored carefully. Granuflex should not be
used in the presence of an anaerobic infection.
How to use it
It is best applied warm avoiding unnecessary stretching and allowing a 3-4 cm margin all around the
wound overlapping if necessary. Change only when leakage or "strike" through occurs. Duoderm is
useful on low exudating wounds or as a protective layer.

Can be left up to seven days.
Bibliography:
Burgess, B. (1993) A comparative prospective randomised trial of the performance of three hydrocolloid dressings. Professional
Nurse 8(7): 3-6.
Harding, K., Cutting, K. and Price, P. (2000) The cost-effectiveness of wound management protocols of care. Br J Nurs 9(19 Suppl):
S6-S24.
Meaume, S. & Gemmen, E. (2002) Cost-effectiveness of wound management in France: pressure ulcers and venous leg ulcers. J
Wound Care, 11: 219-24.
Thomas, S., Banks, V., Bale, S., Fear-Price, M., Hagelstein, S., Harding, K. G., Orpin, J. and Thomas, N. (1997) A comparison of
two dressings in the management of chronic wounds. J Wound Care 6(8): 383-386.
34
Hydrocolloid
COMFEEL PLUS
Equivalent to GRANUFLEX COST CODE D for 10x10cm dressing
Dressing type: HYDROCOLLOID Manufacturer: Coloplast Ltd
What is it?
Comfeel Plus is a hydrocolloid dressing with calcium alginate in the form of a wafer with a bevelled edge.
The wafer is permeable to water vapour but impermeable to bacteria. Comfeel Plus is available in a
variety of sizes and shapes.
How does it work?

Creates a moist environment conducive to autolytic debridement (this may lead to an initial increase in
wound size). The moist environment also increases mitosis and encourages angiogenesis and the
formation of granulation tissue and allows epithelialisation. Comfeel Plus reacts with exudate to form a
viscous yellow gel that can resemble pus.
Advantages
1. Can be used to debride necrotic wounds by rehydration and autolysis
Disadvantages
1. Sensitivity or skin maceration can develop with prolonged use
Wounds to use it on
Use on black, yellow, red or pink wounds with moderate exudate. It can be used on clinically infected
wounds but care should be taken and the wound monitored carefully. Comfeel Plus should not be used in
the presence of an anaerobic infection. It is not recommended for use on exposed muscle or bone.
How to use it
Comfeel Plus is best applied warm, avoiding unnecessary stretching and allowing a 3 cm margin all
around the wound. Change only when leakage or "strike" through occurs.

Can be left for up to 7 days.
Bibliography:
Agren, M. (1997) The cytocompatibility of hydrocolloid dressings. J Wound Care 6(6): 272-274.
Goodhead, A. (2002) Clinical efficacy of Comfeel Plus Transparent Dressing. Br J Nurs 11(4): 284, 286-287.
Thomas, S. (1992) A guide to the composition, properties and uses of hydrocolloid dressings and the commercial presentations
available. J Wound Care 1(2): 27-30.
35
Hydrocolloid
TEGADERM Hydrocolloid
Equivalent to GRANUFLEX COST CODE D for 10x12cm dressing
Dressing type: HYDROCOLLOID Manufacturer: 3M Health Care Ltd
What is it?
Tegaderm hydrocolloid (formally Tegasorb) is a hydrocolloid dressing which consist of a hypoallergenic,
hydrocolloid adhesive with an outer clear adhesive cover film impermeable to liquids, bacteria and
viruses. The dressing is composed of polyisobutylene in which are dispersed hydrophilic gelable
polysaccharide particles. The dressing does not contain gelatin, pectin or tackifiers such as colophony or
its derivatives. Tegaderm Hydrocolloid is available in a variety of sizes and oval shapes.
How does it work?

Creates a moist environment conducive to autolytic debridement (this may lead to an initial increase in
wound size). The moist environment also increases mitosis and encourages angiogenesis and the
formation of granulation tissue and allows epithelialisation. Tegaderm Hydrocolloid reacts with exudate to
form a viscous yellow gel that can resemble pus.
Advantages
1. Can be used to debride necrotic wounds by rehydration and autolysis
Disadvantages
1. Sensitivity or skin maceration can develop with prolonged use
Wounds to use it on
Use on yellow, red or pink wounds with moderate exudate. It should not be used on clinically infected
wounds. Tegaderm Hydrocolloid should not be used in the presence of an anaerobic infection. It is not
recommended for use on exposed muscle or bone.
How to use it
Tegaderm Hydrocolloid is best applied warm, avoiding unnecessary stretching and allowing a 2.5 cm
margin all around the wound. The dressing should be applied to dried skin. Change only when leakage or
"strike" through occurs.

Can be left for up to 7 days.
Bibliography:
Thomas, S. (1992) A guide to the composition, properties and uses of hydrocolloid dressings and the commercial presentations
available. J Wound Care 1(2): 27-30.
Banks, V.; Hagelstein, S.; Thomas, N.; Bale, S.; Harding, K. G. (1999) Comparing hydrocolloid dressings in management of exuding wounds
Br J Nurs 8(10): 640-6
Williams, C. (1996) Tegasorb hydrocolloid dressing: advanced formulation Br J Nurs 5(20): 1271-2
36
Hydrofiber
Introduction: Hydrofiber
This is a variant on hydrocolloid with extra absorbent properties, absorbing up to 25 times its own weight
in fluid before loosing its integrity. This type of dressing has to be used with a secondary dressing, e.g. a
hydrocolloid. If the wound is too dry this product tends to adhere to the wound bed making it difficult to
remove.
Aquacel
None
37
Hydrofiber
AQUACEL
COST CODE D 10x10cm dressing
Dressing type: HYDROFIBER Manufacturer: ConvaTec
What is it?
Aquacel hydrofiber dressing is made of a hydrocolloid polymer (carboxymethylcellulose) spun into fibres
and manufactured into a sheet and a ribbon. The sheets are available in three sizes 5x5cm, 10x10cm and
15x15cm.
How does it work?

Aquacel dressing is absorbent and allows fluid into the fibres of the dressing. As exudate wets the
dressing, Aquacel becomes a gel sheet. The gel provides an environment that encourages the healing
and debriding process. There is minimal expansion of the dressing as the fluid is absorbed.
Advantages
1. Aquacel is more absorbent than alginate dressings
2. Vertical wicking reduces maceration of the surrounding skin
3. Deals effectively with moderate to heavy exudate
Disadvantages
1. Can become adhered if the wound is too dry
2. Requires a secondary dressing
3. Of little value in dry wounds
Wounds to use it on
Use on yellow, pink or red moderate to heavy exudating wounds. Aquacel can be used on infected
wounds but it is recommended that regular inspections be carried out. Aquacel is particularly useful in
surgical cavity wounds.
How to use it
The fibre dressing can be used flat or as a loose cavity filler. A secondary absorbent dressing of
Granuflex or DuoDerm can cover this. The gel maintains its integrity and therefore can be removed whole
or it can be washed out of the wound with water or saline.

The dressing can be left for up to seven days or until leakage occurs.
Bibliography:
Foster, L., Moore, P. and Clark, S. (2000) A comparison of hydrofibre and alginate dressings on open acute surgical wounds. J
Wound Care 9(9): 442-445.
Moseley, R., Leaver, M., Walker, M., Waddington, R. J., Parsons, D., Chen, W. Y. and Embery, G. (2002) Comparison of the
antioxidant properties of HYAFF-11p75, AQUACEL and hyaluronan towards reactive oxygen species in vitro. Biomaterials 23(10):
2255-2264.
Williams, C. (1999) An investigation of the benefits of Aquacel Hydrofibre wound dressing. Br J Nurs 8(10): 676-677, 680.
38
Alginate
Introduction: Alginate
Alginate dressings, available in non-woven sheets and ropes, are fibrous products derived from brown
seaweed.
In wounds with moderate to heavy drainage, the alginate forms a gel when it comes in contact with
wound fluid. Capable of absorbing up to 20 times its weight in fluid, an alginate can be used in infected
and non-infected wounds. Because an alginate is highly absorbent, it should not be used with dry wounds
or wounds with minimal drainage; it could adhere and dehydrate the wound, delaying healing.
An alginate dressing is placed into the wound bed as the primary dressing. Then a secondary dressing is
added to hold the alginate in place and maintain the moist healing environment.
Choosing an appropriate secondary dressing is as important as choosing the correct primary dressing.
Foams or hydrocolloids will secure the alginate and keep it from drying out. If the wound is infected, the
secondary dressing should be non-occlusive. A non-occlusive dressing would not harbor bacteria and
would allow the wound to be monitored.
When the secondary dressing is removed, hydration of the alginate should be assessed. If the alginate
has absorbed wound exudate as intended, it will be in a gelled state and easy to remove from the wound.
If the alginate is difficult to remove or if fibrous material adheres to the wound base, the wound is drying
out. In that case, evaluate whether an alginate dressing is still indicated. If so, select a different secondary
dressing to maintain hydration. If not, select a primary dressing that is more appropriate for a wound with
little or no exudate.
Recommended product(s)
Sorbsan
Kaltostat
39
Alginate
SORBSAN
Equivalent to KALTOSTAT COST CODE C for 10x10cm dressing
Dressing type: ALGINATE Manufacturer: Unomedical
What is it?
Sorbsan is a natural product, made from calcium alginate fibres derived from Scottish seaweed
(Ascophyllum Nodosum). It is available as a flat dressing (5x5, 10x10 and 10x20 cm.), ribbon (40 cm) or as
packing (30 cm).
How does it work?

Exudate, rich in sodium, is drawn into the calcium rich dressing along with any contaminating bacteria. The
fibres quickly swell to form a sodium-calcium coagulum creating a warm, moist environment that
encourages healing. Sorbsan gels more easily than Kaltostat. The wound may initially appear to increase in
size as necrotic tissue is removed.
Advantages
1. Versatile, adapts easily to wound cavity or contour
2. Highly absorbent and biodegradable
3. Comfortable for the patient, easy removal as soluble in water/ normal saline
4. Can be used on infected or malodorous wounds
5. No contra-indications, a non-toxic product
Disadvantages
1. A mild "drawing" may be noticed by the patient (reduced by moistening before application)
2. Not suitable for hard or dry wounds or for use in narrow sinuses.
Wounds to use it on
Moderately to heavily exudating green, yellow or red wounds. It can be used on infected wounds.
How to use it
Apply to the wound leaving a margin of at least 2 mm. Cover with secondary dressing. Sorbsan may be
used as a loose cavity filler but care should be taken as the ribbon will swell as it absorbs the exudate. To
change the dressing the non-gelled Sorbsan should be removed from around the wound and the gelled
Sorbsan can be irrigated to remove it.

Daily/every three days
Bibliography:
Thomas S, (1989) Pain and wound management Community Outlook, July 11-15.
Gupta R, et al., (1991) Calcium alginate in the management of acute surgical wounds and abscesses, J. Tissue Viability, 1: 115-
116.
Thomas S, (1992) Alginates; A guide to the properties and uses of the different alginate dressings available today, J. Wound Care,
1: 29-32.
Williams, C. (1994) Sorbsan. Br J Nurs 3(13): 677-680.
Ingram, M., Wright, T. A. and Ingoldby, C. J. (1998) A prospective randomized study of calcium alginate (Sorbsan) versus standard
gauze packing following haemorrhoidectomy. J R Coll Surg Edinb 43(5): 308-309.
40
Alginate
KALTOSTAT
Equivalent to SORBSAN COST CODE C for 7.5x12cm
Dressing type: ALGINATE Manufacturer: ConvaTec
What is it?
A natural dressing product, made from Norwegian seaweed (Laminaria Hyerborea) composed of Calcium
(80%) and Sodium Alginate fibres (20%). It is available as Kaltostat 5x5, 7.5x10, 10x10 and 15x25
dressings and as a "rope" in a 2g pack.
How does it work?

Calcium ions in the alginate fibres react with the sodium ions in the exudate, converting it to a strong
ion-active gel which coats the wound surface, keeping it moist and warm. This is said to reduce wound
discomfort. Kaltostat tends to stay intact even as a gel. When the dressing is removed, there may be a
"glazed" appearance over the wound; this should not be disturbed as the gel contains nutrients that
encourage cell growth. May also be used as a haemostatic agent.
Advantages
1. Easy application and removal, without disturbing wound bed
2. Conformability and comfort for the patient
3. Some haemostatic properties
Disadvantages
1. A mild burning sensation may be experienced when first applied
2. The dressing will harden and become ineffective if allowed to dry out
3. As this dressing expands as it absorbs exudate it should not be inserted into narrow sinuses
4. High Calcium levels may damage keratinocytes
Wounds to use it on
Green through to red wounds with medium to high exudate. May be used on infected wounds.
Haemostatic properties allow it to be used on traumatic, surgical, debrided, bleeding or malignant wounds
How to use it
Cut or fold Kaltostat to the shape of the wound. Secure with a secondary dressing or a semi-permeable
film according to exudate. Leave undisturbed until maximum absorbency reached.

Daily/every 3 days depending on the volume of exudate although may be left up to 7 days
Bibliography:
Thomas, S. (1992) Alginates. J Wound Care 11): 29-32.
Jones, V. and Milton, T. (2000) When and how to use Alginates. Nursing Times 96(29): 2-3.
Paddle-Ledinek, J. E., Nasa, Z. & Cleland, H. J. (2006) Effect of different wound dressings on cell viability and proliferation. Plast
Reconstr Surg, 117: 110S-118S; discussion 119S-120S.
Vanstraelen, P. (1992) Comparison of calcium sodium alginate (KALTOSTAT) and porcine xenograft (E-Z DERM) in the healing of
split-thickness skin graft donor sites. Burns 18(2): 145-148.
Williams, C. (1994) Kaltostat. Br J Nurs 3(18): 965-967.
41
Foam
Introduction: Foam
Foam dressings are semipermeable and either hydrophilic or hydrophobic with a bacterial barrier. They
provide thermal insulation to the wound, create a moist wound healing environment, are nonadherent,
and provide an atraumatic removal.
Foams may be used in conjunction with a topical antimicrobial for infected wounds.
Select foam dressings may be manufactured with an adhesive border (Recommended: Allevyn Adhesive;
Tielle Alternative Mepilex Boarder), which eliminates the need for a securing device. Recommended
foam dressings without an adhesive boarder are Allevyn and Lyofoam. Shaped versions are available
(Heel and Sacrum).
If the foam dressing is to be used as the primary wound contact layer it provides absorption and
insulation.
Foam dressings may also be used as the secondary dressing of choice to absorb moderate to heavy
exudate.
Allevyn
Allevyn Adhesive
Lyofoam
Tielle
Mepilex
Mepilex Boarder
42
Foam
ALLEVYN & ALLEVYN ADHESIVE

COST CODE C for 10x10cm dressing
Dressing type: FOAM Manufacturer: Smith & Nephew
What is it?
Allevyn consists of a layer of soft hydrophilic foam, 4mm thick, bonded to a semi-permeable film. Allevyn
Adhesive is a similar product with low allergy adhesive that adheres well to intact skin but not the wound.
The dressing acts as an effective barrier to water or wound exudate and prevents the passage of
microorganisms through the back of the dressing. The dressing is available in several sizes (5x5cm,
10x10cm, 10x20cm and 20x20cm). A specific heel (Allevyn Heel) and sacral shaped dressing is also
available.
How does it work?

The wound contact layer is a three dimensional polyurethane net which renders the dressing less
adherent to granulation tissue. By virtue of its hydrophilic nature, the foam is capable of absorbing large
volumes of fluid. The semi-permeable backing prevents strike through.
Advantages
1. Able to absorb large volumes of exudate but still maintain a moist wound environment
2. Does not adhere to granulating tissue
3. Easy to use and can be cut to size
Disadvantages
1. Limited value on dry wounds
Wounds to use it on
Yellow, red or pink wounds with moderate to heavy exude. Allevyn Heel should not be used as a
pressure-relieving product.
How to use it
The dressing is available in a number of sizes. Choose a size that will overlap the edges of the wound by
2-3cm and place the white patterned surface next to the wound. Secure Allevyn with tape or bandage.
Water may aid removal of Allevyn Adhesive dressing.

Daily to 7 days depending on the volume of exudate
Biblography
Ameen, H., Moore, K., Lawrence, J. C. and Harding, K. G. (2000) Investigating the bacterial barrier properties of four contemporary
wound dressings. J Wound Care 9(8): 385-388.
Thomas, S. (1993) Foam Dressings: A guide to the properties and uses of the main foam dressings available in the UK. J Wound
Care 2(3): 153-156.
Viamontes, L. & Jones, A. M. (2003) Evaluation study of the properties of two adhesive foam dressings. Br J Nurs, 12: S43-4, S46-
9.
Williams, C. and Young, T. (1996) Allevyn adhesive. Br J Nurs 5(11): 691-693.
43
Foam
LYOFOAM
COST CODE B for 10x10cm dressing
Dressing type: FOAM Manufacturer: Medlock
What is it?
Lyofoam is a soft, open cell hydrophobic foam sheet 8mm thick. The wound contact layer has been heat
treated to collapse the cells of the foam. Available as: 7.5x7.5cm, 10x10cm, 17.5x10cm and 15x20cm,
also available as a tracheostomy dressing.
How does it work?

The dressing absorbs liquid by capillarity; it is freely permeable to gasses and water vapour. In use, the
dressing absorbs blood or other tissue fluids, and the aqueous component is lost by evaporation through
the back of the dressing. The pores however can become occluded if the wound is dirty or produces large
volumes of exudate.
Advantages
1. Maintains a warm moist environment facilitating rehydration and autolysis
2. Lyofoam is a good thermal insulator and will keep the wound warm
3. Secondary dressing is not required
4. Can be used as protection e.g. on the foot or for newly epithelialised skin
Disadvantages
1. The dressing cannot absorb large amounts of viscose exudate (Allevyn is more absorbent.)
2. Lyofoam can adhere to the wound surface in some situations
Wounds to use it on
Lyofoam is a useful and versatile material and can be used on a variety of exudating wounds including
leg ulcers, decubitus ulcers, diabetic foot ulcers, sutured wounds, burns and graft donor sites and
tracheostomy wounds. It should not be used on wounds with a dry scab or hard black necrotic tissue.
How to use it
Dressings should be cut to size allowing a 2-3cm overlap. Place the shiny side of the dressing next to the
wound. In wounds with copious amounts of exudate allow for a larger overlap as this will increase the
absorptive power of the dressing. Secure with tape but not an occlusive film.

Daily/week depending on volume of exudate.
Bibliography:
Hughes LE, et al., (1986) Wound management in the community - comparison of Lyofoam and Melolin, Care-Science and Practice,
7(3): 64-67.
Pessenhofer, H., Stangle, M. (1992) The effect of a two-layered polyurethane foam wound dressing on the healing of venous leg
ulcers, J. Tissue Viability, 2(2): 57-61.
Thomas S, (1993) Foam Dressings: A guide to the properties and uses of the main foam dressings available in the UK., J.Wound
Care, 2(3): 153-156.
Williams, C. (1999) The benefits and application of the Lyofoam product range. Br J Nurs, 8: 745, 748-9.
44
Foam
MEPILEX & MEPILEX BOARDER

Equivalent to: Mepitel non adherent / Allevyn COST CODE C for 10x10cm
Dressing type: NON ADHERENT / FOAM Manufacturer: Molnlycke
What is it?
Mepilex is a non adherent absorbent dressing made from polyurethane foam. MEPILEX BORDER is an
island dressing of the same material. The outer surface of the foam is bonded to a vapour permeable
membrane which acts as a barrier to liquid and micro-organisms. The wound contact layer is a soft
silicone that does not stick to the surface of a wound or cause trauma to delicate or fragile tissue.
Available in sizes 10cmx 10cm, 15cm x15cm, 20cm x 20cm.
How does it work?

The soft silicone layer (Safetac TM) is slightly tacky but not adhesive. This layer prevents skin stripping
and does not cause pain on removal. The gentle adhesion prevents maceration by inhibiting lateral
drainage of exudate onto the surrounding skin.
Advantages.
1. Mepilex has been demonstrated to reduce wound pain in different types of wounds.
2. Where other dressings have low adherence to the wound bed Safetac is non adherent.
3. The foam can be used as protective padding.
4. Can be used on infected wounds if infection is treated.
Disadvantages
There are no contraindications for the use of Mepilex.
Wounds to use it on
Mepilex is suitable for all types of wounds with moderate to high exudate. The dressing absorbs exudate
and maintains a moist wound-healing environment whilst reducing the risk of maceration.
How to use it
Remove the protective film and place the sticky side on to the wound. The dressing should overlap the
margins by two centimetres. Mepilex can be cut to size or shapes. When in position the dressing can be
held in place with a retention bandage. Mepilex Border requires no secondary dressing.

Dressing change will depend on the amount of exudate and the size and type of wound. It can be left
undisturbed for up to 7 days.
Biblography:
Dykes PJ., Heggie R., Hill SA. (2001) Effects of adhesive dressings on the stratum corneum of the skin. J Wound Care 10(2): 7-10.
45
Foam
TIELLE
COST CODE C 11cm x 11cm dressing
Dressing type: FOAM Manufacturer: Johnson & Johnson
What is it?
Tielle is an island dressing with a multi-layered structure. It consists of a piece of highly absorbent foamed
hydrogel made from polyurethane, located in the centre of an adhesive polyurethane membrane coated
with an acrylic adhesive. A piece of non-woven fabric is placed between the foam and the adhesive
backing to act as a wicking layer and facilitate uniform dispersion of exudate throughout the absorbent
foam. The dressing is available in several sizes (11x11cm, 15x15cm, 15x20cm, 18x18cm), a shaped
sacral dressing is also available.
How does it work?

The central island gently expands as exudate is absorbed. The absorbent layers are arranged to avoid
maceration at the wound edge. This allows the wound to remain moist but not macerated encouraging
healing and auto-debridement where necessary.
Advantages
1. The foam layers are capable of absorbing more fluid than a hydrocolloid dressing.
2. The adhesive layer is thin and flexible.
3. The dressing does not adhere to granulating tissue.
4. It is easy to cut and shape and dressing to accommodate body contours.
5. Tielle is waterproof and impermeable to bacteria but is permeable to moisture vapour
Disadvantages
1. Limited value on dry wounds.
Wounds to use it on
Use on moderately exuding yellow, red and pink wounds. Tielle is particularly useful for pressure sores,
heel ulcers and traumatic wounds.
How to use it
Choose a dressing size that will allow the wound to be covered by the island part of the dressing. Wetting
the adhesive on removal of the dressing will reduce trauma.

May be left for up to seven days dependant on the amount of exudate.
Bibliography:
Ballard, K. (2001) The Tielle family of dressings: overview of the product range. Br J Nurs 10(12): 808-814.
Carter, K. (2003) Hydropolymer dressings in the management of wound exudate. Br J Community Nurs, 8: suppl 10-6.
Collier J (1992) A moist, odour-free environment. A multicentred trial of a foamed gel and a hydrocolloid dressing. Professional
Nurse 7(12):804, 806, 808
Diehm, C. & Lawall, H. (2005) Evaluation of Tielle hydropolymer dressings in the management of chronic exuding wounds in
primary care. Int Wound J, 2: 26-35.
Mellor, J. & Boothman, S. (2003) TIELLE* hydropolymer dressings: wound responsive technology. Br J Community Nurs, 8: 14-7.
Naylor, W. (2001) Using a new foam dressing in the care of fungating wounds. Br J Nurs 10(6 Suppl): S24-30.
46
Deodorisers
Introduction: Deodorisers
Wound odour can be a significant problem for patients, particularly those with non-healing or malignant
wounds. Three products can be used in this situation.
Clinisorb uses activated charcoal to absorb odour and is designed to be used as a secondary dressing or
within a bandage system.
Actisorb Silver 220 is also based on activated charcoal but also contains silver as an antimicrobial agent
and can be used as a wound contact layer
As odour is usually due to bacterial, particularly anaerobic, activity Metronidazole Gel can also be
effective as an odour reducing agent.
Clinisorb
AlternativeProduct(s)
Metronidazole gel
Actisorb Silver 220
47
Deodorisers
CLINISORB
COST CODE C for 10.5x10.5cm dressing
Dressing type: DEODORISER Manufacturer: CliniMed Ltd
What is it?
Activated charcoal cloth produced by carbonising and activating a knitted viscose rayon fabric,
sandwiched between 2 layers of calendered viscose rayon.
How does it work?

Activated charcoal can adsorb volatile molecules such as those responsible for wound odour.
Advantages
1. Easy to apply
2. Effective in the management of all types of malodorous wounds
Disadvantages
1. Not a primary dressing
2. Not readily conformable
Wounds to use it on
May be used to contain the odour produced by all types of malodorous wounds, but only as a secondary
dressing.
How to use it
Clinisorb Odour Control Dressing should be applied over a suitable primary dressing, and held in place
with tape or a bandage as appropriate. Because both sides of the dressing are the same, it does not
matter which surface is placed downwards. The dressings may also be shaped or cut to size if required

The product can be used for as long as it remains dry. The frequency of dressing change will depend
upon whether the dressing becomes wet. Once the charcoal cloth comes into contact with exudate, its
odour adsorbing properties are reduced and a change is recommended.
Bibliography
Thomas S, (1992) Current Practices in the Management of Fungating Lesions and Radiation Damaged Skin, Surgical Materials
Testing Laboratory, Bridgend, 1992.
Lawrence JC, Lilly, HA. Kidson, A. (1993) Malodour and dressings containing active charcoal, Proceedings of the 2nd European
Conference on Advances in Wound Management, Ed Harding KG, Cherry G, Dealey C, and Turner TD, Macmillan Magazines Ltd,
73-74.
Williams, C. (2000) CliniSorb activated charcoal dressing for odour control Br J Nurs 9(15): 1016-9
48
Deodorisers
ACTISORB SILVER 220

COST CODE D for 10.5x10.5cm dressing
Dressing type: ANTIMICROBIAL and Manufacturer: Johnson & Johnson

DEODORISER
What is it?
Activated charcoal cloth with silver chemically and physically bound to the carbon fibres. This active
fabric is sealed inside a nylon envelope that eases handling and reduces fibre loss. It is used as an
antimicrobial, wound cleanser and deodoriser. The dressings are available in 6.5cm x 9.5cm, 10.5cm x
10.5cm and 10.5cm x 19cm sizes.
How does it work?

The activated charcoal cloth absorbs bacteria, bacterial toxins and odour. Sufficient silver is present
within the dressing to act as an antimicrobial agent.
Advantages
1. Easy to apply
2. Effective against a wide range of bacteria
Disadvantages
1. May adhere to dry wounds
2. Cannot be cut to size
Wounds to use it on
Suitable for all green or yellow exuding malodorous wounds including leg ulcers, fungating carcinomas,
faecal fistulae and pressure sores.
How to use it
Apply Actisorb Silver directly to the wound. In the presence of delicate skin use Actisorb Silver over an
N-A dressing to prevent damage. Cover with an absorbent layer and a retention bandage.
DO NOT CUT THIS DRESSING

Depending on the state of the wound the Actisorb Silver component of the dressing may be left in place
for up to 7 days. The absorbent layer of the dressing may need to be changed more frequently
particularly in the case of heavily exudating or grossly malodorous wounds.
Bibliography
Lansdown, A. B., Williams, A., Chandler, S. & Benfield, S. (2005) Silver absorption and antibacterial efficacy of silver dressings. J
Wound Care , 14: 155-60.
Muller, G., Winkler, Y. & Kramer, A. (2003) Antibacterial activity and endotoxin-binding capacity of Actisorb Silver 220. J Hosp Infect,
53: 211-4.
Mulligan, C. M., Bragg, A. J. and O'Toole, O. B. (1986) A controlled comparative trial of Actisorb activated charcoal cloth dressings
in the community. Br J Clin Pract 40(4): 145-148.
Williams, C. (1994) Actisorb Plus. Br J Nurs 3(15): 786-788.
49
Deodorisers
METRONIDAZOLE GEL
Equivalent to: ANABACT COST CODE E for 20g
Dressing type: DEODORISER Manufacturer: Pharmacy
What is it?
Metronidazole gel is a colourless transparent hypromellose gel containing 8% Metronidazole and
Benzalkonium chloride.
Anabact is a colourless gel containing 7.5% Metronidazole, hydroxybenzoate and propylene glycol.
Available in: 15gm and 30gm tubes.
How does it work?

Metronidazole gel has two actions. The gel itself helps to provide a moist environment which promotes
debridement by autolysis. Metronidazole is active against a range of anaerobic and aerobic bacteria and
is therefore active against the odour produced by these bacteria.
Advantages
1. Provides a warm moist environment
2. Effective odour control agent especially for malignant wounds and leg ulcers.
Disadvantages
1. Should be avoided in patients with known Metronidazole or Parabens allergy
2. Should not be used during pregnancy or lactation
3. Must not be exposed to strong sunlight or UV light.
Wounds to use it on
Malodorous wounds, fungating tumours, pressure sores and leg ulcers.
How to use it
The Gel should be applied liberally to the wound surface and covered with a secondary dressing or film
depending on the volume of exudate. This product should not be used long term, alternative dressings
being used when bacterial load is no longer a problem.

Daily/As required
Bibliography:
Ashford R, et al., (1984) Double blind trial of metronidazole in malodorous ulcerating tumours. Lancet, i: 874-5.
Bale, S., Tebbie, N. & Price, P. (2004) A topical metronidazole gel used to treat malodorous wounds. Br J Nurs, 13: S4-11.
Jones PH, et al., (1978) Treatment of anaerobically infected pressure sores with topical metronidazole. Lancet, i: 214.
Thomas S, et al., (1991) The antimicrobial properties of two metronidazole medicated dressings used to treat malodorous wounds,
Pharm. J., 246: 264-266.
Thomas S, (1992) Current practices in the management of fungating lesions and radiation damaged skin, Surgical Materials Testing
Laboratory, Bridgend.
Bower M, et al., (1992) A double-blind study of the efficacy of metronidazole gel in the treatment of malodorous fungating tumours,
Eur. J. Cancer, 28a: 888-889.
50
Antimicrobials
Introduction: Antimicrobials
Antimicrobials are agents that either kill or inhibit the growth and division of micro-organisms. They
include antibiotics (oral or IV) which act on specific cellular target sites, antiseptics, disinfectants and
other agents which act on multiple cellular target sites.
When using antimicrobials the objective must always be to provide optimum conditions to support rapid
healing. In selecting antimicrobial agents to reduce or eradicate micro-organisms, choice must be
influenced by the specificity and efficacy of the agent, its cytotoxicity to human cells, its potential to select
resistant strains and its allergenicity. The range of topical antimicrobial agents currently used includes
products containing iodine (cadexomer iodine and povidone iodine) and products containing silver (silver
sulfadiazine and silver-impregnated dressings). Honey is also antimicrobial and acts as a debriding agent.
It also helps with odour control.
Antimicrobial products should only be used where it is considered that the bioburden is a barrier to
healing. Use should be limited to short periods (no more than 2 weeks) and if there is no improvement
refer the patient for further assessment and treatment.
Another means of reducing microbial load is the application of maggots. Not only do they remove
bacteria, but they provide both debridement and enhancement of healing. Larval removal of Gram-
positive bacteria is more efficient than the removal of Gram-negative bacteria, so greater numbers of
maggots might be required for a wound infected with Gram-negative bacteria.
The table below provides a comparison of the listed antimicrobial categories.
Gram +ve Gram ve Fungi Endospore Viruses Resistance

Honey +++ +++ +++ 0 + 0
Iodine +++ +++ +++ +++ ++ 0
Maggots +++ ++ ND ND ND 0
Silver +++ +++ + ND + +
ND= No data
Iodoflex
Acticoat Absorbant
Aquacel Ag
Actisorb Silver 220
Flamazine
MediHoney
Inodine
Acticoat 7
Betidine Ointment
51
Antimicrobials
ACTICOAT ABSORBANT / ACTICOAT 7

COST CODE F for 10x12.5cm dressing
Dressing type: ANTIMICROBIAL Manufacturer: Smith & Nephew
What is it?
Acticoat is available as Acticoat Absorbent and Acticoat 7.
Acticoat Absorbent is an alginate dressing incorporating nanocrystalline silver and provides a highly
absorbent antimicrobial dressing. Available sizes are 5cm x 5cm and 10cm x 12.5cm.
Acticoat 7 consists of three layers of a fine silver coated polyethylene mesh and two layers of non-woven
fabric. All 5 layers are welded together. The silver is applied to the mesh by a vapour deposition process
forming nanocrystals of metallic silver. Available sizes are 10cm x 12.5cm and 15cm x15cm.
How does it work?

Nanocrystalline silver exhibits an antibacterial activity against a wide range of Gram-negative and Gram-
positive bacteria, yeasts and fungi.
Advantages
1. Fast acting and long lasting antimicrobial dressing
2. Provides a high level of available silver
3. Sustained silver release, can be left in place for up to 7 days
Disadvantages
1. It is expensive to use and application warnings must be noted
3. Care should be taken with secondary dressing
4. Some patients find this dressing painful
5. Care needed in choice of wound for this product; needs to be appropriate to be beneficial
Wounds to use it on
Yellow or green, infected or heavily colonised and heavily exudating wounds that have not/will not
responded to conventional dressings. Use when a reduction of bacterial load is necessary. Acticoat
Absorbent is designed specifically for very highly exudating wounds. Acticoat 7 has been used as a
secondary dressing over Mepital for skin grafts.
How to use it
Both dressing should be cut to shape and can be moistened with water (not saline) and must not be
used with any oil based products or other active dressings or antimicrobials. Secondary dressings should
be an inert absorbent product chosen according to the level of exudate. Acticoat products should be used
for short periods only and stopped once bacterial load has been decreased.

Can be left in place for 7 days. May require more frequent change in heavily exudating wound.
Bibliography:
Ip, M., Lui, S. L., Poon, V. K., Lung, I. & Burd, A. (2006) Antimicrobial activities of silver dressings: an in vitro comparison. J Med
Microbiol, 55: 59-63.
Strohal, R., Schelling, M., Takacs, M., Jurecka, W., Gruber, U. & Offner, F. (2005) Nanocrystalline silver dressings as an efficient
anti-MRSA barrier: a new solution to an increasing problem. J Hosp Infect, 60: 226-30.
Tredget, E. E., Shankowsky, H. A., Groeneveld, A. and Burrell, R. (1998) A matched-pair, randomized study evaluating the efficacy
and safety of Acticoat silver-coated dressing for the treatment of burn wounds. J Burn Care Rehabil 19(6): 531-537.
Wright, J. B., Lam, K. and Burrell, R. E. (1998) Wound management in an era of increasing bacterial antibiotic resistance: a role for
topical silver treatment. Am J Infect Control 26(6): 572-577.
Wright, J. B., Lam, K., Hansen, D. and Burrell, R. E. (1999) Efficacy of topical silver against fungal burn wound pathogens. Am J
Infect Control 27(4): 344-350.
52
Antimicrobials
IODOFLEX
COST CODE E for 5g
Dressing type: CADEXOMER Manufacturer: Smith & Nephew
What is it?
Iodoflex consists of medicated hydrophilic polysaccharide beads that contain 0.9% Povidone iodine. This
is held within the structure of a cadexomer polymer and is slowly released when the dressing is hydrated.
Iodoflex is available in 5gm, 10gm and 17gm sizes.
How does it work?

The polysaccharide beads take up fluid and swell. If placed on a sloughy or infected wound, bacteria and
cellular debris are taken up by capillary action and are trapped in the spaces between the beads. Iodine is
slowly released into these spaces to work on the bacteria. The same capillary action ensures that Iodine
concentrations remain at the lowest at the wound surface.
Advantages
1. Effective cleanser active against a wide range of gram-negative and gram-positive bacteria and fungi.
2. Biodegradable
3. The low % iodine slowly released does not delay healing or effect fibroblasts.
Disadvantages
1. Not suitable for use on a dry, necrotic wound.
2. Can cause local skin reactions and cannot be used in patients with known iodine sensitivity
3. The maximum single application is 50gm and the weekly application must not exceed 150gm
Wounds to use it on
Iodoflex is recommended for the treatment of infected, moist, sloughy green and yellow wounds. In some
chronic wounds Iodoflex has stimulated growth factors and white cell activity and therefore encouraged
healing
How to use it
Prior to application of Iodoflex dressing one of the protective carrier layers is removed and the paste is
placed directly in contact with the wound. The second carrier layer is then generally removed but it can be
left in place if required. Removal is best accomplished by irrigation.

Daily/ weekly depending on nature of wound and volume of exudate
Bibliography:
Akiyama, H., Oono, T., Saito, M. & Iwatsuki, K. (2004) Assessment of cadexomer iodine against Staphylococcus aureus biofilm in
vivo and in vitro using confocal laser scanning microscopy. J Dermatol 31: 529-34.
Bianchi, J. (2001) Cadexomer-iodine in the treatment of venous leg ulcers: what is the evidence? J Wound Care 10: 225-9.
Gilchrist, B. (1997) Should iodine be reconsidered in wound management? European Tissue Repair Society. J Wound Care 6(3):
148-150.
Hansson, C. (1998) The effects of cadexomer iodine paste in the treatment of venous leg ulcers compared with hydrocolloid
dressing and paraffin gauze dressing. Cadexomer Iodine Study Group. Int J Dermatol 37(5): 390-396.
Moore, K., Thomas, A. & Harding, K. G. (1997) Iodine released from the wound dressing Iodosorb modulates the secretion of
cytokines by human macrophages responding to bacterial lipopolysaccharide. Int J Biochem Cell Biol, 29, 163-71.
Zhou, L. H., Nahm, W. K., Badiavas, E., Yufit, T. and Falanga, V. (2002) Slow release iodine preparation and wound healing: in vitro
effects consistent with lack of in vivo toxicity in human chronic wounds. Br J Dermatol 146(3): 365-374.
53
Antimicrobials
AQUACEL Ag
COST CODE E 10x10cm dressing
Dressing type: ANTIMICROBIAL HYDROFIBER Manufacturer: ConvaTec
What is it?
Aquacel hydrofiber dressing is made of a hydrocolloid polymer (carboxymethylcellulose) spun into fibres
and manufactured into a sheet and a ribbon. The sheets are available in three sizes 5x5cm, 10x10cm and
15x15cm. Aquacel Ag contains 1.2% ionic silver that adds antimicrobial properties to the dressing.
How does it work?

Aquacel dressing is absorbent and allows fluid into the fibres of the dressing. As exudate wets the
dressing, Aquacel becomes a gel sheet. The gel provides an environment that encourages the healing
and debriding process. There is minimal expansion of the dressing as the fluid is absorbed. Aquacel Ag
releases silver ions in the presence of wound exudate. This prevents colonisation of the dressing and
provides an antimicrobial barrier to protect the wound, locking bacteria within the gel.
Advantages
1. Aquacel is more absorbent than alginate dressings
2. Vertical wicking reduces maceration of the surrounding skin
3. Deals effectively with moderate to heavy exudate
4. Aquacel Ag provides an affective antimicrobial barrier
Disadvantages
1. Can become adhered if the wound is too dry
2. Requires a secondary dressing
3. Of little value in dry wounds
Wounds to use it on
Use on yellow, pink or red moderate to heavy exudating wounds. Aquacel Ag can be used on infected
wounds but it is recommended that regular inspections be carried out. Aquacel is particularly useful in
surgical cavity wounds.
How to use it
The fibre dressing can be used flat or as a loose cavity filler. A secondary absorbent dressing of
Granuflex or DuoDerm can cover this. The gel maintains its integrity and therefore can be removed whole
or it can be washed out of the wound with water or saline.

The dressing can be left for up to seven days or until leakage occurs.
Bibliography:
Caruso, D. M., Foster, K. N., Blome-Eberwein, S. A., Twomey, J. A., Herndon, D. N., Luterman, A., Silverstein, P., Antimarino, J. R.
& Bauer, G. J. (2006) Randomized clinical study of Hydrofiber dressing with silver or silver sulfadiazine in the management of
partial-thickness burns. J Burn Care Res, 27: 298-309.
Foster, L., Moore, P. and Clark, S. (2000) A comparison of hydrofibre and alginate dressings on open acute surgical wounds. J
Wound Care 9(9): 442-445.
Jones, S. A., Bowler, P. G., Walker, M. & Parsons, D. (2004) Controlling wound bioburden with a novel silver-containing Hydrofiber
dressing. Wound Repair Regen, 12: 288-94.
Wound Care, 14: 155-60.
Moseley, R., Leaver, M., Walker, M., Waddington, R. J., Parsons, D., Chen, W. Y. and Embery, G. (2002) Comparison of the
antioxidant properties of HYAFF-11p75, AQUACEL and hyaluronan towards reactive oxygen species in vitro. Biomaterials 23(10):
2255-2264.
Williams, C. (1999) An investigation of the benefits of Aquacel Hydrofibre wound dressing. Br J Nurs 8(10): 676-677, 680.
54
Antimicrobials
ACTISORB SILVER 220

COST CODE D for 10.5x10.5cm dressing
Dressing type: ANTIMICROBIAL and Manufacturer: Johnson & Johnson

DEODORISER
What is it?
Activated charcoal cloth with silver chemically and physically bound to the carbon fibres. This active
fabric is sealed inside a nylon envelope that eases handling and reduces fibre loss. It is used as an
antimicrobial, wound cleanser and deodoriser. The dressings are available in 6.5cm x 9.5cm, 10.5cm x
10.5cm and 10.5cm x 19cm sizes.
How does it work?

The activated charcoal cloth absorbs bacteria, bacterial toxins and odour. Sufficient silver is present
within the dressing to act as an antimicrobial agent.
Advantages
1. Easy to apply
2. Effective against a wide range of bacteria
Disadvantages
1. May adhere to dry wounds
2. Cannot be cut to size
Wounds to use it on
Suitable for all green or yellow exuding malodorous wounds including leg ulcers, fungating carcinomas,
faecal fistulae and pressure sores.
How to use it
Apply Actisorb Silver directly to the wound. In the presence of delicate skin use Actisorb Silver over an
N-A dressing to prevent damage. Cover with an absorbent layer and a retention bandage.
DO NOT CUT THIS DRESSING

Depending on the state of the wound the Actisorb Silver component of the dressing may be left in place
for up to 7 days. The absorbent layer of the dressing may need to be changed more frequently
particularly in the case of heavily exudating or grossly malodorous wounds.
Bibliography
Wound Care , 14: 155-60.
Muller, G., Winkler, Y. & Kramer, A. (2003) Antibacterial activity and endotoxin-binding capacity of Actisorb Silver 220. J Hosp Infect,
53: 211-4.
Mulligan, C. M., Bragg, A. J. and O'Toole, O. B. (1986) A controlled comparative trial of Actisorb activated charcoal cloth dressings
in the community. Br J Clin Pract 40(4): 145-148.
Williams, C. (1994) Actisorb Plus. Br J Nurs 3(15): 786-788.
55
Antimicrobials
FLAMAZINE
Equivalent to: SILVER SULPHADIAZINE COST CODE F for a 20g tube
Dressing type: ANTIMICROBIAL Manufacturer: Smith & Nephew
What is it?
Flamazine is a broad-spectrum white hydrophilic antibacterial cream containing silver sulphadiazine 1%
in an oil and water base.
How does it work?

It is an effective topical antimicrobial agent active against most strains of Gram-positive and Gram-
negative bacteria found as wound pathogens (including Pseudomonas) as well as some types of yeasts
and fungi.
Advantages
1. Broad antimicrobial spectrum
2. Easy to apply
3. No discomfort on application
4. Can be left for up to 48 hours
Disadvantages
1. Some patients are sensitive to sulphonamides
2. Use with caution on large wounds due to potential absorption of silver and sulphonamide components
3. Should not be used on pregnant women or neonates
4. Use with caution if hepatic or renal function impaired
Wounds to use it on
Infected, yellow or green wounds with low to medium exudate.
Treatment of soft tissue injuries such as burns or fingertip injury.
For short-term use on leg and pressure ulcers.
How to use it
Apply a layer of 3-5mm of Flamazine and cover with an absorbent secondary dressing. Flamazine may
also be used under an occlusive glove for hand injuries and burns. This product should not be used long
term, alternative dressings being used when bacterial load is no longer a problem.

Daily/Every 48 hours
Bibliography:
Bishop, J. B., Phillips, L. G., Mustoe, T. A., VanderZee, A. J., Wiersema, L., Roach, D. E., Heggers, J. P., Hill, D. P., Jr., Taylor, E.
L. and Robson, M. C. (1992) A prospective randomized evaluator-blinded trial of two potential wound healing agents for the
treatment of venous stasis ulcers. J Vasc Surg 16(2): 251-257.
Edwards, J. (2002) Flamazine Product Focus. Journal of Community Nursing 16(2): 22-24.
56
Antimicrobials
MEDIHONEY WOUND GEL

COST CODE E for 10g
Dressing type: ANTIMICROBIAL - HONEY Manufacturer: Medihoney
What is it?
Medihoney Antibacterial Wound Gel is a high viscosity formulation of a wax with MEDIHONEY (80%), a
mixture of proprietary honeys including Leptospermum species that have a range of antibacterial actions
effective against a broad spectrum of bacteria including antibiotic resistant strains such as MRSA
How does it work?

The Gel is said to have three actions, protection, cleaning and healing. Hydrogen peroxide and an acidic
wound environment are produced by the action of glucose oxidase. The high osmotic potential of the Gel
assist debridement and move fluid and debris into the Medihoney. The Gel maintains a moist wound
environment, reduces bacterial load and because of the wax content of the Gel wound pain often
associated with high levels of honey is reduced.
Advantages
1. Maintains a warm moist environment
2. Promotes debridement
3. High honey concentration
4. Antimicrobial and anti-inflammatory actions
5. Reduces malodour
6. No known allergens
Disadvantages
1. Not suitable for high exudating wounds

2. Can be painful even with the wax content
3. Wound edge maceration can occur
Wounds to use it on
The Gel can be used on infected acute and chronic wounds or when autolytic debridement is necessary.
It is also effective in controlling malodour and may be used on fungating or patient with sensitivities.
How to use it
Apply to the wound bed in a 3mm thick coat ensuring full contact with the wound bed. Cover with a
secondary dressing (e.g. foam). This product should not be used long term, alternative dressings being
used when bacterial load is no longer a problem.

The Gel may be left on the wound for three to seven days depending on the exudate level.
Bibliography:
(2005) Natural Approaches to Wound Management: a focus on Honey and Honey-based Dressings. Wounds UK Supplement, 1: 1-
60.
Dunford, C. E. & Hanano, R. (2004) Acceptability to patients of a honey dressing for non-healing venous leg ulcers. J Wound Care,
13: 193-7.
Lusby, P. E., Coombes, A. & Wilkinson, J. M. (2002) Honey: a potent agent for wound healing? J Wound Ostomy Continence Nurs,
29: 295-300.
Lusby, P. E., Coombes, A. L. & Wilkinson, J. M. (2006) A comparison of wound healing following treatment with Lavandula x allardii
honey or essential oil. Phytother Res, 20: 755-7.
Simon, A., Sofka, K., Wiszniewsky, G., Blaser, G., Bode, U. & Fleischhack, G. (2006) Wound care with antibacterial honey
(Medihoney) in pediatric hematology-oncology. Support Care Cancer, 14: 91-7.
57
Antimicrobials
INADINE
COST CODE A for 10x10cm dressing
Dressing type: ANTISEPTIC Manufacturer: Johnson & Johnson
What is it?
Inadine is a sterile, low adherent knitted fabric dressing impregnated with a polyethylene glycol base
containing 10% Povidone iodine. It appears yellow-brown in colour and comes in individual packets. It is
available as 5cm x 5cm and 9.5cm x 9.5cm sizes.
How does it work?

Povidone Iodine has a rapid and prolonged germicidal action against a wide range of organisms including
Gram-positive and Gram-negative bacteria, fungi, protozoa and viruses. It is also active against bacterial
spores. Its activity persists in the presents of necrotic tissue, purulent exudate, blood and serum whilst the
golden brown colour remains.
Advantages
1. Wide spectrum of activity
2. Useful colour change indicating need for dressing change
3. Easy to apply.
4. Non-adherent.
Disadvantages
1. Retards healing and lowers the tensile strength of the wound
2. Is an allergen
3. Causes irreversible micro-circulation damage and interferes with collagen synthesis and damages
fibroblasts
4. May accumulate systemically leading to thyrotoxicosis in patients with pre-existing thyroid disease and
should not be used during pregnancy, during lactation and should be used with caution in the presence
of hepatic and renal disease and on patients receiving Lithium therapy.
Wounds to use it on
Use in low exudate, shallow wounds. It is useful for the prophylaxis/treatment of a wide range of bacterial
and fungal infections.
How to use it
Peel the Inadine from the protective sheets and apply 1-2 layers over the wound and cover with a
secondary dressing. This product should not be used long term, alternative dressings being used when
bacterial load is no longer a problem.

Change when the yellow-brown colour turns to white.
Bibliography:
Han, K. H. and Maitra, A. K. (1989) Management of partial skin thickness burn wounds with Inadine dressings. Burns 15(6): 399-
402.
Adams, I. (1985) Wound care in accident and emergency. Inadine dressing. Nursing (Lond) 2(42): (suppl) 6-7.
Lineaweaver, W., Howard, R., Soucy, D., Mcmorris, S., Freeman, J., Crain, C., Robertson, J. & Rumley, T. (1985) Topical
antimicrobial toxicity. Archives of Surgery, 120, 267-270.
58
Antimicrobials
BETADINE OINTMENT
Equivalent to INADINE COST CODE B for 20g tube
Dressing type: ANTISEPTIC Manufacturer: Seton Health Care
What is it?
Betadine antiseptic water soluble ointment contains 10% Povidone Iodine.
How does it work?

As an antiseptic, it should be used short term in the presence of infection or to prevent infection where
antibiotic therapy is inappropriate. Povidone Iodine has a rapid and prolonged germicidal action against a
wide range of organisms including Gram positive and Gram-negative bacteria, fungi, protozoa and
viruses. It is also active against bacterial spores. Whilst the golden brown colour remains its activity
persists.
Advantages
1. Wide spectrum of activity (Gram-negative and Gram-positive bacteria, spores, fungi and viruses)
2. Germicidally active whilst brown colour remains evident, unaffected by blood, pus etc.
Disadvantages
1. Retards healing and lowers the tensile strength of the wound
2. Iodine is an allergen
3. Antiseptics are known to retard healing and lower the tensile strength of the wound. In addition
irreversible micro-circulation damage occurs which compromises fibroblasts and interferes with
collagen synthesis
4. May accumulate systemically leading to thyrotoxicosis in patients with pre-existing thyroid disease
should not be used during pregnancy, lactation or in patients on Lithium therapy.
Wounds to use it on
Wounds requiring treatment of infection or with a high bacterial load. This product should not be used
long term, alternative dressings being used when bacterial load is no longer a problem.
How to use it
Should be used short term, apply the ointment directly to the wound and cover with a secondary dressing
dependent on the amount of exudate.
The ointment should be changed when the colour changes to white. Maximum recommended use is
alternate days. The total used for one dressing change should not exceed 50 grams.
Bibliography:
Daroczy, J. (2002) Antiseptic efficacy of local disinfecting povidone-iodine (Betadine) therapy in chronic wounds of lymphedematous
patients. Dermatology 204(Suppl 1): 75-78.
Goldenheim, P. D. (1993) An appraisal of povidone-iodine and wound healing. Postgrad Med J 69(Suppl 3): S97-105.
Gilchrist, B. (1997) Should iodine be reconsidered in wound management? European Tissue Repair Society. J Wound Care 6(3):
148-150.
Lineaweaver, W., Howard, R., Soucy, D., Mcmorris, S., Freeman, J., Crain, C., Robertson, J. & Rumley, T. (1985) Topical
antimicrobial toxicity. Archives of Surgery, 120, 267-270.
Juhasz, I. (2002) Experiences with the use of povidone-iodine-containing local therapeutics in dermatological surgery and in the
treatment of burns: testing for allergic sensitization in postsurgery patients. Dermatology 204(Suppl 1): 52-58.
Vehmeyer-Heeman, M., Van Den Kerckhove, E., Gorissen, K. & Boeckx, W. (2005) Povidone-iodine ointment: no effect of split skin
graft healing time. Burns, 31: 489-94.
59
Advanced Products
Introduction: Advanced Products

Advanced products should only be used following wound assessment by a member of the Wound Care
and Tissue Viability Team. The use of these products should be carefully monitored and their
effectiveness audited.
60
Advanced Products
PROMOGRAN & PROMOGRAN PRISMA

ADVANCED PRODUCT COST E (F for Prisma)
Dressing type: PROTEASE MODULATOR Manufacturer: Johnson & Johnson
What is it?
Promogran is composed of a matrix of collagen and oxidised regenerated cellulose. A recent
development is the incorporation of silver into this product (PROMOGRAN PRISMA)*.
How does it work?

The matrix absorbs liquid to form a gel that binds with, and inactivates, matrix metalloproteinases
(MMPs). This upregulates the action of the growth factors and is postulated to stimulate healing. Silver
has been suggested to enhance the effect of Promogran.
Advantages
1. Stimulates chronic wounds that are not responding to conventional dressings.
2. Case studies suggest that when used on wounds improvements are seen.
Disadvantages
1. Cost.
2. Some clinical trial data to prove its clinical use.
3. Care needed in choice of wound for this product; needs to be appropriate to be beneficial
Wounds to use it on
Clean, debrided red wounds that are slow to heal. Is appropriate for diabetic foot ulceration, leg ulcers
and arterial ulceration.
How to use it
Apply the hexagonal shaped dressing, which can be cut to size, to the wound. The dressing needs to be
moist to be effective. As the dressing is naturally degradable it can be left on the wound. Secondary
dressings are required such as Tielle. It can be placed under compression bandaging.

Determined by the wound and the exudate. Daily changes may be necessary where exudate is high in
other wounds may be left for up to 3 days.
* Studies on this product are ongoing
Bibliography:
(2005) Wound care executive meeting report: 10-11 March 2005 Barcelona Spain. J Wound Care, 14(9): 1-15 (Suppl).
Cullen, B., Smith, R., McCulloch, E., Silcock, D. and Morrison, L. (2002) Mechanism of action of PROMOGRAN, a protease
modulating matrix, for the treatment of diabetic foot ulcers. Wound Repair Regen 10(1): 16-25.
Ghatnekar, O., Willis, M. and Persson, U. (2002) Cost-effectiveness of treating deep diabetic foot ulcers with Promogran in four
European countries. J Wound Care 11(2): 70-74.
Lobmann, R., Zemlin, C., Motzkau, M., Reschke, K. & Lehnert, H. (2006) Expression of matrix metalloproteinases and growth
factors in diabetic foot wounds treated with a protease absorbent dressing. J Diabetes Complications, 20: 329-35.
Veves, A., Sheehan, P. and Pham, H. T. (2002) A randomized, controlled trial of Promogran (a collagen/oxidized regenerated
cellulose dressing) vs standard treatment in the management of diabetic foot ulcers. Arch Surg 137(7): 822-827.
61
Advanced Products
VACUUM ASSISTED CLOSURE (VAC)

ADVANCED PRODUCT COST Therapy unit hire 39/day
Disposables 21 to 29 (Foam)/ 26 (Canister)
Dressing type: Exudate management system Manufacturer: KCI
VAC therapy is for use in complex wounds where

Stimulation of healing is required to achieve closure.
Where exudate from a cavity wound is uncontrolled and requiring frequent dressing change.
Where bacterial load is not controlled by conventional dressing
VAC therapy is expensive to use. Hiring charges are based on a daily rate and there is the added cost of
consumables that are required on a regular basis. The decision to use VAC is one made jointly between
the patient, senior nursing and medical staff. This should be discussed with the Nurse Consultant or
Tissue Viability Nurse who holds a register of patients treated in this way. Evaluation of progress and
decision to discontinue / continue therapy must be made, where possible, by the same staff initiating
therapy and treatment should be reviewed at least at weekly intervals. Initial assessment and
documentation of the wound should include photography.
Staff should have specific training in its use. Training can be provided by the Nurse Consultant, TVNs,
members of the vascular or plastic nursing team or by the staff from KCI. It is recommended that when
applying or changing the VAC, assistance is available to ensure a good fit and seal. When difficulties
occur KCI staff can be contacted directly for assistance (Tel: 0800 9808880).
What is VAC (Vacuum Assisted Closure)
Also called vacuum therapy or negative pressure system the VAC is a sophisticated development of the
application of topical negative pressure to the wound bed. The dressing consists of an open pore foam
placed on to the wound that is cut to the size of the wound. The foam is then covered with a transparent
adhesive film drape that is firmly sealed to surrounding healthy skin. Suction tubing is connected to the
foam through a hole cut in the drape film using the provided TRAC Pad. This is then connected to the
VAC therapy unit via a disposable canister that collects the wound fluid.
The pressure setting is dependent on the type of wound, the level of exudate and the duration of VAC
therapy. The negative pressure setting is adjustable, 125mmHg being the maximum therapeutic level for
Granufoam, for White Foam a pressure of 150mmHg is usual. The suction can be applied continuously or
intermittently according to the wound requirements and patient comfort. When applied the negative
pressure reduces the foam size and volume of the wound.
There is evidence demonstrating benefit in a range of acute (plastic surgical, orthopaedic and traumatic
wounds) and chronic wounds including dehisced surgical wounds, pressure ulcers and diabetic foot
ulcers. The clinical benefits in other wound types are supported by case examples and by published
clinical series. (see EWMA Position Paper - (www.ewma.org)).
The VAC systems available are:
VAC ATS has a canister capacity of 500ml. A Freedom VAC is also available which is portable and
suitable for community use however the collection canister only holds 300ml may require more frequent
change. Two faom types are available, black GranuFoam and White Foam the use of which is described
in the flow chart below.
Advantages of VAC
Control and reduction of exudate and oedema within the wound and surrounding tissue.
Control and reduction of bacterial load within the wound and surrounding tissue.
Enhancement of debridement by above actions
Increase in local blood flow through reduction in local tissue pressure.
The mechanical action results in protein and matrix synthesis stimulating granulation
Reduces the need for as frequent dressing change
Demonstrated to be suitable for used on many types of wounds
62
Advanced Products
Foam shapes are available for difficult to manage areas
Disadvantages of VAC
VAC and the consumables which are bought separately are costly
The suction can be painful when used on some patients or wound types
Not suitable on wounds where a seal on the surrounding skin cannot be maintained
Patient mobility is reduced by attachment to therapy unit
Indications for the use of VAC therapy

VAC should be used where conventional dressing products are inappropriate or have failed to achieve
the required aims of wound bed preparation or exudate management.
Can be used on:
Acute and traumatic wounds
Sub-acute wounds such as dehisced incisions
Pressure ulcers
Chronic non healing open wounds e.g. diabetic foot wounds, meshed grafts or flaps
Contra-indications for the use of VAC therapy

Fistulas to organs or body cavities
Necrotic tissue with hard or dry eschar
Osteomyelitis (untreated)
Malignancy.
Caution should be used with patients with bleeding disorders or on anticoagulants or when
applied directly to a fresh surgical wound when bleeding has not been controlled
An algorithm to guide decision-making when choosing the correct foam, therapy system and dressing
technique for TNP therapy:
Adapted from Conservative management of pressure ulcers: The role of topical negative pressure
therapy (Vowden, 2006)
63
Advanced Products
Availability
VAC therapy units are kept in the hospital equipment store in Medical Physics. Emergency VAC units are
held on Ward 19 and 26. All other areas should contact the Wound Care Team who will support use and
monitor progress. NOTE these units should not leave the hospital. In the hospital VAC canisters and
dressings should be ordered from stores.
For patients discharged with VAC therapy ongoing transfer of care and arrangements for community
equipment will be co-ordinated by the Wound Care Team or by Ward 19 or 26.
In the community the therapy units are hired directly from KCI.
Bibliography:
Armstrong, D. G. & Lavery, L. A. (2005) Negative pressure wound therapy after partial diabetic foot amputation: a multicentre,
randomised controlled trial. Lancet, 366: 1704-10.
Ballard, K. and Baxter, H. (2000) Developments in wound care for difficult to manage wounds. Br J Nurs 9(7): 405-408, 410, 412.
Deva, A. K., Buckland, G. H., Fisher, E., Liew, S. C., Merten, S., McGlynn, M., Gianoutsos, M. P., Baldwin, M. A. and Lendvay, P.
G. (2000) Topical negative pressure in wound management. Med J Aust 173(3): 128-131
Josty, I. C., Ramaswamy, R. and Laing, J. H. (2001) Vaccum assisted closure: an alternative strategy in the management of
degloving injuries of the foot. Br J Plast Surg 54(4): 363-365.
Loree, S., Dompmartin, A., Penven, K., Harel, D. & Leroy, D. (2004) Is Vacuum Assisted Closure a valid technique for debriding
chronic leg ulcers? J Wound Care, 13: 249-52.
Mendez-Eastman, S. (1998) Negative pressure wound therapy. Plast Surg Nurs 18(1): 27-29, 33-37.
Scherer, L. A., Shiver, S., Chang, M., Meredith, J. W. and Owings, J. T. (2002) The vacuum assisted closure device: a method of
securing skin grafts and improving graft survival. Arch Surg 137(8): 930-933; discussion 933-934.
Stannard, J. P., Robinson, J. T., Anderson, E. R., Mcgwin, G., Jr., Volgas, D. A. & Alonso, J. E. (2006) Negative pressure wound
therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma, 60: 1301-6.
Webb, L. X. (2002) New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg 10(5): 303-
311.
64
Advanced Products
LarvE (STERILE MAGGOTS)

ADVANCED PRODUCT COST 50 per pot
Dressing type: BIOSURGERY Manufacturer: Zoobiotic
What is it?
Sterile larvae (maggots) supplied for use in wound management are those of the common green bottle
Lucilia Sericata. This is a second line treatment where quick removal of necrotic and infected material is
required. Available as free-range maggots or contained in a bag (Biobags).
How does it work?

When applied to the wound they are 2-3mm long. Once in place they produce powerful proteolytic
enzymes that degrade and liquefy necrotic tissue. The maggot then ingests the liquefied necrotic tissue
and infective material reducing the non-viable tissue and bacterial load at the wound bed. It has been
reported that the use of LarvE can reduce wound pain and stimulate granulation tissue.
Advantages Disadvantages
1. Rapid but selective method of 1. Availability
debridement 2. Slow when compared to sharp or surgical debridement
2. Reduces bacterial load including MRSA 3. Not suitable for all wounds
3. Stimulation of healing 4. Effectiveness limited by environment
4. Non toxic non allergenic 5. Aesthetic aspects
6. Disposal within 24 hours of removal.
Wounds to use it on
Necrotic or infected black green yellow wounds. LarvE are not effective on hard dry eschar and
rehydration may be necessary with a hydrogel prior to application. Their use should be a joint decision
between the patient, senior nursing and medical staff and should be re-evaluated at each dressing
change. Advice on use can be obtained from the Tissue Viability or Wound Care Teams. Excessively dry
or moist wounds may lead to larval death. LarvE are used:
Where sharp debridement may expose bone or joint
Where autolytic debridement has failed or is contraindicated
To control infection
Prior to skin grafting.
How to use it
The dressing system intends to retain the LarvE at the wound whilst maintaining the correct environment
for LarvE and the optimum effectiveness of treatment. A hole, the size and shape of the wound is cut out
of a sheet of hydrocolloid and placed over the surrounding skin. The LarvE are placed on the wound with
a net over the LarvE on the wound that is fixed to the hydrocolloid with sleek tape. Moistened secondary
non-occlusive dressings are placed over the area. Further instructions are sent with each order of LarvE.
Dressing change/ LarvE removal.

The LarvE should be removed three to four days and disposed of in double yellow bags for incineration
within 24 hours of removal.
Availability:
LarvE are ordered the day prior to application from Zoobiotic (0845 2301810) A Help Line is also
available on 0845 2306806. No delivery Monday
Bibliography:
Jones, M. and Thomas, S. (2000) Larval therapy. Nurs Stand 14(20): 47-51; quiz 53-44.
Thomas, S., Jones, M., Shutler, S. and Jones, S. (1996) Using larvae in modern wound management. J Wound Care 5(2): 60-69.
Rayman, A., Stansfield, G., Woollard, T., Mackie, A. and Rayman, G. (1998) Use of larvae in the treatment of the diabetic necrotic
foot. The Diabetic Foot 1(1): 7-13.
Steenvoorde, P., Jacobi, C. E. & Oskam, J. (2005) Maggot debridement therapy: free-range or contained? An in-vivo study. Adv
Skin Wound Care, 18: 430-5.
65
Advanced Products
XELMA
COST CODE F 1ml applicator
Dressing type: EXTRACELLULAR MATRIX Manufacturer: Molnlycke

REPLACEMENT
What is it?
Xelma is a degradable solution of amelogenin, a natural protein originally isolated from periodontal
ligament, in Propylene Glycol Alginate designed to restore a temporary ECM and support wound healing
in hard-to-heal wounds.
How does it work?

When Xelma is applied to a wound the proteins assemble into large aggregates providing an extracellular
matrix protein equivalent for cell attachment, proliferation and migration human dermal fibroblasts. It also
increases the expression of Vascular Endothelial Growth Factor.
Advantages
1. Easy to apply
2. Effective treatment for hard-to-heal venous ulcers
3. Fits well with weekly dressing regimen
Disadvantages
1. Cost
2. Limited data outside of venous ulcers
3. Limited availability to specialist wound care centres
Wounds to use it on
Non-infected, non-healing venous leg ulcers with minimal slough that have failed to respond to effective
compression bandaging and standard dressings. Following discussion with Pharmacy and Medicines
Management this product should only be under the direct supervision of the Wound Healing Unit.
How to use it
2
Using the applicator, which provides sufficient Xelma for a 20cm wound, apply a thin layer of the protein
solution to the wound bed weekly and cover with a non-adherent secondary dressing (e.g. Mepilex)
appropriate to the exudate level. The outer dressing may be changed more frequently if needed.

Weekly
Bibliography:
Grayson, R. E., Yamakoshi, Y., Wood, E. J. & Agren, M. S. (2006) The effect of the amelogenin fraction of enamel matrix proteins
on fibroblast-mediated collagen matrix reorganization. Biomaterials, 27: 2926-33.
Mirastschijski, U., Konrad, D., Lundberg, E., Petter Lyngstadaas, S., Jorgensen, L. N. & Agren, M. S. (2004) Effects of a topical
enamel matrix derivative on skin wound healing. Wound Repair Regen, 12: 100-108.
Vowden, P., Romanelli, M., Peter, R., Bostrom, A., Josefsson, A. & Stege, H. (2006) The effect of amelogenins (Xelma) on hard-to-
heal venous leg ulcers. Wound Repair Regen, 14: 240-6.
Vowden, P., Romanelli, M. & Price, P. (2007) Effect of amelogenin extracellular matrix protein and compression on hard-to-heal
venous leg ulcers. Journal of Wound Care, 16, 189-195.
66
BANDAGES USED IN WOUND CARE
Class For Function and uses in wound care Products
1 Retention Conforming Retention Bandages: These K band, Tubifast,

bandages are used to simply hold a Tubigauze
dressing in place they consist of lightweight
elastomeric fibres allowing conformability
but no power to the bandage.
2 Support Light support bandages: These can be used Crepe bandages

to prevent oedema and providing support for
minor sprains. These bandages have limited
elasticity. If used at full extension can be
used to provide support over a joint without
generating significant levels of compression.
Sub bandage padding is recommended
when using crepe.
3 Compression bandages (Elastic)

Type 3 is subdivided 3a, 3b and 3c dependant on the level of compression
All support or compression bandages are multi component and must be applied
over soft padding such as Soffban (Profore #1)
No bandage should be applied as a single layer for leg ulcer patients.
3a Light Applied at 50% stretch and 50% overlap Profore #3 (Litepress)

compression provides a sub-bandage pressure of 14-
17mmHg. This is equivalent to Class 1
K-Plus & Ko-Flex
(British Standard) hosiery.
3b Moderate Applied at 50% stretch and 50% overlap in a Profore #4 (Co-plus)

compression spiral provides a sub bandage pressure
of18-24mmHg and is suitable for the
management of mild oedema and is
effective in prevention or management of
venous disease on a normal sized limb. This
is equivalent to Class 2 (British Standard) or
Class 1 (European Standard) hosiery.
3c High Applied at 50% stretch and 50% overlap in a Profore plus or

compression spiral provides a sub bandage pressure of
25-35mmHg and is used as part of a multi- Tensopress
component bandage system on patients
with large limbs this is equivalent to Class 3
(British Standard) or Class 2 (European
Standard) hosiery.
Short stretch Applied in a spiral with a 50% overlap. Form Panalast, Actico
compression a rigid containment layer improving venous
return during exercise. Used on mobile
patients to treat lymphoedema and venous
disease.
Varistretch Applied in a spiral with 50% overlap and Proguide

approximately 50% stretch. Markers on the
bandage are design to assist application
67
Orthopaedic wool bandage
Orthopaedic wool bandage (Profore #1 = Soffban natural) is cotton orthopaedic wool bandage it is
conformable and comfortable used under bandages both as an absorbent layer and is used to protect
bony prominences from pressure.
Orthopaedic wool with a crepe bandage can, when required, be used as an initial bandage system for
patients with cellulitis, trauma, leg ulceration or lymphoedema prior to the assessment of the patient with
a leg wound.
Application of compression bandages
Any compression bandages or hosiery must only be applied following Doppler assessment and
calculation of ankle brachial pressure index (ABPI) (Vowden, Goulden and Vowden 1996; Vowden and
Vowden 2001) and not applied if ABPI is less that 0.8 where referral to The Wound Healing Unit or
vascular team is necessary who may suggest some degree of compression following assessment.
The correct application of high compression bandages requires both an understanding of the scientific
principles behind their use and a practitioner skilled in their correct application. Only suitably trained heath
care professionals should apply compression systems. Incorrectly applied bandages and hosiery may not
only be ineffective they may actually lead to deterioration in the condition of the limb and, in extreme
cases, may lead to amputation, particularly if compression therapy is used inappropriately on an
ischaemic limb.
The correct application of a graduated compression bandage demands a degree of technical skill that can
only be acquired through training and maintained by repeated practice (Vowden and Vowden, 2002). The
Wound Care and Tissue Viability teams provide training. The local policy should be in line with National
guidance and expert group opinion (Anderson, 2006).
Regardless of the type of compression system chosen it is important to identify at risk areas, such as
bony prominences, prior to the application of bandages. Multi-layer bandage systems, which contain an
orthopaedic wool layer, are specifically designed to accommodate different sizes and shapes of limb and
this can overcome the problems associated with generating excessive bandage tension, and therefore
pressure, when applying compression.
The four-layer bandage system is a combination of bandage components which combine the action of
both elastic and stiff bandages. The choice of components must be applied according to limb size. The
sub bandage pressure of the appropriate combination is 40mmHg. This bandage regimen is used to treat
venous leg ulceration and gross oedema.
Compression hosiery systems
Two layer compression hosiery systems can be effectively used for patients who are able to provide self-
care or whose care can be provided by untrained staff or carers who are supervised and monitored by the
trained registered Health Care Professional. These systems are useful if the ulceration is small of low
exudating and the wound care can be managed with an adhesive dressing.
Work is on-going to determine the favoured system as there are differences in fit and patient acceptability
the choice must be made for the individual patient.
Further information on compression components and the use of each system will be provided in
the training package provided by the Wound Healing Unit or Tissue Viability Nurses.
68
Components in the 4 layer compression bandage system according to ankle circumference:
Ankle circumference Bandage Components
Less than 18 cm 2 orthopaedic wool layers - extra padding protects thin limbs
1 cotton crepe
1 Class 3a - elastic (Profore #3 or K-Plus)
1 Class 3a cohesive (Ko-Flex)
OR
1 Class 3b - cohesive (Profore #4)
18-25 cm 1 orthopaedic wool layer

1 cotton crepe
1 Class 3a - elastic (Profore #3 or K-Plus)
1 Class 3a cohesive (Ko-Flex)
OR
25-30 cm 1 orthopaedic wool layer

1 Class 3c - high compression bandage (Profore plus or Tensopress)
Greater than 30 cm 2 orthopaedic wool bandages - necessary for extra length required
1 Class 3a - elastic (Profore #3)
1 Class 3c high compression bandage (Profore plus or Tensopress)
The components for each bandage system should not be interchangeable.
Note effective compression will result in a decrease in oedema and a reduction in ankle circumference.
The limb should therefore be re-measured frequently and appropriate changes be made in the bandages
used. For the majority of patients the ankle circumference will be between 18-25 cm.
Bibliography:
Anderson, I. (2006) Should health care assistants apply compression bandages? Nurs Times, 102: 36-7.
Charles, H. (1999) Short-stretch bandaging in the treatment of venous leg ulcers. Jouranl of Wound Care 8(6): 303-304.
Moffatt, C. J., Franks, P. J., Oldroyd, M., Bosanquet, N., Brown, P., Greenhalgh, R. M. and McCollum, C. N. (1992) Community
clinics for leg ulcers and impact on healing. British Medical Journal 305(6866): 1389-1392.
Moffatt, C. (1997) Know how. Four-layer bandaging. Nursing Times 93(16): 82-83.
Moffatt, C. J., Simon, D. A., Franks, P. J., Connolly, M., Fielden, S., Groarke, L. and McCollum, C. N. (1999) Randomised trial
comparing two four-layer bandage systems in the management of chronic leg ulceration. Phlebology 14(4): 139-142.
Moffatt, C. (2002) Four-layer bandaging: from concept to practice. Int J Low Extrem Wounds, 1: 13-26.
Vowden, K. R., Barker, A. and Vowden, P. (1997) Leg ulcer management in a nurse-led, hospital-based clinic. J Wound Care 6(5):
233-236.
69
Guidelines For The Management Of A Malignant Wound
Aims of Management
Probably the most important aspect in the management of these particular lesions is the switch of
emphasis from healing as the primary aim to quality of life maintenance through good symptom
management (Grocott, 1995). The four most common symptoms requiring intervention are exudate,
odour, bleeding and pain.
Malignant lesions may display both ulceration and proliferation. Ulcerated wounds being typically crater
like in appearance, while those with proliferating features tend to develop a raised cauliflower like form.
These features may combine to form a rolled edge to an ulcerated area.
Although these lesions occur anywhere on the body, most (over 80%) tend to appear in the head, neck
and breast region (Haisfield-Wolfe, 1997) and typically in the older patient (> 70 yrs) (Ivetic and Lyne,
1990; Thomas, 1992) although usually associated with advanced cancer, malignant wounds may be
present for decades particularly if the underlying disease is localised (Naylor et al, 2001) or slow growing.
Exudate
The volume and type of exudate may vary considerably. The aim is comfortable and secure control.
Appropriate dressing selection according to exudate level is essential. In selected cases wounds with
high exudate benefit from either stoma appliances or absorbent pads over a non-adherent contact layer.
It is important to work with the patient to find the best method and products (Grocott, 1995). VAC should
not be considered for malignant wounds.
Malodour
Recognised as probably the most distressing symptom from the patients perspective, the malodorous
wound is characterised by anaerobic bacteria and necrotic tissue (Haughton and Young, 1995). Surgical
or sharp debridement is not recommended as these wounds have an increased tendency to bleed.
Autolytic debridement and control of bacterial load is therefore the treatment of choice in this situation.
Metronidazole Gel can be applied topically or Metronidazole given systemically although side effects
(nausea, neuropathy and alcohol intolerance) may affect compliance. Activated charcoal (with or without
silver), Honey Dressing or Occlusive dressings can be used to reduce odour. Alternative therapies such
as Natural Live Yoghurt or the use of Essential Oils on the clothing or in the room may help.
Pain
Pain should be managed in accordance with local policy and with reference to the WHO cancer pain
guidelines.
Dressing products should be non-adherent, Mepilex or Actiform cool being useful products. A moist but
not macerated environment is favourable using dressings that require less frequent changes. Skin can be
protected with Cavilon spray. The following agents could be considered to help at dressing change:
Entonox, EMLA cream, Topical opiods in a hydrogel, NSAIDs or Lignocaine gel
Bleeding
Ensure the dressing used is non-adherent. Alginates or Hydrfibre dressings can reduce bleeding.
Alternative methods are Haemostatic surgical sponges, topical adrenaline if necessary consider referral
to a surgeon for cautery or ligation.
Bibliography
Grocott, P. (1995) The palliative management of fungating malignant wounds. J Wound Care 4(5): 240-242.
Grocott, P. (1995) Assessment of fungating malignant wounds. J Wound Care 4(7): 333-336.
Haughton, W. and Young, T. (1995) Common problems in wound care: malodorous wounds. British Journal of Nursing 4(16): 959-
963.
Haisfield-Wolfe, M. (1997) Malignant cutaneous wounds: a management protocol. Ostomy Wound Management 43(1): 56-66.
Ivetic, O. and Lyne, P. (1990) Fungating and ulcerating malignant lesions: areview of the literature. Journal of Advanced Nursing
15(1): 83-88.
Mcdonald, A. & Lesage, P. (2006) Palliative management of pressure ulcers and malignant wounds in patients with advanced
illness. J Palliat Med, 9: 285-95.
Naylor, W., Laverty, D. and Mallett, J. (2001). Handbook of Wound Management in Cancer Care, Oxford: Blackwell Science.
Seaman, S. (2006) Management of malignant fungating wounds in advanced cancer. Semin Oncol Nurs, 22: 185-93.
Thomas, S. (1992). Current Practices in the Management of Fungating Lesions and Radiation Damaged Skin, Mid Glamorgan: The
Surgical Materials Testing Laboratory.
70
PACE GUIDELINES
Guideline for the Risk Assessment and Prevention of Pressure Ulcers
71
Guidelines for the Diagnosis and management of leg ulcers
72
Management of patients with Diabetes (foot ulceration)
73
Guidelines, policies and other supporting literature
Guidelines and Policies
Clinical Practice Guidelines. The Management of Patients with Venous Leg Ulcers RCN institute 1998.
(http://www.data.rcn.org.uk)
Diabetes National Service Framework (as it relates to the management and prevention of diabetic foot
ulceration) (http://www.doh.gov.uk/nsf/diabetes/index.htm)
Guidance on the use of debriding agents for difficult to heal surgical wounds. NICE (2001)
(http://www.nice.org.uk)
NICE guidelines on pressure ulcer risk assessment and prevention (Guidelines B) NICE (2001)
(http://www.nice.org.uk)
A rapid and systematic review of the clinical effectiveness and cost-effectiveness of debriding agents in
treating surgical wounds healing by secondary intention. (http://www.hta.nhsweb.nhs.uk)
Specialist Wound Care Societies and Journals

ETRS - European Tissue Repair Society, Wound Healing Institute, Churchills Hospital Headington Oxford
OX3 7LJ (http://www.etrs.org)
EWMA - European Wound Management Association, PO Box London SE1 8TT (http://www.ewma.org)
LUF - Leg Ulcer Forum (http://www.legulcerforum.org)
TVS - Tissue Viability Society, Wessex Rehabilitation Unit Odstock Hospital Salisbury
(http://www.tvs.org.uk)
WCS - Wound Care Society, PO Box 263, Northampton NN3 4US (http://www.woundcaresociety.org)
Specialist Journals
International Wound Journal (http://www.internationalwoundjournal.com)
Journal of Tissue Viability (http://www.tvs.org.uk/Journal/Current.html)
Journal of Wound Care (http://www.journalofwoundcare.com)
World Wide Wounds (http://www.worldwidewounds.com) includes link to Surgical Materials Testing

Laboratory (SMTL) (http://www.smtl.co.uk) with dressings information on (http://www.dressings.org/)
Wound Repair and Regeneration (http://www.blackwellpublishing.com/)
Wounds UK (http://www.wounds-uk.com)
74
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79
Appendix I - Wound Care Service Profile
The Wound Healing Unit

Clinical Leads
Kathryn Vowden
Nurse Consultant (For Patients with Acute and Chronic Wounds)
Tel 01274 364466 Mobile: 07774 779321
kath.vowden@bradfordhospitals.nhs.uk
Peter Vowden Professor of Wound Healing Research

Consultant Vascular Surgeon
Tel 01274 364466
Specialist Wound Care and Research Nurses (Tel: 01274 382086 or 364466)
Janet McGowan
Victoria Warner
Jane Megson
Leg Ulcer and Complex Wound Clinic (Tel: 01274 364092)

Claire Varley
Matthew Pilcher
Diabetic Foot Ulcer Clinic (Tel: 01274 364314)

Anne DArcy
The University of Bradford

Wound Care Modules and Certificate of Tissue viability at The School of Health Studies
Postgraduate M-level Courses including Debridement
Kath Vowden Jane Collins and Jackie Lisle (Tel: 01274 236401)
Contact details
Address: The Wound Healing Unit, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ
Referrals: To the above address or by fax or phone
Secretary: Ext: 01274 364466 Int: 4466
Fax: Ext: 01274 364807 Int: 4807
Community Tissue Viability Service

Manager
Lorraine Oxborough
Tissue Viability Nurses

Helen Fearnley (Mobile: 07957160602)
Ayesha Clarkson (Mobile: 07939637435)
Leg Ulcer specialist Nurse

Lesley Ogden (Mobile: 07984786572)
Contact details
Address: The Tissue Viability Team

Westbourne Green Community Health Centre, Bradford
Tel 01274 202584
Fax 01274 202585
Referrals: To the address above or by fax or telephone
80
Appendix II - Example wound management chart
81
82

Wound Management

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Wound

Authors: Kathryn and Peter Vowden

(a) Inflammatory phase: 0-3 days

(b) Destructive/Migratory phase: 2-5 days

(d) Maturation phase: 24 days - 1 year

ii. Growth factors, cytokines and chemokines and their influence on

iii. Wound types and categorisation

iv. Factors delaying wound healing

13. Presence of Tumour

14. Local Factors

Patient assessment can be thought of on four levels (Morison, 1992)

This should allow you to identify and record in a care plan:

Assessment should include:

Non-blanchable erythaema of intact skin.

Partial thickness skin loss involving

Full thickness skin loss involving damage to

Extensive destruction, tissue necrosis, or

Reproduced from EPUAP Guide to pressure ulcer grading: http://www.epuap.org/grading.hmtl

Application of TIME to dressing selection

Tissue Management - necrosis

Infection and Inflammation - bacterial balance

Wound Colonisation and Infection

Moisture Management - exudate

Other factors that are important in wound care

Types of cleansing fluid

Prior to debridement all patients will have:

Contra-indications for sharp debridement by nursing staff

Cautions for conservative sharp debridement

Nurses wishing to undertake Sharp debridement:

Complications of sharp debridement

1. Primary - This is in contact with the wound.

Cost effective wound care

Choosing the ideal dressing

1. Maintain high humidity

2. Removes excess wound exudate

3. Permit thermal insulation

6. Non-fibre shedding/ non-toxic

7. Non-adhesive, comfortable and conforming

Dressing Cost Code

BAND B are priced between 50p and 1.49

BAND C are priced between 1.50 and 1.99

BAND D are priced between 2.00 and 2.49

BAND E are priced between 2.50 and 4.99

BAND F are priced above 5.00

Advanced Wound Care Products

Advanced Product Manufacturer Approximate costs

Introduction: Low/Non adherence dressings

Dressing type: LOW ADHERENCE Manufacturer: Johnson & Johnson

How does it work?

Minimum and maximum changing times

Dressing type: NON ADHERENT Manufacturer: Molnlycke

How does it work?

Minimum and maximum changing times

Dressing type: LOW ADHERENCE Manufacturer: Hartmann

How does it work?

Minimum and maximum changing times

Dressing type: FILM Manufacturer: 3M Health Care Ltd

How does it work?

Minimum and maximum changing times

OPSITE FLEXIGRID & OPSITE PLUS

Dressing type: FILM Manufacturer: Smith & Nephew

How does it work?

Minimum and maximum changing times