Dressing Application Criteria Developed and compiled by

Transcription

Dressing Application Criteria
Developed and compiled by:
Jennifer Byrnes Wound Management Nurse Practitioner
Royal Darwin Hospital
January 2013
CONTENTS
Wound Management Principles……………………………………………………………………………....p3
How to Manage Different Wound Types……………………………..……………………………………p4
Wound assessment using TIME…………………………………….……………………………………………p7
Assessing leg and foot ulcers………………………………………….…………………………………………p8
Wound Products by Generic Name:
Acrylic dressings………… eg:.Tegaderm Absorbent.……….………………………………………p9
Alginates……………………………eg:Sorbsan, Algisite M, kaltostat, Seasorb…………………….p10
Atraumatic dressings………… eg:.Mepilex, Mepitel……….………………………………………p11
Cadexomer Iodine………………. eg: Iodosorb…………………………………………………………p12
Capillary wicking dressings …… eg: Vacutex, Advadraw………………………………………p13
Chemical…………………………………………………………………………………………………………..p14
Flaminal…………………………………………………………………………………….….P14
PHMB Prontosan and AMD Foam………………………………………………………P15
Exudate managers………… eg: Mesorb, Zetuvit………………………………………………………p16
Films………………………………… eg: Opsite, Tegaderm…………..……………………………………p17
Fixation sheets………………… eg: Fixomul, Hyperfix, Mefix…..…………………………………p18
Hydrocolloids……………………… eg: Comfeel, Duoderm……….………………………………….p19
Hydrogels……………………………… eg: Solosite, Intrasite,……………….…………………………p20
Hypertonic Saline…………………… eg: Mesalt, Curasalt …………………………………………p21
Impregnated gauzes………………… eg: Jelonet, Cuticerin, Adaptic ………………………….P22
Impregnated Polyurethane Foam…… eg. Polymem …………………….……………………p23
Island dressings………………………………… eg: Primapore, Cutiplast ………………………….P24
Non Adherent Dressings (NAD)…………eg: Telfa, interpose, melonin…………………….p25
Odour Absorbing……………………………… eg: Carbonet, Actisorb ……………………………p26
Polyurethane Foam………………………… eg. Allevyn, Biatain, Lyofoam ……………………p27
Retention Stockings…………………………eg Tubifast, Tensofast…………..…………………p28
Silver dressings………………………………… eg: Acticoat, Mepilex AG…………………………P29
Acticoat……………………………………………………………………………………….P29
Mepliex AG, Allevyn AG………………………………………………………………..P30
Topical negative pressure wound therapy eg: VAC, PICO, Vac Via…….……………..p31
Tubular Bandages……………………………………… eg… Tubigrip, Tensogrip …………………P32
Using Tubular bandages for venous compression therapy…………p33
Zinc Bandages………………………………….eg. Zip Zoc, Viscopaste, Steripaste………………p34
Glossary……………………………………………………………………………………………………………………..p35
2
Document Compiled by Jennifer Byrnes Wound Management Nurse Practitioner RDH January 2013
To understand how to manage a wound, firstly it is essential to have
understanding of the following:
1. Physiology of the wound healing process
a. Inflammatory phase
b. Reconstruction phase
c. Maturation phase
2. Factors that inhibit wound healing
a. Underlying disease: diabetes, cancer, renal disease, liver disease
b. Nutritional status
c. Medications that inhibit wound healing e.g. steroids
d. Other treatments the patient may be undergoing e.g. radiotherapy.
e. Age, obesity, smoking, alcohol
3. the mode of healing that is occurring
a. Primary intention
b. Delayed primary intention
c. Secondary intention
d. Surgical intervention ie Graft or Flap
When providing wound care remember to do the following:
Assess the wound (consider factors that affect wound healing)
i. Type of wound (Acute / Chronic)
ii. Exudate amount, type, colour and odour
iii. Surrounding Skin
iv. Pain
v. Infection / inflammation
vi. Wound clinical appearance; granulating, sloughy, necrotic, epithelising, overgranulating
Determine the underlying aetiology of the wound
Determine the goal of care
i. To heal
ii. To maintain
iii. To palliate
Remember in all wound care DO NO HARM.
If you are unsure ask senior nurse in your area or contact wound
resource person in your area or you can contact RDH wound nurse on
pager #0977 or via phone 89228101 / 0400547979
3
How to Manage Different Wound Types
Necrotic Wounds:
• Require hydration (!check aetiology first,)
• Use a Hydrogel dressing
• Sharp debridement (Check aetiology if no pulse do not perform sharp debridement)
• Surgical debridement may be necessary
• Score thick necrotic tissue if necessary
• If no signs of anaerobe infection use film or hydrocolloid to assist in faster rehydration
!Never rehydrate dry Gangrene (black fingers and toes)
• Paint with Betadine™ and leave it dry!
• Wet gangrene should be converted to dry gangrene by this process
(Edmonds, Foster, & Sanders 2008)
Sloughy Wounds:
• Need Autolytic Debridement
i. Low exudate use Hydrogel
ii. Moderate to high exudate use Hypertonic saline (caution with painful wounds)
iii. High exudate use Calcium Alginate
• May need sharp debridement
i. Sharp debridement accelerates the healing process
ii. This stimulates the inflammatory response
• May need mechanical debridement (wet to dry)
i. Short term only. 3-5 days maximum
ii. Ensure appropriate analgesia is provided
Infected wounds
• Topical antimicrobial dressings i.e. Silver or Cadexomer Iodine
• Acticoat™ is the dressing of choice for bite wounds / dirty traumatic wounds
• Use Cadexomer iodine on sloughy infected wounds, do not use Acticoat on thick slough
• Avoid occlusive dressing for anaerobic infections
! High exudate:
Acticoat absorbent™ (silver calcium alginate)
Cadexomer iodine powder (for small wounds only)
! Low exudate:
Acticoat™ sheet (requires ongoing moisture)
Cadexomer iodine ointment (for small wounds only)
Remember:
Acticoat™ is an anti-inflammatory dressing which is effective on over 150 different pathogens,
and is active on Pseudomonas, MRSA, Gram –ve, Gram +ve Bacilli, viruses, spores & fungi.
Is a broadspectrum topical antimicrobial, which kills pathogens within 30 minutes of contact.
Cadexomer Iodine stimulates the inflammatory process as a result stimulates static wounds
and reduces colonisation / bioburden of wounds.
Heavily colonised wounds not actively infected
• Use chemical wound products ie Flaminal™ or PHMB
! High exudate:
Flaminal Forte™ (gel with calcium alginate) or AMD™ Foam
! Low exudate:
Flaminal Hydro™ or Prontosan™ Gel
4
If high bioburden use prontosan™ wash, then rinse with saline prior to Flaminal™ application.
Betadine™ wash can also be used, apply for 2 mins then wash thoroughly with saline prior to
dressing application, this technique is effective in reducing wound colonisation especially MRSA.
Granulating Wounds:
• No debridement necessary
• High exudate use Calcium Alginate with foam as secondary cover
• Low exudate use Hydrogel to promote moist environment.
Overgranulation:
• Pressure pad: (see photo guide do multiple straps to gain effect)
! Use Foam or Gauze pad strap this firmly in place with Fixomul™
! Fixomul™ cut down to the box to get non-stretch weave!!
! Pull strap firmly in alternating directions to gain adequate pressure
•
Caustic stick / Silver nitrate stick:
! Apply paraffin to good skin
! Treat overgranulation with silver nitrate stick
•
Surgical or sharp removal.
! Check if on anticoagulant therapy
Superficial wounds
• Need protection and maintain moist environment
• Hydrocolloid , Film or Foam can be used
Bleeding wounds:
• Pressure
• Calcium Alginate
• Gel foam (used primarily in theatre for bleeding areas, no standard wound care stock)
• Impregnated packs e.g. adrenaline or cocaine
Exposed Bone or Tendon:
• Keep hydrated but avoid maceration
• High exudate Calcium Alginate
• Low exudate Hydrogel
Skin tears and fragile skin:
• Use Atraumatic dressings
• Mepitel™ remains intact for 14 days
• Change secondary dressing (usually exudate manager) PRN
Key Tips………….
• If it is Wet you want to control the exudate
• If it is Dry you want to hydrate it. Caution make sure you know the aetiology
• Remember the Whole person!!
• Be cost effective
• If in doubt ask!
5
Jenni is available Mon to Fri 8 to 4pm on 0400547979 or pager #0977 [email protected].
Email of photographs are also accepted for consult where necessary.
Please aim for clear photos with 1x close up and 1x wide shot of wound
Phone wound nurse once emailed to ensure these have been received
Polycom technology can be used for virtual consults in remote areas that have the video link service
available. Wound nurse polycom contact number is 89228288.
!ALERT!!!! ! !ALERT!!!! ! !ALERT!!!! !
!Never Rehydrate Dry Gangrene (black fingers and toes)
• Do not attempt sharp debridement on these wounds
• These wounds have no blood flow, an small cut will lead to further
wound deterioration
• Let wound dry, it will then demarcate and auto-amputate
• Betadine™ will assist in drying out wound and provide a antimicrobial
barrier against pathogens whilst it undergoes this process
(Edmonds, Foster, & Sanders 2008)
Caution
Auto amputation can be painful ensure adequate analgesia
is provided for patients undergoing this process
6
T
I M
E
Is an acronyn used for wound assessment process, products may have a
classification to fit into these categories as you go through this booklet
T
=
TISSUE VIABILITY
Assess viability of tissue.
Remove any non viable tissue either by autolytic or conservative sharp
debridement.
Aim is to have viable tissue for best wound healing outcomes.
I
=
INFLAMMATION AND / OR INFECTION
Assess if inflammation or infection is present.
Signs include increase exudate, odour redness, pain, oedema and heat.
Reduce bioburden by using antimicrobial dressings.
If systemic infection is present treat with antibiotics.
Aim is to have wound clear of bioburden, treatment of active infection and
reduction of chronic inflammation due to bioburden.
M
=
MOISTURE IMBALANCE
Assess level of moisture in the wound.
A WET wound can lead to maceration and further wound breakdown
A DRY wound can slow the healing process by development of thick slough,
eschar and necrotic tissue.
Aim is to have a moist wound environment by either absorbing exudate in
wet wounds or adding moisture to dry wounds.
E
=
EDGE OF WOUND
Assess the edge of the wound.
If wound edge does not advance in 2-4 weeks reassessment of current wound
therapy is required.
If edges are rolled or raised or undermining or dry crust is present wound
closure may be compromised.
Aim to ensure edges of wound come together in a timely manner by
addressing all components of T I M and addressing each of these sections.
7
Assessing Leg and Foot ulcers
!If a pulse is weak or absent do not attempt sharp debridement
! !
Venous
Arterial!
Legs
• Hair usually present
• Dark staining in gator
region (haemosiderin)
• Skin is dry and flaky
• Often has eczema /
dermatitis
•
•
•
•
•
• Lower 3rd of leg
• Usually above medial
malleoli
• Distal areas toes and
• Soles of feet and in
feet
areas prone to friction,
• In areas prone to
pressure and trauma
trauma or friction shin
malleoli heels, toes
• Punched out appearance • Size and shape vary
• Deep with pale base
• May have callous build
up at wound edges
• Low exudate
• Varied
Site
Exudate
• Large, with ragged
edges
• Shallow base
• Large amount
Wound
bed
• Dark granulation tissue
• May contain slough
Oedema
• Oedematous legs
• May have thin ankles
with oedema above this
• Present in all areas
(femoral, popliteal,
posterior tibial & pedal)
• ABI is 0.8 to 1.1
• Moderate, dull ache
• Pain is relieved by
elevating the limbs
Size /
shape
Pulses
Pain
Pale legs
Thin shiny skin
No hair on limb or toes
Leg pallor on elevation
Thickened nails
Diabetic
• Unremarkable
• Feet may be dry and flat
due to neuropathy
• Pale granulation tissue
• Dry slough or necrotic
tissue
• Localised to wound area
• Often sloughy with
infection or heavy
colonisation
• Localised only
• Absent or weak
• ABI is <0.8
• Bounding
• Usually present
• ABI >1.1 due to
calcification of vessels
• Abnormal sensation may
be experienced if
neuropathy is present
• Often painless wounds
• Extreme pain
• Pain is relieved by
dangling the limb
• Claudication (cramping)
on mobilisation
!Sharp debridement on arterial wounds may lead to further wound deterioration.
!Some leg wounds will be a combination of venous and arterial deficiency.
!Compression should only be applied by trained staff to prevent complications.
Compression must not be applied until exact aetiology is determined or wound
deterioration may occur.
Take extra precaution when using DVT prophylaxis stockings e.g .TEDS™ on limbs with
compromised flow as pressure injury or ulceration may occur.
Ensure pressure off loading is performed especially in patients with compromised arterial flow
or sensation i.e. diabetics & renal patients.
8
ACRYLIC DRESSSINGS
M = MMOOIISSTTUURREE IIMMBBAALLAANNCCEE
Generic Name: Transparent adhesive acrylic dressing
Trade Names: Tegaderm Absorbent etc
Types:
Flat sheet
Description:
A transparent adhesive acrylic dressing formed in a
variety of shapes with the capacity for absorption of fluid
Indication:
•• For use on low to moderate exudate wounds
•• For use over donor sites
•• Can be primary or secondary dressing (calcium alginate beneath)
•• Can be left intact for up to seven days (dependant on exudate amount)
•• Primary role is to absorb exudate / moisture control
Tips:
• Wound can be viewed through dressing
• Acrylic pad must be bigger than the size of the wound it is applied to
• Heavily exudating wounds may lead to maceration i.e. may require
more regular changes
9
ALGINATEES (FFOORR WET W
WO
OU
UN
ND
DSS)
Generic Name: Calcium Alginate
Trade Names: Algisite M, Sorbsan, Kaltostat, Seasorb, Algoderm etc
Types:
Description:
Sheet, Ribbon, Rope
Calcium alginate formed from seaweed.
Indication:
• For moderate to high exudate wounds
• Primary dressing for deep & shallow wounds
• Has haemostatic ability (use for bleeding wounds)
• Forms a gel to promote a moist wound environment
• Is an autolytic debrider for wet sloughy wounds
• Can be left intact for 3-5 days.
• Can be used on bone / tendon (if moderate exudate)
• For use in either clean or infected wounds
• Requires secondary dressing either exudate manager or foam
Tips:
• If alginate is white and dry on dressing removal it is the wrong dressing
as there is not enough exudate, consider changing to a hydrogel
• Cut to size of wound do not overlap onto intact skin
• Do not mix with hydrogel as alginate forms into a gel with exudate
• Do not wet prior to application
Caution:
• Do not place in sinuses where the bottom cannot be seen
• Apply lightly when used as packing to allow space to absorb exudate
10
ATRAUMATIC DRESSINGS
SSkkiinn tteeaarr pprroottooccooll aanndd ffrraaggiillee sskkiinn
Generic Name: Silicone
Trade Names: Mepitel, Mepilex,
Types:
Sheet, Foam, Mesh
Description: Silicone dressing designed to prevent trauma on removal
of dressing, it gently adheres to intact skin without causing trauma.
Indication:
• For wounds with fragile skin, minimises tissue trauma on removal of
dressing
• Mepitel™ can be used on skin tears, fungating tumors, fragile sites
prone to bleeding.
• Mepitel™ requires a secondary dressing. change secondary PRN and
leave Mepitel™ intact (7-14 days), change if pores are clogged
• Foam can be left 3 – 5 days depending on exudate, remove once foam
pad is soaked
• Mepitel™ requires secondary dressing, usually exdudate manager
• Apply adhesive side down
Tips:
• Mepilex foam: change when foam is soaked
• Mepitel change 7 – 14 days as long as pores are not clogged
• A 2cm overlap onto intact skin is required for to maintain adhesion of
silicone safetac™ dressings
NOTE: Mepitel is not a daily dressing!!
It must be left intact with secondary dressing changed PRN.
11
CADEXOMER IODINE (FFOORR IINNFFEECCTTEEDD W
WO
OU
UN
ND
DSS)
I = INNFFEECCTTIIOONN / INNFFLLAAMMMMAATTIIOONN
Generic Name: Cadexomer Iodine
Trade Names: Iodosorb™
Types:
Ointment, Powder or Paste
Description: Iodine based dressing in a starch based polymer
(cadexomer) that contains a 0.9% iodine, providing sustained release
iodine over 3 days. Provides a broad spectrum antimicrobial effect.
Indication:
• For wounds that are infected especially MRSA and pseudomonas
• Wounds with heavy bioburden
• Forms a gel at wound base which becomes and autolytic debrider
• Use on infected and heavily colonised wounds
• Use as an autolytic debrider of sloughy infected wounds
• Reduces wound malodour
• Ointment use for dry wounds
• Powder use for wet wounds
• Requires a secondary dressing (foam or exudate manager)
• Stimulates static wounds
Tips:
• Ensure all residual dressing is removed prior to reapplication,
residual dressing appears as a yellow / white gel in the wound base
• Is a 3rd daily dressing, requires this time for iodine to absorb
Caution:
Do not use on:
• Patients sensitive to iodine
• Patients with hyperthyroidism or Graves’ disease
• Children under the age of 12yrs
• Pregnant or lactating women
12
CA
APILLLIARY WICKING DRESSING
Generic Name: Capillary Wicking
Trade Names: Vacutex™, Advadraw™ etc
Types:
Flat sheets
Description: Compressed cotton fibre with a capillary wicking action,
creates the similar effect to topical negative pressure dressing e.g.
Vac™, without the need of a machine.
Cut into strips for application
into narrow wounds
Spiral cut to improve length
of dressing
Indication:
• For moderate to high exudate wounds, high absorbency capacity
• Capillary action similar to topical negative pressure (VAC)
• Added layers increase exudate management capacity
• Wear time 2-3 days
• Change when top layer is soaked
Tips:
• Requires sharp scissors for cutting
• Can be used as flat sheet, cut into strips for sinuses to act like a
straw, pulling exudate away
• Cut into spiral effect to get long strips for deep sinuses
• Fenestrate dressing if going over elbows or knees for flexibility
•
Caution:
• Do not place on healthy skin, as it will cause maceration
• Do not leave intact for extended periods of time as adhesion to
wound bed may occur
• Do not use on bleeding wounds, as this will accelerate bleeding
13
CHEMICAL DRESSINGS
2 Types: Flaminal (page 14) and PHMB (page 15)
Type 1
Generic Name: Enzyme alginogels®
Trade Names: Flaminal Forte™, Flaminal Hydro™
Types:
Gel
Description: Gel based matrix, with enzymatic action that absorbs
micro-organisms into this matrix, where free radicals breakdown the
micro-organisms wall. Consists of glucose oxidase and lactoperoxidase
which is effective on pseudomonas and MRSA
Indication:
• For wounds that are heavily colonised / heavy bioburden
• Effective on MRSA, VRE, E.coli and pseudomonas
• Gel structure maintains moist wound environment
• Gel acts as autolytic debrider
Flaminal Forte™
• has alginate fibres to aid in gel structure and has a higher absorbency
capacity.
• For use on moderate exudate wounds with heavy bacterial burden
Flaminal Hydro™
• Has a gel structure but absorbency capacity is low.
• For use on low to now exudate wounds with heavy bacterial burden
NOTE: Single patient use tubes, apply patient label to tube once opened.
Tube can be kept with patient until expiry date if tube is well sealed and
not contaminated
14
CHEMICAL DRESSINGS
Type 2
Generic Name: PHMB Polyhexamethylene Biguanide
Trade Names: Prontosan wash, Prontosan gel, AMD foam
Types:
Wash, Gel, Foam
Description: Is a fast acting broad spectrum antimicrobial which is
effective in reducing bioburden of wounds is effective on a broad range
of pathogens including MRSA and is also effective on some viruses.
Indication:
• For wounds with heavy bioburden especially MRSA, VRE & Candida
• AMD foam is applied directly to wound base to reduce bioburden
• Prontosan™ has added betaine that disrupts bacteria’s cell electrical
balance leading to death of the cell.
• The betain surfactant loosens and aids in removal of biofilm from the
wound base. It is not absorbed and is safe to human cells.
• Prontosan wash should be placed on wound only left for 15 – 20 mins
then washed off with saline.
• Wash can be kept for 8 weeks after opening (if not contaminated)
• Foam is a primary dressing only, gel requires secondary dressing
Caution:
• Care should be taken to not have prontosan™ on periwound skin as
repeated contact will cause skin irritation and breakdown
• Place barrier cream around wound prior to application of PHMB wash
• Do not use on pregnant women
• Do not use intraocularly, middle/ inner ear or for joint or peritoneal
lavarge
15
EXUDATE MANAGER
RS
Generic name: Exudate managers
Trade Names: Zetuvit, Mesorb, Mextra, Absorb etc
Types:
Soft pads various sizes
Description: Highly absorbent dressing with a low sheer wound
contact layer and a fluid repellent backing. It has a cellulose pulp
centre that wicks fluids into the dressing to control exudate.
Indication:
• For wounds heavily exudating wounds
• Can be used as primary or secondary dressing
• Absorbs fluid amounts greater than 6 x a standard combine can hold
• Recommended as secondary dressing over mepitel
• Mesorb™ apply white side to wound
• Zetuvit™ apply white side to wound
• Secure with either tape around the edges or retention stocking
Caution:
• Do not cut these dressings as the dressing will fall apart and it will
be incapable of managing exudate.
• Can become heavy when dressing is soaked with exudate
16
FIILMS
Generic Name: Semipermeable adhesive film dressing
Trade Names: Opsite, Tegaderm, Bioclusive, Nikoderm etc
Types:
Sheets, Spray, Island dressing with incorporated pad
Description: A thin membrane of polyurethane with acrylic adhesive,
that is semipermeable allowing moisture to pass through via
evaporation (MVTR) but is impermeable to micro-organisms.
Indication:
• For low to no exudate wounds
• Provides protection and creates moist environment
• Use over areas to create moisture for rehydration e.g. hydrogel on
necrotic tissue, use film as an occlusive secondary dressing
• Can be used to establish a waterproof dressing
• Not for use on infected wounds
Tips:
• Use barrier film wipe prior to application to for increased adhesion
• Apply barrier film wipe to edge of film after application to reduce
risk of edges lifting
• IV films allow more moisture / gaseous exchange to occur,
they do not create moist wound environment for healing
Caution:
• DO NOT use IV films for sealing of topical negative pressure dressings
(VAC) due to porous nature of these films they will not be able to
maintain the seal required to conduct this type of wound therapy.
17
FIXATION SHEETS
ADHESIVE TAPE
Generic Name: Polyacylate Fixation Tape
Trade Names: Fixomull, Hyperfix, Mefix, Omnifix etc
Types:
Sheets in roll
Description: Is a non woven polyester with a polyacrylate adhesive
tape, designed to hold dressings insitu.
Indication:
• For fixation of dressings over wounds
• Should not be used a primary dressing on wound
• Do not cover foam dressings with fixation sheet, only secure around
edges of dressing (covering reduces foams absorbency capacity)
• Conforms to body contours aids in holding dressings insitu
Tips:
•
•
•
•
Use adhesive remover to aid removal (silicone or citrus based)
If no adhesive remover apply oil, wrap in cling wrap for 4 hrs then
remove gently (will require washing of periwound skin post removal)
Do not remove without the aid of either above techniques as tissue
damage may occur
Use Mepitel™ under fixation sheet where graft fixation is required, this
will protect new graft tissue
Caution:
• Dressing is not licensed as a primary dressing by the TGA (Carville 2012)
• Do Not use on fragile skin, use retention stockings instead to hold
dressings isitu
18
HYDROCOLLOIDS
Generic Name: Hydrocolloid
Trade Names: Comfeel, Duoderm etc
Types:
Sheet, Paste and Powder
Description: Pectin gelatine and carboxymethelcellulose combination
with or without calcium alginate cross linking fibres.
Indication:
• Not for use over exposed bone or tendon
• Self adhering
• Not for use on infected wounds
• Wear time seven days, or when leaking
• Must be changed when leakage occurs
• Leave intact if dressing centre is white (gel has formed and is donating
to wound bed beneath), change when white area turns brown
Tips:
• DO NOT cut to size of wound
• Must have 2cm overlap onto good skin or leakage will occur
• Do not cover with fixation sheet (Fixomul™) as dressing cannot be
visualised, therefore unable to determine when change is necessary.
• In dry eschar / necrotic tissue a thin layer of hydrogel can be applied
to wound base prior to application of hydrocolloid to improve
rehydration of area.
19
HYDROGELS
Generic Name: Hydrogel
Trade Names: Solosite, Intrasite, Solugel, Aquaclear etc
Types:
Gel, Impregnated Gauze, Sheet
Description: Glycerin amorphous based gel with large amounts of
water and small amounts of carboxymethelcellulose glycol
Indication:
• Use for autolytic debridement of dry slough and necrotic tissue
• Can be used over exposed bone or tendon
• Can be used on deep or shallow wounds
• For deep wounds use intrasite conformable™ or gel soaked gauze to
keep gel at the wound base
• For shallow dry wounds a hydrogel sheet e.g. Aquaclear™ is good for
donating moisture in these wound types
• Can be left intact for 3 to 5 days
• Do not use on wet wounds as maceration will occur
• Can be used on clean or infected wounds
Tips:
•
•
Avoid application of gel to intact skin as maceration may occur
Aquaclear requires 2cm overlap onto intact skin (will not macerate)
Caution:
!Never Rehydrate Dry Gangrene (black fingers and toes)
NOTE: Single patient use tubes, apply patient label to tube once opened,
discard after one week
20
HYPERTO
ON
NIC SALINE
T = TIISSSSUUEE VVIIAABBIILLIITTYY
Generic Name: Hypertonic Saline Gauze
Trade Names: Mesalt, Curasalt etc
Types:
Impregnated Gauze,
Description: Gauze delivery system impregnated with hypertonic
saline solution
Indication:
• For cleaning thick slough and debris from wound bed
• Will clean wounds with heavy bioburden
• Can be let intact up to 3 days
• For moderate to heavy exudate wounds
Caution
• Dressing must be cut to wound size, avoid overlap onto healthy skin
• Can be painful, avoid use in painful wounds
• Do not use on dry wounds
• Do not use over exposed bone or tendon.
21
IMPREGNATED GAUZE
Generic Name: Impregnated Gauzes
Trade Names: Jelonet, Adaptic, Cuticerin, Paratulle etc
Types:
Gauze consistency with various impregnation
Description: Gauze or cotton, woven or non woven with an oil
or paraffin base, it may or may not contain medication
Indication:
• For preventing dressings adhering to wound base
• Some impregnated gauzes have medication added e.g
! Bactrigras has chlorhexidine
! Inadine has iodine
Tips:
• In cavities where maggot infestation may have occurred use triple
layer of non medicated dressing to create occlusive environment,
this suffocates the maggots which can then be irrigated out at next
dressing change
Caution
• Dressing with woven cotton (Jelonet™ / Paratulle™) can shed fibres
into wound base, these must all be removed at each dressing change
22
IMPREGNATED POLYURETHANE FOAM
Generic Name: Impregnated Polyurethane Quadra Foam
Trade Names: Polymem, PolyWic, PolyMax
Types:
Sheet, Cavity filler
Description:
A polyurethane foam impregnated with glycerine and
surfactants in either an adhesive or non adhesive format.
Indication:
• For use on low to moderate exudate wounds
• Surfactant aids in wound base cleansing
• Does not breakdown non viable tissue
• Wear time dependant on exudate amount usually 1 to 3 days
• Dressing must be in contact with wound base (do not apply any other
type of dressing beneath polymem, except polywic)
Tips:
• Dressing must be changed when 75% of the wound size has struck
though the dressing (not 75% of the entire dressing)
• If cavity is present use polywic™ to gain contact with wound base
• Use polymax™ for heavier exudating wounds as it has a higher exudate
management capacity
• Initial dressings increase wound exudate so more frequent dressings
may be required initially
Caution:
• Should not be used on high exudate wounds
• Topical environment can lead to periwound maceration, i.e. take
particular care when using in Darwin / Gove region, monitor dressing
changes more frequently
23
ISLAND DR
RESSINGS
Generic Name: Island dressing
Trade Names: Primapore, Cutiplast, Compose, Mepore etc
Types:
Adhesive pads of varying sizes
Description: A low absorbent layer no adherent layer with an adhesive
backing of a fixation sheet or film.
Indication:
• For low to no exudate
• Has minimal absorbency capacity
• Dressings without waterproof backing i.e. primapore™ / compose™
must be changed once wet or if strikethrough occurs
• Dressings without waterproof backing do not donate moisture or aid in
maintaining a moist environment
• For wounds healing by primary intention or epidermal wounds
Caution:
• Wet island dressings that do not have a waterproof backing (ie Film
backing) become a portal for infection
• Do not use as a secondary dressing on moderate to high exudate
wounds due to low absorbency capacity and risk of becoming a portal
for infection
24
NON A
ADHERENT DRESSINGS (NA
AD)
Generic Name: Non adherent dry or film coated dressing
Trade Names: Telfa, Interpose, Melonin, Melolite etc
Types:
Non-adhesive pads of varying sizes
Description: Non adherent wound contact layer with thin polyester
film that is bonded to a cotton or acrylic pad. NAD’s are usually the
contact layer used in island dressings
Indication:
• For low to no exudate
• Has minimal absorbency capacity
• Must be changed once wet or if strikethrough occurs
• For wounds healing by primary intention or shallow low exudate
wounds
• Does not donate moisture or aid in maintaining a moist environment
Caution:
• If NAD is used as primary dressing it must be changed once strike
though occurs
• Wet NAD’s become a portal for infection
25
ODO
OUR ABSORBING
G DRESSINGS
Generic Name: Odour absorbing dressing
Trade Names: Carboflex, Actisorb, Carbonet, Kaltocarb etc
Types:
Sheet form
Description: Dressing combined with activated charcoal that absorbs
both exudate and odour caused by bacteria
Indication:
• For malodorous wounds
• Absorbs exudate, the carbon eliminates odour
• For low to moderate wounds only
• Dressings with calcium alginate as contact layer can be applied
directly to wound base e.g. Carboxflex™ and Kaltocarb™
• Calcium alginate dressings are for bleeding wounds or oozing wounds
Caution:
• Do not cut to size as dressing my shed or disintegrate
26
POLYURETHANE FOAM
Generic Name: Polyurethane Foam
Trade Names: Allevyn, Biatain, Lyofoam etc
Types:
Sheet
Description: Polyurethane foam with or without an adhesive backing
that has the ability to absorb exudate and dispel via evaporation, with
a moisture repellent backing.
Indication:
• For moderate to high exudate wounds
• Can be used as a primary or secondary dressing
• Provides thermal insulation of the wound base
• Can be adhesive or non adhesive
• Can be left intact for up to 7 days
• Requires changing when strikethrough reaches edge of dressing
• Can be used as a protective dressing over superficial low exudate
wounds
Tips:
• For non adhesive foam do not cover entire sheet with tape e.g.
Fixomull™ as this will reduce the ability for foam to evaporate
moisture from the dressing resulting in less absorbency capacity
27
RETENTION STOCKINGS
Generic Name: Retention stocking / tubular retention bandage
Trade Names: Tubifast, Tensofast etc
Types:
Sheet form
Description: Light weight tubular bandage, which does not cause any
compression or constriction to the area it is applied to. It comes as a
two way stretch cotton tubular bandage roll.
Indication:
• For retaining dressings insitu without the need of bandages
• For holding non adhesive dressings insitu e.g. exudate managers and
non adhesive foams without the need of adhesive tapes
• Does not apply restriction or compression to limbs it is applied to
• For use of retaining dressings insitu on fragile skin
Tips:
• Coloured line indicates size of retention stocking
• See side of box for recommended application to each body part
• Red x-small arms and legs
• Green small arms and legs
• Blue for normal sized leg and arms
• Yellow for larger legs and normal size thighs
• Larger sizes are available for torso use
28
SILVER DRESSINGS: (Acticcoat)
Generic Name: Nanocrystalline Silver
Trade Names: Acticoat, Acticoat Absorbent, Acticoat Flex
Types:
Sheet, Ribbon, Mesh and Calcium Alginate
Description:
A dressing coated with a nanocrystalline silver particles
which enhances bactericidal effect and reduction of inflammation
Indication:
• For use on actively infected wounds, and wounds with high bioburden
or wounds at a high risk of developing infection
• Effective on MRSA, Psuedomonas, VRE, Gram –ve, Gram +ve Bacilli
Viruses, Spores and Fungi
• Kills pathogens within 30 minutes of contact is bactericidal
• Has an anti-inflammatory effect
• Sheet and flex can be used on wet to dry wounds
• Acticoat Absorbent is calcium alginate for wet wounds, apply dry
• Acticoat sheet and flex can be covered with damp gauze and Fixomull™
and wet BD to daily when showering (Must be kept wet to remain active)
Tips:
• Is a 3rd daily dressing, a double layer of Acticoat sheet can last for 7 days
• Acticoat sheet and flex are safe to overlap onto healthy skin
• Acticoat Absorbent must be cut to wound size to prevent maceration
• In low exudate wounds use hydrogel on top of Acticoat sheet and flex,
the cover with foam to maintain moisture
• Apply Acticoat sheet blue side down for maximum effect
• Painful wounds apply silver side down, a smear of hydrogel beneath the
Acticoat sheet
• Acticoat must be wet with water not saline.
• Do Not wet Acticoat Absorbent it is a calcium alginate
Caution:
• Do Not use on wounds with thick slough, use cadexomer iodine instead
29
SILVEER DRESSIN
NGS:(Mepiilex Ag / Allevyn Ag / SSD)
Generic Name: Ionic silver
Trade Names: Mepilex Ag, Allevyn Ag, Silver Sulfadiazine (SSD)
Types:
Foam, Atraumatic Silicone, 1% cream (aqueous)
Description:
Ionic silver for the prevention or management of
bacterial burden of wounds
Indication:
• For use on wounds that are heavily colonised / heavy bioburden
• Use to prevent active infection occurring
• Mepilex AG™ has silicone atraumatic adhesive for fragile skin
• Allevyn AG™ is a polyurethane foam impregnated with SSD cream
Allevyn AG comes in both adhesive and non adhesive foam
• SSD cream requires daily application with secondary dressing
Tips:
• Both foams can be left intact for up to 7 days
• Both foams can overlap onto healthy skin
• Not best option for active infection (use Acticoat instead)
• Not known to have anti-inflammatory effect
Caution:
• Requires contact with wound base to achieve antimicrobial effect
• Do not use as a secondary dressing i.e. on top of calcium alginate etc
• Do not apply other dressings beneath these dressings
• Avoid SSD cream on healthy skin as it can lead to maceration
• SSD cream may be used for primary burns management if Acticoat™ is
not available (Liaise with Burns Nurse for best dressing option)
30
TOPICAL NEGATIVE PRESSSUREE THERAPY
VAC// RENAYSIS/ PICO
Generic Name: Topical Negative Wound Pressure Therapy, TNP
Trade Names: VAC, Renaysis, PICO, Prevera, Vac Via etc
Types:
Machines of various sizes, some are disposable
Description:
Creates topical negative pressure over the wound
surface to assist in wound contraction, stimulation of collagen and
fibrin synthesis, whilst reducing oedema and increasing blood flow.
Uses foam or gauze as the primary contact layer
Indication:
• For use on wounds to stimulate growth of new granulation tissue
• For low to high exudate wounds, can be use on clean or infected wounds
• For fixation of grafts
• For growth of granulation tissue over exposed bone and tendon
• For acceleration of closure of wounds with large deficits
Tips:
• Use white foam for painful wounds (requires higher pressure setting to
achieve same result increase level by 50mmHg, (ie.125 needs to be 175)
• Use white foam over bone and tendon
• Non sting barrier wipes assist in gaining seal
• The hole for suction pad must be size of a 50c piece
• 3rd to 4th daily dressings, for graft fixation leave intact 5 days
Caution
• Do Not use over actively bleeding wounds
• Use with caution in patients on anticoagulant therapy
• Avoid use on ischaemic limb wounds
• Do not use on wounds with thick slough or non viable tissue, requires
debridement prior to TNP application
• Do Not use IV opsite™ for sealing TNP dressings as it will be ineffective
• Do Not put foam directly on intact skin as tissue damage will occur
31
TUBULAR BANDAGES
Generic Name: Tubular bandages
Trade Names: Tubigrip, Tensogrip etc
Types:
Tubular banadge
Description:
Tubular bandage with elastic fibres which conforms to
limbs whilst providing supportive level of compression.
Indication:
• For light compression of limbs
• Multiple layers are used to increase compression level
• For assistance in reduction of oedema of limbs
• For support of limbs following strains and sprains
• For use on grafts post fixation and commencement of scar
management
Tips:
• In patients with diagnosed venous insufficiency, where there is no
trained staff to proved compression therapy a multi layered
compression system can be used to gain 25-30mmHg.
• The three layer system is demonstrated on the following page,
accurate measurements are required to ensure correct sizing is
achieved
Caution:
• Do not use to hold dressings insitu (use retention stockings instead)
• When using tubular bandages on legs the foot must be incorporated to
prevent swelling below the bandage i.e. Toe to Knee
• Do not use on patients with fragile skin the elasticity can cause skin
tears to occur, (use retention stocking instead)
• Do not use on patients with Arterial disease / insufficiency
32
TUBULAR BANDAGES COMPPREESSION
Not trained to apply compression therapy?
A single layer of tubular bandage exerts 8-10mmHg
When using the modified multi layer tubular bandage as alternative to
compression bandaging the following process should be attended.
• Select size as per manufacturers instructions
• 1st layer apply Toe to knee (8 -10 mmHg)
• 2nd layer apply Toe to mid calf (16 - 20mmHg)
• 3rd layer apply toe to above ankle (24 -28mmHg)
• Note this must be removed at night (when patient is in bed)
(Normal compression level for Venous Leg Ulcer compression is 30-40mmHg)
Caution:
• Should only be used on patients with diagnosed venous congestion
33
ZZINC BANDAGES
Generic Name: Zinc Impregnated Bandages
Trade Names: Viscopaste, Steripaste, Zip Zoc etc
Types:
Flat bandage or Tubular bandage
Description:
A bandage impregnated with zinc plus or minus
preservatives, paraffin or Icthammol
Indication:
• For legs with vascular dermatitis / eczema
• Limbs with multiple small leaking lesions with periwound skin
irritation
• Dressing is designed to remain intact for 7 days
• Can be used under compression bandages
• Small patches can be used on wounds as a primary dressing
Tips:
• Zip Zoc™ being a tubular bandage is easiest to use no specialised
bandage technique required
• Flat bandages must be applied in a pleated overlap fashion (from toe
to knee to prevent constriction and oedema occurring
• Do not apply flat bandages in continuous spiral bandage technique as
constriction may occur
Caution:
• Some patients are sensitive to preservatives in these bandages, it is
recommended to patch test patients who may fit this category
• Caution when bandaging patients with limb oedema, use strips of
bandage vertically up the limb on these patients instead of the pleated
overlap approach
34
G
GLOSSARY
AABBII
Ankle brachial Index, a test used to determine arterial
and venous blood flow of lower limbs
AANNTTIIM
MIICCRRO
OBBIIAALL
An agent that prevents the growth of harmful microbes
in the wound environment
AAUUTTOOLLYYTTIICC
is a process where with the provision of moist
environment non-viable tissue is broken down in the
wound bed.
BBAACCTTEERRIIAALL BBUURRDDEENN
The amount of bacteria on the wound bed, large
numbers may delay wound healing
BBAACCTTEERRIICCIIDDAALL
An agent that has the ability to kill bacteria
BBIIO
OBBU
URRDDEENN
The amount of micro-organisms on the wound bed,
large numbers may delay wound healing
BBIIO
OFFIILLM
M
A polysaccharide matrix that houses multiple microorganisms within its protective barrier, it can coat the
wound base and penetrate into deeper tissue. It is
impermeable to anitibiotics and most antimicrobials
CCLLAAU
UDDIICCAATTIIO
ONN
Pain experienced usually in the calf region when
walking, occurs in patients with compromised arterial
flow to lower limbs, pain is eased by resting
CCO
OLLO
ONNIISSAATTIIO
ONN
Where there are a large number of one or more species
of micro-organisms populate the wound base in large
numbers, these may delay wound healing but are not
causing an active infection
CCO
ONNTTAAM
MIINNAATTIIO
ONN
Presence of unwanted micro-organisms in either the
wound or wound product
DDEEBBRRIIDDEE // DDEEBBRRIIDDEEM
MEENNTT
Removal of non viable tissue from the wound base
using various techniques
EEPPIITTH
HEEIILLIIAALL
The last layer of cells deposited in the wound healing
cascade, where wounds are at the final stage of
healing
EEPPIITTH
HEELLIISSIINNGG
Regeneration of epithelial cells to gain wound closure
35
EESSCCH
HAARR
Necrotic or devitalised tissue in the wound
EEXXU
UDDAATTEE
Fluid produced by the wound
GGAANNGGRREENNEE
Death of healthy tissue leading to necrossis usually due
to poor arterial supply to limbs, can lead to bacterial
invasion and susequent putrefication
GGRRAANNU
ULLAATTIIO
ONN
Growth of connective tissue and blood vessels
H
HAAEEM
MO
OSSTTAATTIICC
An agent that assistings in gaining heamostasis by
stemming bleeding in wounds
H
HAAEEM
MO
OSSIIDDEERRIINN
Brown staining in the lower third of the legs due to
leakage of redblood cells into surrounding tissue, the
breakdown of these cells leads to deposits of iron in
the surrounding tissue causing this staining
IINNFFEECCTTIIO
ONN
Where pathogens invade the wound or body. Local and
systemic signs indicate that an invasion has occurred,
this can include tissue destruction, increased exudate
and odour
IINNFFLLAAM
MM
MAATTIIO
ONN
A localised chemical response to harmful stimuli in the
body, it is characterised by a vascular response where
increased blood flow / redness is seen in affected area.
However there may be no signs of active infection
M
MAACCEERRAATTIIO
ONN
Tissue that is exposed to moisutre for a prolonged
period of time, resulting in tissue appearing wet,
white, wrinkly and mobile. This leads to softening or
destruction of tissue due to reduction of tensile
strength
M
MAALLLLEEO
OLLII
A bony prominence found on either side of the ankle
joint
M
MAALLO
ODDO
OU
URR
a distinctive unpleasent odour
M
MVVTTRR
Moisture vapour transfer rate, relating to the ability of
a dressing to provide gaseous exchange and evapourate
moisture
NNAANNO
OCCRRYYSSTTAALLLLIINNEE
is a small particle that has the dimensions that are
equal to or smaller than 100 nanometers
NNEECCRRO
OTTIICC
dead tissue and cells
36
N
NEEUURROOPPAATTHHYY
function of nerves (motor, sensory, and autonomic) are
altered resulting in altered sensation of the area
NNO
ONN--VVIIAABBLLEE
Not alive, dead, non functional
O
OVVEERRGGRRAANNU
ULLAATTIIO
ONN
where granulation tissue rises above normal skin level
margins, excess growth of granulation tissue
PPAALLLLO
ORR
paleness of skin, lighter colour than normal
PPEERRII--W
WO
OU
UNNDD
Tissue that surround the wound margins
PPO
OLLYYU
UEERRTTHHAANNEE
a type of foam of various thicknesses
PPRRIIM
MAARRYY DDRREESSSSIINNGG
The dressing that will be in contact with the wound
base
PPRRO
OPPH
HYYLLAAXXIISS
An agent used to prevent or defend against something
occurring
SSEECCO
ONNDDAARRYY DDRREESSSSIINNGG
Covers over the primary dressings, it does not come
incontact with the open wound base
SSEEM
MIIPPEERRM
MEEAABBLLEE
Only permits certain molecules to pass through its
surface
SSIINNUUSS // SSIINNU
USSEESS
a cavity or channel where the base may or may not be
visable
SSLLO
OU
UGGH
H // SSLLO
OU
UGGH
HYY
non viable tissue found in the wound
VVIIAABBIILLIITTYY
pertaining to if tissue is alive and able to heal
37
FFOR FFURTHER INFORMATION PLEASE REFER TO:
T
TH
HEE A
AU
USST
TR
RA
ALLIIA
AN
NW
WO
OU
UN
ND
DM
MA
AN
NA
AG
GEEM
MEEN
NTT A
ASSSSO
OC
CIIA
AT
TIIO
ON
N
SST
TA
AN
ND
DA
AR
RD
DSS FFO
OR
RW
WO
OU
UN
ND
DM
MA
AN
NA
AG
GEEM
MEEN
NT
T
38
R
REFERENCES / BIBLIOGRAPHY
Angel.D, Sperring.B., (2006) Dressing Selections Guidelines. Royal Perth
Hospital. WA.
Australian Wound Management Association (2010) Standards for Wound
Management [online].Available from www.awma.com.au
Bale.S., & Harding.K., (2003) Managing patients unable to tolerate
therapeutic compression. British Journal of Nursing (Tissue Viability
Supplement), Vol12; No2; PP s4-13.
Bryant.R.A, & Nix.D.P, (2012) Acute & Chronic Wounds: current
management concepts. Mosby Inc Riverport Dr, St Louis, Missouri, USA.
Carville,K.,(2012) Wound Care Manual Silver Chain Foundation
(incorporated) Osborne Park Western Australia
Edmonds,M.E, Foster,A.V.M & Sanders,L.J. (2008) A Practical Manual of
Diabetic Foot Care. Blackwell publishing inc., Main St, Malden,
Massachusetts, USA.
Flecther.J. (2007) Wound Assessment and the TIME framework. British
Journal of Nursing, Vol 16, No 8.
McCulloch.J.M & Kloth.L.C (2010) Wound Healing Evidence Based
Management. F.A. Davis Company, 1915 Arch Street. Philadelphia, PA.
USA.
39

Dressing Application Criteria Developed and compiled by

Transcription

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