Wound Care Formulary Guidelines - August 2020 FINAL

Wound Care Guidelines
and
Dressing Formulary
This Cambridgeshire and Peterborough System Wide Formulary is
written and supported by:
Cambridgeshire Community Services
Cambridgeshire and Peterborough Foundation Trust
Cambridgeshire and Peterborough Clinical Commissioning Group
Cambridge University Hospitals NHS Foundation Trust
North West Anglia NHS Foundation Trust
Royal Papworth Hospital NHS Foundation Trust
Date produced: August 2020 Review Due: August 2022

Version 5.0 Page 1 of 33
Background
The Wound Care Guidelines have been written by the Tissue Viability Team and is based on a wide range of clinical evidence and peer
reviews.
A group of district nurses, practice nurses, tissue viability nurses (TVN), clinical management and members of the Medicine Optimisation
Team (MOT) have selected the dressings for the Wound Care Formulary.
The present products were selected on the current clinical evidence and cost consideration. A multidisciplinary steering group meets four
times a year to review any clinical evidence on new products as well as its cost implication. Any suggestions on new products can be
made by contacting either the TVN or MOT.
Medicines Optimisation Team Tissue Viability Team

E-mail: CAPCCG.prescribingpartnership@nhs.net Tel: 01223 266540
E-mail: cpm-tr.tissueviability@nhs.net
Tissue Viability Team Date: August 2020 Review: August 2022
August 2020 Version 5.0 Cambridgeshire & Peterborough System Wide Wound Care Guidelines and Dressings Formulary Page 2 of 33
Contents
Page
Wound Assessment and Management Guidelines 4
TIME – Principals of Improved Wound Healing 8
Antibacterial Guidelines 9
Guideline 1: Necrotic Wounds 11
Guideline 2: Black Heels/Toes 12
Guideline 3: Sloughy Wounds 13
Guideline 4: Granulating Wounds 14
Guideline 5: Infected Wounds 15
Guideline 6: Epithelialising Wounds 16
Guideline 7: Skin Tears/Pre-Tibial Lacerations 17
Guideline 8: Non-Complex Burns (Suitable for Outpatient/Primary Care Management) 18
Supplementary Guideline for Complex Burns Assessment 19
Guidelines for the Assessment and Management of Leg Ulcers 20
Dressings Criteria/Characteristic 21
Formulary Choices 22
References 31
Appendix 1 – Wound Assessment Form 32
Wound Assessment and Management Guidelines
1. Scope
Cambridgeshire and Peterborough Foundation Trust, general practices and nursing homes for those caring for patients with
wounds, Cambridgeshire Community Services (children services).
2. Purpose
To ensure the correct assessment and management of patients with wounds.
3. Introduction
• Choosing a wound dressing depends greatly on a holistic assessment of the patient and their wound; the patient should be at
the centre of all care decisions made.
• Wound assessment should be a systematic process accurately documented on the wound assessment and management care
plan.
• Dressings should be selected from the Trust Wound Care Formulary unless otherwise advised by a specialist.
• Patients with complex needs should be referred to the most appropriate speciality.
4. Responsibilities
All health care professionals involved in the direct assessment and management of wounds.
5. Wound assessment
• A documented holistic and wound assessment should be done as soon as possible after admission to the caseload.
• The evaluation does not need to be completed at every dressing change if there is little change in the wound condition but
document “no change in wound condition”. Dressing change must be recorded.
• Progress of the wound must be fully reassessed and documented.
• Any deteriorating wound must have a full re-assessment/evaluation completed and action taken (see general wound care
guidelines).
• In the case of a chronic wound (at 2-4 weeks), the wound should be reassessed weekly (every two weeks at a minimum).
5.1 Completion guide for wound assessment
Patient details & date of initial assessment

All details must be completed.
Type of wound
Circle the relevant box
How long has the wound been present?

Write length of duration, not the date when the patient came on caseload unless they coincided
Factors which may delay wound healing

Tick all relevant boxes, add extra information as appropriate (check patient’s medical notes).
Medications
Tick all relevant boxes, add extra information as appropriate.
Date referred to
Tick all relevant boxes; discuss referrals with colleagues and GPs. Do not over-refer to similar specialities, e.g. plastics,
dermatology, tissue viability (see general wound care guidelines below for appropriate routes of referral).
Drawing/photograph
Please illustrate wound. Use photography (verbal or written consent) – tape measures are available in the dressing packs. Write
date, patient initials only and the NHS patient’s number four (4) last numbers on the tape measure. Take a minimum of two
photographs: one to situate the wound on the body and one closer to the wound. Download and attach to SystmOne or protected
system used.
Location of wound/s
Please indicate on body map where the wound is situated.
Wound dimension
Please measure as accurately as possible or indicate if this is an estimation.
• Length = head to toe furthest points, measured in centimetres.
• Width = side to side furthest points, measured in centimetres.
• Depth = may be estimated as very difficult to assess safely and accurately. A sterile gloved finger or wound swab can be used
to probe.
• Category PU = if the wound is a pressure ulcer please indicate its category.
• Undermining = area tracking, measure with a probe and indicate direction.
Wound bed
Please estimate percentage of different tissue type in each box.
Suture/clips
Specify and indicate removal date.
Exudate levels
Please complete using the following guidelines:
• High = needs daily or more dressing changes and saturated each time.
• Moderate = needs dressing changes every 2-3 days and soiled but not soaked.
• Low = needs weekly or less dressing changes and dressing dry or minimally soiled.
Wound edges/surrounding skin

Please indicate as outlined.
Pain
Please assess patient and indicate action. Please refer for medical intervention/pain team.
Clinical signs of infection

Please indicate and swab if necessary. If the patient is at risk of developing an infection, ensure that daily vital signs are taken.
Treatment objectives
These objectives should be suitable for most patients, but a more individualised care plan may need to be added.
Use the appropriate objectives according to the phases of healing.
1. Patient comfort – although could be used for most patient’s wound care it is more suitable for “end of life” patient where no
active treatment (e.g. debridement) may not be suitable. Can be associated with odour control.
2. Absorption: for wound with large exudate where the main objective is containing the fluid.
3. Infection control: for infected wound. It can be associated with odour control
4. Odour control: see above
5. Debridement: active treatment
6. Promote granulation: active treatment – post or concurrent to debridement
7. Promote epithelialisation: active treatment – concurrent to granulation
Cleansing solution
Please document saline or water. Other solutions are not recommended unless required for a specific clinical need.
Clean thoroughly surrounding skin and wound to remove some slough, dressing debris or exudate.
Dressing choice
Choose from the Wound Care Formulary, review wound progress or deterioration and document the rationale for dressing changes
during period of care.
Frequency of dressing change

Please document, dependent on exudates, dressing used and progress of wound.
Signed/print name/designation
This is a legal requirement and must be accompanied by printing name legibly if using paper.
TIME – Principles of Improved Wound Healing (Wound Bed Preparation)
Clinical Observations WBP clinical actions Impact of your clinical actions Clinical outcomes
T Debridement (episodic or continuous) Viable wound bed

Restoration of wound base and
Tissue non-viable or • Autolytic, sharp surgical, enzymatic,
repair of the damaged tissue
deficient mechanical or biological
Remove infected foci Reduced bacterial counts and/ or Resolution of bacterial

controlled biofilm and inflammation imbalance,
I • Topical/systemic antibiotics
• Topical antimicrobials • Lower Inflammatory cytokines Reduced inflammation
Infection or inflammation • Lower protease activity
• Anti-inflammatories Improved biofilm control
• Increase growth factor activity
Apply moisture balancing dressings
Or • Maceration avoided
Compression
• Reduction in excessive fluid
M Or
• Reduced oedema
Moisture balance
Moisture imbalance NPWT (negative pressure wound
therapy) • Desiccation avoided
Or • Restored epithelial cell migration
Other methods of removing fluid
Re-assess cause Migrating keratinocytes and

E • Debridement responsive wound cells. Advancing edge of wound
Edge of wound non- • Peri wound protectant Restoration of appropriate Reduce size
advancing or undermined • Other corrective therapies Protease profile.
Regeneration and • Skin grafts, biological agents, NPWT • Epithelialisation

Repair tissue/wound closure
Social factors • Social situation, patient choice • Engage patient
Adapted from: Schultz et al (2003) Wound Bed Preparation. Wound Rep Reg Vol 11 pp1-28. Leaper D et al (2012). Extending the TIME Concept. Int Wound. 9
(Suppl) 21:1-19. Atkin L et al (2019) Implementing Timers.J Wound Care: 28 (3 Suppl 3): S1- S49
Antibacterial Guidelines
• Evidence concerning the efficacy of topical antimicrobial agents in the management of wounds remains equivocal.
• Independent and better designed and comparative trials to assess efficacy and cost implications are needed.
• Reports of resistance are still limited but misuse of these products, especially silver products must be avoided.
Reassess the management of all wounds treated with antibacterial products after two weeks.
Consider the clinical effectiveness (has the wound progressed?) as well as the cost effectiveness of the product.
• Iodine products are recommended as first choice antibacterial dressings unless the patient has a history of allergy.
• Iodine products should be used with caution and under close medical observation for patients with thyroid disease.
Inadine™ (3M/KCI) • Suitable for superficial, low exudate wounds

Non-adherent dressing
• Useful for drying ischaemic wounds
impregnated with 10% povidine
iodine ointment • Dressing colour fading from dark brown to white indicates loss of antibacterial efficacy and needs
to be changed
Iodoflex™ (Smith & Nephew) • Suitable for sloughy, exuding wounds

Cadexomer (starch) iodine
• Mouldable to shape of wound
(0.9%) paste.
Iodine released is proportional to • Dressing colour fading from dark brown to white indicates loss of antibacterial efficacy and needs
the exudate absorbed by the to be changed
starch in the dressing
• Can be left in place for 3 days
Other Antimicrobials
Honey: Activon ™ Manuka • Suitable for sloughy wounds, will debride effectively.
Honey tube or Activon ™ • Might cause minimal discomfort at first due to osmotic effect.
Tulle (Advancis) • Controls odour very effectively.
• Cut to size so the tulle can be in direct contact with the wound base or use viscous honey (tube).
• Dressing colour will fade as the honey is absorbed
2d choice AB dressing • No toxicity.
• Can be used long term
• Suitable for diabetics – although the honey is not absorbed into the blood stream, we advise
monitoring the levels of patients with diabetes.
Cutimed Sorbact® • Bacterial binding dressing (no chemically or pharmacologically active substance)
(3M/KCI) • Must be applied to moist wound and be in contact with wound bed
• Suitable for all exudating wounds with a secondary dressing
• No toxicity, no bacterial resistance, no allergy
• May appear to make wound worse in the first few days before wound start to progress towards
3d choice AB dressing healing.
• Do not use in combination with ointments and creams as binding effect is impaired.
• Useful for fungal infection in skin folds and groins
• In some cases, it could be used in prevention of local infection if patient is at high risk – contact
TVN to discuss.
Silvercel™ (3M/KCI) • Useful for debriding wounds
Silver impregnated alginate • Useful to control odour and bleeding
dressing • Pack wound lightly
• Do not change daily. The silver in the dressing is active for 3 days
th
4 choice AB dressing • Known sensitivity to silver and alginates
• Use only if other antibacterial dressings have been tried or are inappropriate.
Acticoat™ (Smith & Nephew) • Only available via TVN if recommended by the Tissue viability team.
Nanocrystalline silver coated low • Rapid release/ fast action silver
adherent dressing • Suitable to control over granulation
• Use only if other antibacterial dressings have been tried or are inappropriate.
• Use for 2 weeks then review.
Toxicity of silver on the healing process is still unclear but caution and overall reduction in its usage is recommended.
Contact Tissue Viability Nurses if prolonged use is necessary as other alternative products may be more suitable.
Wound Care Guidelines
Guideline 1: Necrotic Wounds
Aim: To aid debridement by providing a moist environment
Is the wound on the Yes Refer to guideline 2 (Black heels/ toes)

heel or foot?
No
Is the wound infected?

Yes Refer to Guideline 5 (Infected Wounds)
No
Notes
Is the wound exudate Dressing Choice Wound Care
Depth: May be difficult to assess
Hydrogel (Activheal®) Hydrogel (Activheal®) fully until necrosis has lifted.
AND AND
Low Yes
Hydrocolloid (Tegaderm™ Hydrocolloid (Tegaderm™ Surrounding Skin: If wound exuding
Hydrocolloid / Granuflex®) Hydrocolloid / Granuflex®) or skin is fragile, protect with no
sting barrier film.
Hydrofibre (Aquacel®) Loosely pack/cover wound with Nutrition: Assessment must be
Yes AND hydrofibre carried out and appropriate referral
Medium
Hydrocolloid (Tegaderm™ Cover with hydrocolloid made.
Hydrocolloid / Granuflex®) Change as above
Specialist Input:
Hydrofibre (Aquacel®) Loosely pack/ cover wound with Sharp debridement must be carried
Large AND hydrofibre out by a doctor or Tissue Viability
Foam (ActivHeal® Foam / Cover with foam or padding and Nurse only.
Yes Biatain® silicone foam, secure Seek further advice for patients with
TegadermTM foam) or Padding Change as above diabetes or arterial problems.
Guideline 2: Black Heels/Toes
Aim: To protect and maintain infection free
Is the wound infected? Yes Refer to Guideline 5 (Infected Wounds)
No
Dressing Choice Wound Care

Refer to Foot Clinic/
Is the patient diabetic? Yes
Podiatry for further Inadine™ Apply Inadine™ to wound
investigation and Notes
No
Padding Cover with padding
Bandages: Tight or
compression bandages
Check blood glucose Wool bandage Apply wool bandage
Yes must not be used for
for undiagnosed Crepe bandage or Tubular Secure with Tubular
patients with diabetes or
diabetes Yes Refer to bandage bandage (Comfifast®) or
arterial problems unless
physician Crepe bandage.
No under close supervision of
All bandages must be from
Specialist team.
Toe to Knee
Surrounding Skin: If wound
Refer to GP and TVN
is exuding or skin is fragile,
protect with no sting barrier
film.
Pressure: must be relieved to prevent further damage by
using a foot protector or pillow Nutrition: Assessment must
be carried out and
appropriate referral made.
Specialist Input:
Does the wound
Aim to keep blister intact Seek further advice for
present as a blister? Yes Remove source of
Do not apply dressing and allow natural re- patients with diabetes or
(Blood or clear fluid friction/ pressure
absorption arterial problems.
filled)
Guideline 3: Sloughy Wounds
Aim: To aid debridement of slough by providing a moist environment
Is the wound infected? Yes Refer to Guideline 5 (infected wounds)
No
Is the slough dry? Yes Treat as necrotic (Guideline 1)
No
Notes
Is the wound exudate Dressing Choice Wound Care Slow/static debridement: consider larvae
therapy.
Hydrogel (Activheal®) Apply gel to base of wound Cavities: Consider Topical Negative
AND Cover with hydrocolloid Pressure therapy, refer to Tissue Viability
Hydrocolloid (Tegaderm™ Change when exudates marking Nurse for advice.
Low Yes
Hydrocolloid / Granuflex®) is visible 1cm from edge of Very High Exudate: consider above or
dressing or if leaking / dislodged wound drainage bags, refer to Tissue
Viability Nurse for advice.
Hydrofibre (Aquacel®) Loosely cover/ pack wound with
AND hydrofibre Surrounding Skin: If wound exuding or skin
Medium Cover with hydrocolloid fragile, protect with no sting barrier film.
Yes Hydrocolloid (Tegaderm™
Change as above Nutrition: Assessment must be carried out
Hydrocolloid / Granuflex®)
and appropriate referral made.
Hydrofibre (Aquacel®) Loosely cover/ pack wound with
Specialist Input: Sharp debridement must
AND hydrofibre
Large be carried out by a doctor or Tissue
Yes Foam (ActivHeal® Foam/ Cover with foam or padding or Viability Nurse only.
Biatain® silicone, TegadermTM superabsorbent and secure
foam) or Padding or Change as above Seek further advice for patients with
Superabsorbent dressing diabetes or arterial problems.
Guideline 4: Granulating Wounds
Aim: To promote granulation and provide a healthy base for epithelialisation
Is the wound infected? Yes Refer to Guideline 5 (infected wounds)
No
Is the wound hyper- Yes Check for infection and refer to TVN for advice
granulating?
No Notes
Bleeding: Use an alginate to act as a
Is the wound exudate Dressing Choice Wound Care haemostat (Kaltostat®).
Cavities: Consider Topical Negative
Hydrocolloid (Tegaderm™ Apply Hydrocolloid or Foam Pressure therapy, refer to Tissue
Hydrocolloid / Duoderm®) Change when exudates marking Viability Nurse for advice.
Yes OR is visible 1cm from edge of Very High Exudate: Consider wound
Low Foam (ActivHeal® Foam / dressing or if leaking / dislodged drainage bags, refer to Tissue
Biatain® silicone foam, Hydrocolloid can be in place 5-7 Viability Nurse for advice.
Tegaderm foam) days
Surrounding Skin: If wound exuding
or skin fragile, protect with no sting
Hydrofibre (Aquacel®) Loosely pack/ cover wound with
barrier film.
AND hydrofibre
Medium Yes
Hydrocolloid (Tegaderm™ Cover with hydrocolloid Nutrition: Assessment must be
Hydrocolloid / Granuflex®) Change as above carried out and appropriate referral
made.
Hydrofibre (Aquacel®) Loosely pack/ cover wound with Specialist Input: Seek further advice
AND hydrofibre for patients with diabetes or arterial
Foam (ActivHeal® Foam/ Cover with foam or padding and problems.
Large Yes
Biatain® silicone foam, secure
Tegaderm TM foam) or Padding or Change as above
Superabsorbent dressing
Guideline 5: Infected Wounds
Aim: To treat infection systemically and decrease bacterial burden at the wound site
- Take swab and treat infection with systemic antibiotics until symptoms resolve
Check guidelines for use of antibacterials; follow flow chart below for dressing
Does the wound look Yes choice
infected? (See notes) Treat wound for two weeks then review
Avoid topical antibiotics
Is the wound exudate Dressing Choice Wound Care
Iodine (Inadine™) Apply Inadine™ or Activon Manuka Notes

OR Honey Tube
Low Yes Clinical signs of infection:
Activon Tulle or Activon Manuka Inflammation, erythema
Honey Tube Change Inadine™ daily, Honey every
(redness), increased pain,
Appropriate secondary dressing 2 d to 3d day.
odour, pus, heat, pyrexia,
friable (bleeds easily).
Surrounding Skin: If wound
exuding or skin fragile, protect
Medium Yes Iodine (Iodoflex™) Apply Iodoflex™
with no sting barrier film.
OR or Activon Manuka Honey Tube to
Activon Tulle, Activon Manuka Honey the wound or Nutrition: Assessment must
Tube or Cutimed ® Sorbact® Cutimed Sorbact® be carried out and
Cover with Cover with foam dressing appropriate referral made.
ActivHeal®foam / Biatain® silicone / Change every 2-3 days
Specialist Input: Seek further
Tegaderm TM foam or padding
Large Yes advice for patients with
diabetes or arterial problems.
Is wound condition Silvercel®

Cut to size of wound and apply
unchanged after 2 Cover with foam dressing or super For further antibacterial
Yes Change every 3 days depending on
weeks of above care absorbent advice refer to the TV Team
odour and amount of exudate
plan?
Guideline 6: Epithelialising Wounds
Aim: To provide a moist, atraumatic environment to complete healing
®
Is the wound reducing No
in size? Refer to TVN for advice
Yes
Is the wound exudate? Dressing Choice Wound Care Notes

Protection: Of the wound site is
Apply hydrocolloid or low adherent to essential for complete healing/
Hydrocolloid thin (Duoderm®) wound maturation.
Change if exudates marking is 1cm Surrounding Skin: If wound exuding
Low Yes
OR from edge of dressing or if the or skin fragile protect with no sting
dressing is dislodged barrier film.
Low adherent (Atrauman®) and
Hydrocolloid can be in place for 5-7 Nutrition: Assessment must be
Foam/Cosmopor E
days. carried out and appropriate referral
made.
Reassess wound as unlikely to be Use Cutimed® Sorbact® for 2 weeks Fragile/Sensitive Skin: Silflex® can
Medium Yes epithelialising and refer to to control potential excess of bacteria be considered as alternative
appropriate guideline dressing as it can remain on the
wound for 7 days.
Reassess wound as unlikely to be Specialist Input: Seek further
Yes Use Cutimed® Sorbact® for 2 weeks
Large epithelialising and refer to advice for patients with diabetes or
to control potential excess of bacteria
appropriate guideline. arterial problems.
Guideline 7: Skin tears/ Pre-tibial lacerations
Aim: To provide a protective environment to promote healing and prevent further trauma
® Is the wound
presenting a large Yes Refer to A&E or Plastic Surgeons
surface area or deep
tissue exposed?
Dressing Choice Wound Care
No
Kaltostat® Apply pressure when securing

Is the wound and If bleeds through do not remove,
bleeding? Yes
Padding apply further padding on top and Notes
Appropriate secondary dressing refer to A&E if bleeding persists
No Surrounding Skin: If wound
exuding or skin fragile, protect
Can wound edges be Steri-strip not recommended for Check wound after 2 days with no sting barrier film.
brought together majority of skin tears but if used Leave Steri-strips for further 3-5 days Nutrition: Assessment must
Yes
without force apply without tension if skin flap is be carried out and
viable appropriate referral made.
No Low adherent Atrauman® / Silflex®) See tissue adhesive for linear wound
Padding or Biatain silicone Specialist Input: Seek further
Appropriate secondary dressing. advice for patients with
diabetes or arterial problems.
Is there partial or Do not attempt to steri-strip or force Can consider hydrocolloid
Lower limb injury: Secure
complete skin loss? Yes edges together (Tegaderm™ Hydrocolloid or
dressing with wool bandage
Low adherent (Atrauman® /Silflex®) Granuflex®), can be left in place up
and crepe bandage applied
Padding to 5 days. Use caution on fragile skin.
from toe to knee.
Appropriate secondary dressing
Tissue adhesive (Liquiband
Hydrogel (Activheal® hydrogel) - for Apply gel to open haematoma only Optima not on FP10 or
open wounds only Foam or padding to protect formulary): training/
Is there a significant Foam (ActivHeal® Foam/ Biatain® Contact TVN for alternative gel i.e. competency is available for
haematoma with or Yes silicone foam) /TegadermTM) or Flaminal® Hydro or Forte. first line services
without skin trauma? padding Refer to A&E or Plastic surgeons for
Appropriate secondary dressing debridement
Guideline 8: Non-Complex burns (suitable for outpatient/ primary care management)
Aim: To provide a protective environment to promote healing and ensure appropriate referral for complex burns
Is the burn complex? (See guideline overleaf) Yes Refer to A&E or Plastic Surgeons
No
Is the burn superficial? Dressing Choice Wound Care

• Skin is dry & intact
Check wound after 48 hours
• Red, blanches under pressure Topical moisturiser or
Yes Should heal within 2-3 days
• Minimal tissue damage Low adherent (Atrauman®)
Can consider a hydrocolloid Notes
• Painful with appropriate secondary
thin (Duoderm®) if no
dressing Surrounding Skin: If
No blistering
wound exuding or
Is the burn superficial-partial thickness? Low adherent (Atrauman®) Check wound after 48 hours skin fragile, protect
• Blisters immediately Gauze or absorbent padding, Should heal within 10-21 days with no sting barrier
• Red in areas, moist & exuding Yes
depending on exudate if no infection film.
• Brisk capillary refill Secure with appropriate Can consider Flamazine® if
Nutrition:
• Painful & sensitive to temperature changes secondary dressing antibacterial is indicated
Assessment must
No be carried out and
appropriate referral
Is the wound deep-partial thickness (deep dermal)? made.
• Pale/white/creamy in colour, may have large
blisters
• Less moist initially Refer to Emergency See over for Burns
Yes Low adherent (Atrauman®) Department for urgent
• Difficult to assess capillary refill assessment
• Sensitive to deep pressure but not to pin-prick Loosely applied cling film specialist Plastic Surgical guidelines.
advice
No
Is the wound full thickness? Refer to Emergency

No
• May appear waxy white, cherry red, grey or Low adherent (Atrauman®) Department for urgent
leathery Yes Loosely applied cling film specialist Plastic Surgical
• Minimal or no pain, no response to pressure or advice
temperature
• May have less deep & very painful peripheries
Supplementary Guideline for Complex Burns Assessment
Seek further advice for:

• Patient <5yrs or >60yrs.
• Patient is <16yrs & burn is dermal or full thickness involving
>5% Total Body Surface Area (TBSA).
• Patient is adult & burn is dermal or full thickness involving
>10% Total Body Surface Area (TBSA).
• Burn is on face, hands, perineum, feet, flexures.
• Burn is circumferential dermal or full thickness to limbs,
torso or neck.
• Burn is chemical, acid, ionising radiation, high pressure
steam, electrical, suspicion of non-accidental injury.
• Burn is an inhalation injury.
• Patient also has: cardiac or respiratory problems,
immunological conditions, pregnancy, or associated
injuries.
Dressings Criteria
• Non-adherent
• Remove excess exudate and toxic components
• Impermeable to bacteria
• Maintain high humidity at wound dressing interface
• Capable of maintaining a high humidity at the wound site while
• Allows gaseous exchange removing excess exudate
• Provide thermal insulation • Thermally insulating
• Impermeable to micro-organisms • Non-toxic and non-allergenic
• Free from Toxic contaminants • Comfortable and conformable
• Removable without causing trauma • Capable of protecting the wound from further trauma
• Requires infrequent dressing changes
• Cost effective
• Long shelf-life
• Available both in hospital and in the community
Characteristics of the ideal wound dressing (Bryant R, Nix D, 2016)
Formulary Choices
DRESSINGS FOR BOTH PRIMARY AND SECONDARY CARE USE

NPC Supplier Cost per
Category Product Indications for use Dressing Size Unit Issue dressing
code Code
(NHS SC CCG)
XUPAD 10cm x 12cm EJA092 205012 Pack of 25 £0.07
ABSORBENT Use for absorption moderate to XUPAD 10cm x 20cm EJA093 205020 Pack of 25 £0.09
PAD high exudate. XUPAD 20cm x 20cm EJA094 205030 Pack of 15 £0.12
XUPAD 20cm x 40cm EJA095 205040 Pack of 8 £0.24
C-SORB 10cm x 10cm EJE136 206110 Pack of 20 £0.21
SUPER-
Use for absorption of high to very
ABSORBENT C-SORB 10cm x 20cm EJE137 206120 Pack of 20 £0.38
high exudate.
PAD
C-SORB 20cm x 30cm EJE135 206230 Pack of 20 £0.84
TEGADERM FOAM 8.8cm x 8.8cm
ELA371 90610 Pack of 10 £1.26
ADHESIVE (pad 5cm x 5cm)
14cm x 14cm
TEGADERM FOAM (pad 10cm x
ELA176 90612 Pack of 10 £3.39
Use to absorb moderate to high ADHESIVE 10cm + 2cm
exudate. border)
FOAM 10cm x 11cm
Use to protect and pad vulnerable
ADHESIVE TEGADERM FOAM (pad 6cm x
areas. ELA177 90611 Pack of 10 £1.85
Use with caution on fragile skin. ADHESIVE (OVAL) 7.6cm + 1.7cm –
2cm border)
14cm x 15cm
TEGADERM FOAM (pad 10cm x
ELA178 90613 Pack of 5 £4.34
ADHESIVE (OVAL) 11cm + 2cm
border)
BIATAIN SILICONE
Use to absorb moderate to high 7.5cm x 7.5cm ELA425 3343431006 Pack of 10 £1.26
(ADHESIVE)
exudate.
SILICONE FOAM BIATAIN SILICONE
Use to protect and pad vulnerable 10cm x 10cm ELA451 3343531006 Pack of 10 £1.82
ADHESIVE (ADHESIVE)
areas.
Suitable for use on fragile skin. BIATAIN SILICONE
12.5cm x 12.5cm ELA426 3343631006 Pack of 10 £2.30
(ADHESIVE)
DRESSINGS FOR BOTH PRIMARY AND SECONDARY CARE USE continued
code Code
(NHS SC CCG)
Use to absorb moderate to high ACTIVHEAL FOAM
exudate. 5cm x 5cm ELA214 10009113 Pack of 10 £0.77
(NON-ADHESIVE)
Use to protect and pad vulnerable
areas. ACTIVHEAL FOAM
FOAM 10cm x 10cm ELA216 10009115 Pack of 10 £1.14
CUHFT preferred brand is (NON-ADHESIVE)
NON-ADHESIVE
TEGADERM FOAM, patients in
Primary Care may be switched to ACTIVHEAL FOAM
equivalent size of ACTIVHEAL 20cm x 10cm ELA246 10009116 Pack of 10 £2.06
(NON-ADHESIVE)
FOAM.
DUODERM (EXTRA
Use for protection of vulnerable 5cm x 10cm ELM317 S163 Pack of 10 £0.70
THIN FILM)
skin under devices.
Use to secure other dressings/ DUODERM (EXTRA
7.5cm x 7.5cm ELM311 S160 Pack of 5 £0.74
HYDROCOLLOID packing. THIN FILM)
- THIN DO NOT USE ON MOISTURE DUODERM (EXTRA
ASSOCIATED SKIN DAMAGE. 10cm x 10cm ELM050 S161 Pack of 10 £1.22
THIN FILM)
Use on superficial wounds where
absorbency not required. DUODERM (EXTRA
15cm x 15cm ELM051 S162 Pack of 10 £2.64
THIN FILM)
TEGADERM (OVAL) 10cm x 12cm ELM084 90001 Pack of 5 £2.07
Use for debridement of slough/ TEGADERM (OVAL) 13cm x 15cm ELM373 90003 Pack of 5 £4.08
necrosis where clinically
indicated. GRANUFLEX
Use as protection of vulnerable (MODIFIED)
HYDROCOLLOID
skin under devices. GRANUFLEX
- STANDARD 6cm x 6cm ELM151 S155 Pack of 5 £1.50
DO NOT USE ON MOISTURE (BORDERED)
ASSOCIATED SKIN DAMAGE. GRANUFLEX
Use to secure other dressings/ 10cm x 10cm ELM053 S156 Pack of 10 £2.13
(BORDERED)
packing.
GRANUFLEX
(BORDERED)
code Code
(NHS SC CCG)
Use on wounds with moderate to AQUACEL EXTRA 5cm x 5cm ELY377 420671 Pack of 10 £0.74
high exudate. AQUACEL EXTRA 10cm x 10cm ELY378 420672 Pack of 10 £1.77
HYDROFIBRE Useful for cavities or uneven
spaces. AQUACEL RIBBON 1cm x 45cm ELY368 420127 Pack of 5 £1.46
Can adhere if wound is too dry. AQUACEL RIBBON 2cm x 45cm ELY013 S7503 Pack of 5 £1.86
Haemostatic.
ALGINATE Use to control mild-moderate KALTOSTAT 5cm x 5cm ELS229 1004 Pack of 10 £0.67
bleeding.
Use to rehydrate dry slough and
HYDROGEL ACTIVHEAL GEL 8g ELA639 10011131 Pack of 10 £1.05
necrosis to aid debridement.
Use on post-surgical wounds after COSMOPOR E 5cm x 7.2cm EIJ038 900870 Pack of 50 £0.07
48 hours for protection.
NON-OCCLUSIVE Useful for securing other COSMOPOR E 8cm x 10cm EIJ039 900873 Pack of 50 £0.10
ISLAND dressings where occlusion is not
DRESSING required. COSMOPOR E 8cm x 15cm EIJ040 900874 Pack of 50 £0.15
DO NOT USE ON FRAGILE
SKIN. COSMOPOR E 10cm x 20cm EIJ041 900876 Pack of 50 £0.23
Use on superficial wounds to ATRAUMAN 5cm x 5cm EKA024 499550 Pack of 50 £0.24
NON-ADHERENT
protect and line. ATRAUMAN 7.5cm x 7.5cm EKA032 499553 Pack of 50 £0.21
WOUND
Can be used under topical
CONTACT LAYER ATRAUMAN 10cm x 20cm EKA036 499536 Pack of 30 £0.42
negative pressure foam to protect
(NON-SILICONE) ATRAUMAN 20cm x 30cm EKA016 499515 Pack of 10 £1.37
vulnerable tissue.
Pack of
TEGADERM 6cm x 7cm ELW211 1624W £0.10
SEMI- Use to secure other dressings. 100
PERMEABLE Use to protect superficial wounds TEGADERM 10cm x 12cm ELW213 1626W Pack of 50 £0.27
FILM and vulnerable areas. TEGADERM 10 x 25cm ElW215 1627 Pack of 20 £0.62
TEGADERM 20cm x 30cm ELW219 1629 Pack of 10 £2.05
Use on post-surgical wounds
immediately after surgery and for OPSITE POST-OP 8.5cm x 9.5cm ELW051 66000709 Pack of 20 £0.32
POST- first 48 hours.
OPERATIVE Useful for securing other
DRESSINGS dressings. Pack of
Use for protecting superficial OPSITE POST-OP 6.5cm x 5cm ELW052 66000708 £0.13
100
wounds.
code Code
(NHS SC CCG)
INADINE 5cm x 5cm EKB501 P01481 Pack of 25 £0.41

Anti-microbial - iodine
Use on infected superficial
wounds. INADINE 10cm x 10cm EKB095 P01491 Pack of 10 £0.59
Useful for drying ischaemia
areas, diabetic foot wounds. IODOFLEX IODINE
5g tube EKB007 66001301 Pack of 5 £4.63
PASTE
Anti-microbial - honey ACTIVON TULLE 5cm x 5cm EJE027 CR3761 Pack of 5 £1.79
Use on infected wounds.Useful
for debridement and for
stimulating healing in static ACTIVON TULLE 10cm x 10cm EJE028 CR3658 Pack of 5 £2.96
wounds.
BACTERIAL
Liquid honey can be used into ACTIVON MANUKA
CONTROL 25g tube ELZ069 CR3830 Pack of 12 £2.05
sinuses/ tracts. HONEY
Use according to
antibacterial Anti-microbial - silver
guidelines Use on infected, moderate to SILVERCEL 11cm x 11cm ELS150 CAD011 Pack of 10 £3.79
high exudate, sloughy wounds.
If not effective, STOP, remove
dressing and change to SILVERCEL 5cm x 5cm ELS149 CAD050 Pack of 10 £1.65
alternative.
Antimicrobial - DACC CUTIMED SORBACT
technology 4cm x 6cm ELY212 72164-01 Pack of 5 £1.93
SWAB
Binds and removes bacteria and
fungi from wounds in the CUTIMED SORBACT
7cm x 9cm ELY213 72165-01 Pack of 5 £3.13
presence of moisture using a SWAB
physical mode of action without
any chemical or pharmacological CUTIMED SORBACT
2cm x 50cm ELY218 72166-00 Pack of 20 £4.20
active ingredients. RIBBON
Used for managing wet legs and
ICHTHOPASTE 7.5cm x 6m EFA051 4959 Each £5.75
PASTE varicose eczema.
BANDAGES CUHFT: Specialist Nurses
VISCOPASTE 7.5cm x 6m EFA011 4948 Each £5.20
only.
code Code
(NHS SC CCG)
Use to support dressings in K-BAND 5cm x 4m EDB034 810540 Pack of 3 £0.11

place, Not a compression K-BAND 7cm x 4m EDB035 810740 Pack of 24 £0.13
bandage. K-BAND 10cm x 4m EDB039 811040 Pack of 20 £0.16
DRESSING COMFIFAST (RED) 3.5cm x 10m EGP005 F15 Each £2.02

RETENTION COMFIFAST
Used to secure other dressings. 5cm x 10m EGP006 F25 Each £2.17
(GREEN)
Lining limbs beneath other
bandaging. COMFIFAST (BLUE) 7.5cm x 10m EGP007 F35 Each £2.38
COMFIFAST
10.75cm x 10m EGP008 F45 Each £3.47
(YELLOW)
CAVILON BARRIER
FILM FOAM
Use to protect skin from effects 1ml ELY038 3343E Pack of 25 £0.59
APPLICATOR NO
BARRIER of moisture. Barrier film can be
STING STERILE
PRODUCTS used to treat superficial moisture
CAVILON BARRIER
associated skin damage.
CREAM NON- 2g sachet ELY569 3392GS Pack of 20 £0.20
STERILE
Use for securing other
K-FOUR K-SOFT
dressings. 10cm x 3.5m EPA028 761035 Pack of 24 £0.57
(LAYER #1)
Use for padding under K-Lite.
Use for securing other K-FOUR K-LITE
5cm x 4.5cm ECA084 770545 Pack of 16 £0.39
dressings. (LAYER #2)
MULTILAYER Toe to knee for support of lower K-FOUR K-LITE
BANDAGES 10cm x 4.5m ECA100 771045 Pack of 16 £0.78
limb. (LAYER #2)
Long stretch compression – K-FOUR K-PLUS
10cm x 8.7m ECA162 781087 Pack of 24 £2.08
used for the management of (LAYER #3)
lower limb oedema and venous
K-FOUR KO-FLEX
leg ulceration. CUHFT: 10cm x 6m ECD018 791060 Pack of 18 £3.46
(LAYER #4)
Specialist Nurses Only.
Use for the management of limb ACTICO ACTIVA 4cm x 6m EBA030 88307 Each £3.11
oedema and venous leg ACTICO ACTIVA 6cm x 6m EBA031 88308 Each £3.65
SHORT STRETCH
ulceration. ACTICO ACTIVA 8cm x 6m EBA032 88309 Each £4.08
COMPRESSION
CUHFT: Specialist Nurses ACTICO ACTIVA 10cm x 6m EBA016 88310 Each £4.22
Only. ACTICO ACTIVA 12cm x 6m EBA033 88311 Each £5.39
code Code
(NHS SC CCG)
MICROPORE 1.25cm x 9.14m EHU111 1530-0 Pack of 24 £0.19

ADHESIVE Use for securing bandages and
MICROPORE 2.5cm x 9.14m EHU006 1530-1 Pack of 12 £0.36
SURGICAL TAPE supporting devices.
MICROPORE 5cm x 9.14m EHU115 1530-2 Pack of 6 £0.54
To be used on superficial
SILFLEX 5cm x 7cm EKH028 CR3922 Pack of 10 £0.66
wounds to protect and line.
Can be used to bring edges of
CONTACT LAYER skin tears together.
SILICONE Can be used under topical
negative pressure to protect
vulnerable tissue.
Useful for use on fragile skin.
Used for the cleansing of NON-WOVEN
10cm x 10cm ENK132 F821034 Pack of 25 £0.05
wounds. SWABS
To bring edges together in skin
tears, must not be used on 365 STRIPS 6mm x 75mm EIR126 36519064 Pack of 50 £0.10
fragile skin.
Used for the cleansing of
NORMASOL 25ml MRB358 99766774 Pack of 25 £0.13
MISCELLANEOUS wounds.
Latex free pack contains sterile Small EJA045 908810 Pack of 20 £0.42
woundcare 1 x propylene tray SOFTDRAPE
(12cmx10cmx2.5cm) to DRESSING PACK Medium EJA046 908820 Pack of 20 £0.42
accommodate all components VITREX
with 1 x pair examination gloves. Large EJA047 908830 Pack of 20 £0.42
ADVICE ONLY DRESSINGS
Provide on the ADVICE of a Specialist or Tissue Viability Nurse ONLY.
NOT for initiation in Primary Care.
Cost per
NPC Unit dressing
Category Product Indications for use Dressing Size Supplier Code
code Issue (NHS SC
CCG)
To be used on superficial wounds
to protect and line. 5cm x Pack of
Can be used to bring edges of MEPITEL EKH002 290500 £1.47
7cm 5
skin tears together.
SILICONE
Can be used under topical
DRESSINGS
negative pressure to protect
vulnerable tissue. 8cm x Pack of
MEPITEL EKH003 290700 £2.94
Useful for use on fragile and 10cm 5
sensitive skin.
URGOSTART 6cm x Pack of
ELZ884 552301 £3.19
PLUS PAD 6cm 10
PROTEASE Useful for venous leg ulcers, URGOSTART 10cm x Pack of
MODULATOR diabetic foot ulcers (podiatry) and ELZ885 552302 £4.68
PLUS PAD 10cm 10
DRESSING static hard to heal wounds.
URGOSTART 15cm x Pack of
ELZ886 552305 £10.52
PLUS PAD 20cm 10
For low to moderately exudating FLAMINAL 1013-

15g ELG021 Box of 5 £8.12
SPECIALIST wounds. HYDRO U(BLUEHYDRO)
WOUNDCARE
ANTIMICROBIAL
GEL For high to moderately exudating FLAMINAL 1012-
15g ELG023 Box of 5 £8.12
wounds. FORTE U(YELLOWFORTE)
SPECIALIST ONLY DRESSINGS
To be ordered for individual patients by Tissue Viability Nurse only.
NOT TO BE PRESCRIBED IN PRIMARY CARE - Contact CAPCCG.prescribingpartnership@nhs.net for
further support.
NPC Supplier Unit Cost per
Category Product Indications for use Dressing Size dressing
code Code Issue
(NHS SC CCG)
CUHFT: Specialist Nurses 5.5cm x Pack of

ALLEVYN LIFE ELA1132 66801747 £1.12
Only. 5.5cm 10
Use to absorb moderate to 10.5cm x Pack of
high exudate. ALLEVYN LIFE ELA1117 66801748 £2.25
SILICONE FOAM 10.5cm 10
Use to protect and pad
ADHESIVE 16cm x Pack of
vulnerable areas. ALLEVYN LIFE ELA1118 66801749 £4.06
Patients in Primary Care may 16cm 10
be switched to equivalent size 10cm x Pack of
of Biatain Silicone. ALLEVYN LIFE ELA1119 66801751 £3.88
20cm 10
Pack of
KERRALITE COOL 6cm x 6cm EME081 CWL1004 £1.91
5
12cm x Pack of
KERRALITE COOL EME082 CWL1005 £2.80
8.5cm 5
Use to rehydrate dry wounds.
Use to follow skin tear 18 x Pack of
GEL (SHEETS) KERRALITE COOL EME083 CWL1006 £4.05
protocol. 12.5cm 5
Useful in painful wounds,
KERRALITE COOL Pack of
minor burns. 8cm x 8cm EME084 CWL1007 £2.20
BORDER 5
KERRALITE COOL 11cm x Pack of
EME065 CWL1008 £2.94
BORDER 11cm 5
Use on superficial infected 10cm x Pack of

ACTICOAT ELY071 66000791 £8.02
CONTACT LAYER wounds, tissue viability, 10cm 12
ANTIMICROBIAL plastics, vascular and Pack of
dermatology advice only. ACTICOAT 5cm x 5cm ELY141 66000808 £3.45
5
SPECIALIST ONLY DRESSINGS continued
NPC Supplier Unit Cost per
Category Product Indications for use Dressing Size dressing
code Code Issue
(NHS SC CCG)
Helps to reduce inflammation,
prevent maceration,
MEDI-HONEY Pack of
excoriation and irritation 2g sachet ELY374 800 £0.31
BARRIER CREAM 20
resulting from effects of
moisture on the skin.
CAVILON ADVANCED
Use for severe cases of
LIQUID SKIN Pack of
moisture associated skin 2.7ml ELY801 5050G £10.42 each
SKIN PROTECTANT 20
damage.
PROTECTANTS STERILE
PRO-SHIELD FOAM
8213-
AND SPRAY 235ml ELZ536 Each £6.04
0150-08
Use for moisture-associated CLEANSER
skin damage on both intact
PRO-SHIELD
and injured skin. 8213-
BARRIER CREAM 115g ELZ537 Each £9.32
0300-04
NON-STERILE
References
• Bryant R, Nix D (2016) Acute and Chronic Wounds (5th ed) Mosby. USA
• European Wound Management Association (EWMA 2013.). Position Document: Antimicrobials and non-healing wounds. London: MEP Ltd
• European Wound Management Association (EWMA 2013). Position Document: Debridement London: MEP Ltd.
• Flanagan M (2013) Wound healing and skin integrity. Wiley-Blackwell, West Sussex
• International Wound Infection Institute (2016) Wound Infection in Clinical Practice: Principles of Best Practice. Wounds International: London.
• National Institute for Clinical Excellence (2014) The Prevention and Treatment of Pressure Ulcers. NICE, London. www.nice.org.uk
• National Institute for Clinical Excellence (2013) Varicose Veins NICE, London. www.nice.org.uk
• Sign (2010) Management of chronic venous ulcer: a national clinical guideline 120.
• Thomas S (2010) Wound dressing, London
• Wound Care Handbook (2020-2021). The comprehensive guide to product selection in association with the Journal of Wound care. MA Healthcare
LTD, London.
• Wounds UK.(2016) Best Practice Statement: Care of the Older Persons Skin London: Wounds UK www.wounds-uk.com
• Wounds UK (2016). Best practice Statement: Holistic Management of Venous Leg Ulceration. London: Wounds UK www.wounds-uk.com
• Wounds UK (2018). Best practice Statement: Improving Holistic Assessment of Chronic wounds. London: Wounds UK www.wounds-uk.com
• Wounds UK (2019). Best practice Statement: Addressing Complexities in the Management of Leg Ulcers. London: Wounds UK www.wounds-
uk.com
• Resources: www.wounds-uk.com
www.worldwidewounds.com World Wide Wounds
www.ewma.org European Wound Management Association
Appendix 1 – Wound Assessment and Management Chart
Name NHS No DOB

Address GP/Surgery Tel
DN Team Tel
Postcode Residential/Nursing Home Tel
Tel Ward Tel
Standard: In conjunction with Trust Wound Care Guidelines, an assessment and care-plan should be
completed for all patients with wounds.
Date of Initial Assessment DD/MM/YY
Type of Wound(s) Pressure Leg Moisture Skin

(Please circle) Surgical Burn Other
Ulcer Grading Ulcer Lesion Tear
How long has wound
been present?
Factors which may delay wound healing (tick if present, tick nil identified if no factors present)
Medical Conditions Medications
Rheumatoid Arthritis Immobility Steroids
Diabetes Mellitus Incontinence Immunosuppressive
Cardiac Disease Infection Biologics
Anaemia Obesity Anti coagulants
Chronic respiratory disease Malnutrition Cytotoxics
Venous/Arterial Disease Poor nutrition Non steroidal anti-inflammatory
Decreased sensation Smoking Other …………………………..
Allergies Alcohol
Skin sensitivities Concordance Issues Nil identified……………………
Severe acquired immune defects Please specify ……............
…………………………….....
Date referred to: Tissue Viability Team ...…/.…./…. Dietician...../…../.…..

Dermatology …../.…./…. Podiatry/Foot Team …../…../….. Vascular Surgeon …../…../….
Plastic Surgeon …../…../….. Others …../…../….. No specialist referral required.……………………..
Full pain assessment completed and appropriate actions taken Yes No N/A
Wound care-plan discussed/agreed with the patient Yes No Verbal Written
If pressure ulcer, Waterlow risk assessment, SSKIN and check list fully Yes No
completed and reviewed
If No to any of the above, reason for non-completion:
Is it necessary to raise a safeguarding concern? Yes No
Drawing/Photograph Number of Wounds ……………. Location of wound(s)
Lower limb un-healed wounds require full assessment with Doppler measurements at 4 weeks completed?
Yes/No
Reason for non-completion ……………………………………………………………
Name: ……………………………………….... NHS…………….……………………. DOB……………………
Please sign and date every dressing change. Reassess wound as needed using clinical judgement and
record any changes. Wound dimensions need to be measured at least weekly. Ensure that a separate form
is used for each wound.
Dressing Change
Date and Time DD/MM/YY 0.00hrs
Wound Dimension (cm)
Maximum length
Maximum width
Maximum depth
Undermining
Visible Tendon/bone Yes/No
Wound Bed (approx % cover)
Necrotic – black
Sloughy – yellow green
Granulating – red
Epithelialising – pink
Wound edges
Healthy H Rolled RO Raised R
Undermined U
Suture/clips Yes/No/removal date
Exudate levels
High H Moderate M Low L
Type and colour
Surrounding Skin
Macerated M Oedematous O
Excoriated E Fragile F Dry D
Eczema X Healthy H
Wound Pain scale 1 -10 (10 high)
Continuous C Dressing D None N
Clinical signs of infection present: i.e. 2 or more of the following present; pus, odour, deterioration,
spreading erythema, heat, increased pain, increased exudate, abscess, friable tissue.
Infection present? yes/no
If yes, swab taken (date)
Antibiotic therapy commenced (date)
Treatment Objectives
Patient comfort PC
Absorption A Infection Control IC
Debridement D Odour Control OC
Promote granulation G
Promote epithelialisation E
Cleansing Solution
Dressing Choice
(if Topical Negative Therapy in use,
document details here)
Skin Emollient/Cream
Frequency of dressing change
(number of days)
Date of review or healed
Signed
Print name
Designation

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Wound Care Formulary Guidelines - August 2020 FINAL

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Wound Care Guidelines

Date produced: August 2020 Review Due: August 2022

Medicines Optimisation Team Tissue Viability Team

Tissue Viability Team Date: August 2020 Review: August 2022

Patient details & date of initial assessment

How long has the wound been present?

Factors which may delay wound healing

Wound edges/surrounding skin

Clinical signs of infection

Frequency of dressing change

T Debridement (episodic or continuous) Viable wound bed

Remove infected foci Reduced bacterial counts and/ or Resolution of bacterial

Re-assess cause Migrating keratinocytes and

Regeneration and • Skin grafts, biological agents, NPWT • Epithelialisation

Inadine™ (3M/KCI) • Suitable for superficial, low exudate wounds

Iodoflex™ (Smith & Nephew) • Suitable for sloughy, exuding wounds

Is the wound on the Yes Refer to guideline 2 (Black heels/ toes)

Is the wound infected?

Is the wound infected? Yes Refer to Guideline 5 (Infected Wounds)

Dressing Choice Wound Care

Is the wound infected? Yes Refer to Guideline 5 (infected wounds)

Is the slough dry? Yes Treat as necrotic (Guideline 1)

Is the wound infected? Yes Refer to Guideline 5 (infected wounds)

Is the wound exudate Dressing Choice Wound Care

Iodine (Inadine™) Apply Inadine™ or Activon Manuka Notes

Is wound condition Silvercel®

Is the wound exudate? Dressing Choice Wound Care Notes

Kaltostat® Apply pressure when securing

Is the burn superficial? Dressing Choice Wound Care

Is the wound full thickness? Refer to Emergency

Seek further advice for:

• Provide thermal insulation • Thermally insulating

• Impermeable to micro-organisms • Non-toxic and non-allergenic

• Free from Toxic contaminants • Comfortable and conformable

• Requires infrequent dressing changes

• Available both in hospital and in the community

Characteristics of the ideal wound dressing (Bryant R, Nix D, 2016)

DRESSINGS FOR BOTH PRIMARY AND SECONDARY CARE USE

INADINE 5cm x 5cm EKB501 P01481 Pack of 25 £0.41

Use to support dressings in K-BAND 5cm x 4m EDB034 810540 Pack of 3 £0.11

DRESSING COMFIFAST (RED) 3.5cm x 10m EGP005 F15 Each £2.02

MICROPORE 1.25cm x 9.14m EHU111 1530-0 Pack of 24 £0.19

For low to moderately exudating FLAMINAL 1013-

CUHFT: Specialist Nurses 5.5cm x Pack of

Use on superficial infected 10cm x Pack of

Name NHS No DOB

Type of Wound(s) Pressure Leg Moisture Skin

Date referred to: Tissue Viability Team ...…/.…./…. Dietician...../…../.…..

Drawing/Photograph Number of Wounds ……………. Location of wound(s)

Name: ……………………………………….... NHS…………….……………………. DOB……………………

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