1. Our Passion, Your Care. Wound management and dressing selection Edwin T. Chamanga (Tissue Viability Service Lead) 12/02/2014 Our Passion, Your Care.

2. Aims To discuss wound care related clinical challenges. To discuss different wound beds. To explore the concept of wound bed preparation. To discuss wound dressing selection based on the Trust’s formulary.

3. Our Passion, Your Care. Clinical challenges Lacerations / Skin tears Leg ulcers Pressure ulcers Cancerous wounds Surgical wounds Diabetic foot ulcers Traumatic wounds Any other?

4. Our Passion, Your Care. Wound bed types Includes: –Necrotic wound –Sloughy wound –Granulation wound –Epithelialising wound

5. Our Passion, Your Care. Wound bed preperation A framework that can provide a structured approach to the management of wounds using the TIME principle.  TTissue  IInfection and/or inflammation  MMoisture inbalance  EEpidermal margin and extra ’ s! Flanagan and Moffat 2004 EWMA position document Wound bed preparation in practice.

6. Our Passion, Your Care. Wound bed preparation

7. Our Passion, Your Care. Wound management products Identify objectives on the wound bed. Understand what can be reasonable be expected from a dressing. Have information about availability, cost, cost effectiveness, evidence based practice. Is it within the Trust’s wound care formulary? Clinical evidence to date.

8. Our Passion, Your Care. Providing an ideal environment Ability to maintain a moist environment. Allows gaseous exchange. Antibacterial properties and permeable to bacteria. Free from trauma. Fluid handling, removal of exudate.

9. Our Passion, Your Care. Dressing categories Passive Interactive Occlusive

10. Our Passion, Your Care. Passive dressings Protect by simply covering the wound. Offer protection against dehydration. For low exudation, epithelising wounds. Types Low adherent dressing. Low adherent secondary dressing. Silicone technology. Disadvantages: rapid exudates saturation, dry out quickly, adheres to wound surface.

11. Our Passion, Your Care. Interactive dressings Actively interacts with wound surface. Promotes optimal environment for wound healing. Does not allow the wound surface to dehydrate. For clean granulating wounds. Types: Alginates, Hydrocolloids, Hydrofibres, Hydrogels, Semi-permeable films.

12. Our Passion, Your Care. Occlusive dressings Totally seal off the wound from the external environment. Semi/impermeable to moisture. Many interactive dressings are occlusive but not all are both. Types: Hydrocolloids, Foam and Films.

13. Our Passion, Your Care. Rationale for dressing choice To hydrate To debribe To absorb To aid granulation To aid epithelisation To protect

14. Our Passion, Your Care. Alginates Basic elements extracted from seaweed. Absorb exudate, debribe slough and encourage granulation. Forms soft gel in presence of exudate. Provides moist environment. Easily irrigated with normal saline/water for removal.

15. Our Passion, Your Care. Alginates cont: Daily dressing- reduce as wound healing proceeds. Daily dressing if wound is infected. Comfortable. Kaltostat used for haemostatic properties. Not suitable for dry necrotic wounds. Suitable for flat or cavity wounds. Requires secondary dressing. May prevent free drainage of pus or exudate.

16. Our Passion, Your Care. Vapour permeable films General principle: Allows passage of excess exudate away from the wound surface into the atmosphere in form of water vapor. Permeable to water vapor and oxygen. Impermeable to water and micro-organisms. Provides moist healing environment. Comfortable and convenient. Permits wound observation. Resistant to shear and tear.

17. Our Passion, Your Care. Foams dressings Provides thermal insulation. Do not shed properties. Gas permeable. Easily cut or shaped to fit. Low adherent contact layer. Easily removable. Used as primary or secondary dressing.

18. Our Passion, Your Care. Hydrocolloids Are occlusive dressings that contain gel-forming properties. Protects the wound and provides pain relief. Provides moist wound healing environment. Slow absorption of fluid physically changes into gel. Promotes autolytic debridement. Can be left in place up to 7 days depending on level of exudate. Debriding increases wound volume. May cause trauma to surrounding skin if fragile and removed before 5-7 days.

19. Our Passion, Your Care. Hydrogels High water content. Rehydrate wounds. Debribe and clean. Maintains moist wound healing. Gas permeable. Requires secondary dressing. May cause maceration.

20. Our Passion, Your Care. Hydrofibres Soft absorbent gelling fibre. Draws and retains exudate and debris within fibres. Provides moist wound healing. Converts from dry dressing to soft gel on contact with moisture. Removable in one piece. Comfortable and easy to use. Aids autolytic debribement.

21. Our Passion, Your Care. Topical antimicrobials Silver Iodine Honey

22. Our Passion, Your Care. Case study Mr X is a 66 year old male with a history of hypertension and type 2 diabetes with stable glycemic control and peripheral vascular disease. He presented with a diabetic foot ulcer on the right heel that is less than six weeks old. The wound measures 3.5cm in length, 2.4cm in width and less than 0.5cm in depth. The wound bed is 75% covered in slough and 25% pale granulation tissue. The peri-wound skin is macerated and wet. Moderate amount of malodour and thick tenacious exudate is present indicating that the wound is critically colonised. How would you prepare the wound bed?

23. Our Passion, Your Care. Case study Bob is a 47-year-old office worker, who presents with a small ulcer on the dorsum of his left foot. It is becoming increasingly painful, particularly at night. He is feeling generally unwell and has pyrexia. The ulcer has moderate, yellow, sloughy exudate. He also has peripheral vascular disease and is a smoker. How would you prepare the wound bed?

24. Our Passion, Your Care. Case study A 29 year old mother presents to the surgery with a dehisced C-section. The wound bed is exudating moderate amount of exudate with slough on the wound bed. Patient has been commenced on oral antibiotics. How would you prepare the wound bed?

25. Our Passion, Your Care. WOUND DRESSING SELECTION GUIDE TYPE OF WOUND AIMEXUDATE LEVELTYPE OF DRESSING SHALLOW WOUNDCAVITY/SINUS NECROTIC TO REHYDRATE WOUND SURFACE AND REMOVE NECROTIC TISSUE NONE Actiform Cool (Activa) / Intrasite Gel (Smith & Nephew) Granuflex Modified (Convatec) / Tegaderm Oval (3M) / Duoderm Extra Thin (Convatec) SLOUGHY TO AID DEBRIDEMENT OF SLOUGHY TISSUE HIGH MODERATE LOW Sorbsan Plus (Unomedical) / Aquacel sheet (convatec) +/- Tegaderm Foam (3M) / Allevyn Adhesive Foam (Smith & Nephew) Granuflex Modified (Convatec) / Tegaderm Oval (3M) / Duoderm Extra Thin (Convatec) Sorbsan Plus (Unomedical) / Aquacel Ribbon (convatec) +/- Tegaderm Foam (3M) / Allevyn Adhesive Foam (Smith & Nephew) Sorbsan Plus (Unomedical) / Aquacel Ribbon (convertec) +/- Tegaderm Foam (3M) / Allevyn Adhesive Foam (Smith & Nephew) CLINICALLY INFECTED TO TREAT INFECTION, CONTROL ODOUR AND PREVENT CROSS CONTAMINATION HIGH OR MODERATE SYSTEMIC ANTIBIOTICS Inadine (Systagenix) / Iodoflex paste (smith & Nephew) / Activon Tube, Algivon anc Activon Tulle (Advancies medical) / Flaminal Hydro/ Flaminal Forte (Crawford Health Care) / Carboflex (Convatec) / CliniSorb (Clinimed) /Acticoat Flex 7 (Smith & Nephew) / Atrauman Ag (Hartmann) / Urgotul Silver (Urgo) / Aquacel Ag ribbon (Convatec) GRANULATING TO PROMOTE GRANULATION AND PROTECT FRAGILE TISSUE HIGH MODERATE LOW Sorbsan Plus (Unomedical) / Aquacel sheet (convatec) / Sorbion Sachet Extra (H&R Healthcare) / Eclypse (Advancis) / Mesorb (Molnlycke) / Zetuvit E (Hartmann) / Kerramax Care (Crawford) N-A Ultra (Systagenix) + Dressing Pad / Tegaderm Foam (3M) / Allevyn (Smith & Nephew) Mepore Ultra (Molnlycke) / Cosmopore E (Hartmann) Kaltostat (Convatec) / Aquacel Ribbon (Convatec) / Sorbsan Plus (Unomedical) Sorbsan Plus (Unomedical) / Aquacel sheet (convatec) / Sorbion Sachet Extra (H&R Healthcare) / Eclypse (Advancis) / Mesorb (Molnlycke) / Zetuvit E (Hartmann) / Kerramax Care (Crawford) EPITHELIALISING TO PROMOTE EPITHELIALISATION AND PROTECT FRAGILE TISSUE HIGH MODERATE LOW N-A Ultra (Systagenix) / Atrauman (Hartmann) / Urgotul (Urgo) / Allevyn Gentle (Smith & Nephew) / Mepitel One (Molnlycke) Duoderm Extra Thin (Convatec) / Mepore Ultra (Molnlycke)