dressing application criteria developed and compiled by...and is active on pseudomonas, mrsa, gram...

Dressing Application Criteria

Developed and compiled by:

Jennifer Byrnes Wound Management Nurse Practitioner

Royal Darwin Hospital

January 2013

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CCOONNTTEENNTTSS

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

Document Compiled by Jennifer Byrnes Wound Management Nurse Practitioner RDH January 2013

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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


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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


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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!


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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)

• Paint with Betadine™ and leave it dry!

• Wet gangrene should be converted to dry gangrene by this process

• 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


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TTTT IIII M M M M EEEE Is an acronyn used for wound assessment process, products may have a classification to fit into these categories as you go through this booklet

TTTT = TTTTISSUE VIABILITYISSUE VIABILITYISSUE VIABILITYISSUE 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.

IIII = IIIINFLAMMATION AND NFLAMMATION AND NFLAMMATION AND NFLAMMATION AND / / / / OR INFECTIONOR INFECTIONOR INFECTIONOR 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.

MMMM = MOISTURE IMBALANCEMOISTURE IMBALANCEMOISTURE IMBALANCEMOISTURE 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.

EEEE = EDGE OF WOUNDEDGE OF WOUNDEDGE OF WOUNDEDGE 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.


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Assessing Leg and Foot ulcers !!!!If a pulse is weak or absent do not attempt sharp debridement

!!!!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.

!!!! !!!! Venous Arterial!!!! Diabetic

Legs • Hair usually present • Dark staining in gator

region (haemosiderin) • Skin is dry and flaky • Often has eczema /

dermatitis

• Pale legs • Thin shiny skin • No hair on limb or toes • Leg pallor on elevation • Thickened nails

• Unremarkable • Feet may be dry and flat

due to neuropathy

Site • Lower 3rd of leg • Usually above medial

malleoli

• Distal areas toes and feet

• In areas prone to trauma or friction shin malleoli heels, toes

• Soles of feet and in areas prone to friction, pressure and trauma

Size / shape

• Large, with ragged edges

• Shallow base

• Punched out appearance • Deep with pale base

• Size and shape vary • May have callous build

up at wound edges

Exudate • Large amount • Low exudate • Varied

Wound bed

• Dark granulation tissue • May contain slough

• Pale granulation tissue • Dry slough or necrotic

tissue

• Often sloughy with infection or heavy colonisation

Oedema • Oedematous legs • May have thin ankles

with oedema above this

• Localised to wound area • Localised only

Pulses • Present in all areas (femoral, popliteal, posterior tibial & pedal)

• ABI is 0.8 to 1.1

• Absent or weak • ABI is <0.8

• Bounding • Usually present • ABI >1.1 due to

calcification of vessels

Pain • Moderate, dull ache • Pain is relieved by

elevating the limbs

• Extreme pain • Pain is relieved by

dangling the limb • Claudication (cramping)

on mobilisation

• Abnormal sensation may be experienced if neuropathy is present

• Often painless wounds


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AAACCCRRRYYYLLLIIICCC DDDRRREEESSSSSSIIINNNGGGSSS MMM === MMMOOOIIISSSTTTUUURRREEE IIIMMMBBBAAALLLAAANNNCCCEEE

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


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AAALLLGGGIIINNNAAATTTEEESSS (((FFFOOORRR WWWEEETTT WWWOOOUUUNNNDDDSSS))) MMM === MMMOOOIIISSSTTTUUURRREEE IIIMMMBBBAAALLLAAANNNCCCEEE

Generic Name: Calcium Alginate

Trade Names: Algisite M, Sorbsan, Kaltostat, Seasorb, Algoderm etc

Types: Sheet, Ribbon, Rope

Description: 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


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AAATTTRRRAAAUUUMMMAAATTTIIICCC DDDRRREEESSSSSSIIINNNGGGSSS SSSkkkiiinnn ttteeeaaarrr ppprrroootttooocccooolll aaannnddd fffrrraaagggiiillleee ssskkkiiinnn

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.


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CCCAAADDDEEEXXXOOOMMMEEERRR IIIOOODDDIIINNNEEE (((FFFOOORRR IIINNNFFFEEECCCTTTEEEDDD WWWOOOUUUNNNDDDSSS))) III === IIINNNFFFEEECCCTTTIIIOOONNN /// IIINNNFFFLLLAAAMMMMMMAAATTTIIIOOONNN

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


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CCCAAAPPPIIILLLLLLIIIAAARRRYYY WWWIIICCCKKKIIINNNGGG DDDRRREEESSSSSSIIINNNGGG MMM === MMMOOOIIISSSTTTUUURRREEE IIIMMMBBBAAALLLAAANNNCCCEEE

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.

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 • Requires a secondary dressing (foam or exudate manager)

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

Spiral cut to improve length of dressing

Cut into strips for application into narrow wounds


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CCCHHHEEEMMMIIICCCAAALLL DDDRRREEESSSSSSIIINNNGGGSSS III === IIINNNFFFEEECCCTTTIIIOOONNN /// IIINNNFFFLLLAAAMMMMMMAAATTTIIIOOONNN

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


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CCCHHHEEEMMMIIICCCAAALLL DDDRRREEESSSSSSIIINNNGGGSSS III === IIINNNFFFEEECCCTTTIIIOOONNN /// IIINNNFFFLLLAAAMMMMMMAAATTTIIIOOONNN

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


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EEEXXXUUUDDDAAATTTEEE MMMAAANNNAAAGGGEEERRRSSS MMM === MMMOOOIIISSSTTTUUURRREEE IIIMMMBBBAAALLLAAANNNCCCEEE

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


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FFFIIILLLMMMSSS MMM === MMMOOOIIISSSTTTUUURRREEE IIIMMMBBBAAALLLAAANNNCCCEEE

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.


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FFFIIIXXXAAATTTIIIOOONNN SSSHHHEEEEEETTTSSS AAADDDHHHEEESSSIIIVVVEEE TTTAAAPPPEEE

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


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HHHYYYDDDRRROOOCCCOOOLLLLLLOOOIIIDDDSSS MMM === MMMOOOIIISSSTTTUUURRREEE IIIMMMBBBAAALLLAAANNNCCCEEE

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: • For low to no exudate wounds • 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.


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HHHYYYDDDRRROOOGGGEEELLLSSS MMM === MMMOOOIIISSSTTTUUURRREEE IIIMMMBBBAAALLLAAANNNCCCEEE

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: • For low to no exudate wounds

• 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)

• Paint with Betadine™ and leave it dry!

• Wet gangrene should be converted to dry gangrene by this process

NOTE: Single patient use tubes, apply patient label to tube once opened, discard after one week


21

HHHYYYPPPEEERRRTTTOOONNNIIICCC SSSAAALLLIIINNNEEE TTT === TTTIIISSSSSSUUUEEE VVVIIIAAABBBIIILLLIIITTTYYY

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 • Requires a secondary dressing (foam or exudate manager)

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.


22

IIIMMMPPPRRREEEGGGNNNAAATTTEEEDDD GGGAAAUUUZZZEEE

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


23

IIIMMMPPPRRREEEGGGNNNAAATTTEEEDDD PPPOOOLLLYYYUUURRREEETTTHHHAAANNNEEE FFFOOOAAAMMM

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


24

IIISSSLLLAAANNNDDD DDDRRREEESSSSSSIIINNNGGGSSS

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


25

NNNOOONNN AAADDDHHHEEERRREEENNNTTT DDDRRREEESSSSSSIIINNNGGGSSS (((NNNAAADDD)))

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


26

OOODDDOOOUUURRR AAABBBSSSOOORRRBBBIIINNNGGG DDDRRREEESSSSSSIIINNNGGGSSS

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


27

PPPOOOLLLYYYUUURRREEETTTHHHAAANNNEEE FFFOOOAAAMMM MMM === MMMOOOIIISSSTTTUUURRREEE IIIMMMBBBAAALLLAAANNNCCCEEE

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


28

RRREEETTTEEENNNTTTIIIOOONNN SSSTTTOOOCCCKKKIIINNNGGGSSS

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


29

SSSIIILLLVVVEEERRR DDDRRREEESSSSSSIIINNNGGGSSS::: (((AAAccctttiiicccoooaaattt))) III === IIINNNFFFEEECCCTTTIIIOOONNN /// IIINNNFFFLLLAAAMMMMMMAAATTTIIIOOONNN

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


30

SSSIIILLLVVVEEERRR DDDRRREEESSSSSSIIINNNGGGSSS:::(((MMMeeepppiiillleeexxx AAAggg /// AAAlllllleeevvvyyynnn AAAggg /// SSSSSSDDD)))

III === IIINNNFFFEEECCCTTTIIIOOONNN /// IIINNNFFFLLLAAAMMMMMMAAATTTIIIOOONNN 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)


31

TTTOOOPPPIIICCCAAALLL NNNEEEGGGAAATTTIIIVVVEEE PPPRRREEESSSSSSUUURRREEE TTTHHHEEERRRAAAPPPYYY VVVAAACCC/// RRREEENNNAAAYYYSSSIIISSS/// PPPIIICCCOOO

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


32

TTTUUUBBBUUULLLAAARRR BBBAAANNNDDDAAAGGGEEESSS 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


33

TTTUUUBBBUUULLLAAARRR BBBAAANNNDDDAAAGGGEEESSS CCCOOOMMMPPPRRREEESSSSSSIIIOOONNN NNNooottt tttrrraaaiiinnneeeddd tttooo aaapppppplllyyy cccooommmppprrreeessssssiiiooonnn ttthhheeerrraaapppyyy???

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


34

ZZZIIINNNCCC BBBAAANNNDDDAAAGGGEEESSS 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


35

GGGLLLOOOSSSSSSAAARRRYYY AAABBBIII Ankle brachial Index, a test used to determine arterial

and venous blood flow of lower limbs AAANNNTTTIIIMMMIIICCCRRROOOBBBIIIAAALLL An agent that prevents the growth of harmful microbes

in the wound environment AAAUUUTTTOOOLLLYYYTTTIIICCC is a process where with the provision of moist

environment non-viable tissue is broken down in the wound bed.

BBBAAACCCTTTEEERRRIIIAAALLL BBBUUURRRDDDEEENNN The amount of bacteria on the wound bed, large

numbers may delay wound healing BBBAAACCCTTTEEERRRIIICCCIIIDDDAAALLL An agent that has the ability to kill bacteria BBBIIIOOOBBBUUURRRDDDEEENNN The amount of micro-organisms on the wound bed,

large numbers may delay wound healing BBBIIIOOOFFFIIILLLMMM A polysaccharide matrix that houses multiple micro-

organisms within its protective barrier, it can coat the wound base and penetrate into deeper tissue. It is impermeable to anitibiotics and most antimicrobials

CCCLLLAAAUUUDDDIIICCCAAATTTIIIOOONNN Pain experienced usually in the calf region when

walking, occurs in patients with compromised arterial flow to lower limbs, pain is eased by resting

CCCOOOLLLOOONNNIIISSSAAATTTIIIOOONNN 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

CCCOOONNNTTTAAAMMMIIINNNAAATTTIIIOOONNN Presence of unwanted micro-organisms in either the

wound or wound product DDDEEEBBBRRRIIIDDDEEE /// DDDEEEBBBRRRIIIDDDEEEMMMEEENNNTTT Removal of non viable tissue from the wound base

using various techniques EEEPPPIIITTTHHHEEEIIILLLIIIAAALLL The last layer of cells deposited in the wound healing

cascade, where wounds are at the final stage of healing

EEEPPPIIITTTHHHEEELLLIIISSSIIINNNGGG Regeneration of epithelial cells to gain wound closure

36

EEESSSCCCHHHAAARRR Necrotic or devitalised tissue in the wound EEEXXXUUUDDDAAATTTEEE Fluid produced by the wound GGGAAANNNGGGRRREEENNNEEE Death of healthy tissue leading to necrossis usually due

to poor arterial supply to limbs, can lead to bacterial invasion and susequent putrefication

GGGRRRAAANNNUUULLLAAATTTIIIOOONNN Growth of connective tissue and blood vessels HHHAAAEEEMMMOOOSSSTTTAAATTTIIICCC An agent that assistings in gaining heamostasis by

stemming bleeding in wounds HHHAAAEEEMMMOOOSSSIIIDDDEEERRRIIINNN 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

IIINNNFFFEEECCCTTTIIIOOONNN 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

IIINNNFFFLLLAAAMMMMMMAAATTTIIIOOONNN 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

MMMAAACCCEEERRRAAATTTIIIOOONNN 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

MMMAAALLLLLLEEEOOOLLLIII A bony prominence found on either side of the ankle

joint MMMAAALLLOOODDDOOOUUURRR a distinctive unpleasent odour MMMVVVTTTRRR Moisture vapour transfer rate, relating to the ability of

a dressing to provide gaseous exchange and evapourate moisture

NNNAAANNNOOOCCCRRRYYYSSSTTTAAALLLLLLIIINNNEEE is a small particle that has the dimensions that are

equal to or smaller than 100 nanometers NNNEEECCCRRROOOTTTIIICCC dead tissue and cells

37

NNNEEEUUURRROOOPPPAAATTTHHHYYY function of nerves (motor, sensory, and autonomic) are altered resulting in altered sensation of the area

NNNOOONNN---VVVIIIAAABBBLLLEEE Not alive, dead, non functional OOOVVVEEERRRGGGRRRAAANNNUUULLLAAATTTIIIOOONNN where granulation tissue rises above normal skin level

margins, excess growth of granulation tissue PPPAAALLLLLLOOORRR paleness of skin, lighter colour than normal PPPEEERRRIII---WWWOOOUUUNNNDDD Tissue that surround the wound margins PPPOOOLLLYYYUUUEEERRRTTTHHHAAANNNEEE a type of foam of various thicknesses PPPRRRIIIMMMAAARRRYYY DDDRRREEESSSSSSIIINNNGGG The dressing that will be in contact with the wound

base PPPRRROOOPPPHHHYYYLLLAAAXXXIIISSS An agent used to prevent or defend against something

occurring SSSEEECCCOOONNNDDDAAARRRYYY DDDRRREEESSSSSSIIINNNGGG Covers over the primary dressings, it does not come

incontact with the open wound base SSSEEEMMMIIIPPPEEERRRMMMEEEAAABBBLLLEEE Only permits certain molecules to pass through its

surface SSSIIINNNUUUSSS /// SSSIIINNNUUUSSSEEESSS a cavity or channel where the base may or may not be

visable SSSLLLOOOUUUGGGHHH /// SSSLLLOOOUUUGGGHHHYYY non viable tissue found in the wound VVVIIIAAABBBIIILLLIIITTTYYY pertaining to if tissue is alive and able to heal

38

FFFOOORRR FFFUUURRRTTTHHHEEERRR IIINNNFFFOOORRRMMMAAATTTIIIOOONNN PPPLLLEEEAAASSSEEE RRREEEFFFEEERRR TTTOOO:::

TTTHHHEEE AAAUUUSSSTTTRRRAAALLLIIIAAANNN WWWOOOUUUNNNDDD MMMAAANNNAAAGGGEEEMMMEEENNNTTT AAASSSSSSOOOCCCIIIAAATTTIIIOOONNN SSSTTTAAANNNDDDAAARRRDDDSSS FFFOOORRR WWWOOOUUUNNNDDD MMMAAANNNAAAGGGEEEMMMEEENNNTTT

39

RRREEEFFFEEERRREEENNNCCCEEESSS /// BBBIIIBBBLLLIIIOOOGGGRRRAAAPPPHHHYYY

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.

dressing application criteria developed and compiled by...and is active on pseudomonas, mrsa, gram...

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