Skin Care & Wound Dressing Guide 2018

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Lynn Wright
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1 Skin Care & Wound Dressing Guide 2018 This dressing guide provides examples of categories and types of wound dressings available and considerations for use. If unsure of what dressing to use or how to use a specific dressing, please seek advice from a specialist wound care nurse. 1. Skin care includes washing/cleansing the whole limb and creams used as barrier, treatment or moisturiser. 2. Wound assessment identify the goal: is it to rehydrate dry tissue, maintain moisture level, absorb excess exudate, reduce bacterial load or remove non-viable tissue? Is it to protect new epithelial tissue or new skin graft? Or reduce pain or over-granulation? 3. Consider dressing performance and patient comfort: is it adhered to the wound, causing pain or stinging, leaking or causing skin reaction or maceration? 4. Aim for moist wound and dry moisturised skin. Moisturiser/Emollient and Use Emollients soften skin by reducing water loss from the epidermis resulting in softer and more supple skin. Moisturisers add moisture. Both are used to correct dryness and scaling of the skin. Examples of products listed below; check ingredients of other products. For further information see the NZ Formulary Description: Fatty Cream. Use: soap substitute and/or moisturiser. Ingredients: Soft white paraffin, liquid paraffin, cetostearyl alcohol. Sodium lauryl sulphate (SLS) free. Examples: healthe 100g tub or healthe 500g pot. Description: Cetomacrogol. Use: soap substitute and/or moisturiser. Ingredients: Cetomacrogol emulsifying wax, liquid paraffin, soft white paraffin, purified water. Examples: healthe Non-Ionic Cream 100g or 500g; Dermasoft 100g & 375g; Cetomacrogol Cream 500g. Description: Aveeno / DermaVeen. Use: Emollient. Ingredients: Colloidal oatmeal + or - Dimethicone. Examples: Aveeno range; DermaVeen. Description: Sorbolene; Glycerin. Use: soap substitute and/or moisturiser. Ingredients: Cetomacrogol aqueous 90%, glycerol 10%. Examples: Sorbolene Cream with 10% Glycerin. Description: Urea Cream. Use: as moisturiser for hyperkeratotic and/or very dry skin. Ingredients: 10% Urea. Examples: 10% Urea Cream - healthe 100g tube; Nutra-Plus; Aquacare HP. Description: Paraffin. Use: moisturiser for very dry skin. Ingredients: White soft paraffin and liquid paraffin in varying combinations. Examples: White soft paraffin 50% and liquid paraffin 50% healthe 100g tube; Liquid Paraffin (sterile and non-sterile); QV range; Alpha-Keri range (contains wool fat and paraffin); WaterCreme. Description: Emulsifying Ointment. Use: soap substitute and/or moisturiser for very dry skin. Ingredients: Emulsifying wax 30%, white soft paraffin 50%, and liquid paraffin 20%. Examples: Emulsifying Ointment 100g and 500g pot. Description: Aqueous Cream.

2 Use: soap substitute. Ingredients: Petroleum jelly, emulsifying wax, Liquid paraffin, phenoxyethanol, water. Examples: Aqueous Cream 100g tube & 500g pot. Barrier Creams Description: Dimethicone 5% or 10% Barrier Cream. Use: as a barrier to protect skin from maceration/excoriation e.g. for incontinence and/or wound exudate. Emollient/protectant. Ingredients: Dimethicone 5% or 10%. Examples: healthe 100g tube; 555 Barrier; Silicare; Silic 15. Description: Zinc oxide products. Use: Emollient/protectant. Ingredients: Zinc oxide. Examples: Zinc and Castor Oil Cream healthe 20g tube; Zinc Cream or ointment; Sudocrem (+ wool fat); Secura; Curash. NB 1: some Zinc products contain peanut oil. NB 2: May clog incontinence products. Recommend 5% Dimethicone Barrier Cream instead. Sprays and wipes can also be useful to protect the skin. Examples: Cavilon No Sting Barrier Spray 3M 28ml; Secura No-Sting Barrier Film Wipe; Cavilon No Sting Barrier Film Wipe 1ml. Cleansing Solutions Most chronic wounds can be cleaned in a shower or washed in a bowl of water (caution with dry ischaemic wounds). Generally Normal Saline (warmed to body temperature) is used to irrigate granulating wounds (so as not to traumatise new tissue) and to swab wounds that have evident slough/debris/biofilm. Prontosan PHMB + Betaine Surfactant - Solution 1. Description/Function. Wound cleanser. Bottle can be used for 8 weeks after opening (please date). To pierce the bottle, unscrew the cap, remove the white ring and replace the cap. Ampoule is single use. 2. Application. Apply Prontosan soaked gauze to wound for 10 minutes. Rinse /wipe off excess debris with Prontosan. Do not rinse off the Prontosan. Caution: do not use if you are unable to see the wound base. Betadine Surgical Scrub (blue bottle) OR Chlorhexidine 4% surgical wipes 1. Description/Function. Bactericidal wash. Betadine contains 7.5% povidone iodine so check for iodine allergy. Chlorhexidine is the alternative. 2. Application. Wet a combine; pour on 5ml of surgical scrub and wash the skin around the wound area with it. Wash off with water. Use alternate days for 3 weeks, twice a week for 2 weeks, then weekly. White Vinegar soak for wounds with pseudomonas 1. Description/Function. Alter ph to normal acidic levels to reduce bacteria. 2. Application. Soak gauze in 1 part vinegar to 5 parts water. Apply to wound for 5 minutes. Remove the soak; irrigate/swab with Normal Saline & apply dressing. Microdacyn Wound Care Super Oxidised Solution and Gel 1. Description/Function. Reduces bacteria and inflammation. 2. Application. Spray solution directly onto wound til saturated or use as soak for 10 minutes. Rinse /wipe off excess debris with Microdacyn. Do not rinse off the Microdacyn. Use gel if required; 2-5mm thick & leave up to 3 days. Microdacyn Solution can be used before application of any type of dressing, including antimicrobials. Microdacyn Hydrogel is used like an antimicrobial dressing. Use with plain secondary dressings. Date and discard 60 days from opening. Dry Wound - Donate Moisture Hydrogel 1. Description/Function. Rehydrates viable and non-viable tissue. May cause maceration. 2. Application. Cover wound bed to 5mm thickness. Cover with film or hydrocolloid if very dry; otherwise non-adherent mesh dressing, gauze & combine.

3 3. Time to change. When secondary dressing is 80% saturated or strike through is evident. Can remain on wound for up to 3 days. NB: Some hydrogels contain preservatives enabling multi-use for the same patient. 4. Product Examples: Solosite, Intrasite Gel, Hydrosorb Sheet Gel, Nu-gel. Dry to Moist Wound - Retain Moisture Hydrocolloid or Film Hydrocolloid dressing 1. Description/Function. Retains moisture. Works by autolytic debridement. May cause maceration. 2. Application. Apply directly to wound. If cold, warm the dressing between your hands before removing backing paper. Peel back the paper being careful to minimise finger contact with the adhesive surface. Do not stretch the dressing. Gently mould into place for seconds. 3. Time to change. When it is 80% saturated, starts to leak or has been insitu for 7 days. 4. Product Examples: Duoderm, Comfeel, Replicare, Hydrocoll. Film dressing 1. Description/Function. Retains moisture. May cause maceration. 2. Application. Apply directly to wound for abrasions with minimal exudate. Use as secondary dressing to water-proof or secure primary dressing. Use Skin Prep and Remove wipes on fragile skin. 3. Time to change. When it is 80% saturated, starts to leak or has been insitu for 7 days. 4. Product Examples: Tegaderm, Opsite, Hydrofilm, Cutifilm, Mepore Film, Bioclusive, Mepitel Film Moist to Wet Wound - Absorb Moisture Calcium Alginate, Hydrofiber or Foam Calcium Alginate 1. Description/Function. Alginate fibres absorb wound fluid and convert it to a gel-like consistency. For light to moderate exudate and minor bleeding (as promotes haemostasis). 2. Application. Apply directly to wound. Cut close to size of wound as wicks horizontally so excess exudate may cause skin maceration. Needs a secondary dressing. If using in a cavity leave at least 2.5cm outside the wound. Try to ensure that all of the product is removed at dressing change, but fibres left behind will be absorbed by the body. 3. Time to change. When secondary dressing is 80% saturated or strike through is evident or has been insitu for 7 days (except donor sites which may be longer). If it dries out soak with NaCl 0.9% or wet in shower. 4. Product examples: Algisite, Kaltostat, Curasorb, Sorbalgon, Seasorb Hydrofiber 1. Description/Function. Similar to calcium alginates but composed of hydrocolloid fibres. Wicks vertically so exudate does not get onto skin and does not break up on removal. 2. Application. As for calcium alginate. 3. Time to change. As for calcium alginate. 4. Product examples: Aquacel, Durafiber Foam 1. Description/Function. Conforms to the wound bed. Absorbs & retains fluid to create moist environment. The outer layer is generally a breathable waterproof film layer. 2. Application. Choose size 3cm larger than wound. Apply directly to wound. For foams with a waterproof film layer, without borders, edges only need to be sealed with a film dressing do not occlude. Some foams may have a silicone or adhesive border. 3. Time to change. When 80% saturated, leaks or been insitu for 7 days. 4. Product examples: Biatain, Allevyn, Mepilex, Tielle, Polywic, PermaFoam, Kendall Bacterial Burden - Antimicrobial - Silver, Iodine, Honey or PHMB 1. The 2-week challenge should be applied; ie use for 2 weeks at a time and review. 2. Consider the moisture function of the dressing as well as the antimicrobial content. 3. Antimicrobial products may be retained for use by the same patient.

4 Silver Dressings Silver Non-adherent dressing 1. Description/Function. An ointment impregnated, silver containing, wound contact layer. It prevents secondary dressings from sticking to wounds, provides skin care for the wound edges and is effective when bacteria come into direct contact with the dressing. 2. Application. Place directly on wound and skin and cover with absorbent pad. 3. Time to change. May be daily to begin with. Unlikely to have much antimicrobial effect left after 2 days. 4. Product examples: Atrauman Ag Silver Hydrofiber 1. Description/Function. Controlled release of ionic silver as wound exudate is absorbed into the dressing. 2. Application. Choose appropriate size or cut to overlap wound by 2-3cm or cut into a wick. Do not wet prior to application. Wicks vertically so exudate does not get onto skin. Apply appropriate secondary dressing. 3. Time to change. When 80% saturated, leaks or has been insitu for 7 days. 4. Product examples: Aquacel Ag, Durafiber Ag. Silver Non-adherent dressing - Recommended for burns 1. Description/Function. Sustained release of nanocrystalline silver over 3 or 7 days. Allows exudate transport to secondary dressing. 2. Application. Moisten with water. Cut to appropriate size, 1-2 cm bigger than the wound. Without stretching the dressing, apply to the wound, either side down. Requires secondary dressing eg gauze and combine. 3. Time to change. Keep the dressing moist (water). Change the dressing after 3 or 7 days. Moisture may need to be added to the dressing during this time & the secondary dressing may need to be changed. 4. Product examples: Acticoat 3 or 7, Acticoat Flex 3 or 7. Iodine Dressings Iodosorb and Inadine are contra-indicated in Hashimoto's Thyroiditis or any known or suspected Iodine sensitivity, Graves Disease and non-toxic nodular goitre. Iodine is absorbed systemically especially when large wounds are treated. Iodine can cross the placental barrier and is secreted into milk. Do not use on pregnant or lactating women. Not for use on major burns or large injuries or after radio-active iodine treatment. Iodosorb is not to be used on children under 12. Inadine not on babies under 6 months of age. Povidone Iodine 1. Description/Function. Viscose fabric impregnated with10% povidone iodine. Rapidly releases iodine in the presence of wound fluid. 2. Application. Peel off backing paper. Apply directly to wound. Cover with secondary dressing; gauze & combine. No more than 4 dressings to be applied at any one time. See contraindications above. 3. Time to change. As the iodine is released the dressing changes from orange to white; when it is white it needs to be changed. May be daily to begin with. Unlikely to have much antimicrobial effect left after 2 days. 4. Product examples: Inadine. Cadexomer Iodine 0.9% 1. Description/Function. Slow release iodine. Effective against staph aureus & pseudomonas. Forms a gel over wound surface. For wounds with recurrent infections not resolved by antibiotics &/or sloughy wounds where other products have not worked. See contraindications below. 2. Application: Directly on wound 3mm depth. Cover with secondary dressing; Cuticerin, gauze and combine. 3. Time to change. Every 3 days or earlier if turns white. Maximum recommended use 3 weeks, but will depend on surface area being used. 4. Product examples: Iodosorb Honey Dressings

5 Honey Non-adherent dressing 1. Description/Function. An ointment impregnated, honey containing, wound contact layer. It prevents secondary dressings from sticking to wounds, provides skin care for the wound edges and is effective when bacteria come into direct contact with the dressing. 2. Application. Place directly on wound and skin and cover with absorbent pad. 3. Time to change. As the honey is released the dressing changes from yellow to white; when it is white it needs to be changed. May be daily to begin with. Unlikely to have much antimicrobial effect left after 2 days. 4. Product examples: Actilite. Honey and Calcium Alginate 1. Description/Function. Manuka Honey & Calcium Alginate. Osmotic action helps clean the wound and lift debris into the dressing. Autolytic debridement of sloughy and necrotic tissue & removal of malodour. 2. Application. Protect vulnerable wound edges with a barrier cream. Place the dressing onto the wound surface ensuring that it is in contact with the wound bed. Cut with sterile scissors or fold to fit the wound. A secondary dressing should be applied, absorbent enough to manage wound exudate. 3. Time to change. When it has been diluted by wound exudate. May be left in place for up to 7 days depending on wound exudate. If maceration of the surrounding skin occurs more frequent changes are required. 4. Product examples: Medihoney. Honey 1. Description/Function. Manuka honey. 2. Application. Apply a generous coating directly onto wound. Cover with non-adherent dressing and secure. 3. Time to change. Depends on how rapidly the honey is being diluted by the exudate. Daily dressing may be required initially but as exudate levels decrease it can be left insitu for up to 3 days. 4. Product examples: Activon. Non-Adherent Contact Layers that filter Simple non-adherent dressings 1. Description/Function. Low-adherent layer which allows wound to drain. 2. Application. Place directly on wound and skin and cover with absorbent pad. 3. Time to change. When secondary dressing 80% saturated or strike through. 4. Product examples: Cuticerin (Mesh Acetate), Jelonet (Paraffin Gauze), Adaptic, Paranet, Atrauman. Silicone non-adherent dressings 1. Description/Function. Silicone mesh wound contact layer. The Safetac layer prevents the outer dressing from adhering to the wound bed, ensuring atraumatic dressing changes. 2. Application. Remove smaller release film. Apply Mepitel to the wound, allowing at least 1 cm overlap of wound edges (more for larger wounds). Remove upper release film. NB: Moisten tips of gloves/forceps with sterile water/normal saline for easy handling of Mepitel. Gels/topical dressings may be applied over Mepitel. Use absorptive secondary dressing. 3. Time to change. When indicated by level of wound exudate. Can be left up to 14 days with secondary dressing changed as necessary. 4. Product examples: Mepitel, Silflex, Duratouch Other Primary Dressings Film + Pad 1. Description/Function. Waterproof film with pad. 2. Application. Remove backing paper. Apply to wound. 3. Time to change. When pad 80% saturated or up to 7 days. 4. Product examples: Opsite, Tegaderm, Mepore Film, Hydrofilm, Cutifilm Fabric + Pad 1. Description/Function. Adherent dressing with pad. 2. Application. Remove backing paper. Apply to wound.

6 3. Time to change. When pad 80% saturated or up to 7 days. 4. Product examples: Mepore, Asguard, Cutiplast, Primapore, Cosmopor. Self-cleaning Foam Dressing 1. Description/Function. Contains a cleanser, a moisturiser and a super-absorbent starch copolymer. 2. Application. Dressing should be 1-2 cm larger than the wound. DO NOT clean the wound or flush with saline or water between dressing changes. Apply the dressing film side out. DO NOT use any other materials to pack the wound or any topical treatments at the same time. Dramatic increase in wound fluid may be observed during the first few days. 3. Time to change. When the pad is 75% saturated, or when wound fluid is present at an edge of the dressing. 4. Product Example: PolyMem.

WOUND MANAGEMENT PRODUCT FORMULARY

WOUND MANAGEMENT PRODUCT FORMULARY 1 Appendix E Wound Management Formulary s; Advanced Nurse NOT wound management formulary products and NOT for use unless indicated under specialist instruction. Dressings