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1 South West CCAC Wound Management Program – Revised July 2012
South West CCAC Wound Management Program (WMP) - J uly 2012
Table of Contents Page 1. Background and Purpose revised 1
2. Integrated Venous Ulceration (VSU) Service Pathway; Information about VSU, key points and listing of toolkit resources NEW 2-3
3. Guide for treatment of venous dermatitis 4
4. Tubigrip Information and Measuring Guide revised slightly 5
5. Simple Unna’s Boot Instructions 6-7
6. Integrated Diabetic Foot Ulceration (DFU) Service Pathway; Information about DFU, key points and listing of toolkit resources
NEW
8-9
7. Integrated Pressure Ulcer (PU) Service Pathway; Information about PU, key points and listing of toolkit resources NEW 10-11
8. Integrated Open Surgical Wound Service Pathway; Information about Surgical Open Wound, key points and listing of toolkit
resources NEW
12-13
9. Teaching handout for clients Hydrofiber Ag for superficial and partial thickness burns Revised slightly 14
10. Skin Tears - Payne-Martin Classification System NEW 15
11. Information about other wound etiologies and listing of toolkit resources NEW 16
12. Decision Tree and Service Pathway for EST consults Revised – new to this document 17-18
13. Practice Enablers for Cleansing and Dressing Selection by wound characteristics NEW 19-26
14. Integrated Ostomy Service Pathway; Information about ostomies, key points and listing of toolkit resources NEW 27-28
Please note- the list of references for the SWCCAC WMP is now posted on the SWRWCF website under the SWCCAC WMP.
This version of the South West CCAC Wound Management Program contains several new practice enablers to assist clinicians providing
wound care within the community sector. Much of the clinical information found in previous versions now appears in the South West Regional
Wound Care Framework (SWRWCF) Toolkit at: www.woundcare.thehealthline.ca. This online toolkit has been approved and adopted by all of the
Acute Care Hospitals and the CCAC within LHIN2, providing resources for the wound care programs within those organizations.
It is the expectation of the CCAC that the care of clients with wounds by the contracted service provider organizations will be based on
these materials. These were drawn from a variety of resources, including but not limited to the Registered Nurses Association of Ontario (RNAO)
Clinical Best Practice Guidelines, the Canadian Association of Wound Care (CAWC) and Canadian Association for Enterostomal Therapy (CAET) Best
Practice/ Evidence-Based Recommendations.
This document includes several Integrated Service Pathways for individuals with wounds of specific etiology, for the adjunctive therapy
Electrical Stimulation, and for ostomies. One suggestion for using these is to print each service pathway plus the next page, which contains
information about the etiology, key points and lists the SWCCAC documents that must be used, plus other toolkit resources. These pages can be
placed in the package that you have made up containing the etiology-specific paperwork for the admission, and used as a quick reference.MP:
Venous Ulcerations Algorithm April 2011
2 South West CCAC Wound Management Program – Revised July 2012
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Information about Venous Leg Ulcerations (VLU) Item Treat the Cause and Resources
Venous Leg Ulcerations
• Shallow, moist ulcers , irregular in shape with sloping
edges
• Located on gaiter area of leg usually above or near medial
malleolus
• Yellow slough or fibrin with buds of granulation; rarely
have eschar
Cellulitis With Venous Disease
• Cellulitis infection presents as a diffuse, bright red, hot
leg with tenderness and often fever.
• Clear serous exudate pour out of the small openings in
copious amounts
• Large blisters (bullae) can form
• Often cannot tolerate their compression due to pain
Dermatitis With Venous Disease
• Stasis dermatitis causes a red, itchy, &/or dry and scaly
rash, can weep and form crusts.
• Skin appears brown or purple color
• Acute contact dermatitis causes itching, burning red
areas on the leg corresponding to use of topical product
e.g. creams or dressings lanolin, antibiotic creams and
ungs, perfumed, Vitamin A or E etc. or from dressing
exudate being trapped on the skin
Mixed Venous/Arterial Disease
• Mixed symptoms of both venous and arterial disease but
pain is more arterial, cannot use high compression
• ABI between 0.5 and 0.8 should be healable depending
on other co-morbidities, and using safe, low compression
Important Tips
Avoid use of adhesive products and known sensitizers due to
increased sensitivity of people with venous disease
SWCCAC
Documents
that must be
used
• “My Venous Ulcer” - teaching booklet to review with clients
• “My Wound Care-Venous & Compression ”- self-care guide
• SWCCAC Venous Wound Care Plan with time-specific goals
Treat the
Cause
Compression therapy is the cornerstone of VLU treatment
NB* must be prescribed by a physician and should only be
initiated after a lower leg assessment including Ankle Brachial
Pressure Index measurement has been performed.
Compression bandaging is an added skill for clinicians and there
must be an educational component and mentoring to ensure
safety and efficacy in application.
“Compression for Life” is the best method to decrease risk of
recurrences.
SWRWCF
Toolkit
Section F.6
Venous
Ulcers
www.woundcare.thehealthline.ca
B.2.1 Purpose and Instructions for Use for Lower Leg
Assessment – includes photos and definitions of signs and
symptoms of venous and arterial disease
B.2.2 Lower Leg Assessment Form
F.6 Venous Ulcer And Mixed Venous Arterial Ulcers
F.6.1 Background and Extent of Etiology
F.6.2 Clinical Algorithm based on wound bed preparation
F.6.3 Self-Care Teaching Tool
F.6.4 My Venous Ulcer client teaching booklet
F.6.5 Evidence-Based Clinical Interventions (From
SWCCAC WMP 2011)
F.6.5.1 Venous Stasis Ulceration Clinical Interventions
F.6.5.2 Venous Disease With Cellulitis Clinical Interventions
F.6.5.2 Venous Stasis Dermatitis Clinical Interventions
F.6.5 Principles of Compression Bandaging
F.6.7 Resources Best Practice Recommendations for the
Prevention and Treatment of Venous Leg Ulcers: Update 2006.
Wound Care Canada
4 South West CCAC Wound Management Program Revised July 2012
Treatment for Venous Stasis Dermatitis Avoid Sensitizers Moisturize Severely Dry
Scaly Skin
(Xerosis)
Topical Corticosteroid
Preparations
Client Teaching
Perfume, latex, dyes, lanolin or
wool alcohols, balsam of peru,
cetylsterol alcohol, parabens,
colophony propylene glycol,
neomycin, rubber, some adhesives,
framycetin or gentamycin (Sibbald
et al. 2007)
Glaxal Base (ask pharmacist if
not on shelf), Cliniderm or
Moisturel lotions (not cream) or
plain Vaseline petrolatum
ointment to keep the skin
healthy and free of dry scales.
Products
containing urea
such as Uremol or
Atractain should
be used sparingly
Stop if any signs of
dermatitis occur.
Use for only two weeks at a time
(if being applied more frequently
than 2 x/ week) –they thin the skin
over time, making it more likely to
break down or develop a rebound
dermatitis.
-Compression for life
-Rubbing or scratching an
involved area (even
through the bandage) will
extend the rash x 3 more
days (Sibbald et al. 2007)
Guidelines for management of different categories o f venous eczem a
Severe EczemaVery potent corticosteroid for 3-4 weeks +
emollient
No EczemaDaily emollient (unless wrapped)
Infected Eczema
Highly potent corticosteroid; antiseptic +
astringent agent and oral antibiotics
Mild EczemaModerately potent
corticosteroid for 3-4 weeks
Weeping EczemaAs for infected but
without oral antibiotics
Grey et al. 2006
Arrows indicate direction of possible change in con dition of eczema
From Grey , J.E., Enoch, S., Harding, K.G. 2006 ABC of wound healing Venous and arterial leg ulcers. BMJ 332:347-350.
5 South West CCAC Wound Management Program Revised July 2012
Tubigrip/ Tubifast Information and Measuring Guide Tubigrip is an interwoven stockinette with covered latex rubber yarns providing compression and support used for joint and venous conditions.
Low, low-medium, medium and high compression can be obtained, depending on the size used and the size of the limb that it is applied to.
*Wash Tubigrip 3 times only—it loses compression by the 4th
wash.
If client is unsure about whether they can wear compression, start with one layer or start with low compression and increase as tolerated.
Precautions: Do not use in the presence of symptoms of Arterial disease unless the ABPI is > 0.6 and/or a wound care expert or vascular surgeon have
assessed the safety.
Do not apply Tubigrip over an existing compression bandaging system unless increased compression is the goal.
Perform a lower leg assessment including ABPI if you are going to use it for moderate or high compression on the lower legs.
Tubigrip-tubular measuring guide for correct sizing to obtain desired compression* Alternate sizing method for 10-15 mm Hg** (2 layers)
Widest width
of limb
LOW - 5-10 mm Hg
(2 layers same size)
Size - CCAC + [Mölnlycke]
codes
MEDIUM – 10-20mm Hg
(2 layers same size)
Size – CCAC + [Mölnlycke]
codes
HIGH - 20-30 mm Hg
(2 layers same size)
Size - CCAC + [Mölnlycke]
codes
Size & SWCCAC
Code
Appropriate for**
Limb size**
10cm - 13.9cm none none none B- 7009 [1436] Small hands and arms 13-16 cm.
14cm - 14.9cm C-7010 [1443] B- 7009 [1436] none C-7010 [1443] Medium arms, small ankles 16-20 cm
15cm - 24cm D -7011 [1437] C-7010 [1443] B- 7009 [1436] D -7011 [1437] Large arms, med. Ankles, small knees
20-24 cm
25cm - 35cm E -7012 [1434] D -7011 [1437] C-7010 [1443] E -7012 [1434] Large ankles, medium knees, small
thighs 24-28 cm
36cm - 44.9cm F -7013 [1438] E -7012 [1434] D -7011 [1437] F -7013 [1438] Large Knees, medium thighs 28-36 cm
45cm - 50cm G – 7014 [1439] F -7013 [1438] E -7012 [1434]
G – 7014 [1439] Large thighs 36-46 cm
51cm - 60cm G – 7014 [1439] F -7013 [1438]
61cm - 70cm G – 7014 [1439] *Information provided by Convatec 2005. **Information provided by Molnlycke 2010
To achieve graduated 30 mm Hg compression using Tubigrip tubular:
1. Use sizing for LOW compression
2. Cut first layer to go from above toes to below the knee providing 8 mm Hg.
3. Cut second layer to go from the toes to below the knee proving an additional 8 mm Hg.
4. Cut the third layer to fit from the toes to above the ankle in the gaiter area, providing a total of 24 mm Hg at the ankle (Melhuish et al 2000) -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Tubifast dressing retention bandage does not provide any compression, can be washed many times and can also be used to secure IV tubing.
Use as a liner between the skin and the tubigrip to ease the application or hold dressings in place on difficult areas such as elbows or knees.
Stretch the tubifast over the affected area- cover area below and above dressing by several cm. for adequate retention. Line colour & SWCCAC Code Product Usage** Width
Red - 7015 Small limbs 3.5 cm
Green- 7016 Small and medium limbs 5 cm
Blue -7017 Large limbs 7.5 cm
Yellow -7018 Extra-large limbs, heads, children’s trunks 10.75 cm
6 South West CCAC Wound Management Program Revised July 2012
Application of Simple Unna’s Paste Boot
General Information & Terminology: Simple Unna’s Paste Boot: Named after German dermatologist Paul Gerson Unna, it consists of a paste bandage containing zinc oxide ointment, 3 to 4 inches wide and 10 yards long (SWCCAC Code 2900)and wrapped in a spiral with fan-folds to prevent constriction and ischemia, and covered by a spiral wrapped kling gauze bandage. It is used for the treatment of venous stasis ulcers and other venous insufficiencies of the leg (Instructions follow) Duke’s Boot: Created at Duke’s University in the late 1980’s, consists of a hydrocolloid dressing over the ulcer, covered by zinc paste bandage in fanfold spiral wrap, orthopedic padding and the original Coban retentive cohesive compression bandage (SWCCAC Code 4200). As of Sept. 2010, this is the ONLY safe application for compression with the original Coban that 3M Canada recommends. Modified Duke’s Boot: Consists of a primary dressing over the wound, the zinc paste bandage in fanfold spiral wrap,a layer of orthopedic padding, and a layer of compression bandage specified by wound care specialist (e.g the original Coban - retentive cohesive compression bandage (SWCCAC Code 4200) or short-stretch compression- Comprilan (SWCCAC 4201.02,03,05)
Mechanism of Action for Simple Unna’s Paste Boot: - A rigid or inelastic system. The paste bandage hardens over 24 hours to the consistency of cardboard, and provides hemodynamic support, protecting the skin and potentiating the calf muscle pump action when the individual ambulates. This improves the blood flow particularly on the deep veins and reduces edema. As the edema reduces, the wraps must be replaced to fit the smaller leg size. Indications: Provides a support system that can be utilized upon admission in the absence of signs of severe ischemia, when ABIs cannot be obtained due to edema or calcified vessels (see Contraindications). � Refer to vascular surgeon particularly if there is continuing rest pain. Mixed arterial and venous ulcer with arterial insufficiency: low compression (Burrows et al.
2006) for ABI: 0.5-0.8 (Marston and Vowden 2003) (moderate ischemia), Ankle Sprain with venous insufficiency or atrophy � Localized atopic dermatitis or venous dermatitis � Can be used for mobile or immobile patients, works best if patient is able to ambulate some of the time. Precautions
� Acute skin infections
� History of congestive heart failure
� Atrophy of muscles
� History of dermatitis- many patients are sensitive to some of the constituents of paste bandages, such as parabens preservatives, so it is advisable to patch test the patient with a small strip of bandage over at least 48 hours.
� Even if no sensitivity is noted with a patch test, an individual may go on to develop sensitivities on the involved limb, and any increase in dermatitis should result in the paste wrap being discontinued.
Contra-indications: If any of the following signs and symptoms are present, do not implement Unna’s Boot without a doctor’s order and a vascular assessment such as ABI’s or segmental compression studies
� Pain in legs and feet when laying in bed with legs elevated and relieved by putting leg over the side of the bed or getting up and walking around
� Cold legs or feet
� Symptoms of intermittent claudication (characterized by muscle pain or cramping in the legs triggered by a certain amount of activity, such as walking, but disappears after a few minutes of rest. The location of the pain depends on the location of the clogged or narrowed artery. Calf pain is most common.)
� Diabetic microangiopathy (Damage to small blood vessels and capillary circulation causing retinopathy, nephropathy, neuropathy, diabetic foot disease)
� Dependent rubour/ pallor with elevation
7 South West CCAC Wound Management Program Revised July 2012
Application of Simple Unna’s Paste Boot
� Loss of feeling or protective sensation so that the individual could not detect discomfort if the wrap were too tight.
Advantages � Comfortable and soothes skin � Protects skin from scratching
Disadvantages � Sticky sensation in warm weather � Contact Dermatitis may occur in some patients � Less effective for non-ambulatory patients � Pressure decreases with reduced edema (reapply) � Cannot absorb large amounts of drainage and exudate may “strike-through” requiring changing. � It does not provide compression during periods of inactivity.
Technique Clean the patient's skin thoroughly by washing with tap water (not saline or sterile water) using a mild soap (Dove for sensitive skin) and rinse well. Pat to dry with a clean towel (not 4x4”s). Cleanse the wound as per Sections 10a & b Wound Cleansing Techniques. Add moisturizer to normal skin or topical corticosterioid if ordered for dermatitis. Have patient flex the knee and dorsiflex (toes to nose) the foot to prevent pressure over the tibialis anterior tendon. Apply Unna's boot using a fanfolded layered application without any tension, smoothing the wrap with your hands using the following method: Start at the base of the toes (metatarsophalangeal joints). Wrap upward in a spiral manner, overlapping about 50% of the previous layer, without pressure, stopping at the lateral side of the leg with each turn, and fold back on itself (see ----- in diagram), avoiding any circumferential wrap that would cause constriction and potential pressure necrosis. This allows for expansion if edema should increase, preventing constriction. You must also allow for spread of the metatarsal bones and heel pad during gait. Continue the spiral, over the heel and upward to the tibial tubercle, being sure not to compress the peroneal nerve, which is just below the head of the fibula. Each turn must be done at an angle to avoid compromising the circulation. If desired, 6-8 layers of paste wrap can be fanfolded back and forth just over the ulcer to create a semi-occlusive dressing. If bony prominences along anterior foot and leg are evident, use folded gauze to cushion these areas. Finish below tibial tubercle of knee, about 1 inch below the knee. If constriction develops as the dressing hardens, make a 2-inch slit in it below the knee. Place gauze on the outer side of the paste wrap over the ulcer area to absorb exudate and prevent strike-though (Strike-through is defined as the point at which absorbed fluid reaches the outer surface or edge of a dressing) (Thomas and Fram 2001) Wrap the Unna's boot with gauze kling-style bandage applied in a figure-8 pattern (this will be less likely to slip and fall down than a spiral wrap). Change q 3-4 days in the first week and decrease as able. Patient Teaching- as per ‘My Venous Ulcer’ booklet. This procedure is from the the CarePartners ET NOW P&P- used with permission. Connie Harris (2008). Editorial assistance Sandra J. Landolt MD FRCPC (Internal Medicine) FRCPC (Dermatology) Consultant in Medical Dermatology and Internal Medicine as pertains to the skin.
8 South West CCAC Wound Management Program Revised July 2012
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Information about Diabetic Foot Ulcerations (DFU) Item Treat the Cause and Resources
Neuropathy of the feet in people with diabetes leads to:
• Changes in muscle and bone alignment causing
deformities and areas of high pressure
• Loss of protective sensation (LOPS)
• Callus formation
Greater than 85% of lower leg amputations are precipitated
by diabetic foot ulcers (Jones 2006), while 15% of DFUs end in
amputation (Snyder et al. 2010).
• Early detection and appropriate treatment of these
ulcers may prevent many amputations.
• Most DFU’s occur at areas of increased pressure - 90%
of diabetic plantar ulcers are attributed to pressure
(Orsted, Searles,Trowell et al 2006).
Requires multi-disciplinary team approach
• Assess circulation
• Offload pressure
• Debridement
• Optimize nutritional intake
• Surgical interventions
Key Points
• Pain in an insensate foot can signify deep
infection/osteomyelitis
• Erythema extending more than 2 cm indicates a limb-
threatening infection
• Avoid occlusive dressings (e.g. hydrocolloids) on
plantar foot ulcers
• Manage exudate, prevent contamination through wet
dressings and protect peri-wound skin
• Treat infection immediately(usually needs systemic
treatment)
SWCCAC
Documents
that must be
used
• “My Diabetic Foot Ulcer” - teaching booklet to review with
clients
• “My Wound Care-Diabetic Foot Ulcer”- self-care guide
• SWCCAC Diabetic Foot Ulcer Care Plan with time-specific goals
Treat the
Cause
Offloading (relieving) the pressure from the ulcer is the
cornerstone of DFU treatment – obtained from a certified
orthotist/ pedorthist/ chiropodist/or prodiatrist. Orthotics will be
needed to prevent recurrence.
SWRWCF
Toolkit
Section F.1
Diabetic Foot
Ulcers
www.woundcare.thehealthline.ca
B.2.1 Purpose and Instructions for Use for Lower Leg
Assessment – includes photos and definitions of signs and
symptoms of diabetic neuropathic disease and arterial
disease
B.2.2 Lower Leg Assessment Form
F.1 Diabetic Foot Ulcers
F.1.1 Background and Extent of Etiology
F.1.2 Clinical Algorithm based on wound bed preparation
F.1.3 University of Texas Wound Classification System of
Diabetic Foot Ulcers
F.1.4 Self-Care Teaching Tool
F.1.5 My Diabetic Foot Ulcer client teaching booklet
F.1.6 Evidence-Based Clinical Interventions
F.1.7 Resources
i) Orsted, H., Searles, G., Trowell, H., Shapera, L., Miller, P.,
Rahman, J. (2006). Recommendations for the prevention,
diagnosis and treatment of diabetic foot ulcers: Best Practice
Update. 2006. Wound Care Canada 4(1):R39-51. Please see PDF.
Used with Permission.
ii) Botros,M., Goettl, K., Parsons,P., Menzildzic, S., Morin, C.,
Smith,T., Hoar, A., Nesbeth,H. and McGrath,S. Best Practice
Recommendations for the prevention, diagnosis and treatment of
diabetic foot ulcers: Update. 2010. Wound Care Canada 4(1):R39-
51.
10 South West CCAC Wound Management Program Revised July 2012
11 South West CCAC Wound Management Program Revised July 2012
Suspected Deep Stage I Stage II Stage III Stage IV Unstageable Tissue Injury
NPUAP Staging System for Pressure Ulcers (Updated 2007). Used with permission. Reproduction of the National Pressure Ulcer Advisory Panel (NPUAP) materials in this document does not imply endorsement by the NPUAP of any products, organizations, companies or statements made by any organization or company. You can never “back-stage” an ulcer –e.g. once a stage
IV, always a stage IV.
Information about Pressure Ulcers (PU) Item Treat the Cause and Resources
A pressure ulcer (historically called a decubitus ulcer or bed
sore) is a localized area of tissue necrosis that results when
soft tissue is compressed (pressure, shear, and friction)
between a bony prominence and an external surface.
Pressure and shear deprives the tissue of nutrients, and
oxygen so that cells die and the ulcer formation begins next to
bone progressing outwards. Other contributing factors include
moisture (wound exudate, stool and urine), external friction,
malnutrition, immobility, altered sensation and dementia.
Pressure ulcers are staged based on degree of tissue injury
using the NPUAP staging system (see above & Section F.3.3)
In addition to clinicians should be knowledgeable about
AVOIDABLE and UNAVOIDABLE pressure ulcers and Skin
Changes At Life’s End (SCALE) .
Requires multi-disciplinary team approach
• Assess circulation
• Redistribute pressure
• Debridement
• Optimize nutritional intake
• Surgical interventions
Pressure Ulcer Prevention is now a required organizational
practice with Accreditation Canada.
Key Tips
Bed rest should NEVER be part of the plan of care for pressure
ulcers. De-conditioning starts in as little as 24 hours.
Turning schedules and optimal mobilization are needed even
with pressure redistribution devices.
SWCCAC
Documents
that must be
used
• “My Pressure Ulcer” - teaching booklet to review with clients
• “My Wound Care-Pressure Ulcer”- self-care guide
• SWCCAC Pressure Ulcer Care Plan with time-specific goals
Treat the
Cause
Offloading (relieving) the pressure from the ulcer is the
cornerstone of Pressure Ulcer treatment – an Occupational
Therapist consult is needed to assess for the correct device
SWRWCF
Toolkit
Section
www.woundcare.thehealthline.ca B. 3.2 Interdisciplinary Pressure Ulcer Contributing Factors Assessment
Tool.
F.3.1 Background and Extent of Etiology of Pressure Ulcers
includes photographs of pressure ulcer stages, definition of
avoidable and unavoidable pressure ulcers and Kennedy’s
Terminal Ulcer (Skin Changes at Life’s End [SCALE])
F.3.2 Clinical Algorithm based on wound bed preparation
F.3.3 NPUAP Staging System for Pressure Ulcers (Updated 2007)
F.3.4 Self-Care Teaching Tool
F.3.5i My Pressure Ulcer client teaching booklet
F. 3.5ii Pressure Ulcer Prevention teaching booklet
F.3.6 Selection of Surfaces for Pressure Redistribution
F.3.7 Evidence-Based Clinical Interventions
F.3.8 Resources: Keast D.H. , Parslow, N. Houghton, PE.,
Norton,L. and Fraser, C. (2006) Best Practice Recommendations
for the Prevention and Treatment of Pressure Ulcers: Update
2006. Wound Care Canada 4(1):R19-29.
Power Point Voice Over: Prevention of Skin Breakdown from
Pressure Ulcers
12 South West CCAC Wound Management Program Revised July 2012
South West CCAC Integrated Surgical Open Wound Service Pathway
Clinical Resources:CAWC: Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds
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Refer to ETN/WCS
Block of 2 visits
FV within
14 days (sooner if
Enterocutaneous
Fistula)
Refer to VNA*
Block of 24 visits over 8
weeks periods-if incision is only gaping slightly &/or with
minimal exudate, the block
visits and length of time
would be less
Teach & Reduce
Dietitian- Indicators for RAI-
CA or – HC
blood sugar hx
0-7 days Visiting Nurse
Initiates SWCCAC Surgical
Open Wound Care Plan
Performs Hx and Physical
Assessment.
If lower limb , is edema
present?
Does wound need debrided?
Does wound probe to bone or
is it infected?
Is wound healable?
Initiate wound
care
Provide teaching
with Surgical
Wound materials
Complete PSPR &
WCSR
YESETN/WCS
performs ABPI
and LLA/
debridement if
needed; modifies
local wound care
if needed
Is dressing
frequency
appropriate? (See
SWRWCF Toolkit
E.1.3 SWCCAC
Daily Visits as
Exceptional
Situation)
Contact Physician
for alternate
treatment plan to
reduce visit
frequency
21 to 28 days-
frequency has
decreased to 3 x week;
size of the wound has
decreased by
20-30%
Contact Physician with
recommendations &
place chart on HOLD
unless follow-up
needed (indicate
frequency of visits on
PSPR)
Request referral for ETN/
WCS for re-assessment
if ETN/WCS on HOLD,
contact to resume Wound has NOT
healed at 3 months
Refer to PT for
EST assessment
(see EST Initiation
Process flow
chart)
ETN/WCS
reassesses and
revises plan of
care using
principles of
WBP:
Contact Physician
with
recommendations
& place chart on
HOLD unless
follow-up needed
21 to 28 days
continue plan of care ,
initiate chronic disease
self-management plan,
begin discharge
planning for client
independence and
prevention–
WCSR q 3 weeks
(healable); or with
PSPR for maintenance/
palliative
CCAC Referral for
Surgical Open Wound
Conducts assessment=
RAI-CA SEC=93
Wound Heals
by week 12-
Discharge Client-
Complete PSPR
and WCSR
Maintenance/
palliative:
Continue Plan
of Care –
Complete
WCSR with
PSPR
YES
YES
Refer to ETN/WCS Block of
3 visits over 12 weeks if
ETN/WCS not on HOLD
Legend
ABPI= Ankle Brachial Pressure Index
ETN/WCS= Enterostomal Therapy Nurse or Wound Care Specialist
Nurse
LLA= Lower Leg Assessment
Start or End
Assess/ Action /
Document Decision
Healable
Wound: Request
Referral to PT for
EST assessment,
plan joint visit
when PT contacts
agency;
WCSR q 3 weeks
PT mobilization/ mobility issues
PSW - if indicated
Request referral
for ETN/WCS for
assessment and
treatment,
possible ABPI and
LLA and/ or
debridement
Wound healed or Client
independent with wound
care
Discharge Client- Complete
PSPR and WCSR
NO
NO
Is an
enterocutan-
eous fistula
present?
YES
YES
13 South West CCAC Wound Management Program Revised July 2012
Information about Surgical Open Wounds Item Treat the Cause and Resources
Open surgical wounds include:
• Incision and drainage (I&D) of abscesses
• Non-healing incisions with necrosis, separation or dehiscence
• Closed wounds healing by primary intention without signs of
complication but with drainage
• Signs and symptoms of surgical site infection (SSI)
• Those healing by secondary intent (healing from the base
upwards by the growth of new tissues) or tertiary intent
Failure to heal may be a result of infection or patient co-morbid
factors such as malnutrition, other disease processes, immuno-
compromise, smoking, and end-of-life.
Key points (if packing has been ordered):
• If you cannot visualize the entire wound base such as in
tunnels or undermined areas, ONLY use wound products have
high tensile strength and do not disintegrate when moist
• If using hydrofibers or alginates in cavity wounds, remember
that they will expand with exudate -- only fill 80% of the depth
• Never use more than one piece of packing material in a wound
• Always leave a ‘tail’ of packing outside the wound for easy
retrieval and removal
• Wound packing must be firm enough to prevent premature
bridging of granulation tissue in the base, causing pockets and
future abscesses, yet:
o allow the wound to contract and heal from the base
and
o serve as a conduit or wick to allow the exudate to
drain.
• Avoid packing tightly at the opening of a tunnel or sinus- it can
plug the exit, causing increased pressure within the cavity as
the exudate volume increases, and extension of the cavity.
SWCCAC
Documents
that must be
used
• SWCCAC Surgical Open Wound Care Plan with time-
specific goals
• ‘My JP Drain Care’
• ‘My Surgical Wound’ - teaching booklet to review with
clients
• ‘My Wound Care-Surgical Open Wound’- self-care
guide
Treat the
Cause
Optimize nutrition, treat infections, maintain tight blood
glucose levels—all factors that contribute to non-healing
surgical wounds.
SWRWCF
Toolkit
Section F. 5
www.woundcare.thehealthline.ca
SURGICAL WOUND (CLOSED AND OPEN)
F.5.1 Background and Extent of Etiology; Instructions
for use of tools.
F.5.2 Algorithm
F.5.3 Self-Care Teaching Tool
F.5.4 My JP Drain Care
F.5.5 ‘My Surgical Wound’ Patient Teaching Handout
F.5.6 Evidence-Based Clinical Interventions for closed,
open and incision and drainage surgical wounds (found
in 5.1)
F.5.7 Resources- Orsted, H.L., Keast, D.H., Kuhnke, J.,
Armstrong, P., Attrell, E., Beaumier, M., Landis, S.,
Mahoney, J.L., Todoruk-Orchard, M. (2010) Best Practice
Recommendations for the Prevention and Management
of Open Surgical Wounds. Wound Care Canada, 8 (1)pp.
6-34. Erratum Table 3 WCC 8(2)pp. 34.
14 South West CCAC Wound Management Program Revised July 2012
Patient/ Client Teaching: Aquacel AG ® Method for Superficial and Partial-Thickness Burns (SWCCAC Codes 2504, 2506)
Your doctor or the wound care specialist has ordered a dressing for your burn that is not changed every day. The purpose of the dressing is to prevent infection, to reduce your discomfort, and to reduce the need to disrupt the burn with frequent dressing changes. ** Please take these instructions with you if you s ee your family doctor or need to go to emergency fo r any reason.
Day Information Application day (Recommended for the day the burn happens or up to Day 3. Sometimes it can be applied later than this)
This is a dressing that looks a bit like ‘felt’ called hydrofiber. It contains silver (Ag) which helps to prevent infections. It is usually applied dry onto the burn, but it can be moistened it if there is not a lot of drainage from your burn, or if it is being applied over a joint. When the dressing becomes moist with the drainage from the burn, it forms a soothing gel. It should stay on your burn for up to 14 days without being removed. As the skin heals, the dressing will harden on the burn and is the colour of the drainage. It may need more than one piece of the dressing, which should be overlapped by 6 cm. It will be covered with a non-stick dressing and/ or an absorbent dressing, which will be changed more often.
Day 1 (after Aquacel Ag dressing is applied)
The nurse or doctor will remove outer dressing and inspect to make sure that the silver dressing has not moved around, exposing the burn to the air. They may need to add more pieces of the dressing, with a 6 cm overlap. And apply a new outer non-stick dressing and/ or an absorbent dressing.
Day 3 (only when dressing is applied at time of burn)
If the dressing has not stuck to the burn at 72 hours, the entire dressing should be removed so that the burn can be checked to see if it has progressed to a full-thickness burn or if it is infected. If so, an alternate treatment will be required. If the hydrofiber Ag dressing is soaked with drainage, it should be replaced with only one thickness (except for the overlap). Otherwise, only the outer non-stick dressing and/ or an absorbent dressing, should be changed.
Days 6, 10, 14: The outer dressing should be removed every 2-3 days, depending on how much drainage there is. As the burn heals and new skin grows, the silver dressing will start to detach and can be trimmed away with scissors, starting at the edges of the burn. It is important to trim the loosened dressing so that it does not catch on the outer dressing and accidentally pull the hydrofiber Ag dressing off.
Once all of the Hydrofiber Ag has loosened:
Any remaining small open areas can be dressed with: pre- moistened hydrofiber Ag and cover dressing as before. Healed areas should be treated with a moisturizer to keep the skin healthy.
Important things to know: If the silver dressing is stuck to the wound, it should not be removed by anyone who is not familiar with the way this dressing works. The only reason to remove it is if infection or a more serious burn is suspected. Trying to remove it dry can cause pain and trauma to the burn. It must be moistened to slowly soak it off. Call the nurse if:
There is increased or different drainage or the dressing doesn’t seem to be staying in place There is unusual or increased pain in the wound The dressing has moved or shrunk, leaving areas of the burn exposed The dressing has stiffened over a joint and needs to be moistened to allow you to move the joint You have a fever higher than 38°C (100°F) --- old er individuals may have fever at a lower temperature
37°C (99°F) References: Aquacel Ag
® for Burns information, Convatec, Montreal, PQ. and Saba et al. 2009 J Burn Care Res 30(3):380–385. Revised July 2012.
15 South West CCAC Wound Management Program Revised July 2012
Skin Tears Skin tears are caused by shearing, friction or blunt trauma that causes separation of skin layers, resulting in partial - or full-thickness wounds
Payne-Martin Classification for Skin Tears: Category and Description Photograph Resources
Category 1 – Skin tears without tissue loss:
Linear (full thickness or flap partial thickness).
Photograph courtesy of Kim LeBlanc, Dawn Christensen and Wound Care Canada.
Used with permission.
F.4 SKIN TEAR
4.1 Background and Extent of
Etiology; Instructions for use of
other sections;
4.2 Algorithm
4.3 Skin Tear Classification and
Risk Assessment/ Risk Intervention
tool
4.4 Client/Patient Teaching and
Learning Resources
4.5 Evidence-Based Clinical
Interventions
4.6 Resources
4.7 Power Point Voice Over
Resources:
Links to OTN:
‘Prevention of Skin Breakdown
from Skin Tears and Pre-Tibial
Injuries ‘
‘Prevention of Skin Breakdown
from Skin Tears and Pre-Tibial
Injuries’
Category 1 –
Flap type (partial thickness): epidermis and dermis are separated. Flap can be
completely approximated or approximated to expose no more than 1mm of the
dermis.
Photograph courtesy of Kim LeBlanc, Dawn Christensen and Wound Care Canada.
Used with permission.
Category 2 – Skin tears with partial tissue loss (scant tissue loss type or moderate to
large loss) “Scant Category 2 skin tear”- 25% or less of the epidermal flap is lost.
Photograph courtesy of Kim LeBlanc, Dawn Christensen and Wound Care Canada.
Used with permission.
“Moderate Category 2 skin tear”- more than 25% is lost. Photograph courtesy of Kim LeBlanc, Dawn Christensen and Wound Care Canada.
Used with permission.
Category 3 – Skin tears with complete tissue loss (absent epidermal flap)
16 South West CCAC Wound Management Program Revised July 2012
Other Types of Wou nds In addition to the previous wound pathways by etiology, the SWRWCF toolkit has resources on other wound etiologies.
Section F: Principles Of Treatment Based On Etiology (Treat The Cause) F.2.Pilonidal Sinus - Will be available by June 30, 2012.
2.1. Background and Instructions for use; References
2.2. Algorithm (PDF)
2.3. Care Plan (PDF)
2.4. Flow Sheet
2.5. Client/Patient Teaching and Learning Resources
2.6 Resources: Conference proceedings: Harris, C., Laforet, K., Sibbald, R.G. Pilonidal Sinus Wounds: Etiology and evidence-based management.
Wound Care Canada. 2012. 10(1):pp. 28-29. Used with permission.
F.7 Malignant Wound
7.1 Instructions for use
7.2 Algorithm
7.3 Self-Care Teaching Tool (to be developed)
7.4 Client/Patient Teaching and Learning Resources (to be developed)
7.5 Clinical Interventions (See 7.1)
7.6 Resources (See 7.1)
7.7 References (See 7.1)
F.8 Superficial and Partial Thickness Burns
8.1 Instructions for use
8.2 Algorithm
8.3 SWCCAC Self-Care Teaching Tool for hydrofiber (also included in this booklet)
8.4 Client/Patient Teaching and Learning Resources (to be developed)
8.5 Clinical Interventions (See 8.1)
F.9 Inflammatory Ulcers (Section to be developed Summer-Fall 2012)
F.10 Lymphedema (Section to be developed Summer-Fall 2012)
F.11 Arterial Ulcers (Section under development Summer 2012)
11.1 Background and instructions for use (will be available by June 30)
11.5 Clinical Interventions (will be available by June 30)
17 South West CCAC Wound Management Program Revised July 2012
DECISION TREE FOR ADJUNCTIVE THERAPY (E-STIM) FOR WOUND CARE – See also Adjunctive Therapy Assessment and
Initiation Process Flow Sheet
At 3 weeks:Is the wound ≤ 37.5% healed?
Has nutrition been
optimized?
Have pressure issues
been resolved?
Infection:
resolved or responding
to treatment?
Refer to Dietitian
Refer to
Occupational
Therapy
Refer back to
Physician
Continue with Best
Practices
Can you answer YES to
each of the following Best
Practice questions?
Are blood sugars well
controlled?
NO NO
Are there any contraindications
present?
YES
YES
YES
Not appropriate for
EST Rx
Complete ‘Request for EST
Assessment’ form and
submit to the CCAC
At 3 months:Is the wound 100%
healed?
Discharge from
services
NO
Refer back to
Physician
NO
On admission:? SCI
On admission:≥ 5 cm
2and/or > 6 months
duration
DIABETIC FOOT PRESSURE VENOUS
YES YES YES
NO NO NO
YES
YESNO
S
T
A
R
T
Compression
optimized where
edema exists?
Wound protected
from contamination?
Debridement
performed?
Revisit Best Practices for Wounds
YES YES YES
NO
NO NO
18 South West CCAC Wound Management Program Revised July 2012
ADJUNCTIVE THERAPY ASSESSMENT AND INITIATION PROCESS FLOW – See also Adjunctive Therapy Decision Tree
Identifies client who
may be appropriate
for EST based on
Decision Tree
Identifies client who
may be appropriate
for EST based on
Decision Tree
Identifies client who
may be appropriate
for EST based on
Decision Tree
Completes “Request
for Electrical
Stimulation Therapy
Assessment” form
and submits to the
CCAC
Completes “Request
for Electrical
Stimulation Therapy
Assessment” form
and submits to the
CCAC
Is referral for EST
appropriate? Refer to
Decision Tree.
Add PT Service indicating EST in
local distinction. Block of 10
visits over 3 mos. Send offer
Explore other options with
referral source.
Connect with visiting RN
to schedule joint
assessment visit
Send update to
visiting RN
Receive update.
Await call from PT to
schedule joint visit.
Conduct joint
assessment
visit.
Is client appropriate
for EST?
NO
Complete PSPR. Complete
communication to physician.
Complete EST Equipment
and Supply order form and
submit to CCAC
Enter Equipment
and Supply order in
CHRIS and send to
McNiece Tens
Complete DC PSPR with
rationale for non-admit to EST
program
Schedule joint
visit with RN
for initiation of
EST – allow
at least 4
business
days to
ensure
delivery of
equipment
and supplies
Deliver Equipment and
Supplies to client’s home
within 2 days of
receiving order
Conduct joint visit
to initiate
treatment.
Ensure visiting
nurse
understands plan
and that it is
incorporated into
nursing care
plan.
NO
YES
YES
Contraindications: cancer (active, local or potential mets) osteomyelitis inflammatory ulcers cardiac pacemaker in close proximity
severe arterial insufficiency (ABI <0.5) pregnancy active DVT or thrombophlebitis over excitable tissue (head, neck, head)
dressings or residues (zinc, silver, iodine, calcium, sodium chloride hypertonic solution)
19 South West CCAC Wound Management Program Revised July 2012
SWCCAC WMP: Wound Cleansing and Dressing Selection Enabler
All Resources available at www.woundcare.thehealthline.ca Topic
PowerPoint Voice-Over Segments
Links to OTN Webcasts
Other On-line Resources
Function of Dressings
SWRWCF: Function of Wound Dressings (55
min)
SWRWCF: Matching Dressings to Wound
Characteristics including High Exudate
Management (32 min)
H.PRODUCT SELECTION AIDES
H.2 CAWC PRODUCT PICKER
H.2.1 Purpose and Instructions for Use of CAWC
Product Picker Tool/ purchase information for
poster H.2.2 CAWC Product Picker Tool –print as 8.5 x
14”
H.4 Industry how-to files of all of the dressings in
the HealthPro contract, 8.5 x 14”
• The absorbent capacity of a dressing is defined as: ‘the volume of fluid contained in the dressing at the time at which strike-through occurs’.
Strike-through is defined as: “the point at which absorbed fluid reaches the outer surface or edge of a dressing” (Thomas and Fram 2001
http://www.worldwidewounds.com/2001/december/Thomas/absorbency-wound-dressings.html).
• In addition to absorbing exudate, many dressings also allow the exudate to evaporate through the outer dressing over a period of time.
• This is called the moisture vapour transmission rate (MVTR).
• The SW CCAC has attempted to identify how much exudate various dressings can handle, indicated by [1+] etc.
• The descriptions of the exudate amounts indicated with * are from the Bates-Jensen Wound Assessment Tool (BWAT) (Toolkit Section B.6):
o Small [1+] *Wound tissues wet; moisture evenly distributed in wound; drainage involves 25% of dressing,
o Moderate [2+] *Wound tissues saturated; drainage may or may not be evenly distributed in wound; drainage involves 25-75% of
dressing
o Large [3+] Wound tissues saturated with drainage involving 75-100% of the dressing
o Copious [4+]*Wound tissues bathed in fluid; drainage freely expressed. Copious exudate often requires more frequent dressing
changes if the dressing is unable to contain the exudate for extended periods of time.
• See the SWRWCF Toolkit Section E.1.3 Daily Visits as Exceptional Situation for Healable and Maintenance/Palliative Wounds.
• The following table (pages 20- 26) is new and is intended as a practice enabler to match dressings to the wound characteristics.
20 South West CCAC Wound Management Program Revised July 2012
Wound Assessment Type of
Intervention
Treatment Choices
1. Open Surgical
Incision (incision
may still be sutured
or stapled but there
are small
dehiscence’s or
incision line is
exudating). Please
see tunnels and
undermining for
open surgical
wounds (Section 9).
Goal: Absorb
exudate, protect
from external
contaminants,
prevent infection
and allow healing.
Cleansing: DO NOT flush or irrigate as you may force surface bacteria deeper into the incision. Pour solution or
cleanse with sterile gauze and saline. Always cleanse from incision line out to avoid introducing
bacteria from skin.
Primary
Dressing:
Choose a non-adherent dressing with a secondary absorbent dressing, or a combination dressing that
provides non-adherent, absorptive and resistance to bacteria.
o Hydrofiber [2+]
Secondary
Dressing:
o Hydrocolloid thin [1+]
o Surgical strip dressing [1+]
2. Clean Epithelializing
Wound
Goal: Provide
environment
conducive to wound
healing without
trauma
Cleansing:
DO NOT irrigate with pressure higher than 7 PSI - pour room or body temperature solution over the
wound bed; cleanse the periwound skin.
Do not use antimicrobial solutions.
Choice of
Dressing:
Choose a
dressing that
can be left insitu
as long as
possible to
avoid disruption
of the migrating
epithelium.
If the wound depth is <1-2 mm with minimal exudate consider:
o Transparent Film Membranes [1+] (some exudate will evaporate-can be used over alginate
dressings)
o Hydrogel only if very dry (use under other dressings)
o Absorbent Clear Acrylic Dressing [2+] q 7-14 days or more (Retains moisture and growth factors,
decreased need for frequent dressing changes)
o Thin hydrocolloid [1+] q 5-7 days (Retains moisture and growth factors)
o Non-adherent foam border dressing [2+]
21 South West CCAC Wound Management Program Revised July 2012
Wound Assessment Type of
Intervention
Treatment Choices
3. Clean Granulating
Wound decreasing
in size 20-30% in 3-4
weeks*
Goal: Provide
environment
conducive to wound
healing without
trauma
Cleansing: DO NOT irrigate with pressure higher than 7 PSI - pour room or body temperature solution over the
wound bed; cleanse the periwound skin.
Do not use antimicrobial solutions.
Primary
Dressing:
o Hydrofibres and alginates [1+ to 2+] - form a gel-like mass on the wound surface (require
secondary dressing)
o NPWT [2+ to 4+]
Secondary
(Cover)
Dressing:
o Composite dressings [2+ to 3+] (can be primary or secondary)
o Foams border dressings [2+ to 3+] (can be primary or secondary) (Not appropriate for daily
dressing changes)
o Hydrocolloids [1+ to 2+] (can be primary or secondary)
o Ultra-absorbent dressings [3+ to 4+]
4. Clean Granulating
Wound NOT
decreasing in size
20-30% in 3-4
weeks*
*Granulating
wounds not
decreasing in size
may have a
localized infection
or chronic
inflammation
Goal: Treat chronic
inflammation to
reduce MMPs and
promote healing,
resolve biofilm or
local infection
preventing healing
Cleansing: Irrigate with 7-15 PSI using at least 150 ccs of solution or a smaller amount of a commercial spray
wound cleanser with surfactants at room or body temp.
Cleanse and protect the periwound skin. Primary
Dressing:
Antimicrobial dressings with ‘pro-inflammatory’ actions to “kick-start” acute inflammation:
o Cadexomer iodine ung. [1+]
o Povidone iodine [0],
o Manuka Honey [all <1+ to 2+] (all require secondary dressing)
Chronic inflammation:
o Calcium Alginates [2+] (contribute to the initial inflammatory response required to start
healing),
o Protease Inhibitor dressings [<1+] (remove or reduce chronic inflammatory cells from wound
surface and provide growth factors)
Secondary
(Cover)
Dressing:
Do NOT use
occlusive
dressings if
infection is
suspected
o Composite dressings [2+ to 3+]
o Foams border dressings [2+ to 3+] (Not appropriate for daily dressing changes)
o Hydrocolloid dressings [1+ to 2+]—but not if on a plantar foot surface
o Ultra-absorbent dressings [3+ to 4+]
22 South West CCAC Wound Management Program Revised July 2012
Wound Assessment Type of
Intervention
Treatment Choices
5. Necrotic healable
wound
(debridement is
appropriate)
Goal: debridement
of necrotic tissue,
prevent infection,
and support healing.
Cleansing: Irrigate with 7-15 PSI using at least 150 ccs of solution or a smaller amount of a commercial spray
wound cleanser at room or body temperature. Cleanse and protect the periwound skin. Foul odour
indicates aneorobes (see # 6)
Primary
Dressing:
If slough:
o Hydrocolloid [1+ to 2+] (Promotes autolytic debridement and granulation- does not require a
secondary dressing, but hydrofiber [2+] can be used under it)
o Hydrogels [1=] (Add moisture to support autolytic debridement with correct secondary
dressing)
o Hypertonic Gauze [1+] (Supports autolytic debridement- there may be an increase in the
amount of drainage and the size of the wound during initial treatment) o NPWT (Supports autolytic debridement but wounds should be reasonably debrided prior to
starting (check organizational policy & procedure for % of necrotic tissue allowed)
If eschar: Have ET or WCS nurse cross-hatch hard eschar before applying hypertonic gel [0] and cover
with woven gauze dressing (not non-woven gauze or absorbent pads)
Secondary
(Cover)
Dressing:
o Composite dressings [2+] with water-proof or occlusive outer layer (Support autolytic
debridement)
o Foams [2+ ]with transparent film or waterproof outer layer (Support autolytic debridement)
6. Necrotic non-
healable wound
where debridement
is NOT appropriate
Goal: stabilize and dry
necrotic tissue to allow
gradual auto-
amputation or
epithlialization under
the eschar, without
extension or infection.
Cleansing: If there is exudate, cleanse the periwound skin. Pat dry. The intent is to allow the necrotic tissue to
dessicate and remain stable; a topical application of povidone-iodine solution (not detergent scrub) or
Chlorhexidine is appropriate.
Primary
Dressing:
Warning- “Application of moisture retentive dressings in the context of ischemia and or dry
gangrene can result in a serious life- or limb-threatening infection”.
If a non-stick surface is not required, simply saturate a gauze with either povidone-iodine or chlorhexidine and place it to cover the necrotic tissue and the wound edges. As the necrotic tissue dries and dessicates over time, there will be less absorption of the antiseptic solution. If a non-stick dressing is needed, povidone-iodine non-adherent dresssing can be used. Or, leave open to air after ‘painting’ with antiseptic, or cover with a loose non-woven gauze that will
not be occlusive or adhere to the necrotic tissue. Secondary
(Cover)
Dressing:
Use inexpensive gauze, or if exudate is large, choose an Ultra-absorbent dressing [3+ to 4+]
23 South West CCAC Wound Management Program Revised July 2012
Wound Assessment Type of
Intervention
Treatment Choices
7. Malignant
Goal: Decrease
odour and bleeding,
maintain dignity
Cleansing: Foul odour indicates presence of aneorobes- use antimicrobial solution, &/or topical Metronidazole
vaginal cream or gel. Painful or friable tumor tissue may not tolerate irrigation with 7-15 PSI or hand-
held shower. Warm the solution to body temperature to decrease discomfort, may have to use pour
or compress method of cleansing until pain is controlled.
Primary
Dressing:
o Topical Metronidazole vaginal cream or gel for anerobic odour
o Non-Adherent (soft silicone wound contact layer, Petrolatum, non-adherent mesh, Mylar
perforated polyester film) [0] to reduce pain and avoid trauma causing bleeding (will require
secondary dressing)
o Charcoal dressings [1+ to 2+] to adsorb odour (some can be used as the primary dressing while
others are layered on top of primary dressing –all require a cover dressing)
o Calcium alginate [2+] for friable, bleeding wounds
Secondary
(Cover)
Dressing:
o Composite dressings [2+ to 3+]
o Foams border dressings [2+ to 3+] (Not appropriate for daily dressing changes)
o Ultra-absorbent dressings [3+ to 4+]
8. Wound with debris
or contamination/
Superficial & Partial
thickness burns
Goal: Effective
cleansing and
debridement of
debris or
contamination/
healing of superficial
& partial thickness
burns with minimal
discomfort and
prevent infection.
Cleansing: Irrigate with 7-15 PSI using at least 150 ccs of solution or a smaller amount of a commercial spray
wound cleanser at room or body temperature. Cleanse and protect the periwound skin. May cleanse
small burns with lukewarm tap water and mild soap
Primary
Dressing:
Choose a
dressing that
manages
exudate and
protects peri-
wound skin
Wounds with Debris:
o Hydrocolloid [1+ to 2+] (Promotes autolytic debridement and granulation- does not require a
secondary dressing)
o Hydrofibers [2+] (promote autolytic debridement and bacteria adhere and are trapped by
fibers]
o Hydrogels [1=] (Add moisture to support autolytic debridement with correct secondary
dressing)
o Hypertonic Gauze [1+] (Supports autolytic debridement- there may be an increase in the
amount of drainage and the size of the wound during initial treatment) Superficial & Partial Thickness Burns: Choose a primary antimicrobial dressing if desired for
prophylaxis, cover with moisture retentive secondary – unless using HydrofiberAg superficial/partial
thickness burn protocol (www.woundcare.thehealthline.ca SWRWCF Toolkit Section F.8.4)
Secondary
(Cover)
Dressing:
o Composite dressings [2+ to 3+]
o Foams dressings [2+ to 3+] (Not appropriate for daily dressing changes)
o Ultra-absorbent dressings [3+ to 4+]
24 South West CCAC Wound Management Program Revised July 2012
Wound Assessment Type of
Intervention
Treatment Choices
9. Tunneling or
Undermined
Wound
Goal: Gradual
contraction of
tunnel or
undermining and
growth of healthy
granulation tissue
from base until dead
space is gone and
epithelialization can
occur.
Cleansing: Irrigate using a 5Fr catheter or “soft-cath” with a 30-35 cc. syringe and 150 to 500 cc. solution at room
or body temperature. Irrigate until returns are clear. Gently palpate over undermined or tunneled
areas to express any irrigation solution that is retained.
Do not force irrigation when resistance is detected. Consult physician if sharp debridement needed.
Primary
Dressing:
General Principles:Both have the potential for infection and abscess formation.
Wound packing must be firm enough to prevent premature bridging of granulation tissue in the base,
causing pockets and future abscesses, yet:
o allow the wound to contract and heal from the base and
o serve as a conduit or wick to allow the exudate to drain.
Avoid packing tightly at the opening, as this can plug the exit leading to increased pressure within the
cavity as the exudate volume increases, causing painful extension of the cavity (Birchall & Taylor
2003).
Fill dead space” with filler dressings such as :
o Hypertonic Gauze [1+] (Helps to reduce edema and exudate)
o Hydrofibres and Calcium alginates [2+] (Form a gel-like mass on the wound surface in
combination with exudate but must retain integrity so that they can be removed in one piece -
Lee et al. 2009 recommend that you not use hydrofibers in tunnels where you cannot see the
bottom)
• NPWT [4+] –does not require a secondary dressing
If biolfilm or localized infection is suspected or present:
o AMD ribbon packing [<1+] or kerlix [1+]
o Gauze ribbon packing [<1+] buttered with Cadeomer iodine
o Hypertonic Gauze [1+] (Helps to reduce edema and exudate)
o Hydrofiber/aginate Ag [2+] (Form a gel-like mass on the wound surface in combination with
exudate but must retain integrity so that they can be removed in one piece - Lee et al. 2009
recommend that you not use hydrofibers in tunnels where you cannot see the bottom)
o Nanocrystalline AG [1+]
Secondary
(Cover)
Dressing:
o Composite dressings [2+ to 3+]
o Foam dressings [2+ to 3+] (Not appropriate for daily dressing changes)
o Ultra-absorbent dressings [3+ to 4+]
25 South West CCAC Wound Management Program Revised July 2012
Wound Assessment Type of
Intervention
Treatment Choices
10. Localized &
Spreading Infection
Goal: Resolve infections
and prevent recurrence.
(this information also
appears in the
SWRWCF Toolkit
Section E.3 Wound
Infection Treatment)
Cleansing: Two-week challenge: May use a 10 – 14 day cleansing regime with an antimicrobial solution
(prolonged use of antiseptics is NOT recommended but may be appropriate for maintenance
wounds). Irrigate with 7-15 PSI using at least 150 ccs of solution or a smaller amount of a commercial
spray wound cleanser at room or body temperature. **NB- do not use Chlorhexidine near
the ear due to the danger of hearing loss if the product enters the ear canal****
Cleanse and protect the periwound skin.
May need to increase dressing frequency until S&S of infection decrease.
Primary
Dressing:
Localized infection: use topical antimicrobial dressings:
o Povidone Iodine mesh [0] dressings not for highly exudative wounds)
o AMD antimicrobial - packing strips [<1+], kerlix roll [ 1+]
o Hydrofiber Ag [2+] (may need to be pre-moistened)
o Nancystalline Ag [1+]
o Ag Hydrofiber-Alginate [2+]
o Cadexomer iodine ung. [1+] care to be taken on bone or tendon which may be at risk of
dehydration with lower exudate levelsviii)
o AMD antimicrobial transfer foam [1+] (may require a non-adherent contact layer)
Spreading infection: will need systemic antibiotics in addition to thorough wound cleansing and
antimicrobial dressings as above Secondary
(Cover)
Dressing:
Prevent strike-through of secondary dressings (where exudate soaks through or leaks from sides,
creating a pathway for bacteria)
Do not use occlusive dressings in presence of or suspected anerobic infections.
o Composite dressings [2+ to 3+]
o Foam dressings [2+ to 3+] (Not appropriate for daily dressing changes). Use with caution on
plantar foot dressings where increased exudate may cause maceration and extension of
wound.
o Ultra-absorbent dressings [3+ to 4+]
26 South West CCAC Wound Management Program Revised July 2012
Wound Assessment Type of
Intervention
Treatment Choices
11. Maintenance Wd.
Goal: To prevent
infection and
extension if
possible, and assess
readiness to adapt
lifestyle choices to
allow healing.
Cleansing: Cleansing will be dependent on characteristics of wound bed. Low-toxicity antiseptic cleansers are
generally used ongoing.
Primary
Dressing:
Advanced wound products that promote moist wound healing are more expensive than gauze or
cotton-based products, but usually require less frequent dressing changes.
Choose dressings as per characteristics of wound..eg. if tunnels or undermining, refer to that section.
Secondary
(Cover) Drsg:
o Abdominal pads [2+]
o Ultra-absorbent dressings [3+ to 4+] 12. Painful Wounds
Goal: Assess and
manage pain WITH
dressing change,
pain AFTER dressing
change and pain
BETWEEN dressing
changes. See
SWRWCF Toolkit
Section B.5.1-5 for
resources
Cleansing: Painful tissue may not tolerate irrigation with 7-15 PSI or hand-held shower. Warm the solution to
body temperature to decrease discomfort, may have to use pour or compress method of cleansing
until pain is controlled. Primary
Dressing:
Protect painful wounds from trauma at dressing removal:
o Clear Acrylic dressing [2+]
o Foam with silicone contact layer [2+]
o Hydrocolloid [1-2+] May need to add absorbent layer (hydrofiber or alginate) –does not
require secondary dressing
o Non-Adherent (soft silicone wound contact layer, Petrolatum, non-adherent mesh, Mylar
perforated polyester film) [0]
Pain Control Dressing:
o IBU foam [2+] Releases ibuprofen in the presence of exudate for shallow wounds not
extending into the subcutaneous tissue
Topical Analgesia:
o Morphine can be prescribed mixed with Intrasite gel to use topically for extremely painful
palliative wounds (e.g.malignant wounds), evidently without risk of systemic absorption. A
treatment guideline can be found at http://www.elht.nhs.uk/pdf/10.pdf
o Topical lidocaine preparations can also be used in painful wounds at dressing change, or
injected into the tubing going to the dressing of topical negative pressure wound therapy prior
to the dressing change. Systemic absorption is high when applied to wound surfaces, and
should only ever be used under physician or nurse practitioner orders
Secondary
(Cover)
Dressing:
o Composite dressings [2+ to 3+]
o Foam dressings [2+ to 3+] (Not appropriate for daily dressing changes)
o Hydrocolloiod [1-2+]
o Ultra-absorbent dressings [3+ to 4+]
27 South West CCAC Wound Management Program Revised July 2012
Ca
se M
an
ag
er
ET
N/W
CS
AC
TIO
NS
NU
RS
ING
AC
TIO
NS
28 South West CCAC Wound Management Program Revised July 2012
Information about Ostomies Item Treat the Cause and Resources
People living with new ostomies have many needs related to:
• altered method of elimination,
• a change in body image,
• psychosocial and physical needs,
• knowledge of dietary restrictions and concerns,
• self-care deficit around managing the new Ostomy—products,
skin care, what is normal, what is not
• acceptance by: self, loved ones and others
• confidence in ability to manage self-care or be cared for
• trust that activities of daily living can be resumed, and that a
good quality of life is possible.
In addition, many are either recovering from a debilitating disease
(e.g. Crohn’s or Ulcerative Colitis) or are facing chemotherapy and
radiation for a diagnosis of cancer.
The RNAO Clinical Best Practice Guidelines for Ostomy Care and
Management reviews the existing body of evidence around care.
The 3 major ostomy product manufacturers now have continuum of
care programs available - Hollister Secure Start, Coloplast and
Convatec- Life Embrace. Clients are under no obligation to stay with
the company providing samples once sample period is up. This is
simply a way for them to experience different products related to their
pouching needs, and to offer support once the CCAC has discharged
the client.
Ontario ADP (Assistive Devices Program) Grant
If the ostomy is permanent, or the client will have a temporary ostomy
for longer than 6 months, they are entitled to receive the Ontario
Government grant of $600.00 / 12 months.
If the client is receiving social assistance benefits under Ontario Works,
Ontario Disability Support Program, or Assistance to Children with
Severe Disabilities, or are a resident in a Long Term Care Facility, they
may be able to receive $800.00 per ostomy.
SWCCAC
Documents
that must be
used
• SWCCAC Care Plan with time-specific goals
• ‘My Ileostomy/ My Colostomy/ My Urostomy -
teaching booklet to review with clients
• ‘My Ostomy Care’- self-care teaching guide
• SWCCAC Ostomy Discharge Instructions (individualize
these to your geographic area for vendors)
SWRWCF
Toolkit
Section G-
Ostomy
www.woundcare.thehealthline.ca
G.1 Algorithm (to be developed)
G.2 SW CCAC Ostromy Toolkit - Care Plan
G.3 Peristomal Skin Assessment Tool (Coloplast) (to be
posted by June 30)
G.4 Self-Care Teaching Tool
G.5 Ostomy Teaching Handouts
5.1 Types of Ostomy
5.1a My Ileostomy
5.1b My Colostomy
5.1c My Urostomy
5.2 SWCCAC Ostomy Discharge Instructions
5.3 Acute Care Ostomy Discharge Summary (to be posted
by June 30)
G.6 Enterocutaneous Fistula (to be developed)
G.7 Resources:
G.7a RNAO Clinical Best Practice Guidelines Ostomy Care
and Management (link)
G.7b CAET Best Practice Guidelines Enterocutaneous
Fistula (link)
G.7c Helpful Hints in Caring for Ostomies (to be
completed)