Date ………………. Care Home/nurse name: ………….......……Patient Details: Contact Tel No. ………………………………………… Pt Name: D.O.B. : NHS No.

Address

GP Name Wound Type:

No. of wounds being treated : Frequency of Dressing Change:

DO NOT order more than 2 WEEKS SUPPLY.

The dressings below are not the full list found on the local formulary. This can be found at http://www.harrogateformulary.nhs.uk/chaptersSub.asp?FormularySectionID=26, other formulary dressing can be requested at the

end of the form. Restricted (red) or non formulary dressings can only be ordered if a clear reason is stated.

DressingsType of dressing Product Size No of

individual

dressings

required

Comments

Dressing packs

Nurse ItSmall/Medium

Nurse It contains 1 pair of powder free, latex free nitrile

gloves,1 large apron, 1 Disposable bag/2 sterile fields, paper

towel, paper measuring tape, seven non-woven swabs,

disposable forceps, disposable bagMedium/Large

Primary Wound

Contact LayerAtrauman

5cm x 5cm Primary wound contact layer. Non-adherent polyester mesh,

1mm pore size and impregnation of neutral triglycerides,

prevents penetration of granulation tissue into dressing.

Petrolatum free, effective up to 7 days

7.5cm x 10cm

10cm x 20cm

20cm x 30cm

ActivHeal Silicone Wound Contact Layer

5cmx7.5cm To be used where adherence of products to a wound is likely A

sterile wound dressing consisting of a knitted polyester fabric

coated with silicone adhesive on both sides

Only to be used if being left in place for 7 days

10cmx10cm

10cmx20cm

15cmx15cm

Absorbent Dressings

Xupad

10cm x 12cm For moderate to highly exuding wounds. May be used as

primary or secondary dressing.10cm x 20cm

20cm x 20cm

20cm x 40cm

Adhesive tape Chemipore 2.5cm x 5mPermeable non-woven synthetic tape

Tubular Stockinette

Comfifast Blue line

7.5cm x 1m Tubular bandage for retention purposes.

7.5cm x 3m

7.5cm x 5m

Comfifast Yellow line10.75cm x 1m Tubular bandage for retention purposes.

10.75cm x 3m

Absorbent Perforated Dressing

365 Non-woven Dressing

6cm x 8cm Low absorption capacity and only suitable for lightly exuding

superficial wounds.

Low adherence dressings with adhesive border.

10cmx10cm

10cm x 15cm

10cm x 20cm

10cm x 25cm

Film Dressing

365 Film

4cm x 5cm Film dressings to be used only as a primary dressing on lightly

exuding wounds.6cm x 7cm

10cm x 12cm

10cm x 15cm

15cm x 20cm

Dressings

1 | P a g e

Alginate/Hydrofibre

ActivHeal Alginate

5cm x 5cm Shallow/Sloughy wounds. Highly absorbent. Forms a gel on

contact with wound exudate. A secondary dressing is required.10cmx10cm

10cm x 20cm

Aquacel1cm x 45cm

Soft, sterile ribbon dressing composed of Hydrofiber (sodium

carboxymethylcellulose). For medium to high exuding wounds.

Should be covered with an appropriate secondary dressing.2 x 45cm

Hydrocolloids

Comfeel Plus Ulcer

4cm x 6cm For low exuding wounds.Absorbent hydrocolloid dressing with

added alginate for absorption.10cm x 10cm

15cm x 15cm

Comfeel Plus Transparent

5cm x 7cm For no or low exudate

Useful for traumatic wounds, superficial burns, skin abrasions

or removal of foreign bodies

10cm x 10cm

15cm x 15cm

HydrogelAquaform

8g For low exuding / dry “flat” wounds.

15g

Foam AdhesiveActivHeal Silicone Foam Adhesive

7.5cm x 7.5cm Foam dressing with gentle silicone adhesive border

For low to moderately exuding wounds10cm x 10cm

12.5cm x 12.5cm

Biatain Silicone

7.5cm x 7.5cm These dressings may be kept in place for up to 7 days.

For patients with sensitive and/or fragile skin.10cm x 10cm

10cm x 10cm

12.5cm x 12.5cm

15cmx15cm

17.5cm x 17.5cm

Biatain Silicone Lite

5cm x 5cm Choose dressing type appropriate to level of exudate &

position of wound.7.5cm x 7.5cm

10cm x 10cm

12.5cm x 12,5cm

Non-Adhesive Foam

Advazorb

5cm x 5cm Can be used as primary or secondary dressings depending on

wound type, site, size, depth, tissue type, exudate levels.7.5cm x 7.5cm

10cm x 10cm

10cm x 20cm

12.5cm x 12.5cm

15cm x 15cm

20cm x 20cm

Antimicrobial

Povitulle

5cm x 5cm The term ‘antimicrobial’ refers to disinfectants, antiseptics and

antibiotics. Antimicrobial dressings should be used on locally infected wounds or wounds with spreading infection. Antimicrobial use should be reviewed after 2 weeks.

9.5cm x 9.5cm

Bandages

For venous leg

ulceration with a

Doppler reading

>0.8mmHg and a

holistic assessment,

which excludes the

presence of arterial

disease, multi-layer

compression – (4 layer

system - 40mmHg) is

the gold standard (or

40mmHg treatment

hosiery)

K-Soft(padding)

10cm x 3.5m For absorption of any excess exudate, comfort for patient and

increase conformability of limb for application of outer

bandage. Also used in application of compression bandage to

protect & shape leg.10cm x 4.5cm (long)

K-Lite(retentive non-

compression bandage)

10cm x4.5m For retention of dressings

10cm x 5.25cm

(long)

K-Plus(type 3a compression

bandage)

10cm x 8.7cm Multi-layer compression bandaging regime for ankle size 18-

25cm:

K-Soft, K Lite, K-Plus, Ko-Flex10cm x 10.25m

(long)

Ko-Flex (type 3c compression bandage)

10cm x 6m

10cm x 7m (long)

Date ………………. Care Home/nurse name: ………………

2 | P a g e

Patient Details Contact Tel No. ……… Name D.O.B. : NHS No.

Address

GP Name Wound Type:

No. of wounds being treated : Frequency of Dressing Change:

DO NOT order more than 2 WEEKS SUPPLY.

The dressings below are not the full list found on the local formulary. This can be found at http://www.harrogateformulary.nhs.uk/chaptersSub.asp?FormularySectionID=26, other formulary dressing can be requested at the

end of the form. Restricted (red) or non formulary dressings can only be ordered if a clear reason is stated.

DressingsType of dressing Product Size No of

individual

dressings

required

Comments

Bandages (continued)

Urgo KTwo

Ankle size up to

18cm (short)

2 layer compression bandage system.

For venous leg ulcerations with a Dopler reading >0.8mmHg.

Ankle 18-25cm

Ankle 25-32cm

Urgo KTwo Reduced

Ankle 18 – 25cm Reduced compression bandage kit. Some patients may present with alternative bandaging regimes.

Please continue with treatment as advised and contact consultant/ specialist for further information as appropriate

Ankle 25 – 30cm

Actico cohesive(compression)

10cm x 6m

Short stretch compression bandage for venous leg ulceration, oedema and lymphoedema

Actico Cohesive is applied at full stretch with a 50% overlap

over padding layer (e.g. K-Soft)

Compression Hosiery Kits

Activa leg ulcer hosiery kit

S An alternative first line treatment for venous leg ulceration, with

a Doppler reading >0.8mmHg and a holistic assessment,

which excludes the presence of arterial disease

Delivers 40mmHg

Treatment hosiery kits contain 2 liners and 1 medical stocking

Packs of replacement liners are available

M

L

XL

XXL

Actilymph hosiery kit

S European standard hosiery

For treatment of venous leg ulcers with oedema, , with a

Doppler reading >0.8mmHg and a holistic assessment, which

excludes the presence of arterial disease

M

L

XL

XXL

Formulary requests not listed above Restricted (red) or Non Formulary requests (reason must be stated or the product cannot be supplied

Product name Product size Quantity Product name Product size Quantity

Further forms can be found at : http://www.harrogateandruraldistrictccg.nhs.uk/formulary/

3 | P a g e