South West CCAC Wound Management Program (WMP) - July … · 5 South West CCAC Wound Management Program Revised July 2012 Tubigrip/ Tubifast Information and Measuring Guide Tubigrip

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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3 South West CCAC Wound Management Program Revised July 2012

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


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.


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


Size – CCAC + [Mölnlycke]

codes

HIGH - 20-30 mm Hg


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


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


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.


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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


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.1.3 University of Texas Wound Classification System of

Diabetic Foot Ulcers


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.



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.3.3 NPUAP Staging System for Pressure Ulcers (Updated 2007)


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


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


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


SURGICAL WOUND (CLOSED AND OPEN)

F.5.1 Background and Extent of Etiology; Instructions

for use of tools.

F.5.2 Algorithm


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.


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.


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.



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.



“Moderate Category 2 skin tear”- more than 25% is lost. Photograph courtesy of Kim LeBlanc, Dawn Christensen and Wound Care Canada.


Category 3 – Skin tears with complete tissue loss (absent epidermal flap)


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)


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


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


may be appropriate

for EST based on

Decision Tree


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)


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.


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+]



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




Intervention

Treatment Choices

5. Necrotic healable

wound

(debridement is

appropriate)

Goal: debridement

of necrotic tissue,

prevent infection,

and support healing.


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+]



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 Foams border dressings [2+ to 3+] (Not appropriate for daily dressing changes)


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.


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 Foams dressings [2+ to 3+] (Not appropriate for daily dressing changes)




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 Foam dressings [2+ to 3+] (Not appropriate for daily dressing changes)




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 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.




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 Foam dressings [2+ to 3+] (Not appropriate for daily dressing changes)

o Hydrocolloiod [1-2+]



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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


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)