University Health Network Policy & Procedure Manual

University Health Network Policy & Procedure Manual Clinical Manual Skin & Wound Assessment & Management This policy is under review and revision. Some of the procedures may not reflect current practice at UHN. Please use your discretion when following this policy or seek advice from Pamela Savage, CNS, PMH, at 16-6007. Policy Patients admitted to the hospital will undergo an initial skin assessment by nursing staff within 24 hours of admission, on a weekly basis, and upon deterioration in condition. The Braden Pressure Ulcer Risk Assessment (form 3245) must be completed and documented on each patient by the nursing staff within 24 hours of admission. (See also Braden Scale for Predicting Pressure Sore Risk (Table 1).) Nursing staff must repeat the Braden Scale on all patients daily. See Assessment and Management of Contributing Factors for Pressure Ulcers (Table 4). Note: The Braden Scale is being systematically introduced throughout UHN as of January 2003. Not all nursing units will be documenting the Braden Scale at the time of this policy posting. All authorized Registered Nurses at UHN can initiate topical treatment to all patients at UHN who have stage 1 or 2 skin breakdown due to pressure, friction, shear or moisture or are at risk for developing skin breakdown related to moisture, shear, friction and pressure as per Medical Directive MDGEN005 Initiation of Topical Treatments to Superficial Skin Breakdown. The members of the Nursing Clinical Leadership Team in Skin and Wound Care can initiate topical treatment and diagnostic tests as per Medical Directive MDGEN006 Initiation of Topical Treatments & Diagnostic Tests for Pressure Ulcers & Other Chronic Wounds. Nursing staff will employ preventative measures within practice guidelines to successfully manage skin integrity of those patients at risk. In collaboration with the multi-disciplinary team, nursing staff will manage the identified causative and contributing factors of pressure, shear, friction, moisture, trauma, immobility, malnutrition, dehydration, sensory deficit, moisture/incontinence, disease processes, cachexia/obesity, lymphodema, medications, previous ulcers and appropriate local wound care. See Guidelines for Topical Treatment of Pressure Ulcers (Table 3). Page 1 of 15

Procedure Assessment 1. Complete all data elements of the skin assessment as outlined on the electronic chart. 2. Complete the Braden Pressure Ulcer Risk Assessment (form 3245). (See Braden Scale for Predicting Pressure Sore Risk (Table I). Apply the interventions based on Braden's categories (sensory perception, mobility, activity, moisture, nutrition, friction and shear), rather than a total score. If a patient scores less than 4 in any of the categories refer to Assessment & Management of Contributing Factors for Pressure Ulcers (Table 4). 3. Identify cause and contributing factors such as friction, shear, pressure, malnutrition, dehydration, trauma, immobility, medications, disease, and moisture/incontinence. 4. If wound present, assess after cleansing for: location size (length x width and depth in centimetres) colour of wound bed (red, yellow black) undermining/sinus tracts amount/type colour of drainage/exudate (serous, sero-sanguinous, sanguinous, green, purulent) odour tissue bleeding, wound edges (maceration, rolled) condition of surrounding skin (induration, redness, temperature, edema) duration of wound pain 5. Notify the physician if the patient is exhibiting signs and symptoms of infection. Note: Routine culturing is avoided unless the patient displays a change in clinical symptoms indicating local/systemic infection, e.g., elevated temperature, elevated WBC or delayed healing. If the patient has more than one wound with the same etiology, only one swab is necessary. See Wound Swab policy # 3.140.001. Page 2 of 15

Sensory Perception Ability to respond meaningfully to pressurerelated discomfort Moisture Degree to which skin is exposed to moisture Table 1 Braden Scale for Predicting Pressure Sore Risk 1. Completely Limited Unresponsive (does not moan, flinch or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR limited ability to feel pain over most of body surface. 1. Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. 2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR has a sensory impairment, which limits the ability to feel pain or discomfort over 1/2 of body. 2. Very Moist Skin is often, but not always, moist. Linen must be changed at least once a shift. Activity 1. Bedfast 2. Chairfast Degree of physical activity Mobility Ability to change and control body position Confined to bed. 1. Completely Immobile Does not make even slight changes in body or extremity position without assistance. Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 2. Very Limited Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 3. Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or need to be turned. OR has some sensory impairment, which limits ability to feel pain or discomfort in 1 or 2 extremities. 3. Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day. 3. Walks Occasionally Walks occasionally during day, but for very short distances with or without assistance. Spends majority of each shift in bed or chair. 3. Slightly Limited Makes frequent though slight changes in body or extremity position independently. 4. No Impairment Responds to verbal commands. Has no sensory deficit, which would limit ability to feel or voice pain or discomfort. 4. Rarely Moist Skin is usually dry. Linen requires changing only at routine intervals. 4. Walks Frequently Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours. 4. No Limitations Makes major and frequent changes in position without assistance. Indicate Appropriate Numbers Below Page 3 of 15

Nutrition Usual food intake pattern Friction and Shear Table 1 Braden Scale for Predicting Pressure Sore Risk 1. Very Poor Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement. OR is NPO and/or maintained on clear liquids or IVs for more than 5 days. 1. Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation lead to almost constant friction. 2. Probably Inadequate Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding. 2. Potential Problem Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair restraints, or other devices. Maintains relatively good position in chair or bed most of the time, but occasionally slides down. 3. Adequate 4. Excellent Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered. OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs. 3. No Apparent Problem Moves independently in bed and in chair and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. Total Score: Note: Bed and chair bound individuals or those with impaired ability to reposition should be assessed upon admission for their risk of developing pressure ulcers. Patients with established pressure ulcers should be reassessed periodically. Patients with a total score of 16 or less are considered at risk of developing pressure ulcers. (15 or 16 = low risk; 13 or 14 = moderate risk; 12 or less = high risk) Barbara Braden and Nancy Bergstrom, 1988 Page 4 of 15

Table 2 Staging Pressure Ulcer National Pressure Ulcer Advisory Panel (NPUAP) Revised 1998 Stage 1 Stage 2 Stage 3 Stage 4 Unstageable Stage 1 pressure ulcers exhibit observable pressure-related alteration of intact skin with indicators that, compared to the adjacent or opposite area on the body, may include changes in one or more of the following skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). Stage 2 pressure ulcers present with partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage 3 pressure ulcers exhibit full-thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage 4 pressure ulcers present with full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage 4 pressure ulcers. Ulcers that present with eschar or any necrotic tissue cannot be staged until the devitalized tissue is removed. Taken Directly from Dot Weir Pressure Ulcers: Assessment, Classification, and Management in Chronic Wound Care: A Clinical Source Book for Healthcare Professionals third Edition, 2001 Co Edited by Krasner, G. Rodeheaver and G. Sibbald, Pages 619 627. Page 5 of 15

Table 3 Guidelines for Topical Treatment of Pressure Ulcers Note: Consult the Wound Care Team for Stage 3, 4, and unstageable pressure ulcers, diabetic ulcers, and vascular ulcers. This is not an all-inclusive list but rather guidelines to assist the multidisciplinary team. Colour Clinical Presentation Treatment Objectives Topical Treatment Interventions Comments Red Due to moisture (e.g., incontinence, diaphoresis) Non-pressure related Redness and /or maceration/ denuding over areas not necessarily subjected to pressure (e.g., skin folds, groins, under breasts) Protect skin from moisture. Control/contain moisture Skin barrier (e.g., Proshield or Cavilon ) Transparent dressing (e.g., Tegaderm ) with Cavilon wipe, spray or cream Hydrocolloid (e.g., Tegasorb thin) with Cavilon wipe, spray or cream If yeast present, Proshield barrier cream is the barrier cream of choice with any anti-fungal topical cream or ointment Red Stage 1 Intact skin Usually over bony prominence Soft tissue with induration and warmth Non-blanching erythemea x 30 minutes Relieve pressure and shearing Protect skin from friction and further damage Skin barrier (e.g., Proshield or Cavilon ) Transparent dressing (e.g., Tegaderm ) with Cavilon wipe, spray or cream Hydrocolloid (e.g., Tegasorb thin) with Cavilon wipe, spray or cream Red Stage 2 Superficial appearance, clean state, presence of pale pink to beefy red granulating bed or pink epithelial tissue Presence of partial thickness skin loss Small amount of serous or serosanguinous exudate Protect granulation tissue Maintain clean wound Keep wound moist Heal wound Cleanse/irrigate with N/S +/- Hydrogel (e.g., Tegagel, Normlgel ) Cover with a hydrocolloid (e.g., Tegasorb ) or a transparent dressing (e.g., Tegaderm ) Page 6 of 15

Table 3 Guidelines For Topical Treatment of Pressure Ulcers Colour Clinical Presentation Treatment Objectives Topical Treatment Interventions Comments Red Stage 3 & 4 Deep clean state with presence of a palepink to beefy red granulating bed or pink epithelial tissue at edges Presence of full thickness loss of skin and extends to subcutaneous tissue Small amount of serous or serosanguinous exudate Protect granulation tissue Maintain clean wound Keep wound moist Heal wound Protect from Infection Cleanse/irrigate with N/S Hydrogel (e.g., Tegagel, Normlgel ) with absorbent dressing to cover (e.g., Alldress ) or Ca-alginate (e.g., Tegagen ) with foam to cover (e.g., Mepilex ) Yellow Yellow/Red Stage 2, 3, 4 or unstageable Yellow Wound bed covered by string-like necrotic debris, often yellow, green or grey in colour (slough) Yellow/Red Granulation tissue may also be visible Moderate or large amount of serous or sero-purulent exudate Either may have: Little or no exudate Odour Clinical signs of infection Consult with Wound Care Team for Stage 3, 4, or unstageable Debride and cleanse to remove exudate and necrotic fragments and reduce odour Manage exudate Protect surrounding skin Cleanse/irrigate N/S then either Hydrate or manage moisture: Hydrate, (i.e., Normlgel, Tegagel ) Manage exudate, (e.g., Mesalt, foams, caalginate) Hypertonic saline gel (e.g., Hypergel ) use with caution for unstageable yellow wounds and consult with Wound Care Team For surrounding skin use a skin barrier (e.g., Cavilon, Proshield ) If clinical signs or symptoms of infection notify MD Page 7 of 15

Table 3 Guidelines For Topical Treatment of Pressure Ulcers Colour Clinical Presentation Treatment Objectives Topical Treatment Interventions Comments Black Unstageable Appearance: Wound bed covered partially or completely by thick necrotic leathery black surface (eschar). Possible exudate. Pus, fibrous material may be present at wound edges May have odour Surrounding skin may be erythemetous, tender and firm Consult with Wound Care Team member Debride eschar Reduce odour Exceptions: Dry black leg ulcers of vascular or diabetic etiology Patient factors such as hematological contraindications, end stage disease Cleanse with N/S Apply hydrogel to surface (Normlgel, Tegagel ) or enzymatic agent (Santyl ) or hypertonic saline gel (Hypergel ) If ulcer known vascular or diabetic origin then MD or wound Care Team will advise care Adapted from Vancouver Hospital & Health Science Centre Patient Care Guidelines Revised 12/99 Page 8 of 15

Table 4 Assessment & Management of Contributing Factors for Pressure Ulcers Contributing Factors Assessment Management Strategies Friction and Shear Risks: HOB greater than 30 Restlessness and agitation Requires assistance for repositioning Use a lift sheet (draw sheet) to reposition the patient in bed. Consider overhead trapeze. Minimize layers of linens under the patient. Avoid use of synthetic sheepskins. Maintain the head of bed at the lowest level (ideally less than 30 ) consistent with medical conditions, patient tolerance and other restrictions. Avoid sliding or dragging the patient during transfers. Consider Occupational Therapist consult to assess sitting position and need for positioning techniques and devices. Transparent dressings (e.g., Tegaderm ) or barrier film (e.g., No Sting Barrier Film ) may be applied to bony prominences to help reduce friction. Pressure Risks: Inability to change positions independently Bony prominences Fecal incontinence Tissue edema Disease processes Assess: Bed and chair surfaces Establish a turning schedule for the patient as often as every 2 hours including patients who are using pressure reducing support surfaces. When side lying, avoid positioning the patient directly on the trochanter. Instead, turn the patient off their back at a 30 angle. Position patients without pressure directly on their heels. Consider consulting Occupational Therapy for pressure relief devices/splints. Do not massage bony prominences. Do not use plastic or rubber donut-type devices and sheepskin. Use positioning devices such as pillows or foam wedges to keep bony prominences from direct contact with one another. Promptly remove bedpans. Keep linens free of stray objects and ensure patient is not lying on tubes or drains. Consider Occupational Therapy consult to assess sitting position and need for positioning techniques and pressure relief devices. Limit seating periods if the patient is unable to frequently reposition. When pressure reduction devices are used ensure support surfaces are properly used and maintained Consider use of a pressure relief mattress or chair cushion. Page 9 of 15

Table 4 Assessment & Management of Contributing Factors for Pressure Ulcers Contributing Factors Assessment Management Strategies Trauma Maintain optimal skin conditions Immobility/Sensory Deficits Malnutrition/History of Weight Loss Dehydration Moisture/Incontinence Medications Disease Processes Assess: Ability to: turn transfer to chair ambulate feel pain and discomfort communicate Assess: Ability to feed self Dentition Swallowing Intake Cachexia Edema Assess: Fluid intake and output Skin turgor Mucous membranes Cognition Assess: Urinary and fecal incontinence Excessive perspiration Baseline elimination patterns Assess: Use of high-risk medications, e.g., sedatives, steroids, chemotherapy Assess: Presence of cardiovascular, vascular, endocrine, renal, CNS or malignancy Protect fragile at risk skin by: Bathing patient gently with soft cloths using a ph balanced mild soap. Moisturizing skin with emollient cream to improve or prevent dryness. Minimizing excess moisture on skin. If urinary and or fecal incontinence is present see management strategies for moisture/incontinence. Using only high quality, absorbent under pads next to skin. Avoid plastic backed under pads (e.g., blue pads) that trap moisture and heat. Encourage optimal activity; position change, chair, ambulation. Consider: use of a pressure relief mattress or chair cushion Occupational Therapy consult for seating pressure relief devices Physiotherapy consult for gait aids Refer to management strategies for pressure, friction, shear and trauma. Assist with feeding, as needed, oral hygiene. Refer to: Dietician: plan for nutritional support and supplementation management strategies for pressure, friction, shear, trauma and disease processes Dentist, if needed Maintain a minimum of 1.5 liters per day fluid intake unless contraindicated. Assist with intake as needed. Promote continence. Limit use of plastic against skin. Use nonirritant cleanser and barrier cream (e.g., Proshield ) after each episode of incontinence. Refer to Acute Care Nurse Practitioner in Geriatrics for continence management. Refer to management strategies for trauma and for immobility/sensory deficits. Avoid use of adhesives on skin. Consider consults with appropriate services to assist with management of underlying diseases. Page 10 of 15

Intervention Skin Barriers Hypo allergenic polymeric waterproof solution/water resistant cream with dimethcone Product Names: Proshield 3M Cavilon No Sting Barrier Film 3M Cavilon Durable Barrier Cream Transparent Dressings Consists of a thin film backing with a non-latex, hypoallergenic adhesive; breathable allowing good oxygen and moister vapour exchange; waterproof and impermeable to liquids and bacteria 3M Tegaderm Hydrocolloid Dressing A dressing containing a hydrophilic, absorbent material that provides absorption of wound drainage, supports a moist healing environment and protects the wound from outside contaminants while allowing for extended wear time Product Names: 3M Tegasorb Hydrocollid Dressing 3M Tegasorb Hydrocollid THIN Dressing Table 5 Interventions for Chronic Wounds Indications To prevent skin damage from exposure to urine, feces, body fluids and adhesives To protect the peri-wound area from irritation To prevent maceration To cover or protect wounds, to maintain a moist environment for wound healing, may be used as a secondary dressing over gauze, alginates or hydrogels; as a protective cover over at-risk skin (i.e., Stage 1 pressure ulcers, abrasions, skin tears and blisters, chafed skin or skin continuously exposed to moisture). May be used to maintain a moist wound environment to facilitate autolytic debridement As a protective dressing on at-risk skin and Stage 1 pressure ulcers. For use on wounds including partial and full thickness wounds such as Stage 2 and Stage 3 pressure ulcers; leg ulcers, skin tears, abrasions, first and seconddegree burns and donor sites 3M Tegasorb Hydrocollid THIN Dressing may be used as a protective dressing or on superficial, minimally draining wounds 3M Tegasorb Hydrocollid Dressing may be used on minimal to moderately draining wounds May be used to support autolytic debridement Special Considerations (Including contraindications) Not to be used as the only covering in situations requiring dressing protection from bacterial contamination or penetration such as IV sites, full or partial thickness wounds or infected areas. Although not common, may sting when applied to irritated skin. May be used over topical pharmaceuticals; removal of barrier required before application of topical pharmaceuticals. Not intended: to replace sutures or other primary wound closure methods for exudating wounds or wounds with undermining or sinus tract for application over infected wounds Not to be applied: over rashes related to fungal, viral, or bacterial infections where topical pharmaceuticals are required at regular intervals over diabetic foot ulcers to lower limb ulcers where vascular supply is insufficient for healing Not intended for application over infected wounds. Use on suspected or confirmed infected wounds only after consultation with the wound care team or MD. For example, may reduce wear time or may be used in conjunction with another dressing such as a calcium alginate or a hydrogel. Not intended for use in highly exudating wounds or wounds with undermining or sinus tracts. May remain in place up to 7 days depending on wound drainage and condition. Not to be applied: over rashes related to fungal, viral, or bacterial infections where topical pharmaceuticals are required at regular intervals over diabetic foot ulcers. to lower limb ulcers where vascular supply is insufficient for healing Page 11 of 15

Intervention Hydrogels Hydrogels are normal Saline or water based clear, non-adherent, viscous liquids Product Names: 3M Tegagel Normlgel Alginate Dressings Highly conformable, absorbent non-woven primary dressing that forms a gel when exposed to wound drainage 3M Tegagen available as sheets or rope. Foams A flexible and absorbent polyurethane foam pad with a moisture vapour permeable polyurethane film backing Product Names: Mepilex Mepilex border Silicone Gel Mesh Dressing Promotes the passage of exudate into an absorbent cover dressing while protecting surrounding skin from maceration Mepitel Table 5 Interventions for Chronic Wounds Indications Provides moisture to a dry wound; maintains a moist healing environment and promotes autolytic debridement Can be used as the primary dressing for dry or minimally draining partial and full thickness wounds Can be used to saturate gauze or ribbon packing for pack tunneled or undermined wounds For partial and full thickness wounds with moderate to heavy drainage Can be used: as a primary dressing for pressure ulcers, arterial ulcers, venous ulcers, diabetic ulcers, donor sites, trauma wounds and other dermal lesions to control minor bleeding to maintain a moist environment for wound healing and promoting autolytic debridement if wound is infected but has no bactericidal properties Indicated for use on leg ulcers, pressure ulcers, traumatic wounds, painful wounds, wounds with compromised peri-wound skin May be used as a primary dressing on shallow, exudating wounds and a cover dressing for deeper wounds For the preservation of granulating wound bed with wound cleansing and dressing changes. For dressing that adheres causing pain and requires soaking for removal. For use as a primary dressing. Special Considerations (Including contraindications) Should not be used on moderate to heavily draining wounds. Use in infected wounds should only occur after careful consideration of alternatives. Consider Skin Barrier around peri-wound area to protect skin at wound edges. Must be secured with a cover dressing. Do not use to fill tunneled or sinus tract in wound. Not to be applied: over diabetic foot ulcers to lower limb ulcers where vascular supply is insufficient for healing Must be secured with a cover dressing. Not intended for use in dry wounds, deep cavities or sinuses. Consult with wound care team or MD for wounds other than Stage 1 or Stage 2 pressure ulcers such as for arterial or lower limb ulcers where vascular supply is insufficient for healing. Not indicated for surgical implantation or use on third degree burns. May remain in place for up to 7 days depending on drainage and wound condition. If patient has clinical signs of infection the use of Mepilex may be continued if appropriate treatment is initiated. Not intended for dry wounds. Do not use with hydrogels not intended for pressure reduction relief or padding. Do not use with hydrogels. Leave in place for 5 to 7 days to allow the healing process to continue undisturbed. Change the outer dressing/gauze; wrap daily or as indicated by wound drainage. When used in treatment of bleeding wounds cover with a moist absorbent dressing until bleeding has stopped. May be used with Vacuum Assisted Closure (VAC). Page 12 of 15

Intervention Non Adherent Impregnated Dressings Vaseline impregnated mesh Jelonet Table 5 Interventions for Chronic Wounds Indications May be used to minimize adherence and trauma to granulating tissue May provide some moisture retention For use as a primary dressing Special Considerations (Including contraindications) Not intended for use over sloughed, necrotic wound beds. Do not layer product. Non Adherent Cover Dressing for Adsorption Multi-layer, absorbent, semi-permeable film wicks exudate vertically not laterally Alldress Ultra Absorbent Dressing: Highly absorbent, air permeable, fluid repellent strike-through exudate barrier and low adherent wound contact layer Mesorb Non Adherent, Non Impregnated Dressings To reduce trauma to wound Telfa Sterile Sodium Chloride Impregnated Dressing: Vicose polyester gauze dressing impregnated with 15% crystalline sodium chloride Mesalt As a cover dressing for all phases of wound healing Cover dressing for heavily draining wounds May be used in conjunction with Mepitel Appropriate for minimally draining wounds to minimize adherence and trauma to the wound bed For wounds with moderate to heavy drainage Wounds in the yellow inflammatory phase, including infected wounds Change as indicated by the primary dressing or wound drainage. May be used with hydrogels, alginates, and sodium chloride impregnated dressings. Do not use with hydrogels. Not intended for highly exudating wounds. Increase in the amount of drainage and the size of the wound during initial treatment will occur with Mesalt due to reduction of edema and removal of wound debris. Discontinue when wound drainage has decreased to a point that there is insufficient drainage to saturate the Mesalt dressing in a 24-hour period. Contraindicated for dry wounds and dry eschar fused to all wound margins. Page 13 of 15

Intervention 20% Hypertonic Saline Wound Gel Hypergel Cadexomer Iodine 0.9% concentration of iodine contained in a three dimensional lattice which is slowly released into the wound providing antimicrobial effect Iodosorb Table 5 Interventions for Chronic Wounds Indications Wounds covered with dry necrotic eschar or slough Intended for softening and removal of dry necrotic tissue A topical application for the treatment of chronic exudate in wounds, e.g., Leg ulcers. When applied to wounds it reduces bacterial count In chronic leg ulcers it accelerates healing and reduces pain. Eradicates more than 150 pathogens Special Considerations (Including contraindications) Consider scoring eschar before application of Hypergel. Dressings should be changed every 24 hours or when wound drainage is visible under the dressing. Should be discontinued when less than 25% of the wound area is covered by eschar and the wound has begun to drain. There may be an increase in the amount of drainage and the size of the wound during initial treatment due to reduction of edema and removal of necrotic debris. Patient may experience pain at the wound edges; protect with liberal amounts of skin barrier. Consider administration of analgesia before dressing change. Do not use in wounds with no devitalized tissue such as granulating wounds, wounds with moderate to heavy drainage and wounds which have a compromised arterial blood flow. For ointment and paste a single application should not exceed 50 g. The total amount of ointment or paste used in one week must not exceed 150 g. The dressing should be changed approximately 3 times a week or when the Iodosorb ointment or paste has become saturated with wound exudate, indicated by a loss of colour. If wound exudating heavily daily dressing changes may be needed. Each time the dressing is changed and at the end of treatment the remaining Iodosorb should be gently removed from the wound surface with either a stream of sterile water or saline or with a sterile swab. The duration of treatment should not exceed 3 months in any single course of treatment. Should not be used in patients with known or suspected iodine sensitivity. Contraindicated in Hashimoto s Thyroiditis. In patients with a prior history of hyperthyroidism it is not recommended to use iodine-containing products. Should not be used in the case of non-toxic nodular goitre and in children Should not be used in pregnant or lactating women. Page 14 of 15

Intervention Nanocrystalline Silver Coated Dressing Ionized silver is a three-ply material consisting of an absorbent layer sandwiched between two layers of polyethylene coated with nanocyrstalline silver that provides an antimicrobial barrier for wounds Acticoat Collagenase Ointment Enzymatic debriding agent Santyl Collagenase Ointment Table 5 Interventions for Chronic Wounds Indications For burns, grafts, donor sites and contaminated or infected wound beds. Delivers fast acting infection control. Eradicates more than 150 pathogens. Minimizes disruption to the wound site. Provides a clean, moist woundhealing environment. For debridement of dermal ulcers or severely burned areas. Special Considerations (Including contraindications) Iodosorb may be absorbed systemically especially when large wounds are treated. Patients with severely impaired renal function or a history of any thyroid disorder are more susceptible to alterations in thyroid metabolism with chronic Iodosorb therapy. An adherent crust can form when Iodosorb paste dressing is not changed with sufficient frequency. There is a potential interaction of iodine with lithium and therefore co-administration is not recommended. Do not use any oil-based topical antimicrobial in conjunction with Acticoat. Use only sterile water to clean wound or moisten dressing. Dressing should be: maintained in a moist condition examined every 24 hours and changed if necessary based on the amount of exudate or the condition of the wound The need to change the dressing should be considered at least every 3 days. Silver deposits on the peri-wound skin are not harmful and may provide bacterial barrier. Soaks containing metal ions or acidic solutions such as Burow s solution should be avoided because of the metal ion and low ph, which can have a definite adverse effect on the enzyme s activity. Ointment should be confined to the area of the lesion in order to avoid the possible risk of irritation or maceration of normal skin. Use a barrier around peri-wound area. Santyl does not damage newly forming granulating tissue. Contraindicated in patients who have shown local or systemic hypersensitivity to collagenase. Page 15 of 15