Pressure ulcer grades I II Barnsley Community Services wound care formulary Grade I pressure ulcer Grade II pressure ulcer Non blanching erythema Superficial break in the skin III IV (intact skin) 2014 – 2016 SWYPFT Community Tissue Viability Service Apollo Court Medical Centre Grade III pressure ulcer Grade IV pressure ulcer A deeper wound penetrating the dermis Damage to full thickness skin with cavity: may expose underlying structures, bone, muscle or tendons Tel: 01226 209885 Fax: 01226 209888 Access the Wound Care Policy on the Trust’s intranet Supporting products 3M Coban2 / Coban2 Lite Aspen Two layer compression kits: CO-FLEX UBZ & CO-FLEX TLC Autonomed Seal-tight Shower Proof Wound Protector BSN Easyfix Toe Bandages (5cm x 4m pack of 12) Crawford Kerraped (foot wear / long term bandages) Synergy Comfi-fast Tubular Bandage Job no: 6041 NOV14 © South West Yorkshire Partnership NHS Foundation Trust Is the wound on a foot? Is the patient diabetic? Yes Yes PROTOCOL 1 PROTOCOL 5 Melolin Tricotex Softpore Clearpore Refer to TV nurse for Doppler prior to debriding ActivHeal Hydrogel Granuflex Aquacel Extra Kerralite Cool Sorbsan / Kerrafibre PROTOCOL 2 PROTOCOL 6 Take a swab and inform the doctor Duoderm Range Clearfilm / Hydrofilm Atrauman Silflex Aquacel Extra Sorbsan / Kerrafibre Drawtex PROTOCOL 3 PROTOCOL 7 Cutimed Sorbact Swab Iodoflex Inadine / Povitulle Activon Tube Algivon Plus Actilite Flaminal Hydro / Forte Metronidazole Gel ActivHeal / Contact / Foam Island Allevyn Life Tegaderm Foam Adhesive Aquacel Foam Adhesive Aquacel Extra Sorbsan / Kerrafibre / Sorbsan Plus Xupad / C Sorb / Flivasorb Kerramax Care Drawtex PROTOCOL 4 PROTOCOL 8 Iodoflex Algivon Plus Cutisorb Sorbact Swab / Ribbon Flaminal Hydro / Forte Aquacel Extra Sorbsan / Kerrafibre Drawtex Refer ALL diabetic foot ulcers to MDT foot clinic WOUND MANAGEMENT FLOW CHART No No Is there any ischaemia? Yes No Are there any signs of infection? Yes No Are there any sloughy or necrotic tissue? Is the wound clean? Are there clinical signs of infection or do the results confirm infection? Yes Yes Is the wound flat? PROTOCOL 3 No No Yes PROTOCOL 5 if the wound is shallow if the wound is shallow PROTOCOL 6 if the wound is deep No Yes PROTOCOL 4 if the wound is deep No PROTOCOL 1 if the wound is dry PROTOCOL 2 if the wound is moist PROTOCOL 7 If the wound is malodorous, additionally consider the use of odour reducing dressings if the wound is shallow + wet PROTOCOL 8 if the wound is deep + wet Refer to the beginning/seek advice Reporting pressure damage All pressure ulcers should be reported e.g. Occurred in your care (incidence) or Already existing when admitted into your care (prevalence) Medium/Heavy Exudating Medium/Heavy Exudating PROTOCOL 9 Tissue Viability Specialist Nurse advice only T.N.P. Therapy – VAC / Talley / PICO Larvae Therapy Flowtron Therapy Versajet Therapy Vibropulse Aquacel Ag Promogram / Prisma Jelonet Zip Zoc Coviden AMD Foam Malodorous WOUNDS Malodour is caused by bacteria – refer to protocols 3 and 4 above