Page 163 - Clinical Managers Orientation Binder

4/11/2019

VNSNY Wound Treatment Guidelines

Exudate: Scant to Small (TIW) Exudate: Moderate to Large
Non Absorptive dressings (BIW-TIW)
• Hydrogel Absorptive Dressings
Promotes a moist healing environment, prevents tissue dehydration and • Calcium Alginate or a hydrofiber
promotes autolytic debridement (e.g.Aquacel)
• Hydrogel with Silver (AG) Absorbs excess drainage to maintain moisture balance and promote
For wounds presenting with bioburden and or s/s of infection autolytic debridement
• Calcium Alginate or Hydrofiber with
• Triad Hydrophilic Wound Dressing- alternative Silver (AG)
for difficult to dress areas. Zinc – oxide based hydrophilic paste For wounds presenting with bioburden and or s/s of infection
absorbs up to moderate exudate , facilitates autolytic debridement. •
Can be used within the wound bed and in a thin layer to the Foam- manages small to large levels of exudate – broad
range of options adhesive/ non adhesive and specialized shapes
periwound. for heel and sacrum
• Super absorbent products e.g. Optilock used as a
primary dressing on partial-thickness and full-thickness wounds.
OptiLock® can also be used as a secondary dressing on full-
thickness wounds Eclypse super absorbent dressing for
large wounds i.e. entire leg with venous ulcer.
• Mesalt- manages wound with more than 25% slough
with moderate to large exudate.
**MD and Insurance approval required for all wound treatments**

VNSNY WOUND TREATMENT GUIDELINE
* Blue box with asterisk indicates appropriate treatment
Tunneling/ Necrotic Tissue: Necrotic Infected/Critically
Granular Depth Undermining Slough Tissue:Eschar colonized
Product Type Objective: Objective: Objective: Objective: Objective: Objective:
Refer To VNSNY Keep Moist Fill Space Fill Space Debride Debride Reduce Bioburden
Wound Care Formulary Exudate Exudate Exudate Exudate Exudate Exudate
For Specific Products By Name S M/L S M/L S M/L S M/L S M/L S M/L

Hydrogel Wound Gel / Gauze *<25% *<25%
Maintains moisture balance to facilitate either
granulation or autolytic debridement * * * slough eschar
Available as an antimicrobial
Hydrocolloid Wafer * *<25%
Maintains moisture balance to facilitate either slough
granulation or autolytic debridement *
Available as an antimicrobial
Hydrocolloid/Hydrophilic paste *<25%
Fills depth & maintains moisture balance to * * slough
facilitate granulation or autolytic debridement
Calcium Alginate or Hydrofiber *<25%
Absorbs exudate to maintain moisture balance slough
Available as an antimicrobial * * *
Foam *<25%
Absorbs exudate to maintain moisture balance slough
Available as an antimicrobial *
Antimicrobial
(Silver, Cadexomer Iodine, AMDs)
Available in gels, foams, alginates, hydrofiber, * *
gauze pads/packing strips and collagen dsgs
Debriding Agents: * 100% eschar *
Enzymatic: Collagenase/Santyl should first be
crosshatched
Needs MD prescription. * *
Cannot be used with silver products by MD
Cadexomer Iodine: Iodosorb/Iodoflex
Debrides slough,antimicrobial, absorbs *
exudate
*
Mesalt Sodium Chloride
Impregnated Dressing * * *
Cleanses debrides slough, absorbs exudate
*Must tx * Must tx
Negative Pressure Wound TX * * * * * * * * infection infection

© Visiting Nurse Service of New York 2010, Reprinted with the permission of Visiting Nurse Service of New York, all rights reserved 20
revised.9.18.18
10