South West Regional Wound Care Program’s Dressing Selection and Cleansing Enabler – HEALABLE WOUNDS

Wound Appearance

Description Eschar Primarily Slough or Mixed Fibrin Granulating **** Epithelializing **** Open Surgical Incision Closed Wounds and/or
Granulating/Slough Wound (small dehiscence along Skin at Risk
Tissue otherwise intact incision)

Exudate Level None → Moderate Small → Large Small→ Large Small → Moderate Small→ Moderate Small  Moderate None
Depth Unknown Full  Partial Thickness Full → Partial Thickness Full Thickness → Superficial Partial Thickness  Closed
Superficial Superficial
Treatment Objective Debride (unless the eschar Cleanse, protect, moist Cleanse, protect, moist Cleanse, protect, moist Cleanse, protect, moist Cleanse, protect, moist Protect
is stable and on a heel . If wound healing, fill dead wound healing, fill dead wound healing, fill dead wound healing wound healing, fill dead
stable eschar is on a heel space, debride space, debride space space
use the maintenance
enabler)*

Cleansing (min. 100 mL of 7-15 PSI irrigation NS or 7-15 PSI irrigation NS or 7-15 PSI irrigation NS or POUR NS or sterile water POUR NS or sterile water POUR NS or sterile water Tap water
room/body temperature sterile water or commercial sterile water or commercial sterile water or commercial solution solution solution
solution) ** wound cleanser wound cleanser wound cleanser

Suggested Dressing Have ET/WCS cross-hatch Hypertonic dressing [1+] Hypertonic dressing [1+] Hydrogel [0] (max 3 days) Hydrogel [0] (max 3 days) Hydrogel [0] (max 3 days) Film [1+]
Products and Rate hard eschar first! (daily) (daily) Or +/- Non-Adherent +/- Non-Adherent Or
Changes*** Or Or Calcium Alginate [2+] (max Synthetic [0] (max 7-14 Synthetic [0] (max 7-14 Hydrocolloid [1-2+] (max 7
Hypertonic dressing [1+] Hydrogel [0] (max 3 days) Hydrogel [0] (max 3 days) 7 days) days) days) days)
(daily) Or Or Or Or Or Or
Or Hypertonic dressing [1+] Hypertonic dressing [1+] Hydrophilic Fiber [2+] (max Calcium Alginate [2+] Calcium Alginate [2+] Clear Acrylic [2+] (max 21
Hydrogel [0] (max 3 days) buttered with a Hydrogel buttered with a Hydrogel 7 days) +/- Non-Adherent +/- Non-Adherent days)
Or [0] (daily) [0] (daily) Synthetic [0] (max 7 days) Synthetic [0] (max 7 days)
Hypertonic dressing [1+] Or Or Cover Choices: Or Or
Exudate capacity of buttered with a Hydrogel Cadexomer Iodine [1+] Cadexomer Iodine [1+] Hydrocolloid [1-2+] Hydrophilic Fiber [2+] Hydrophilic Fiber [2+]
dressings: [0] (daily) buttered on Calcium buttered on Calcium +/- Film [1+] (max 7 days – +/- Non-Adherent +/- Non-Adherent
[0] = none Alginate [2+] or Hydrophilic Alginate [2+] or Hydrophilic do not use on plantar foot Synthetic [0] (max 7 days) Synthetic [0] (max 7 days)
[1+] = small Cover Choices: Fiber [2+] (max 3 days) Fiber [2+] (max 3 days) wounds)
[2+] = moderate Hydrocolloid [1-2+] Or Cover Choices: Cover Choices:
+/- Film [1+] (max 7 days) Cover Choices: Cover Choices: Clear Acrylic [2+] (max 21 Hydrocolloid [1-2+] Hydrocolloid [1-2+]
[3+] = large Or Hydrocolloid [1-2+] Hydrocolloid [1-2+] days) +/- Film [1+] (max 7 days – +/- Film [1+] (max 7 days)
Foam [1-3+] +/- Film [1+] (max 7 days) +/- Film [1+] (max 7 days) Or do not use on plantar foot Or
Dressing wear times are +/- Film [1+] (max 7 days) Or Or Foam [1-3+] (max 7 days) wounds) Clear Acrylic [2+] (max 21
found in brackets ( ) Or Foam [1-3+] (max 7 days) Foam [1-3+] (max 7 days) Or Or days)
Composite [2-3+] Or Or Composite [2-3+] (max 7 Clear Acrylic [2+] (max 21 Or
+/- Film [1+] (max 7 days) Composite [2-3+] (max 7 Composite [2-3+] (max 7 days) days) Foam [1-3+] (max 7 days)
More resources at: Or days) days) Or Or
www.swrwoundcareprogram.ca
Gauze sealed by Film [1+] Or Or Foam [1-3+] (max 7 days) Composite [2-3+] (max 7
(for daily changes ONLY) Gauze +/- Film seal [1+] Gauze +/- Film seal [1+] Or days)
(for daily changes ONLY) (for daily changes ONLY) Composite [2-3+] (max 7
days)

If the wound is superficial you may consider having your

* Only debride healable wounds. secondary dressing be your primary contact layer as well.
** If antimicrobial effect is required, consider topical antiseptic cleansers, i.e. chlorhexadine 2% or 4% (for pseudomonas – must soak x 5 min. minimum), povidone-iodine, or ¼ strength acetic acid (for pseudomonas only – must soak x 5 min. minimum).
*** If antimicrobial effect is required, consider topical antimicrobial dressings, i.e. silver compounds, iodine compounds, chlorhexadine derivatives, honey, or gentian violet and methylene blue.
**** For stalled granulating or epithelializing wounds consider cadexomer iodine or pocidone iodine to initiate acute inflammation or calcium alginate or protease inhibitor dressings to address chronic inflammation.
ALSO, may consider pain controlling dressings for painful exudating wounds, biologic dressings for stalled granulating +/- epithelializing wounds in the absence of infection or large drainage, charcoal dressings for odor control (once the cause of the odor has been investigated and treated if able, and adjunctive therapies as indicated.
Disclaimer: The information herein is for general informational purposes only and is not intended, nor should it be considered, as a substitute for professional medical advice. Always seek the advice of the attending physician or other qualified healthcare provider regarding a medical condition or treatment. Dressing selection cannot take place in isolation
– a holistic patient assessment is MANDATORY.