Wound Care Formulary - NHS Rotherham

Wound Care Reference Guide 

The Rotherham 

NHS Foundation Trust 

The Rotherham 

Foundation Trust 

& 

NHS Rotherham 

Wound Care Formulary

Wound Management Formulary 


Introduction 

Notes for using the formulary 

The wound care formulary aims to provide a clinically 

effective, appropriate and cost effective choice of products 

to manage the vast majority of wounds. 

All dressings on the formulary are for general use with the 

exception of those indicated for specialist prescribing 

It must be emphasised that an holistic wound assessment 

must take place prior to choosing a dressing (see wound 

care guidelines) 

• The formulary should not be used in isolation and 

should not replace sound clinical judgement 

• Tissue viability nurses should be referred to as 

necessary ( see wound care guidelines) 

• Dry black heels must not be re hydrated, necrosis due 

to arterial insufficiency must not be re-hydrated seek 

further advice from tissue viability team 

• Specialist products must only be used following 

discussion with\assessment by the tissue viability 

nurses 

• It is expected that the vast majority of wound care 

products will be selected from this formulary. 

• Should a product be required that is not listed the 

rationale for this must be supplied in writing on the 

exception reporting form (see appendix 1). This will 

aid in the updating process of the formulary. 

• Antimicrobial products must only be used where 

there is an increased risk of infection or clinical signs 

of infection are apparent. Once an infection has 

resolved, treatment with an antimicrobial dressing 

must be stopped. Only approved tissue viability link 

nurses\district nursing sister should initiate the use of 

an anti-microbial or silicone dressing 

• If a wound has clinical signs of infection or fails to 

improve with an anti-microbial dressing a wound swab 

must be taken. 

• In the community setting only approved tissue viability 

link nurses\district nursing sister should initiate the 

use of an anti-microbial or silicone dressing 

• In the acute setting antimicrobial dressings should 

only be initiated by an approved tissue viability link 

nurse or Tissue viability nurse 

• In the community when prescribing dressings a 

maximum of 1 weeks supply should be prescribed 

ensuring that there are sufficient dressings to last until 

the next evaluation regardless of the pack size. 

Choosing the ideal dressing 

There are two different categories of dressings: 

1 Primary - This is in contact with the wound 

2 Secondary - This is not in contact with the wound but it 

covers the primary dressing. When choosing a secondary 

dressing ensure its compatibility with the primary wound 

contact layer. 

There are many hundreds of wound products available, 

all having slightly different properties. The ideal wound 

management choice is dependent on the type, depth 

and colour of the wound in conjunction with the stage of 

healing and what the main objective of treatment is: e.g. 

debridement or protection. 

Dressing choice should be influenced by the level and type 

of exudates.



The ideal dressing is considered to be, one that ensures 

optimal healing and addresses the following 

• Maintain high humidity 

• Removes excess wound exudates 

• Permits thermal insulation 

• Impermeability 

• Gaseous exchange 

• Non fibre shedding/nontoxic 

• Non adhesive, comfortable and conforming 

Care of ischemic wounds 

The toes and sometimes the foot can be affected by so 

called “dry gangrene” in chronic arterial insufficiency. The 

tissues are black shrivelled and dry. Whilst it is traditionally 

called gangrene there is no infective process. The tissues 

are undergoing spontaneous breakdown and drying. 

It is important that these areas, unlike other wounds, are 

kept dry Introducing moisture carries the risk of infection. 

Ideally the areas should be left exposed to the air. If 

a dressing is required it should be light, dry and allow 

circulation of air. 

Guidelines for Good Practice in the management 

of wounds 

• Always employ an holistic approach to wound 

management: e.g. investigate any underlying 

problems (see wound care guidelines) 

• Wounds should not be routinely cleansed (with the 

exception of exuding non-healing chronic wounds) 

• Good hand hygiene must be practised at all times 

(see hand hygiene policy) 

• MUST (Malnutrition Universal Screening tool) 

assessment must be completed and acted upon 

• It is essential that a date be set for reassessment 

of the wound and that any changes in treatment 

following reassessment are recorded (see wound care 

guidelines 

• Wounds should not be left exposed or wrapped 

in a dressing towel. The action of dehydration and 

reduction in wound temperature is detrimental to 

wound healing 

• A multi-disciplinary approach must be taken in wound 

care 

• A clear explanation of the action of certain types of 

dressing treatment must be explained to the patient 

• Avoid layering of dressings, most products are 

designed as a primary dressing, use of more products 

only reduces the effectiveness of the product 

• All dressings should be disposed of in accordance 

with clinical waste guidelines 

• In the community setting all dressings must be 

prescribed (with the exception of total purchase of 

dressings pilot sites). Within the hospital setting all 

dressings used should be documented in the nursing 

record Any prescription only medications used in 

wound management must be recorded on the drug 

chart 

• For any wound not progressing as anticipated 

consider referral to the tissue viability team (see 

wound care guidelines) 

Information and practice guidelines for the products 

included in the formulary

:Layout 1 16/05/2007 11:24 Page 15 

Waterlow Pressure Ulcer 

Waterlow Pressure Ulcer Prev 

Waterlow Pressure UlcerPrev 

Waterlow Pressure Ulcer Ulcer Prev 

4524_Col Wound:Layout 1 16/05/2007 11:24 

Prevention / Treatment Guide 

WATERLOW PRESSURE ULCER PREVENTION/TREATMENT GUIDE 

RING SCORES WATERLOW IN TABLE, PRESSURE ADD TOTAL. ULCER MORE LCER THAN PREVENTION/TREATMENT 11 SSCORE/CATEGORYCAN GUIDE BE USED 

RING BUILD/WEIGHT SCORES IN TABLE, SKIN TYPE ADD TOTAL. SEX 

EX SMORE THTHAN THAN 1 MMALNUTRITION S1 SCORE/CATEGORYCAN SCREENING TOOL BE (MST) USED 

FOR HEIGHT VISUAL RISK 

WATERLOW AREAS 

AGE GE 

(Nutrition Vol.15, No.6 1999 - Australia 

SKIN PRESSURE TYPE SEX 

ULCER 

EX SLCER PREVE 

PREVENTION/TREATMENT M MALNUTRITION SCREENING GUIDE TOOL (MST) 

RING SCORES IN VISUAL TABLE, RISK ADD TOTAL. AGE MALE MMORE GE E 

MORE 1 1 THTHAN A THAN AA- - HAS 1 S1 PATIENT (Nutrition SCORE/CATEGORYCAN 

LOSTVol.15, No.6 B1999 - WEIGHT - Australia LOSS 

BE USED 

SCORE 

BUILD/WEIGHT 

FOR AVERAGE HEIGHT 

HEALTHY 0 

AREAS 

BMI = 20-24.9 0 TISSUE PAPER 1 

WE WEIGHT RECENTLY 

FEMALE ALE 2 2 

0.5 - 5kg = 1 

AVERAGE BUILD/WEIGHT HEALTHY SKIN TYPE 0 MALE SEXM 

ABOVE AVERAGE 

DRY 1 EX SE 1 1 A A - HAS A -YES 

MHAS PATI MALNUTRITION PATIENT - - GO GO TO TO LOST BB 

SCREENING B - 5WEIGHT -TOOL 10kg LOSS (MST) = 2SCORE 

BMI FOR = 20-24.9 HEIGHT VISUAL RISK 

0 TISSUE PAPER 1 14 AGE 1- 49 49 1 1 WE NO NO WEIGHT- - GO RECENTLY GO TO TO CC 

BMI = 25-29.9 1 OEDEMATOUS 1 FEMALE ALE2 

2 

100.5 - 15kg - 5kg = 3= 1 

AREAS 

GE 

(Nutrition Vol.15, No.6 1999 - Australia 

YES UN UNSURE YES - GO - GO - TO GO BTO C B 

ABOVE AVERAGE 

DRY 1 

OBESE 

CLAMMY, PYREXIA 1 

505 - 64 64 2 2 

> 515kg - 10kg = 4= 2 

AVERAGE 

HEALTHY 0 14 MALE - 49 1 M49 E 1 1 

1 A A -NO 

AHAS - NO HAS PATI PATIENT - GO AND - TO GO LOST CTO C 

B - WEIGHT 

BMI > 30 2 DISCOLOURED 

656 - 74 74 3 3 

SCORE 2 

unsure 10 - 15kg LOSS 

= 2= SCORE 3 

BMI = 25-29.9 20-24.9 10 

OEDEMATOUS TISSUE PAPER 11 

WE 

UN UNSURE WEIGHT RECENTLY 

OBESE 

CLAMMY, 

BELOW AVERAGE 

GRADE PYREXIA 1 1 

50 FEMALE - 64 5 64 ALE 2 2 

2 

- GO TO C 

0.5 > - 15kg = 41 

2 

C CC- - PATIENT YES YES EATING - GO - AND GO TO POORLY TO B 

ABOVE AVERAGE 

DRY 1 

B NNUTRITION SCORE 

757 - 80 80 4 4 

BMI 

BMI 

> 30 

< 20 

2 DISCOLOURED 

3 BROKEN/SPOTS 65 - 74 6 74 3 3 

SCORE 2 

unsure 5 - 10kg = 2 

14 - 149 49 1 1 OR OR NO LACK NO OF OF - APPETITE GO - GO TO TO C C 

BMI = 25-29.9 1 OEDEMATOUS 1 

If > 2 refer 10 - for 15kg nutrition = 3 

BMI=Wt(Kg)/Ht (m) 2 GRADE 2-4 3 818 + 5 5 

BELOW AVERAGE 

GRADE 1 2 

C C‘NO’ -‘NO’ PATIE C 

= 

-UN 

= PATIENT UNSURE 

0; 0; ‘YES’ EATING SCORE - GO TO 

= 

POORLY = 11 

C assessment / intervention 

75 - 80 75 80 644 

42 

N NUTRITION > 15kg SCORE= 4 

OBESE 

CLAMMY, PYREXIA 1 

50 - 64 2 

BMI < 20 3 BROKEN/SPOTS 

OR OR LACK LACK OF APPET OF APPETITE 

AND 

If > 2 refer for nutrition 

CONTINENCE 

MOBILITY 

BMI=Wt(Kg)/Ht (m) 

SPECIAL RISKS 

2 GRADE 2-4 3 81 + 86 745 

53 

SCORE 2 

unsure = 2 

BMI > 30 2 DISCOLOURED 

65 - 74 3 

‘NO’ ‘NO’ = 0; = ‘YES’ 0; ‘YES’ SCORE SCORE = 1 = 1 assessment / intervention 

BELOW AVERAGE 

GRADE 1 2 

C C -CPATIE 

- PATIENT EATING POORLY N NUTRITION SCORE 

75 -780 80 4 4 

COMPLETE/ C 

FULLY 0 

TISSUE OR LACK 

MA MALNUTRITION 

OF APPETITE 

BMI CONTINENCE 

< 20 3 BROKEN/SPOTS 

MOBILITY 

OR LACK OF APPET 

NEUROLOGICAL If > 2 refer for nutrition DEFICIT 

CATHETERISED 0 RESTLESS/FIDGETY 1 8 5 

SPECIAL RISKS 

‘NO’ = 0; ‘YES’ = 1 assessment / intervention 

BMI=Wt(Kg)/Ht URINE INCONT. 1 APATHETIC 2 

TERMINALCA 

CACHEXIA 8 DIABETES, MS, CVA 4-6 

COMPLETE/ C 

(m) 2 GRADE 2-4 3 81 + 5 ‘NO’ = 0; ‘YES’ SCORE = 1 

FULLY 0 

TISSUE TISSUE 

FAECAL INCONT. 2 RESTRICTED 3 

MULTIPLE MA MALNUTRITION NEUROLOGICAL DEFICIT 

CATHETERISED ORGAN ORGAN FAI FAILURE 8 MOTOR/SENSORY 4-6 

CONTINENCE 0 RESTLESS/FIDGETY MOBILITY 1 

SPECIAL RISKS 

URINE URINARY INCONT. + FAECAL 1 BEDBOUND 

SINGLE SINGLE ORGAN ORGAN FAI FAILURE 

PARAPLEGIA (MAX OF 6) 4-6 

APATHETIC 2 

TERMINAL TERMINAL CA CACHEXIA 8 DIABETES, MS, CVA 4-6 

INCONTINENCE 3 e.g. TRACTION 4 

(RESP, (RESP, RERENAL, CARDIAC,) 5 

FAECAL COMPLETE/ C 

INCONT. 2 RESTRICTED FULLY 30 

MULTIPLE MULTIPLE ORGAN ORGAN FAI FAILURE 8 

TISSUE TISSUE MAMALNUTRITION 

MOTOR/SENSORY NEUROLOGICAL DEFICIT 4-6 

MAJOR SURGERY or TRAUMA 

CHAIRBOUND 

PERIPHERAL PERIPHERALVASC 

VASCULAR 

URINARY CATHETERISED + FAECAL 0 

BEDBOUND 

RESTLESS/FIDGETY 1 

SINGLE SINGLE ORGAN ORGAN FAI FAILURE 

PARAPLEGIA (MAX OF 6) 4-6 

INCONTINENCE SCORE 3 e.g. WHEELCHAIR 5 

DISEASE DISEASE TERMINAL CACHEXIA 5 8 DIABETES, MS, CVA 4-6 

URINE INCONT. 1 e.g. APATHETIC TRACTION 42 

(RESP, 

TERMINAL (RESP, RENAL, CA CARDIAC,) 5 ORTHOPAEDIC/SPINAL 5 

ANAEMIA ANAEMIA MULTIPLE 

(H(Hb ORGAN < 8) FAILURE 2 8 

FAECAL INCONT. 2 CHAIRBOUND 

PERIPHERAL PERIPHERAL VASCVASCULAR 

ON 

MOTOR/SENSORY 

TABLE MAJOR > 2 SURGERY HR# or TRAUMA 5 

4-6 

RESTRICTED 3 

MULTIPLE ORGAN FAI 

URINARY 10+ SCORE AT + RISK FAECAL e.g. WHEELCHAIR 5 

DISEASE SMOKING SMOKING DISEASE SINGLE ORGAN FAILURE 1 5 ON PARAPLEGIA TABLE > 6 HR# (MAX OF 6) 8 4-6 

BEDBOUND 

SINGLE ORGAN FAI 

ORTHOPAEDIC/SPINAL 5 

INCONTINENCE 3 

(RESP, RENAL, CARDIAC,) 5 

e.g. TRACTION 4 

ANAEMIA (RESP, ANAEMIA RE 

MEDICATI MEDICATION (H (Hb < 8) 2 

- CYTOTOXICS, LONG ON TERM/HIGH TABLE > 2 HR# DOSE STEROIDS, 5 

PERIPHERAL VASCULAR 

MAJOR SURGERY or TRAUMA 

10+ 15+ AT HIGH RISK RISK CHAIRBOUND 

SMOKING PERIPHERAL SMOKING VASC ANTI-INFLAMMATORY 1 

MAX OF 4 

DISEASE 

5 

ON TABLE > 6 HR# 8 

SCORE 

e.g. WHEELCHAIR 5 

DISEASE 

# 

# 

Scores 

Scores 

ca 

can be discounted after 48 hours ORTHOPAEDIC/SPINAL provided patient is recovering normally 5 

MEDICATI ANAEMIA MEDICATION (Hb < 8) - CYTOTOXICS, 2 LONG TERM/HIGH DOSE STEROIDS, 

15+ 20+ HIGH VERY RISK HIGH RISK 

ANAEMIA (H 

TABLE > 2 HR# 5 

SMOKING 

ANTI-INFLAMMATORY 

1 

MAX OF 4 

10+ AT 

© J Waterlow 

© 

RISK 

SMOKING 

ON TABLE > 6 HR# 8 

1985 Revised 2005* 

# Scores # Scores ca can be discounted after 48 hours provided patient is recovering normally 

20+ VERY Obtainable HIGH from RISK the Nook, Stoke Road, Henlade TAUNTON TA3 

TA3 

5LX 

5LX 

MEDICATION - CYTOTOXICS, LONG TERM/HIGH DOSE STEROIDS, 

MEDICATI 

* The 

* 

ANTI-INFLAMMATORY MAX OF 4 

15+ HIGH 2005 RISK revision incorporates the research undertaken 

© J Waterlow © 

by Queensland 

1985 Revised 

Health. 

2005* 

# Scores can be discounted after 48 hours provided 

w 

www.judy-waterlow.co.uk 

patient is recovering normally 

Obtainable from the Nook, Stoke Road, Henlade TAUNTON TA3 TA3 5LX 5LX # Scores ca 

* 

20+ 

The * VERY 

2005 revision 

HIGH 

incorporates 

RISK 

the research undertaken 

© 

REMEMBER TISSUE DAMAGE MAY START PRIOR 

PRIOR 

TO 

TO ADMISSION, ADMISSION, 

TO ANY OF 

IN 

IN 

CAS 

CASUALTY. A SEATED PATIENT IS AT RISK 

by Queensland Health. A 

THE RISK CATEGORIES, THEN PREVENTATIVE w www.judy-waterlow.co.uk 

© J Waterlow 1985 Revised 2005* 

NURSING IS 

ASSESSMENT 

R 

IF THE PATIENT FALLS INTO TA3 

URSING 

ANY5LX 

OF 

TEC C 

THE 

HNIQUES 

RISK CATE 

Obtainable * from the Nook, AND PREVENTATIVE AIDS WILL BE NECESSARY 

REQUIRED Stoke ARoad, COMBINATION Henlade TAUNTON OF GOOD 

A 

NURSING TA3 5LX 

ONS MUST 

TEC C HNIQUES 

BE BEDO 

DOCUMENTED 

AN 

* The 2005 revision ALL ACTIONS MUST BE BE DO DOCUMENTED 

REMEMBER 

incorporates 

TISSUE 

the 

DAMAGE 

research undertaken 

MAY START PRIOR 

PRIOR 

TO 

TO ADMISSION, ADMISSION, 

IN CAS 

IN CASUALTY. A SEATED PATIENT www.judy-waterlow.co.uk 

IS AT RISK 

by Queensland Health. ASSESSMENT 

A 

IF THE PATIENT FALLS INTO ANY 

TO ANY 

OF 

OF 

THE 

THE 

RISK 

RISK 

CATE 

CATEGORIES, THEN PREVENTATIVE NURSING IS 

Skin Care 

General hygene, wNO rubbing, cover with 

PREVENTIONREQUIRED R 

A COMBINATION OF GOOD NURSING 

URSING 

TEC C 

TEC 

HNIQUES 

C HNIQUES 

AN SS 

AND PREVENTATIVE AIDS WILL BE NECESSARY 

an appropriate dressing 

PRESSURE 

A ONS MUST BE BEDO 

DOCUMENTED 

ALL ACTIONS PRIOR MUST BE TO BE DO DOCUMENTED 

ADMISSION, IN CASUALTY. A SEATED PATIENT IS AT RISK 

REDUCING REMEMBER AIDS ATISSUE DAMAGE MAY START PRIOR TO ANY TO OF 

ADMISSION, THE RISK CATEGORIES, IN CAS THEN PREVENTATIVE NURSING IS 

PREVENTION 

Special ASSESSMENT R IF THE PATIENT FALLS INTO URSING ANY OFTEC 

THE C HNIQUES RISK Skin Care 

General hygene, NO rubbing, cover with 

. 

SSCATE 

AND PREVENTATIVE AIDS WILL BE NECESSARY 

WOUND GUIDELINES 

PRESSURE Mattress/beds: REQUIRED 10+ Overlays A COMBINATION or specialist foam OF GOOD mattresses. ANURSING ONS TEC MUST C HNIQUES BE BEDO 

DOCUMENTED 

AN 


es and 

Assessment 

odour, exudate, measure/photograph 

REDUCING AIDS 15+ Alternating pressure overlays, ALLmattresses ACTIONS and MUST BE BE DO DOCUMENTED 

b 

A 

position 

Special 

bed systems 

Skin Care 

General hygene, NO rubbing, cover with 

ss and 

Mattress/beds: 

PREVENTION 10+ 20+ Overlays a 

Bed systems: or specialist Fluidised foam bead, mattresses. low air loss . and 

SS 



WOUND CLASSIFICATION - EPUAP 

PRESSURE 

15+ alternating Alternating pressure mattresses 

es and 

Assessment 

odour, exudate, measure/photograph 

overlays, mattresses and rum of 

A GRADE 1 

Discolouration of intact skin not affected 

REDUCING AIDS bed Note: b 

systems s 

Preventative aids cover a wide spectrum 

ed, 

of 

if 

G 

position 

by light finger pressure (non-blanching 

Special 

20+ specialist Bed p systems: features. Fluidised Efficacy bead, should low be air judged, loss and nce. 

if ss . and 


erythema) 

Mattress/beds: C 

alternating 10+ possible, Overlays a 

pressure on or the specialist basis mattresses of independent foam mattresses. evidence. es and 

Assessment WOUND CLASSIFICATION odour, exudate, measure/photograph - EPUAP 

t some 

This may be difficult to identify in darkly 

Cushions: Note: 15+ No Alternating b 

fPreventative person should pressure aids sit cover in overlays, a wheelchair a wide mattresses spectrum without 

ble 

some rum of 

GRADE 1 

Discolouration position of intact skin not affected 

of and - use 

GA 

pigmented skin 

specialist bed form systems s 

t 

of 

features. 

cushioning. 

Efficacy 

If nothing 

should 

else 

be 

is 

judged, 

available ed, 

if risk) 

- ss use if and 

by light finger pressure (non-blanching 

GRADE 2 

Partial thickness skin loss or damage 

possible, 20+ the Bed pa 

1 

person’s 

on systems: the 

own 

basis Fluidised pillow. 

of independent 

(Consider bead, low infection 

evidence. air loss risk) and nce. 

G 

WOUND erythema) CLASSIFICATION - EPUAP 

involving epidermis and/or dermis 

C 

Cushions: 

No alternating person 

10+ 100mm 

should pressure foam 

sit in 

cushion mattresses 

trum some of 

GRADE 1 

This Discolouration may be difficult of intact to identify skin not in affected darkly 

a wheelchair without some 

The pressure ulcer is superficial and 

f s 

ble ed, - if use 

pigmented by light finger skinpressure (non-blanching

Pressure Ulcer Grading 

Progression of a pressure ulcer 

Grade / Category 1 

Non-blanchable erythema 

intact skin with nonblanchable 

redness of a localised 

area usually over a bony 

prominence. Darker 

pigmented skin may not have 

visible blanching, it’s colour 

may differ from surrounding 

area. The area may be painful, 

firm, soft, warmer or cooler as 

compared to adjacent tissue. 

Grade 1 may be difficult to 

detect in individuals with dark 

skin tones, may indicate “at 

risk” persons * Please note an 

area of non-blanchable tissue 

damage were the skin is not 

broken may develop into a 

deeper pressure ulcer. Observe 

regularly and 

re-grade as appropriate 


Partial thickness loss of dermis 

presenting as 

a shallow open ulcer with a 

red pink wound bed, without 

slough. May also present as 

an intact or open/ruptured 

serum –filled or serosanginous 

filled blister. Presents as a 

shiny or dry shallow ulcer 

without slough or bruising. This 

category should not be used 

to describe skin tears, tape 

burns, incontinence associated 

dermatitis maceration or 

excoriation. 


Full thickness tissue loss. 

Subcutanious fat may be 

visible but bone, tendon or 

muscle are not exposed. 

Slough may be present but 

does not obscure the depth 

of tissue loss. May include 

undermining and tunnelling. 

The depth of a category/stage 

III pressure ulcer varies by 

anatomical location. 

The bridge of the nose,ear, 

occiput and malleolus do not 

have (adipose) subcutaneous 

tissue and category/stage 

III ulcers can be shallow. In 

contrast areas of significant 

adiposity can develop 

extremely deep category / 

stage III pressure ulcers. Bone/ 

tendon is not visible or directly 

palpable. 


Full thickness tissue loss with 

exposed bone, tendon or 

muscle. Slough or eschar may 

be present. Often includes 

undermining and tunnelling. 

The depth of a category/stae 

IV pressure ulcer varies by 

anatomical location. 

The bridge of the nose, ear, 

occiput and malleolus do not 

have (adipose) subcutaneous 

tissue and these ulcers can 

be shallow. Category/stage 4 

ulcers can extend into muscle 

and/or supporting structures 

(e.g. facia, tendon or joint 

capsule) making osteomyelitis 

or osteitis likely to occur. 

Exposed bone/muscle is visible 

or directly palpable

Treatment Guide 

Treatment Guide 

Woundbed Objective Treatment 

Exudate Levels / Primary and Secondary Dressing 

Necrotic/Sloughy 

Tissue 

Local Infection / 

Critical Colonisation 

• Debride 

• Remove Eschar 

• Remove Slough 

• Provide clean base 

for granulation 

tissue 

• Clean up and 

reduce bacterial 

burden 

• Manage infection 

Dressings that 

remove dead 

tissue and 

absorb exudate 

Hydrocolloid 

Hydrogel 

Hydrofibre 


clean up, 

reduce bacterial 

burden and absorb 

exudate 

Anti-microbial 

T 

R 

E 

A 

T 

M 

E 

Hydrofiber / Alginate 

Secondary dressing 

Foam 

Treatment Without a Cavity 



Foam 






Hydrocolloids or Foam 

Versiva XC 




Versiva XC 



Hydrofiber 



Versiva XC 

Hydrocolloids or 

Foam 

Versiva XC 



Granulation 

Epithelialisation 

Fungating Malodorous 

• Granulation and 

tissue growth 

• Provide clean base 

for epithelialisation 

• Protection of 

newly formed 

tissue 

• Promote 

epithelialisation 

and wound 

maturation 

• Manage complex 

wound 

• e.g. bleeding, 

exudate, 

malodour, size, 

site 


support granulation 

tissue growth and 

absorb exudate 

Hydrofibre 

Foam 

Hydrocolloid 


support healing 

and skin protection 

Hydrocolloid 

Foam 

Non Adhesive 

N 

T 

C 

H 

O 

I 

C 

E 

S 

Treatment With a Cavity 

Hydrofiber / Alginate Hydrofiber / Alginate 

Secondary dressing Secondary dressing 

Foam 

Foam 

Versiva XC 


Should not occur Foam 

in clean granulating Versiva XC 

wounds 

May require Hydrofiber 

Alginate depending upon 

exudate 


N/A 


Should not occur in 

clean epithelialising 

wounds 

N/A 

Foam 

Versiva XC 


Hydrofiber / Alginate Hydrofiber / Alginate 

Secondary dressing Secondary dressing 

Foam 

Foam 

Consider anti-microbial Versiva XC 

or charcoal dressing if 

malodorous 




Foam / Versiva XC 

Consider anti-microbial 


malodorous 






malodorous 


Hydrocolloid 

Secondary dressing Foam 

Versiva XC 

Hydrocolloid 

Foam 

Versiva XC 

N/A 

Foam / Island dressing 

Versiva XC 



Foam 

Versiva XC 

Contact Layer 





malodorous

Product Assortment Guide 


Community & 

Hospital 

Community only 

Hydrocolloid 

Comfeel ® Plus Transparent 

Hospital only 

Specialist only 

Comfeel Plus Transparent Dressing consists of a thin layer of 

a self adhesive hydrocolloid containing NaCMC. The dressing 

is permeable to water vapour but impermeable to exudate 

and micro-organisms. Comfeel Plus Transparent dressing is 

ideal for skin abrasions, superficial burns and epithelialising 

wounds. Suitable for vegetarians. 

Duoderm ® Extra Thin 

DuoDERM® Extra Thin dressing is a hydrocolloid dressing 

indicated for the management of lightly exuding wounds. 

It combines a unique ConvaTec hydrocolloid formulation 

that distinguishes it from other hydrocolloid dressings and a 

vapour-permeable outer film to provide an occlusive moist 

environment. 

Hydrofiber 

Aquacel 

Hydrofiber dressing which converts to a soft gel when in 

contact with wound exudate. Aquacel should be placed 

directly onto the wound allowing a 1cm overlap. For cavity 

wounds loosely pack, allowing 2-5cm outside for easy 

retrieval. Requires secondary dressing change. 

Versiva XC 

Highly absorbent composite adhesive and non adhesive 

dressing incorporating Hydrofiber® Technology and gentle 

adhesive for moderate to highly exuding wounds. 

Wound Contact Layer 

Urgotul 

Non-adherent, non-occlusive, flexible contact layer derived 

from TLC (Technology Lipido-Colloid). It is composed of a 

polyester mesh impregnated with hydrocolloid and petroleum 

jelly particles. 

Mepitel 

Mepitel is used in the management of wounds where 

adherence of a dressing to the underlying tissue represents 

a particular clinical problem. Typical applications include 

skin tears or abrasions, surgical excisions, second-degree 

burns, blistering conditions such as epidermolysis bullosa, 

lacerations, partial and full thickness grafts, and skin damage 

following radiotherapy or steroid therapy. 

Tricotex 

TRICOTEX dressings are constructed from knitted viscose 

rayon and are designed to act as an interface between 

ulcerating or granulating wounds and conventional absorptive 

dressings. 

Solvaline N 

Solvaline® N has no right or wrong side. Application is very 

easy as both sides have a perforated, polyester film coating. 

The absorbent layer consists of cotton. It offers a high 

absorption capacity and minimises fluid accumulation. 

The dressings layers are joined together without the use of 

adhesive. Indications: 

• Superficial wounds 

• Post operative treatment 

• First aid (abrasions, cuts) 

• Lightly to moderately exuding ulcerations 

• Minor burns 

• Under compression 

Softpore 

Latex-free surgical adhesive dressing for lightly exuding 

wounds, such as surgical incisions, cuts and abrasions 

Premierpore 

Absorbent, perforated dressing with adhesive border. 

Wounds (including postoperative) with low or moderate 

exudate levels 

Opsite post op 

Vapour-permeable adhesive film dressing with absorbent pad. 

Acute wounds such as cuts, lacerations, minor burns and 

postoperative wounds



Super absorbent 

Kerramax 

Super-absorbent dressing. Exudate and MMPs are absorbed 

and bound inside the dressing with no leakage. Soft, 

conformable and stackable. 

Antimicrobial 

Biatain Ag 

Adhesive polyurethane foam dressing with vapour-permeable 

film backing. Impregnated with silver. 

Non-adhesive polyurethane foam dressing with vapourpermeable 

film backing. Impregnated with silver. Can be used 

under compression. Retention bandage/tape is required. 

Foam 

Biatain 

Biatain Foam Adhesive and Non-Adhesive dressings are 

available in a variety of different shapes and sizes. Contour, 

Heel and Sacral dressings offer the solution for difficult 

to dress areas such as knees, elbows and heels. Biatain 

adhesive dressing provides a bacterial and waterproof barrier. 

All Biatain Foam dressings are able to absorb large amounts 

of exudate and lock it away from the wound bed. Biatain 

Non-Adhesive has a bevelled edge, suitable for use under 

compression. 

Biatain Silicone 

May be used throughout the wound healing process to 

provide exudate handling, padding and protection on a 

variety of wounds including leg ulcers, pressure ulcers, 

superficial burns, donor sites, postoperative wounds, skin 

abrasions and non-infected diabetic foot ulcers. 

Alginate 

Cutimed Alginate 

Binds wound bacteria rapidly and effectively. Reduces 

the bacterial load and supports the natural wound healing 

process. No undesirable side effects, no development of 

bacterial resistance. 

Activon Tube 

Activon Tube is ideal for debriding necrotic tissue, or for 

topping up dressings where the honey has been washed 

away by exudate. Great for using in cavities, just wash away 

with saline solution. 

Activon Tulle 

Activon Tulle is a knitted viscose mesh dressing impregnated 

with 100% Manuka honey. 

Activon Tulle creates a moist healing environment and 

effectively eliminates wound odour whilst providing 

antibacterial action. Activon Tulle is ideally selected for 

granulating or shallow wounds, it’s a good choice when 

debriding or de-sloughing small areas of necrotic or sloughy 

tissue 

Aquacel Ag 

As a primary dressing for moderately to highly exuding 

wounds where there is infection or an increased risk of 

infection. 

Iodoflex 

Iodoflex is used for the treatment of chronic exuding wounds 

such as leg ulcers, pressure ulcers and diabetic ulcers, 

particularly when infection is present or suspected. 

Urgotul SSD 

Non-adherent, non-occlusive antibacterial contact layer 

derived from TLC (Technology Lipido-Colloid). It is composed 

of a polyester mesh impregnated with hydrocolloid, petroleum 

jelly and silver sulphadiazine particles.


Antimicrobial Continued 

Algivon 

Alginate dressing impregnated with 100% Manuka honey. 

Low to moderately exuding wounds. Suitable for cavities, 

and debriding and de-sloughing large areas of necrotic and 

sloughy tissue. 

Actilite 

A broad spectrum antimicrobial dressing for use on low to 

moderately exuding wounds. The dressing is designed to 

protect a wound, promote healing and allow the passage of 

exudate, and can be used on epitheliasing wounds that are 

perceived to be at risk of re-infection. 


Retention bandage 

K-Lite 

For the treatment of Venous Leg Ulcers (2nd layer of K-Four 

multilayer bandage system), light support for sprains and 

strains. Can be used for retention bandaging 

K-Band 

Knitted viscose/nylon conforming retention bandage. Also 

available with silver (K-Band Silver). Latex free. 

K-Band is a type 1 conforming and retention bandage. Has 

2-way stretch for ease of application. 

Inadine 

INADINE® is indicated for the management of ulcerative 

wounds and may also be used for the prevention of infection 

in minor burns and minor traumatic skin loss injuries. 

Charcoal dressing 

Clinisorb 

Sterile activated charcoal cloth sandwiched between layers 

of nylon/viscose rayon cloth. Apply as a secondary dressing 

over an appropriate primary dressing. Exudate will reduce the 

dressing’s effectiveness. Can be cut to size. 

Compression bandage 

Actico 

Compression bandaging of limbs with venous disorder 

and the control and reduction of chronic oedema and 

lymphoedema in the lower limbs and arms. 

K-Four 

K-Four is a four layer compression bandage system, 

providing the gold standard for compression therapy. K-Four 

is composed of a combination of 

K-Soft, K-Lite, K-Plus, Ko-flex. 

Tape 

Scanpor 

Highly permeable, hypoallergenic, colophony-free, nonwoven, 

synthetic, skin-friendly, adhesive tape. 

Tubular bandage 

Comfifast 

Elasticated viscose stockinette 

Actifast 

Elasticated cotton tubular bandage 

Film Dressing 

ClearFilm 

Latex-free surgical adhesive dressing for lightly exuding 

wounds, such as surgical incisions, cuts and abrasions 

Op-Site 

Vapour-permeable adhesive film dressing with absorbent pad.



Hydrogel 

Cutimed Gel 

Clear, amorphous hydrogel with sterile applicator. 

Barrier Cream 

Sorbaderm Barrier Cream 

A white concentrated cream that provides the skin with a 

long-lasting barrier protection and is also a moisturiser. It 

does not reduce absorbency of pads and allows medical 

adhesives to stick to the skin. Fragrance free. 

Sorbaderm No-sting Barrier Film 

An alcohol-free, no-sting formulation that provides a 

protective interface between the skin and bodily waste, fluids, 

adhesive products and friction. Can be used on broken and 

non-broken skin. Available as a spray and foam applicator. 

Specialist Use Only 

Cutimed sorbact 

All chronic and acute wounds that are critically colonised or 

infected including superficial wounds, traumatic wounds, 

postoperative or dehisced wounds, fistulae or abscesses, 

ulcerations (venous, arterial, diabetic, pressure), fungal 

infections. 

Acticoat absorbent 

As an antimicrobial absorbent dressing over partial- and fullthickness 

wounds such as pressure ulcers, venous ulcers, 

diabetic ulcers, burns, donor and recipient graft sites and 

cavity wounds 

Larvae E 

Debridement of slough and necrotic tissue in a wide variety of 

wound types 

Cutimed Protect Cream 

Aim to rebuild skin lipids and restore a healthy moisture 

balance in the skin. Formulated for dry and sensitive skin. 

Cutimed Protect Spray 

Spray and foam applicator that provide a long-lasting 

protective barrier against both, external threats such as 

incontinence or wound fluids that impact the skin. 

VAC 

Compatible with all V.A.C. Therapy Dressings. 

Promogran prisma 

PROMOGRAN® matrix is indicated for the management of 

all wounds healing by secondary intent which are clear of 

necrotic tissue, including: 

•Diabetic ulcers 

•Venous ulcers 

•Pressure ulcers 

•Ulcers caused by mixed vascular aetiologies 

•Traumatic and surgical wounds 

K Two Compression bandage system 

Two-layer compression system comprising: K Tech (first 

layer), a composite bandage formed of wadding and shortstretch 

compressive fabric and K Press (second layer), a 

cohesive, compressive, elastic bandage. Available in sizes 

18-25cm and 25-32cm. Provides an average compression of 

40mmHg.

Product Ordering Information 

Product Size Pack 

Comfeel Plus Transparent 5cm x 7cm 10 




Cutimed Comfeel Sorbact Plus Ribbon Transparent Gauze Dressing 9cm 2cm x 14cm 50cm 10 20 

Cutimed 

Comfeel 

Sorbact 

Plus 

Ribbon 

Transparent 

Gauze Dressing 

9cm 

5cm x 

25cm 

200cm 10 

5 

Cutimed Sorbact Round Swab 3cm 14 

Cutimed Comfeel Sorbact Plus Swabs Transparent 15cm 4cm x x 6cm 15cm 5 

Cutimed Sorbact Swabs 

Comfeel Plus Transparent 

7cm x 9cm 

15cm x 20cm 

5 


Product Size Pack * 

Acticoat Absorbent Antimicrobial Barrier Dres5cm x 5cm 5 

Acticoat Absorbent Antimicrobial Barrier Dres10cm x 12.5cm 5 

Acticoat Product Absorbent Antimicrobial Barrier Rop Size 2cm x 30cm Pack5 

DuoDerm Extra Thin 5cm x 10cm 10 


DuoDerm Extra Thin 7.5cm x 7.5cm 5 

Biatain Ag Adhesive 12.5 x 12.5cm 5 

Biatain 

DuoDerm 

Ag Adhesive 

Extra Thin 9cm 

18cm x 

15cm 

18cm 

105 

Biatain DuoDerm Ag Adhesive Extra Sacral Thin 9cm 23cm x x 25cm 23cm 105 

Biatain Ag Adhesive Heel 

DuoDerm Extra Thin 

19cm x 20cm 

9cm x 35cm 

5 

10 





Biatain Adhesive 10cm x 10cm 10 

Biatain Adhesive 12.5 x 12.5cm 10 


Biatain 

Product 

Adhesive 

Size 

18cm x 28cm 

Pack10 

Biatain Aquacel Adhesive Sacral 1cm 23cm x x 45cm 23cm 5 

Biatain Adhesive Heel 19cm x 20cm 5 

Biatain Aquacel Adhesive 2cm 17cm x Contour 45cm 5 

Aquacel 5cm x 5cm 10 

Aquacel 10cm x 10cm 10 

Biatain Aquacel Silicone 15cm 7.5cm x 15cm 7.5cm 10 5 

Biatain Silicone 10cm x 10cm 10 

Aquacel 4cm x Biatain Silicone 12.5 x 12.5cm 10 

Biatain Aquacel Silicone 4cm 15cm x x 20cm 15cm 105 

Biatain 

Aquacel 

Silicone 

4cm 

17.5 x 

30cm 

17.5cm 

105 



Versiva XC Adhesive 10cm x 10cm 10 

Versiva XC Adhesive XC Adhesive 10cm 14cm x 14cm 10cm 10 

Versiva XC Adhesive 

XC Adhesive 14cm 

19cm x 19cm 

14cm 105 


Versiva XC Adhesive XC Adhesive Heel 19cm 18.5 x 20.5cm 19cm 5 

Versiva XC Adhesive XC Adhesive Sacral 22cm 21cm x 25cm 22cm 5 

Versiva XC Non Adhesive 7.5cm x 7.5cm 10 

Versiva XC Non XC Adhesive Adhesive Heel 18.5cm 11cm x 11cm x 20.5c 10 5 

Versiva XC Non XC Adhesive Sacral21cm 15cm x 15cm 25cm 5 

Versiva XC Non Adhesive 

Versiva XC Non Adhesive 

20cm x 20cm 

7.5cm 7.5cm 

5 

10 

Versiva XC Non Adhesive 11cm x 11cm 10 




Versiva XC Non Adhesive 7.5cm x 7.5cm 10 


Versiva Product XC Non Adhesive Ordering 15cm Information x 15cm 5 



Urgotul 5cm x 5cm 10 







Mepitel 5cm x 7cm 5 






Tricotex 9.5cm x 9.5cm 50 


Solvaline N 5cm x 5cm 100 






Softpore 6cm x 7cm 60 








Kerramax 10cm x 10cm 10 





Biatain Adhesive 10cm x 10cm 10



Biatain Ag Adhesive 12.5 12.5cm 5 

Softpore Biatain Ag Adhesive 20cm 18cm x 18cm 10cm 305 

Softpore 

Biatain Kerramax Ag Product Adhesive Sacral Ordering 25cm 20cm Information 

23cm x 23cm 

10cm 22cm 30 105 

Biatain Ag Adhesive Heel 19cm x 20cm 5 

Softpore Kerramax 30cm 20cm x 10cm 30cm 305 


Size Pack * 

Biatain 

Product 

Adhesive 

Size 

10cm x 10cm 

Pack 

10 

Product Biatain Adhesive Size 10cm 12.5 x x 12.5cm 10cm Pack10 

Adhesive 18cm 18cm 5 

Kerramax Biatain Adhesive Adhesive 10cm 12.5cm 18cm x 28cm 10cm x 12.5c 10 

Cutimed Kerramax Biatain Sorbact Adhesive Ribbon Sacral Gauze Dressing 10cm 18cm 2cm 23cm x 50cm 23cm 22cm 18cm 10 205 

Cutimed Biatain Adhesive Sorbact Ribbon Heel Gauze Dressing 5cm 19cm x 200cm 20cm 105 

Cutimed Kerramax Biatain Adhesive Sorbact Adhesive Round Swab 20cm 18cm 3cm 17cm Contour x 22cm 28cm 10 145 

Cutimed 

Kerramax Biatain Sorbact Adhesive Swabs 

20cm 23cm 4cm x 6cm 

30cm 23cm S 5 

Cutimed Sorbact Swabs 7cm x 9cm Product Biatain Adhesive 19cm Size x 20cm Pack H 5 

* 

Product Biatain Silicone Adhesive Size 17cm 7.5cm Contour x 7.5cm Pack10 

5 

* 

Acticoat Biatain Silicone Absorbent Antimicrobial Barrier Dres5cm 10cm x 5cm 10cm 10 5 

Acticoat Biatain Silicone Absorbent Adhesive Antimicrobial Barrier Dres10cm 10cm 12.5 x 12.5cm 10cm 10 10 5 

Acticoat 

Biatain Silicone Absorbent 

Adhesive 

Antimicrobial Barrier Rop 

12.5cm 

2cm 15cm x x 30cm 15cm x 12.5c 10 

5 


Biatain Silicone 17.5 x 17.5cm 5 

Biatain Adhesive Non Adhesive 18cm 5cm x 7cm 18cm 10 5 

Biatain Adhesive Non Adhesive 18cm 10cm x 28cm 10cm 10 10 


Versiva Biatain Ag XC Adhesive Non Adhesive Adhesive 23cm 10cm 12.5 x 12.5cm 10cm 

23cm 20cmS 10 

5 

Versiva Ag 18cm 18cm Biatain 

XC Adhesive Non Adhesive 19cm 15cm 

14cm x 

14cm 20cm 15cmH 10 

5 

Biatain Versiva Ag XC AdhesiveSacral 23cm 19cm 23cm 19cm Versiva Biatain Ag XC Adhesive Non Adhesive Heel 17cm 20cm 19cm 22cm Contour x 22cm 20cm 5 

Versiva XC Adhesive Heel 18.5 x 20.5cm 5 

Versiva XC Adhesive Sacral 21cm x 25cm 5 

Versiva Product XC Non Adhesive Size 7.5cm x 7.5cm Pack Pack 10 

* 

Versiva Adhesive XC 10cm 11cm x 10cm 11cm Biatain Non Silicone Adhesive 7.5cm x 7cm x 7.5cm 10 

Biatain Versiva Adhesive XC Non Adhesive 12.5 15cm x 12.5cm 15cm 105 

Versiva Biatain Adhesive XC Non Silicone Adhesive 10cm 18cm 20cm x 18cm 20cm 10cm 10 

5 

Adhesive 

Non Adhesive 10cm 

18cm 

x 28cm 

20cm Biatain Silicone 12.5cm x 12.5c 10 5 

Biatain Adhesive Sacral 23cm 23cm Biatain Adhesive Non Silicone Heel Adhesive 15cm 19cm x 20cm 15cm 5 

Biatain Adhesive 17cm Contour 5 

Biatain Non Silicone Adhesive 20cm 17.5cm x 20cm x 17.5c 5 


Size Pack * 

Biatain 

Product 

Silicone 

Size 

7.5cm 7.5cm 

Pack 

10 

Biatain 

Cutimed Silicone Silicone 

Alginate 

7.5cm 

5cm 10cm x x 

5cm 10cm 7.5cm 10 

10 

Biatain Silicone Silicone 10cm 12.5 12.5cm 10cm 10 

Biatain Cutimed Silicone Alginate 10cm 15cm x 15cm 10cm 10 5 

Biatain Silicone Silicone 12.5cm 17.5 x 17.5cm x 12.5c 105 

Cutimed Alginate 10cm x 20cm 10 

Biatain 

Cutimed 

Silicone 

Alginate 

15cm 

2.5cm 

x 

x 

15cm 

30cm 

5 

5 

Biatain Silicone 17.5cm x 17.5c 5 



Versiva Product XC Adhesive Size 14cm x 14cm Pack 10 

Versiva Product XC Adhesive Size 19cm x 19cm Pack 

Biatain Ag Adhesive 12.5cm x 12.5c 5 

Versiva 

Cutimed 

XC Adhesive 

Alginate 5cm 

22cm 

x 

x 

5cm 

22cm 

10 

Versiva XC Adhesive Heel 18.5 x 20.5cm 5 

Versiva Cutimed XC Adhesive Alginate Sacral 10cm 21cm x 25cm 10cm 105 

Versiva 

Cutimed 

XC Non 

Alginate 

Adhesive 

10cm 

7.5cm 

x 20cm 

7.5cm 

10 

Versiva XC Non Adhesive 11cm 11cm 10 

Versiva Cutimed XC Non Alginate Adhesive 2.5cm 15cm x 15cm 30cm 5 



Biatain Ag Adhesive 12.5cm x 12.5c 5 

Biatain Ag Adhesive 18cm x 18cm 5 

Biatain Product Ag Adhesive Ordering 23cm Information x 23cm S 5 

Biatain Ag Adhesive 19cm x 20cm H 5 


Biatain Ag Non Adhesive 5cm x 7cm 5 

Biatain Ag Non Adhesive 5cm x 8cm Cav 5 






Activon Tube 25g 12 


Activon Tulle 5cm x 5cm 5 

Activon Tulle 10cm x 10cm 5 


Aquacel Ag 1cm x 45cm 5 










Iodoflex 5g 5 

Iodoflex 10g 3 

Iodoflex 17g 2 


Urgotul SSD 11cm x 11cm 16 

Urgotul SSD 16cm x 21cm 16 


Algivon 5cm x 5cm 5 

Algivon 10cm x 10cm 5 


Actilite 10cm x 10cm 10 

Actilite 10cm x 20cm 10


Actilite 


10cm x 10cm 10 

Actilite 10cm x 20cm 10 


Inadine 5cm x 5cm 25 

Inadine 9.5cm x 9.5cm 10 


Clinisorb 10cm x 10cm 10 




Actico 4cm x 6m 1 






K-Four 18-25cm 1 


K-Lite 5cm x 4.5m 16 


K-Lite 7cm 10cm x 4.5m 16 

K-Lite 10cm 15cm x x 4.5m 16 

K-Lite 15cm x 4.5 16 



K-Band 5cm x 4m 20 

Product K-Band Size 7cm x 4m Pack 20 


K-Band 

K-Band 

5cm 

15cm x 

4m 

4m 

20 

20 



Scanpor 1.25cm x 10m 1 

K-Band 15cm 4m 20 





Product 

Scanpor 

Size 

7.5cm x 10m 

Pack 

1 

Scanpor 1.25cm x 5mx 1 1 

Scanpor 

1.25cm x 10mx 5 

1 

Scanpor 2.5cm x 10 1 


Scanpor Acti-fast Beige 17.5cm x 1m 10 1 

Acti-fast Beige 17.5cm x 10m 1 

Scanpor 

Acti-fast Blue 

5cm 

7.5cm 

x 

x 

5m 

1m 1 

Scanpor Acti-fast Blue 7.5cm x 10m 3m 1 


Acti-fast Blue 7.5cm x 5m 1 


Product Acti-fast Green Size 5cm x 1m Pack 1 

Comfifast Acti-fast Green Beige Line 1m 5cm x 3m 12 1 

Acti-fast Green 5cm x 5m 1 

Comfifast 

Acti-fast Green 

Blue Line 1m 

5cm x 10m 

12 

1 

Comfifast Acti-fast Red Blue Line 3m 3.5cm x 1m 16 

Comfifast 

Acti-fast Red 

Blue Line 5m 

3.5cm x 10m 16 

Scanpor 7.5cm x 10 1 

ScanporProduct Ordering 

5cm 

Information 

x 5m 1 

Scanpor 5cm x 10m 1 







Comfifast Acti-fast Red Beige Line 1m 3.5cm x 10 121 

Comfifast Acti-fast Yellow Blue Line 1m 10.75cm x 121 

Comfifast Acti-fast Yellow Blue Line 3m 10.75cm x 61 

Comfifast Blue Line 5m 6 

Product Acti-fast Yellow 10.75cm Size x Pack 1 

Comfifast Acti-fast Yellow Green Line 1m 10.75cm x 121 

Comfifast Green Line 3m 6 


Comfifast Green Line 5m 6 

Comfifast 

Biatain 

Product 

Ag 

Red 

Adhesive 

Line 

12.5cm 

Size 

1m 

x 12.5c 

Pack 

12 

5 

ClearFilm 6cm x 7cm 1 

Comfifast Biatain Product Ag Yellow Adhesive Line 18cm 1m 18cm 12 5 

ClearFilm 10cm 

Size 

x 12c 

Pack 

1 

Comfifast Biatain Ag Yellow Adhesive Line 23cm 3m x 23cm S 5 

ClearFilm 12cm x 12c 61 

Comfifast Biatain 

ClearFilm 

Ag Yellow Adhesive Line 19cm 5m 15cm 

x 

x 

20cm 

20c 

H 56 

1 












Product Size Size Pack Pack 

Acti-fast Op-Site Beige 17.5cm 6cm x 7cm x 1m 1 1 

6 

Acti-fast Beige 17.5cm x 10m 1 1 

Acti-fast Blue Product Blue 7.5cm Size Size x 1mPack 

Pack 1 

Acti-fast Cutimed Blue Gel Blue 7.5cm 

7.5cm 8g x 3m 

3m 10 1 

Acti-fast 


7.5cm 15g x 5m 

5m 10 1 

Acti-fast 


7.5cm 25g x 10m 

10 10 1 

Acti-fast Green 5cm x 1m Acti-fast Green 5cm x 1m 1 

Acti-fast Product Green 5cm Size x 3m Pack 


Acti-fast Sorbaderm Green Barrier Cream 5cm 2g x 5m 1 

Acti-fast Acti-fast Green Green 5cm 5cm x x 5m 10m Sorbaderm Barrier Cream 92g 1 

Acti-fast Red Green 5cm 3.5cm x 10m x 1m 1 

Acti-fast 

Product 

Red 3.5cm 

Size 

x 1m 

Pack 

1 

Acti-fast Sorbaderm Red No Sting Barrier Film 3.5cm 1ml x 10m 1 

Acti-fast Sorbaderm Yellow No Sting Barrier Film 10.75cm 3ml x 1m 1 

Acti-fast Sorbaderm Yellow No Sting Barrier Film 10.75cm 28ml x 3m 1 

Acti-fast Yellow 10.75cm x 5m 1 

Acti-fast 

Product Yellow 10.75cm 

Size 

Size x 10mPack 

1 

Cutimed Protect Cream 28g 1 












Acti-fast Red 3.5cm x 1m 1 

Acti-fast Red 3.5cm x 10m 1 











Sorbaderm No Sting 

Product Cutimed Protect Spray 28ml Size Pack 1 

Barrier Film- Foam 

Applicator 1ml 1 

Sorbaderm Product No Sting Barrier Film- Pump Spra Size Pack 

Sorbaderm No Sting 

Cutimed Sorbact Dressing Pad 7cm x 9cm 5 

Barrier Cutimed Film- Sorbact Foam Dressing Pad 10cm x 10c 5 


Applicator Cutimed Sorbact Dressing Pad3ml 10cm x 20c 20 1 

Sorbaderm Cutimed Sorbact No Sting Ribbon Gauze 2cm x 50cm 

Barrier Cutimed Film- Sorbact Pump Ribbon Spray Gauze 28ml 5cm x 200c 

20 

10 1 

Cutimed Sorbact Round Swab 3cm 14 

Cutimed Sorbact Swabs 4cm x 6cm 5 


Sorbaderm No Sting Barrier Film- Foam 1ml 1 


28ml 1 



Cutimed Sorbact Dressing Pad 10cm x 20cm 20



Acti-fast Product Green 5cm Sizex 3m Pack 1 

Acti-fast Product Product 

Green 

Ordering Information 

5cm Sizex 5m Pack 

Cutimed Gel 8g 

110 

Acti-fast Op-Site Green 5cm 6cm x 10m x 7cm 61 

6 

Acti-fast Cutimed Red Gel 3.5cm 15g x 1m 110 

Acti-fast Cutimed Red Gel 3.5cm 25g x 10m 10 

Acti-fast Product Yellow 10.75cm Size x 1m Pack 1 

Acti-fast Cutimed Yellow 

Gel Gel 8g 

10.75cm 8g x 3m 101 

Acti-fast Product Yellow 10.75cm Size x 5m Pack 1 

Acti-fast Cutimed Yellow Gel Gel 10.75cm 15g x 10m 10 10 

Sorbaderm Barrier Cream 2g 

1 

1 

Cutimed Gel Gel 25g 10 10 

Sorbaderm Barrier Cream 92g 1 



ClearFilm Product 10cm Sizex 12cm Pack 1 


ClearFilm Sorbaderm Barrier Cream 2g 12cm 2g x 12cm 1 

ClearFilm Sorbaderm No Sting Barrier Film 15cm 1ml x 20cm 1 1 

Sorbaderm Barrier Cream 92g Sorbaderm No Sting Barrier Film 3ml 1 

Sorbaderm No Sting Barrier Film 28ml 1 



Sorbaderm Sorbaderm No Sting No No Barrier Sting Film- Barrier Foam Film 

3ml 1ml 11 


Sorbaderm No Sting No No Barrier Sting Film- Barrier Pump Film Spra 

28ml 3ml 1 


Sorbaderm No No Sting Barrier Film 

28ml 1 




Cutimed Product Sorbact Dressing Pad 7cm Sizex 9cm Pack 5 

Cutimed Product Sorbact Dressing Pad 10cm Sizex 10cm Pack 5 

Cutimed 

Sorbact Protect 

Dressing Cream 

Pad 10cm 

28g 

x 20cm 20 1 

Cutimed Protect Spray 28ml 1 





Cutimed Protect Spray 28ml 11 

Cutimed Sorbact Dressing Pad 10cm x 10c 5 

Cutimed Sorbact Dressing Pad 10cm x 20c 20 


Cutimed Sorbact Sorbact Dressing Ribbon Pad Gauze 2cm 7cm x 9cm 50cm 205 

Cutimed 

Cutimed Sorbact Sorbact 

Sorbact Dressing Dressing 

Ribbon Pad Gauze Pad 7cm 

5cm 10cm x x 

9cm 

200c 10cm 5 

10 

5 

Cutimed Sorbact Sorbact Dressing Dressing Pad Pad 10cm x 20cm 10c 520 

5 

Cutimed 

Cutimed Sorbact 

Sorbact Sorbact Ribbon 

Round Dressing Gauze Dressing 

Swab 3cm Pad 10cm 2cm x 50cm 

14 

x 20c 20 

20 

Cutimed Sorbact Sorbact Ribbon Swabs Gauze Dressing 4cm 5cm x 200cm 6cm 10 5 

Cutimed 

Cutimed Sorbact Ribbon Gauze 2cm x 50cm 20 20 

Sorbact Sorbact Round Swabs 7cm 3cm x 9cm 14 5 

Cutimed Sorbact Sorbact Swabs Ribbon Gauze 5cm 4cm x x 6cm 200c 10 10 

5 

Cutimed Sorbact Swabs Sorbact 7cm Round Swab 3cm x 9cm 

14 14 

5 



Acticoat Absorbent Antimicrobia 5cm x 5cm 5 

Acticoat Cutimed Absorbent Sorbact Antimicrobial Swabs Barrier Dres5cm 7cm x x 5cm 9cm 5 

Acticoat 

Acticoat 

Absorbent 

Absorbent 

Antimicrobial 

Antimicrobia 

Barrier Dres10cm 

10cm 

x 

x 

12.5cm 

12. 5 

Acticoat Absorbent Antimicrobial Antimicrobia Barrier Rop2cm x 30cm 5 


Acticoat Absorbent Antimicrobia 5cm x x 5cm 55 


Acticoat Absorbent Antimicrobia 10cm x x 12. 12. 55 

Larvae E 

Acticoat Absorbent Antimicrobia 2cm x x 30cm 55 




Biatain Ag Adhesive 12.5 x 12.5cm 5 

Biatain Ag Adhesive 18cm x 18cm 5 

Biatain Ag Adhesive Sacral 23cm x 23cm 5 

Biatain Ag Adhesive Heel 19cm x 20cm 5 



VAC 

Larvae EE 



Biatain Adhesive 12.5 x 12.5cm 10 



Biatain Adhesive Sacral 23cm x 23cm 5 

Biatain Adhesive Heel 19cm x 20cm 5 


VAC 


Sorbaderm Product No Sting Ordering Barrier Information 

Film- Foam Applicator 1ml 1 

Sorbaderm No Sting Barrier 

Film- Foam Applicator 3ml 1 


Sorbaderm 

Promogran 

No 

Prisma 

Sting Barrier 

28cmsq 10 

Film- Pump Spray 

Promogran Prisma 123cmsq 28ml 10 1 



K Two Compression 

K 

System 

Two Compression 

2-layer ankle 

System 

2-layer circumference ankle circumference Short Short 1 

10 K Two cm ankle Compression circumference 18-25cm 1 

10 System cm ankle 10 cm circumference ankle 25-32cm 1 

latex circumference free bandages for ankle 18-25cm 1 

circumference K Two Compression 18-25cm 1 

latex System free 10 bandages cm ankle for ankle 

circumference 25-32cm 1 

12 K Two cm wide Compression bandages for 

ankle System circumference latex free 

18-35cm 1 

12 bandages cm wide for bandages ankle for 

ankle circumference circumference 18-25cm 25-32cm 1 

8 

K 

cm 

Two 

wide 

Compression 

bandages for ankle 


System latex free 

8 cm wide bandages for ankle 


circumference 25-32cm circumference 

2-layer reduced compression 

25-32cm 1 

10cm 

K Two 

wide 

Compression 

for ankle 

circumference System 12 cm wide 18-25cm 1 

2-layer bandages reduced for ankle compression 

10cm circumference wide for ankle 18-35cm 1 

circumference K Two Compression 25-32cm 1 

2-layer System reduced 12 cm compression 

wide 

system bandages latex for free ankle for ankle 18-25cm 1 

2-layer circumference reduced compression 25-32cm 1 

system K Two latex Compression free for ankle 25-32cm 1 

System 8 cm wide 




System 8 cm wide 




System 2-layer reduced 

compression 10cm wide for


Management Of Venous Leg Ulcers 


Premierpore 5cm x 7cm 50 







Op-Site Post Op 30cm x 10cm 20 


Op-Site Post Op 15.5cm x 8.5cm 20 

Op-Site Post Op 9.5cm x 8.5cm 20 

Op-Site Post Op 6.5cm x 5cm 100 





Comfifast Red Line 10m x 3.5cm Each 

Comfifast Medium Green Line 10m x 5cm Each 

Comfifast Large Blue Line 10m x 7.5cm Each 

Comfifast Small Trunk Yellow Line 10m x 10.75cm Each 

Comfifast Adult Beige Line 10m x 17.5cm Each 

Comfifast Adult Trunk Beige Line 1m x 17.5cm Each 

Comfifast Small Limbs Red 1m x 3.5cm Each 

Comfifast Small/Medium Limbs Green 1m x 5cm Each 



Comfifast Large Limbs Blue 1m x 7.5cm Each 



Comfifast Extra Large Limbs/Heads 

/Childrens Trunks Yellow 1m x 10.75cm Each 






Cutimed Protect Skin Barrier Cream 28g Each 

Cutimed Protect Skin Barrier Cream 90g 12 


Cutimed Protect Skin Barrier Spray 28ml Each 

Cutimed Protect Skin Barrier Spray 28ml 12 

Appendix 1 

“A leg ulcer is a loss of skin below the knee on the leg or foot which takes more than 6 weeks to 

heal” (Dale et al, 1983) *ABPI = ankle brachial pressure index 

If ABPI is greater than or 

equal to 0.8 commence 

and maintain the 

following: 

Apply compression 

bandaging 

Use simple dressings 

Advise about elevation 

of leg at rest and 

exercise. 

Assess & ensure 

appropriate pain control 

Assess nutritional status 

Advise on well-balanced 

diet. 

Assess mobility 

Emolient cream applied 

to maintain healthy skin 

If the leg ulcer fails to 

heal after 3 months 

When healed: 

Measure and fit 

compression stockings 

Repeat ABPI 3-6 

monthly. 

Teach patient to apply 

stockings correctly 

Re-inforce health 

education (diet, rest, 

mobility and skin care) 

If a leg ulcer re-occurs, a 

leg ulcer assessment 

should be completed 

once again. 

Evaluate for surgical 

correction if appropriate 

If the leg ulcer fails to heal 

after 3 months 

All clients must be assessed by a 

Health Care Professional trained 

in Leg Ulcer Management 

Leg Ulcer assessment must be 

completed 

Non-venous aetiologies 

excluded eg. chronic ischemia 

diabetes, rheumatoid arthritis, 

hypertension, vasculitus & 

cutaneous malignancy (eg. 

SCC, 8CC, MM, Lymphoma) for 

cardiac failure 

Refer to TV team if ABPI 0.6-0.8 

& asymptomatic Reduced 

compression 15-25mmHg if 

appropriate 

Refer if ABPI 0.6-0.8 & 

symptomatic of arterial disease 

no compression 

Refer to VASC ABPI 1.3 

Refer (with ABPI) if: dermatitis 

and/or contact allergy fails to 

respond to 

primary care treatmentlatypical 

ulcers 

Refer if fixed ankle deformity or 

poor mobility 

Refer if patient at nutritional risk 

(with MUST score of above 2) 

Emergency referral if severe 

dermatitis or celulitis with 

systemic toxicity or 

rapidly deteriorating ulcer 

Emergency referral if ischaemic 

complications of compression. 

Remove bandages immediately 

Refer to TV team (with ABPI) if 

healing has failed to start after 

following these 

Investigations 

Refer to GP/ 

Dermatologist 

Vascular Surgeon 

Urgent Vascular Referral 

no compression 

Member of Diabetic Foot 

Care Team 

TV Team for toe 

pressure 

Dermatogist 

Community 

Physiotherapist 

State Registered 

Community 

Dietician 

To GP/Dermatologist 

Dermatology/Vascular as 

appropriate 

CG7 - Guidelines for the Care and Management of Leg Ulcers — RATIFIED DECEMBER 2010 

First ratification date: October 2009

Wound Care Glossary 

When to use antimicrobials 

Bacteria 

A single cell organism that can damage healthy cells/tissues. 

Bacterial Burden 

The total number of bacteria in a wound, that may or may not 

be causing a host reaction. 

Colonisation 

The presence of replicating bacteria that adhere to the 

Bacterial Balance 

(Contaminated Wound) 

All wounds are 

contaminated, with 

the exception of very 

recent burns. 

The patient’s ability to 

heal overpowers the 

bacteria and normal 

healing progress is 

observed. 

Critically Colonised 

(Critically Colonised 

Wound) 

Although the wound 

is not infected, the 

patient’s ability to 

heal is no longer 

overpowering the 

bacteria and the 

wound healing 

process stalls. 

Infection 

(Infected Wound) 

Bacteria in the wound 

have completely 

overwhelmed the 

patient’s ability to heal 

and the wound area 

shows signs of a host 

reaction. 

woundbed but do not cause cellular damage to the host. 

Critical Colonisation 

An increasing bacterial load on a wound that is intermediate 

between the category of colonisation and infection. Will not heal 

but may not display classic signs of infection. 

Epithelialisation 

The process of the formation of new epithelial tissue - the top 

layer of the skin. 

Granulation Tissue 

The pink to red, moist, fragile tissue that fills in an open wound 

bed during the proliferative (cell division) phase of healing. 

Local Infection 

The host response to bacterial, viral or similar invasion. 

Necrotic Tissue 

Likely signs 

• Normal healing* 

• Normal odour 

• Pink/red healthy 

granulation tissue 

Choice of dressing 

• Dressing without 

antimicrobial 

depending 

on individual 

assessment 

Likely signs 

• Delayed healing 

• Abnormal odour 

• Increased exudate 

• Absent/abnormal/ 

discoloured 

granulation tissue 

• Increased pain at 

wound site 


• Antimicrobial 

dressing 

Likely signs 

• Delayed healing 

• Abnormal odour 

• Excessive/purulent 

exudate 

• Pain at wound site 

• Tenderness/ 

warmth/redness 

of wound 

surroundings 

• Fever 


• Use of antimicrobial 

dressings and/or 

systemic antibiotics 

according to clinical 

judgement and 

local guidelines 

Dead tissue, can be hard in the form of a black eschar or soft 

slough. 

Slough 

Deposits of dead white cells, dead bacteria, etc. in the wound 

bed, yellow in appearance. 

The information provided is intended only as a general guide for the appropriate use of 

antimicrobial in wound care management and should not supercede clinical judgement 

* More than 20-40% reduction in ulcer 

area over the first 2-4 weeks of treatment 

denotes normal wound healing 

is being achieved. 

Based on “Clinical Wound Assessment - 

A Pocket Guide” developed by 

Dr Robert Kirsner, USA 

Dr Sylvie Maume, France 

Dr Christian Münter, Germany 

Dr Gary Sibbald, Canada

Malnutrition Universal Screening Tool 

B APEN 

Advancing Clinical Nutrition 

'Malnutrition Universal Screening Tool' 

MAG 

Malnutrition Advisory Group 

A Standing Committee of BAPEN 

BAPEN is registered charity number 1023927 www.bapen.org.uk 

Step 1 

BMI score 

+ 

Step 2 

Weight loss score 

+ 

Step 3 

Acute disease effect score 

'MUST' 

‘MUST’ is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition 

(undernutrition), or obese. It also includes management guidelines which can be used to develop 

a care plan. 

BMI kg/m 2 Score 

>20 (>30 Obese) = 0 

18.5-20 = 1 

5 days 

Score 2 

It is for use in hospitals, community and other care settings and can be used 

by all care workers. 

This guide contains: 

A flow chart showing the 5 steps to use for screening and management 

BMI chart 

Weight loss tables 

Alternative measurements when BMI cannot be obtained by measuring weight and height. 

Step 4 

Overall risk of malnutrition 

Acute disease effect is unlikely to 

apply outside hospital. See ‘MUST’ 

Explanatory Booklet for further 

information 

Add Scores together to calculate overall risk of malnutrition 

Score 0 Low Risk Score 1 Medium Risk Score 2 or more High Risk 

The 5 'MUST' Steps 

Step 1 

Measure height and weight to get a BMI score using chart provided. If unable to obtain 

height and weight, use the alternative procedures shown in this guide. 

Step 2 

Note percentage unplanned weight loss and score using tables provided. 

Step 3 

Establish acute disease effect and score. 

Step 4 

Add scores from steps 1, 2 and 3 together to obtain overall risk of malnutrition. 

Step 5 

Use management guidelines and/or local policy to develop care plan. 

0 

Low Risk 

Routine clinical care 

Repeat screening 

Hospital – weekly 

Care Homes – monthly 

Community – annually 

for special groups 

e.g. those >75 yrs 

Step 5 

Management guidelines 

1 

Medium Risk 

Observe 

Document dietary intake for 

3 days 

If adequate – little concern and 

repeat screening 


Care Home – at least monthly 

Community – at least every 

2-3 months 

If inadequate – clinical concern 

– follow local policy, set goals, 

improve and increase overall 

nutritional intake, monitor and 

review care plan regularly 

2 or more 

High Risk 

Treat * 

Refer to dietitian, Nutritional 

Support Team or implement 

local policy 

Set goals, improve and increase 

overall nutritional intake 

Monitor and review care plan 


Care Home – monthly 

Community – monthly 

* Unless detrimental or no benefit is 

expected from nutritional support 

e.g. imminent death. 

Please refer to The ‘MUST’ Explanatory Booklet for more information when weight and height cannot be measured, and 

when screening patient groups in which extra care in interpretation is needed (e.g. those with fluid disturbances, 

plaster casts, amputations, critical illness and pregnant or lactating women). The booklet can also be used for training. 

See The ‘MUST’ Report for supporting evidence. Please note that ‘MUST’ has not been designed to detect 

deficiencies or excessive intakes of vitamins and minerals and is of use only in adults. 

All risk categories: 

Treat underlying condition and provide help and 

advice on food choices, eating and drinking when 

necessary. 

Record malnutrition risk category. 

Record need for special diets and follow local policy. 

Obesity: 

Record presence of obesity. For those with 

underlying conditions, these are generally 

controlled before the treatment of obesity. 

Re-assess subjects identified at risk as they move through care settings 

See The ‘MUST’ Explanatory Booklet for further details and The ‘MUST’ Report for supporting evidence. 

© BAPEN

Non-Formulary / New Product 

Request Form 

Notes 

Non Formulary Exception Reporting Form 

To be completed when a non-formulary product is to be used. This will help monitor the appropriateness of 

the present formulary and influence future decision-making. 

Patient ID Number: ……………………………………………………….. Organisation: ………………………… 

GP Practice 

…………………………………………………………………………………………………………………………… 

Tick all that apply 

Type of Wound Wound bed Wound depth Exudate levels Aim of treatment 

description 

Skin Tear/ Epithelialising Superficial Dry Protection 

Laceration 

Surgical Granulating Shallow Minimal Warm moist 

Environment 

Pressure Sloughy Cavity Moderate Rehydration 

Ulcer 

Venous 

Critically 

Deep cavity Heavy Desloughing 

Ulcer 

Colonised 

Arterial Ulcer Infected Sinus Absorption 

Diabetic 

Necrotic 

Odour control 

Ulcer 

Other Fungating Anti-microbial 

effect 

Current Products in use 

Formulary Products Used Duration used Reasons discontinued/not 

suitable 

1. 

2. 

3. 

(Continued overleaf) 

Page 10 of 13 

Information relating to non-formulary products use 

Name of product chosen 

Time used 

Rationale for choice 

Did this product achieve the aims that were highlighted in the rationale for choice? 

Yes 

No 

If no please give reasons 

Name of person submitting this report 

…………………………………………………………………………………………………………………………… 

Base/Hospital 

…………………………………………………………………………………………………………………………… 

Contact number ……………………………………………………… 

Date ………………………………………………………….. 

Signature and Designation 

…………………………………………………………………………………………………………………………… 

Please return completed forms to Tissue Viability Nurses 

Page 11 of 13

Reviewed by: Tissue Viability Service 

Date Published: NOV 2012 

Review Date: Nov 2013

Wound Care Formulary - NHS Rotherham

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