TIME(S) PRODUCT FORMULARY – WOUND CARE

WOUND DRESSING SELECTION

TISSUE HEALING GENERIC DRESSING Formulary Choices:
TIME(S) CARE STEPS
STATUS GOALS TYPE (from your formulary)
HEALING Acrylic
WOUND: -
Protect healing *Choose a Dressing Calcium Alginate
tissue that can remain in
Promote place as long as safely Film/Membrane
Epithelial or Moisture possible to maintain Foam
granulation Balance constant temperature
tissue and moisture balance Gauze
(majority) (uncovering wound Gelling fiber
NON- slows down healing
HEALABLE until optimal moisture Hydrocolloid
WOUND: and temperature are
Stimulate again met.) Hydrogel

T
Healing
Non-adherent
*Choose a Dressing or Acrylic
HEALING
combination of
WOUND: -
dressings that support Calcium Alginate
Debride
autolytic debridement
necrotic tissue Film/Membrane
and can absorb
(except dry
exudate Foam
stable eschar
*Utilize topical
on heels)
autolytics where Gauze
Slough or required for body
Eschar shapes Gelling fiber
(majority) *Utilize biotherapy Hydrocolloid
when appropriate
NON-
with specialized Hydrogel
HEALABLE
dressings (maggot
WOUND: Hydrophilic
therapy)
Dry and
* Dry stable eschar
stabilize
should not be Hypertonic
necrotic tissue
removed from heel
*Treat Cause of Antimicrobials:
infection /
Inflammation a) Honey
*Choose topical

I
antimicrobial primary b) Iodine
Localized or (povidone or
Reduce dressing
Spreading cadexomer)
Bacterial *Choose secondary
Infection or c) PHMB
Burden dressing that can (polyhexamethylene
Inflammation
remain in place as long biguanide)
as possible
Silver
*Systemic Rx
Antimicrobial as
Hypertonic
needed
 Wound too dry Acrylic
choose dressings that: Film/Membrane
HEALING
*Add Moisture Hydrocolloid
WOUND: -
*Require less frequent
Promote Hydrogel
EXUDATE changes
Moisture
AMOUNT: *Prevents trauma Hydrophilic
Balance
1. None when removed Non-adherent layer
2. Scant
NON- Wound too wet Calcium Alginate
3. Small
HEALABLE choose dressings that:
4. Moderate Foam
WOUND: *Absorb moisture
5. Large
Dry and *Indicated for Gauze
stabilize frequent dressing
wound changes Gelling fibers
*Protect peri wound
Hypertonic

M
area from maceration
EXUDATE
*Identify cause of Foam
TYPE:
Absorb exudate unless it is
Serous Exudate from initial response Gauze
to injury/wound Gelling fibers
Sero- Calcium Alginate
Stop small area
sanguineous *Treat underlying
of bleeding Absorbable
cause of bleeding
Absorb Hemostatic agents
when possible
Exudate Non-adherent layer
Purulent Charcoal (odor)
Antimicrobials:
Minimize Odor *Treat underlying a) Honey
Treat Infection cause of purulent b) Iodine (povidone
Absorb drainage – Infection or cadexomer)
Exudate *Control odor c) PHMB
(polyhexamethylene
biguanide)
Silver

E
EDGES:
epithelial Remove
bridging barriers to Conservative Sharp Debridement followed by appropriate dressings
possible? epithelial based on other symptoms of wound
Epiboly bridging

Inflammatory Control
*Monitor to avoid
Swelling Inflammation
chronic swelling – Appropriate dressing

S
Traumatic Timely
treat with for other symptoms
Edema decrease in
compression if needed
edema
Venous *Control swelling with appropriate
Wound Care with
Edema compression bandages, stockings or
Primary Dressings that
Lymphedema Adjustable Velcro Wraps
can be used under
*20-30mmHg or 30-40mmHg
compression
compression
TIME(S) – T=Tissue Viability I=Infection/Inflammation M=Moisture Balance E=Edges S=Swelling
© 2018 Robyn A. Smith, M.Ed., COTA/L, CLWT, CLT May be reproduced in its entirely for non-commercial, clinical use.
2