Date ………………. Care Home/nurse name: ………………
Patient Details Contact Tel No. ………
Name / D.O.B. : / NHS No.Address
GP Name / Wound Type:
No. of wounds being treated : / Frequency of Dressing Change:
DO NOT order more than 2 WEEKS SUPPLY.
The dressings below are not the full list found on the local formulary. This can be found at http://www.harrogateformulary.nhs.uk/chaptersSub.asp?FormularySectionID=26, other formulary dressing can be requested at the end of the form. Restricted (red) or non formulary dressings can only be ordered if a clear reason is stated.
Dressings
Type of dressing / Product / Size / No of individual dressings required / Comments
Alginate/Hydrofibre / Sorbsan / 5cm x 5cm / Shallow/Sloughy Wounds Highly absorbent. Forms a gel on contact with wound exudate. A secondary dressing is required. Squares can be cut or torn into strips and loosely packed into the cavity of deeper wounds. (Can be used on bleeding wounds).
10cmx10cm
10cm x 20cm
Aquacel / 1cm x 45cm / For medium to high exuding wounds. Should be covered with an appropriate secondary dressing.
2x45cm
Super Absorbents / Zetuvit / 10cm x 10cm / For moderate to highly exuding wounds. May be used as primary or secondary dressing.
20cm x 20cm
10cm x 20cm
20cm x 40cm
Antimicrobial / Inadine / 5cm x 5cm / Used as a primary wound contact layer for the prophylaxis & treatment of infections in superficial burns & skin loss injuries.
In diabetic wounds up to 4 layers can be applied.
9.5cm x 9.5cm
Bandages / Comfifast Blue line / 7.5cm x 1m / Tubular bandage for retention purposes.
7.5cm x 1m
Comfifast Yellow line / 10.75cm x 1m / Tubular bandage for retention purposes.
10.75cm x 1m
Absorbent Perforated / Softpore / 6cm x 7cm / Low absorption capacity and only suitable for lightly exuding superficial wounds.
Low adherence dressings with adhesive border.
Shower proof.
10cmx10cm
10cm x 15cm
10cm x 20cm
Adhesive tape / Clinipore / 1.25cm x 5m / Permeable non-woven synthetic tape
2.5cm x 10m
Soft silicone and wound contact layer / Atrauman / 5cm x 5cm / Primary wound contact layer. Non-adherent polyester mesh, 1mm pore size and impregnation of neutral triglycerides, prevents penetration of granulation tissue into dressing. Petrolatum free, effective up to 7 days
7.5cm x 10cm
10cm x 20cm
Urgotul / 5cmx5cm / Able to irrigate through dressing if required.
To be used where adherence of products to a wound is likely.
These dressings are NOT to be used if wound is heavily bleeding. Consider an alginate or UrgoClean as an alternative.
10cmx10cm
10cmx40cm
15cmx15cm
20cmx30cm
Film / C-View / 6cm x 7cm / Film dressings to be used only as a primary dressing on lightly exuding wounds.
10cm x 12cm
12cm x 12cm
Hydrocolloids / Comfeel Plus Ulcer / 4cm x 6cm / For low exuding wounds.
Absorbent hydrocolloid dressing with added alginate for absorption.
10cm x 10cm
15cm x 15cm
Comfeel plus Transparent / 5cm x 7cm / For no or low exudate
Useful for traumatic wounds, superficial burns, skin abrasions or removal of foreign bodies
10cm x 10cm
15cm x 15cm
Hydrogel / Aquaform / 8g / For low exuding / dry “flat” wounds.
15g
Foam / Biatain Silicone / 7.5cm x 7.5cm / Can be used as primary or secondary dressings depending on wound type, site, size, depth, tissue type, exudate levels. In hyper-granulating tissue, which may arise from use of occlusive dressings such as hydrocolloids, changing to a more permeable product such as foam dressings may be beneficial.
These dressings may be kept in place for up to 7 days.
For patients with sensitive and/or fragile skin.
10cm x 10cm
10cm x 10cm
12.5cm x 12.5cm
15cmx15cm
17.5cm x 17.5cm
Biatain Silicone Lite / 5cm x 5cm / Choose dressing type appropriate to level of exudate & position of wound.
7.5cm x 7.5cm
10cm x 10cm
12.5cm x 12,5cm
Urotul Absorb Border / 8cmx8cm / For patients with sensitive and/or fragile skin.
10cmx10cm
13cmx13cm
15cmx20cm
20cmx20cm
Sacrum
Non-Adhesive Foam / Biatain Non-Adhesive / 5cm x 7cm / Can be used as primary or secondary dressings depending on wound type, site, size, depth, tissue type, exudate levels.
10cm x 10cm
10cm x 10cm
15cm x 15cm
Medium/Large
Formulary requests not listed above / Restricted (red) or Non Formulary requests (reason must be stated or the product cannot be supplied
Product name / Product size / Quantity / Product name / Product size / Quantity
Reason for Non formulary request
Date ………………. Care Home/nurse name: ………………
Patient Details Contact Tel No. ………
Name / D.O.B. : / NHS No.Address
GP Name / Wound Type:
No. of wounds being treated : / Frequency of Dressing Change:
DO NOT order more than 2 WEEKS SUPPLY.
The dressings below are not the full list found on the local formulary. This can be found at http://www.harrogateformulary.nhs.uk/chaptersSub.asp?FormularySectionID=26, other formulary dressing can be requested at the end of the form. Restricted (red) or non formulary dressings can only be ordered if a clear reason is stated.
Dressings
Type of dressing / Product / Size / No of individual dressings required / Comments
Multilayer Compression bandaging Full compression / K-Two / Multi-layer compression bandage system (2 layer system).
For venous leg ulcerations with a Dopler reading >0.8mmHg.
K-four / Multi-layer compression bandage system (4 layer system).
For venous leg ulcerations with a Dopler reading >0.8mmHg.
Multilayer compression bandaging for mixed aetiology – reduced compression. / K – two reduced / Reduced compression bandage system.
K-four reduced
Full compression Bandages / Artico cohesive / For use on irregular sized legs
Artico2C cohesive / For use on regular shaped legs.
Compression Hosiery Kits / Activa leg ulcer hosiery kit / To be considered as an alternative to compression bandages if concordance or patient independence is an issue.
Actilymph hosiery kit
Bandages / K-Lite / 10cm x4.5m / For retention of dressings.
Their aim is to keep the dressing close to the wound without inhibiting movement or restricting blood flow.
K-Soft / 10cm x 3.5m / For absorption of any excess exudate, comfort for patient and increase conformability of limb for application of outer bandage. Also used in application of compression bandage to protect & shape leg.
Dressing packs / Nurse It / Small/Medium / Nurse It contains 1 pair of powder free, latex free nitrile gloves,1 large apron, 1 Disposable bag/2 sterile fields, paper towel, paper measuring tape, seven non-woven swabs, disposable forceps, disposable bag