Appendix B – Wound Dressings
Open Resources for Nursing (Open RN)
| Name | Classification | Description | Indication for Use | Instruction for Use | Other |
|---|---|---|---|---|---|
| Duoderm | Hydrocolloid | Contains gel-forming agents, impermeable to outside contaminants, promotes autolysis, reduces pain, and promotes moist wound healing. | Partial or full-thickness wounds; may be used to hold other dressing in place; avoid use with infections or diabetes. | Cleanse wound. Select dressing 1-2 inches larger than wound, apply light pressure to allow body heat to promote adhesion, change 3-5 days and PRN. | Watch for moisture buildup and odor. |
| Tegaderm | Transparent film | Permeable to oxygen and water vapor, protects from environmental contaminants, nonabsorbent, “second skin.” | PICC/IV site covers, dry wounds, contains moisture in wound when desired. | Cleanse wound. Use skin sealant around edges to hold firm. Change 4-7 days. | Use adhesive remover to remove and protect from skin tears in the elderly. |
| Steri-Strip | Adhesive | Surgical tape. | May be used for linear wound closure or placement after removal of staples or sutures on surgical wounds. | Apply adhesive sealant prior to application.
Apply perpendicular to wound edges to promote closure. |
|
| Tubigrip | Compression wrap/skin cover | Woven elastic fabric. | May be used as compression wrap or protection of skin. | Sizes vary from infant to body wrap. | When used as compression, double layer provides low end compression 15-20mm Hg. |
| Vaseline Gauze | Occlusive gauze | Woven gauze impregnated with petroleum. | May be used as a nonadherent dressing or to keep wounds moist. | Frequent changes.
Cleanse wound prior to each application. |
Watch for bacteria buildup and odor. |
| Xeroform Gauze | Occlusive gauze | Petrolatum impregnated gauze dressing with 3% bismuth tribromophenate. | The bismuth tribromophenate works to reduce wound odor easily.
It also has a nonsticking surface and protects the wound from contamination. Used for surgical incisions, donor sites, skin grafts, and first- and second- degree burns. |
Cleanse wound prior to placement.
Place dressing directly over wound. Cover with appropriate cover/ secondary dressing. |
Helps minimize bacterial buildup. |
| Coban | Elastic wrap | Sticks to itself without need for adhesive, pins, or clips. Wrap stays in place and is lightweight, porous, and comfortable for patients. Reduces pain. | Can be used as compression wrap. Holds primary dressing in place. Can be used to protect skin or medical device. | If using wrap as compression, verify pulse first.
Do not apply compression to infected area or exposed bone/organ. |
Do not tape to skin.
If used as compression, check pulse regularly. May be left in place up to 7 days. |
| Iodosorb Gel | Fiber gel | Absorbing fluids; removing exudate slough, and debris; and forming a gel over the wound surface. As the gel absorbs exudate, iodine is released, killing bacteria and changing color as the iodine is used up. | For use in cleaning wet ulcers and wounds such as venous stasis ulcers, pressure injuries, diabetic foot ulcers, and infected traumatic and surgical wounds. | Cleanse wound. Squeeze gel in shape of wound onto sterile gauze, apply to wound, and hold with secondary dressing. | May be used to eliminate pseudomonas bacteria.
Verify allergies prior to use. |
| 2″x2″ Gauze | Gauze | Wound cover. | Cleaning and coverage. | Apply to wound and tape. | Avoid applying tape to skin. |
| 3″x3” 4-ply Nonwoven | Gauze | Wound cover. | Cleaning and coverage. | Apply to wound and tape. | Avoid applying tape to skin. |
| 4″x4” 8-ply Gauze Sponge | Gauze | Wound cover. | Cleaning, coverage, and wet-to-dry. | Apply to wound and tape. | Avoid applying tape to skin. |
| 4″x4” 6-ply Drain Sponge | Gauze | Wound cover, trachea, PEG tube, drain cover/protection. | Use to surround trachea, drain, and PEG tube for protection and drainage absorption. | Cleanse area surrounding tube; apply surrounding the drain site top and bottom. | If applying tape to hold, use minimal tape to protect skin upon removal. |
| 6″x6” Super Sponge (“fluff”) | Gauze | Woven-layered, super absorbent for moderate to large drainage. | Wound cover drainage collection and wet-to-dry. | Cleanse wound. Apply and change as prescribed and wound drainage dictates. | Do not allow drainage-filled gauze to remain on wound surface for extended periods. Promotes bacteria and infection. |
| Abdominal Pad | Gauze | Absorbent of a soft nonwoven outer layer that quickly wicks fluid to a cellulose center. Cellulose quickly absorbs and disperses fluids laterally to prevent pooling. | Wound cover and heavy drainage collection. Keeps moisture off skin. Similar to incontinent pad. | Cleanse wound. Apply as prescribed and wound drainage dictates. | Do not allow drainage-filled pad to remain on wound surface for extended periods. Promotes bacteria and infection. |
| Optilock | Polymer | Super-absorbent polymer core locks in drainage under compression.
Adjusts absorption to the amount of drainage. Protects skin from maceration. Nonadherent wound contact layer. |
Pressure injuries, partial and full-thickness wounds, leg ulcers, lacerations and abrasions, and wounds under compression. | Cleanse wound. Apply to wound bed, and hold in place with tape, wrap, etc.
May be left in place up to 7 days if drainage is minimal. |
Do not allow drainage-filled pad to remain on wound surface for extended periods. Promotes bacteria and infection. |
| Kerlix 4” 6-ply Gauze Roll | Gauze | Prewashed, fluff-dried 100% woven gauze with crinkle-weave pattern for loft and bulk. Provides fast-wicking action, aeration, and absorbency. Comes in large variety of sizes. | Wound cover, wound packing, skin wrap protection, and wet-to-dry. | Cleanse wound and apply. | Change as prescribed. Do not allow drainage-filled gauze to remain on wound surface for extended periods. Promotes bacteria and infection. |
| 4” Stretch Bandage (“Kling”) | Gauze | Nonsterile absorbent gauze roll and stretches and conforms to the body shape and clings to itself as it is wrapped. Conforms to the wound area and offers flexibility to allow for body movement. | May be used to hold dressings in place or wrap for skin protection. | Apply as needed. | Avoid applying tape to skin. Apply tape to Kling to hold.
Comes in large variety of sizes. |
| Adaptic | Contact layer | Nonadhering dressing, primary wound contact dressing designed to minimize wound adherence and prevent maceration. Mesh impregnated with a specially formulated petroleum emulsion, and easy to remove and minimizes pain. | Dry to heavily exuding wounds for which adherence of dressing and exudate is to be prevented. | Cleanse wound. Apply to wound, apply primary dressing, and hold with appropriate dressing or tape. | May be used as a contact layer with wound VAC foam or cover skin tears. |
| Telfa | Composite | Made of cotton fabric with a perforated seal of polyester resin. This perforated seal acts as a nonadherent, preventing the dressing from sticking to the wound and/or acting as a barrier between the wound and excretions. | Covers cuts and abrasions. It is also used to prevent infection to sutured wounds and as an absorbent dressing for wound secretions. | Cleanse wound and apply as primary or secondary (contact) layer.
May be used with topical medications. |
Change daily or when saturated. |
| ¼” Plain Packing Strip | Gauze | 100% cotton, fine mesh gauze ideal for wet-to-dry packing.
Available in plain and iodoform (antiseptic). |
Used for packing or as drainage conduits in nasal, sinus, or tunnel packing. | Cleanse wound. Apply as packing or filler in wound tunnel, nasal passage, or sinus cavity. | Change daily or as prescribed.
Do not cut in small pieces to avoid not being able to locate them for removal. |
| Aquacel Ag (also comes as plain hydrofiber with no additives) | Hydrofiber | Primary wound dressing made from sodium carboxymethylcellulose. Textile fiber and presented in the form of fleece held together by a needle bonding process and is available both as a “ribbon” for packing cavities and as a flat nonwoven pad for application to larger open wounds. Fiber turns to gel when moistened by drainage. | Primary wound dressing to absorb large amounts of drainage. Silver component is antimicrobial. The dressing is easy to remove without causing pain or trauma and leaves minimal residue on the surface of the wound. | Cleanse wound. Apply to surface or lightly pack into wound.
Cover with secondary dressing. |
Some patients may be sensitive to silver.
Silver must remain in place for at least 24 hours to be effective. Change frequency as prescribed by physician. |
| Hydrofera Blue | Antimicrobial foam | Pulls bacteria-laden exudate up and away from the wound, which may facilitate healing. Provides a protective antibacterial cover that inhibits the growth of microorganisms. Foam impregnated with methylene blue. | Pressure injuries, diabetic ulcers, venous stasis ulcers, arterial ulcers, superficial burns, donor sites, post-surgical incisions, trauma wounds, abrasions, and lacerations. | Cleanse wound.
Moisten foam with saline or sterile water. Ring out excess moisture. Apply to wound and hold with occlusive cover (Tegaderm, Duoder). |
Hydrofera Blue foam is effective against microorganisms commonly found in wounds, including MRSA, VRE, and Candida. |
| Polymem (Pink)
Polymem (Silver) |
Foam | Polymem contains a mild, nonionic, nontoxic, tissue-friendly cleansing agent, activated by moisture that is gradually released into the wound bed.
Built-in cleansing capabilities reduce the need to cleanse wounds during dressing changes, which can disrupt the growth of healthy tissue as the wounds heals. Wicks away up to ten times its weight in exudate. The absorption capability activates only if the material detects exudate. Nonstick surface to reduce pain and tissue loss during removal. |
Wounds with small to moderate drainage.
Pressure injuries, diabetic ulcers, venous stasis ulcers, arterial ulcers, superficial burns, donor sites, post-surgical incisions, trauma wounds, abrasions, and lacerations. |
Cleanse wound. Place uncut foam directly on wound. Hold with nonocclusive dressing to allow for moisture evaporation.
May use Kerlix, Kling, or Tubigrip to hold in place. |
May be changed daily or weekly depending on drainage amount.
Silver is most effective when left in place > 24 hours. Some patients complain of pain with use of silver. |
| Aquacel Ag Foam | Foam | Absorbs wound fluid and creates a soft gel, maintaining a moist wound environment. Locks in exudates through vertically wicking, reducing the risk of maceration. Helps minimize pain while in place and during dressing changes. | Wounds with small to moderate drainage. Pressure injuries, diabetic ulcers, venous stasis ulcers, arterial ulcers, superficial burns, donor sites, post-surgical incisions, trauma wounds abrasions, and lacerations. | Cleanse wound. Place uncut foam directly on wound. Hold with nonocclusive dressing to allow for moisture evaporation.
May use Kerlix, Kling, or Tubigrip to hold in place. |
May be changed daily or weekly depending on drainage amount.
Sliver is most effective when left in place > 21 hours. Some patients complain of pain with use of silver. |
| Lyofoam | Foam | Management of moderately to highly exuding wounds. Its high absorbency and fluid-handling capacity, combined with the reduced risk of maceration and leakage, provide a longer wear time. Waterproof backing film acts as a barrier to bacterial and viral penetration. Works under compression. | Moderate to heavy draining wounds. Pressure injuries, diabetic ulcers, venous stasis ulcers, arterial ulcers, superficial burns, donor sites, post-surgical incisions, trauma wounds, abrasions, and lacerations. | Cleanse wound. Place uncut foam directly on wound. Hold with nonocclusive dressing to allow for moisture evaporation.
May use Kerlix, Kling, or Tubigrip to hold in place. |
Monitor dressing frequently and change when saturated with drainage. |
| Mepilex Border | Foam | Absorbs and retains exudate and maintains a moist wound environment. The Safetac® layer seals the wound edges, preventing the exudate from leaking onto the surrounding skin, which minimizes the risk for maceration. The Safetac® layer ensures that the dressing can be changed without damaging the wound or surrounding skin or exposing the patient to additional pain. | For moderate to high exuding wounds, such as pressure injuries, leg and foot ulcers, traumatic wounds, and other secondary healing wounds.
May also be used for skin and pressure injury protection/prevention. |
Clean the wound prior to applying a dressing.
The dressing should overlap the wound bed by at least 2 cm onto the surrounding skin. |
Adhesive border is designed to be peeled back to view wound and reseal multiple times. Monitor wound frequently.
Comes in a variety of sizes. |
| Mepilex Border Ag | Foam | Silver has been added. Silver kills bacteria and might be used both for preventing infection and also on wounds with signs of local infection. The Safetac® layer ensures that the dressing can be changed without damaging the wound or surrounding skin or exposing the patient to additional pain. | For moderate to high exuding wounds, such as pressure injuries, leg and foot ulcers, traumatic wounds, and other secondary healing wounds. | Clean the wound prior to applying a dressing.
The dressing should overlap the wound bed by at least 2 cm onto the surrounding skin. |
Adhesive border is designed to be peeled back to view wound and reseal multiple times. Monitor wound frequently.
Comes in a variety of sizes. Mepilex surgical dressing has a super adhesive border and remains in place for 7-10 days. Some patients complain of pain with use of silver. |
| KCI Granufoam Black | Negative Pressure Wound Therapy (NPWT) | Promotes wound healing through Negative Pressure Wound Therapy (NPWT). This helps draw wound edges together, remove infectious materials, and actively promote granulation. By MD order. | Do not place foam dressings directly in contact with exposed blood vessels, anastomotic sites, organs, or nerves. | Detailed instruction for use available online at the myKCI website. | Consider pain control prior to application and removal. |
