Week 8-9: Dressings & Wound Management

Goal for a wound dressing

Moist wound environment

Moist wound environment can reduce

pt pain

Moist wound environment taps

endogenous enzymes for autolytic debridement

How do wound dressings promote endogenous growth?

They trap endogenous enzymes that are used for autolytic debridement

Moist wound environment preserves

endogenous growth factors

A Moist wound environment facilitates...

all 3 phases of wound healing

Autolytic debridement

using body's enzymes to break down tissue and self debride

How do wound dressings effect scar formation?

Promotes formation of a more cosmetically appealing scar

Too moist of a wound enviroment

maceration

Skin damage

Increased risk of infection

Maceration

softening or dissolution of tissue after lengthy exposure to fluid

Too dry of a wound environment

desiccation

decreased enzyme/ growth factors

Scab/crust formation

Wound dressing purpose

-Create/Maintain a moist environment

-Absorb drainage/exudate

-Fill dead space

-Debride necrotic tissue

-Provide thermal insulation

-Prevent or treat infections

-Promote homeostasis

We pack the wound dead space to

heal it faster and stop abscesses from forming

Dressings have to be

-user friendly

-affordable

· Able to remain in place for long periods of time

· Non-traumatic

· Thermally insulating

What affects the cost of dressings

o Type of dressing

o Size

o Additional features (adhesive boarder)

o Local coverage decisions

Local coverage decisions

· Informs of dressings covered and at what rate

Primary dressing

Contact layer, comes in contact with wound surface

Secondary dressing

Wound dressing placed over the primary dressing that provides increased protection, cushioning, absorption, and/or occlusion.

Primary dressings do not always need

secondary dressings

tertiary dressing

not always necessary, could be what holds the dressing in place or a compression wrap

Medication/topicals are NOT

a dressi g

Frequency for dressing changes

Minimize changing frequency

Why do you want to minimize the changing frequency?

It can change the temperature and wound environment

Dressings most absorptive to least

1. Alginates

2. Semipermeable foams

3. Hydrocolloids

4. Hydrogels

5. Semipermeable films

Gauze dressing most absorptive to least

1. Layers of gauze dressing

2. Gauze pad

3. Nonwoven gauze

4. Woven gauze

Composite dressings

Multilayer dressing made from a combination of wound dressing categories

Interactive dressings

Dressings that create a moist environment and interact with the

wound they cover to stimulate cell activity and growth

Occlusive

Blocks air and gas exchange

Permeable

penetrable; porous; allowing liquids or gas to pass through

Occlusiveness rankings

1. Hydrocolloids

2.Hydrogel sheets

3. Semipermeable foam

4. semipermeable film

5. Impregnated gauze

6. Calcium alginates

7. Fine-weave gauze

8-Loose weave gauze

Absorptive Moisture retentive dressings

Alginates>semipermable foam>hydrocolloids>hydrogels>semipermable fims

Absorptive Gauze dressings

Woven

When do you need to change a wound?

As the wound changes

Things to Remember

· Dressing needs change as a wound changes

· There can be several dressing recipes that are appropriate for a wound

· There is NO one dressing that works for all wounds

· Choices of dressings will depend on what is available to you in clinic/facility

· You must know WHY you are using what you are using

Factors to consider for wound dressing

o Amount of wound drainage

o Condition of wound bed (granular or necrotic)

o Presence of wound infection

o Periwound Skin condition (can it tolerate adhesives?)

o Frequency of dressing changes

o Availability of wound dressings

o Cost of dressing

o Wound location

o What WAS the patient using?

Alginate

Most absorptive dressing made from alginic acid from brown seaweed, fibers create a hydrophilic gel

Alginates are

Most absorptive and are semi occlusive

Hydrocolloids are very

occlusive

Alginates are available in

ribbons, rope, and calcium alginate tipped applicators

Alginate tipped applicators are used for

tunnels

Alginate Fibers react with wound exudate and form a

hydrophilic gel to provide a moist wound environment

Hydrophilic gel

absorbs and retains large amounts of moisture, forming a gel-like substance creating moist wound environment

Why is alginate not used for wounds with o with exposed tendon, joint capsule or bone

§ Because they would dry that area out

Fluff don't stuff

§ Don't stuff in bottom of wound

Advantages of alginate

can absorb 20x it's weight, easy to use in filling cavities or irregular wounds, encourages autolytic debridement, works well under compression, hemostatic

o Can remain on wound for several days

o Fibers will NOT cause irritation if left in wound- they emulsify

Can alginate be used on infected wounds?

Yes

hemostatic

controls or stops bleeding

Disadvantages of alginate

dehydrate since its so absorptive, non-adherent = requires secondary dressing, requires irrigation to remove

Alginates work well for

VI ulcers

Semipermeable foams

nonstick, absorbant, spongelike polymer

Semipermeable foam may have adhesive borders for

absorbing exudate

Semipermeable foam waterproof outer layer

o to prevent strike through drainage

strike through drainage

drainage visible through last layer of dressing (unable to be contained by the dressing)

Do we use semipermeable foams on infections?

No, unless changed daily

Semipermeable foams advantages

o Keeps wound moist & warm

o Provides cushioning

o Permeable to gas but not bacteria

o Promotes autolytic debridement

o Can be left in place for several days

o Can be used under compression dressings

Semipermeable foams permeablity

Permeable to gas but NOT bacteria

Semipermeable foams absorption

Will absorb moderate amount of drainage but not dry out a minimally draining wound if left on for extended period of time

Semipermeable foams disadvantages

o Adhesive type may damage Periwound

o Can roll at edges

o May need secondary dressing

o May macerate Periwound as it absorbs fluid if it doesn't have wicking qualities

Wicking qualities

ability to draw moisture away from the skin and towards the outer surface of the fabric, where it can evaporate more quickly

Hydrofibers

composed of carboxymethylcellulose fibers form gel after contact with exudate

Hydrofibers are neither

o an alginate or a hydrocolloid but it has benefits of both

Hydrofibers advantages

o Absorbs moderate to large amounts of drainage

o Works well under compression dressings

o Can stay in place for several days

o Interaction with wound exudate forms a gel

Hydrofibers disadvantages

May fuse to bloody wound base

can dehydrate the wound

Hydrocolloids

Adhesive wafer composed of gelatin, pectin, and carboxymethyl-cellulose

What should you do before application of hydrocolloid?

Warm it first

Do you use hydrocolloids for infected wounds?

No

Duoderm

hydrocolloid dressing that is a barrier against incontinence and MRSA, hep-B, HIV, and pseudomonas

Should you use hydrocolloids for exposed tendons and fasica?

No its sticky

Hydrocolloid advantages

o Impermeable to bacteria and incontinence/ waterproof

o Encourages autolytic debridement

o Absorbs minimal amount of drainage

o Provides thermal insulation

Hydrocolloid disadvantages

Adhesive can damage periwound

Edges can roll

can cause hypergranulation

Pectin causes an odor upon removal (can be mistaken for infection)

Leaves residual in wound bed

How can using a hydrocolloid be mistaken as infection?

The pectin from the hydrocolloid leaves an odor which can be mistaken as infection

Can hydrocolloids be used on skin

yes

Hydrogel sheets are very

occlusive

Semipermable films allow for

gas exchange

Hydrogels

Water, glycerine based, sheet, or impregnated gauze

Hydrogels may require what else

skin sealant for periwound protection

Hydrogrels if not covered correctly

will dehydrate

Hydrogels used for infection?

no

Hydrogels commonly used for

Blisters, abrasions, skin tears, burns, donor sites, mastitis

Mastitis

inflammation/infection of the breast; most commonly occurs in women who are breastfeeding

Hydrogels are good for use with

arterial wounds

Hydrogel advantages

o Donates moisture to wound

• Good for arterial wounds

o Painless removal

o Can soften eschar

Application of amorphous hydrogel

Put hydrogel on applicator and then put applicator into wound

Change applicator each time applied

Hydrogels disadvantages

o Minimal absorptive qualities

o Non-adhesive requiring secondary dressing

o May macerate Periwound

Semipermeable films

transparent polyurethane membrane, breathes like skin allowing vapor exchange

Semipermeable films good for

minimally draining wounds

abrasions

skin tears

Partial thickness wounds

Too much drainage with semipermeable films can result in

the wound stopped air diffusion and can cause maceration

Semipermeable films application

Apply w/o tension or wrinkles

Semipermeable films for infection?

no

Semipermeable film indications for change

if wrinkle/channel develops

New varieties of semipermeable film

combine film with hydrocolloid or foam aka tegaderm

Semipermeable film advantages

o Self-adhering

o Can see wound

oWaterproof/incontinence proof

o Impermeable to bacteria

o May be used as secondary dressing

How long can a semipermeable film last for?`

5-7 days

Semipermeable disadvantages

o No absorptive qualities

o Poor thermal insulation

o May tear off periwound skin

Silicone dressing

Newer technology, thin and thick foam

silicon dressing brand name

mepilex

mepilex

foam dressing for wounds and ulcers

What dressing is beginning to replace hydrocolloids and transparent films?

Silicone dressings

Silicone dressings used for

Skin tears

Fragile skin (elderly)

Skin grafts

Silicon dressings can be used prophylactically to

reduce friction and sheer injuries