Decision Making for Wound Dressing and Scar Management

Objectives of a comprehensiave wound management

Granular Wound bed

Moist wound bed

Warm wound environment

Manage infections

Eliminate dead space

Healthy periwound and intact skin

Manage tissue loads

Control contributing factors

Enhance pt’s ability to heal

Granular and non draining options

Healing as expect, protect granulation, obtain moist environment, protect periwound

Use: impregnated gauze, transparent film, hydrogel

Granular and draining options

Observe infection, protect granulation, absorb exudate, protect periwound

Use: gauze, alginate, semipermeable foam, hydrocolloid

Necrotic and non draining options

Soften eschar, remove eschar, obtain moist environment, protect periwound

Use: surgical/sharp/enzymatic/autolytic debridement or impregnated gauze, transparent film, hydrogel, hydrocolloid

Necrotic and draining options

Observe infection, absorb exudate, remove eschar, protect periwound

Use: surgical/sharp/enzymatic/autolytic debridement or gauze, alginate, semipermeable foam, hydrocolloid

Wound Infections

Avoid occlusive dressings

Re-bandage daily

Use: impregnated gauze, alginate, semipermeable foam

Wound and skin characteristics

Small: gauze/moisture retentive

Large: gauze

Deep: must be packed to prevent abscess

Tunneling: gauze dresings and frequent changes

Adherent Occlusive Dressing Procedure

For small and medium sized uninfected wounds with good periwound integrity (for hands, arms, legs and trunk)

Date and inital wound dressing

Non-Adherent Occlusive Dressing Procedure

Avoid taping to skin, choose foam/cloth/hypoallergenic paper tape if has to tape to skin

Roll gauze, self-adherent elastic wrap, elastic netting

Wounds with dead space

Fill to prevent premature closure and abscess formation

Alginate ropes for heavy drainage; small weave roll gauze for extensive cavities (use sterile instruments) and leave a wick

Gauze packing strips

Tricks of the trade

Hands: if large/infected; use roll gauze in figure 8 to minimize bulk

Legs and arms: non-adherent dressing for periwound/body hair, secure with roll gauze/elastic wrap/netting

Trunk: use short-stretch compression wraps with caution for adequate respiration; secure with roll gauze/elastic vest/both

Ankle/foot: may need more absorptive dressing and think about footwear

will not be tested

AI ulcers

Protect periwound (moisturize dry skin, avoid adhesives, reduce friction, provide padding)

Address wound bed (choose dressing to moisten wound bed, debride necrotic tissue (autolytic/enzymatic; not sharp))

Maximize circulation (avoid compression and choose shoes to accommodate for bandages)

Education (etiology, interventions, RF modification, foot care (rocker bottom); protect from chem/temp/open wounds)

VI ulcers

Protect periwound (moisturize dry skin, topical steroids to decrease weeping but not too much to avoid sensitization)

Address Wound Bed (absorptive dressing and skin sealants)

Enhance venous return (apply compression and instruct methods to decrease edema)

Education (etiology, interventions, RF modification, foot care)

Benefits of compression

Enhances calf muscle pump

Improves venous return

Decreases peripheral edema

Reduces venous distention

Increases tissue oxygenation

Softens lipdermatosclerosis

Protects limbs from trauma

Limits need for prolonged elevation/bed rest

Compression Parameters

30-40mmHg at ankle

10mmHg at infrapatellar notch

If severe VI, can increase to 40-50 mmHg

If mild AI, can decrease to 20-30mmHg

Compression Types

Paste bandage

Short-stretch compression bandage

Multilayer compression bandage system

Tubular bandages

Compression garments

Paste bandage

For ambulatory pts for up to 1wk

Non elastic compression that hardens into semi-rigid support

Disadvantages: odor, cannot get wet, pruritus, should not be used in humidity, cannot accommodate changes in limb size

Short-stretch compression bandage

Low resting pressure and little distensibility

for ambulatory and non ambulatory pts

Disadvantages: needs training for PT and pt, slippage

Multilayer compression bandage system

Inner layer absorbs drainage and provides padding

Middle layer absorbs drainage

Outer layers provide compression

Tubular bandages

Allows for graduated compression (OTC)

Disadvantages: generic shapes and sizes, bandage loses shape and compression quickly

Compression Garments

For long-term management (knee high) range from 20-55 mmHg

Use lowest effective level of compression possible

Used at all times except sleeping and bathing (replace 3-6m)

Pressure Ulcers

Protect periwound (moisturize dry skin, use skin sealants)

Address Wound Bed (choose dressings to provide a moist wound bed, synthetic if uninfected, debride necrotic, control infection, charcoal for odor) (do not debride stable, hard, dry eschar covered wounds in ischemic limbs)

Minimize pressure

Support Surface Technology (consider Braden components, repositioning, transfers, tissue status, BW, deformities)

PT interventions for pressure injuries

Flexibility to minimize contractures

Strengthening to aid with mobility, weight shifts, pelvic floor to manage incontinence

Aerobics to improve CV endurance for mobility and activity

Bed mobility to minimize friction and shear

Pt intervention precautions for NU

May not show signs of infection due to decreased inflammatory response/PVD

Monitor blood sugar (hyperglycemia common with infections, hypoglycemia may occur)

Keys to wound care for NUs

offload NU

Trim callus flush with epithelial surface

Use petrolatum-based moisturizer daily and use toe spacers if enclosing toes in bandage

Total contact casting

Modified short leg casts used for Wagner grade ½ ulcers

Assists wound healing (disperse WB forces, controls edema, protects from trauma, assists with pt adherence)

CI: osteomyelitis, gangrene, fluctuating edema, active infection, ABI <0.45

Gait training and exercise for NUs

PWB with AD

Alter gait pattern to decrease plantar pressure (step to, slower steps, shuffling)

1st MTP extension, TCJ DF, STJ motion; aerobics for glycemic control

Footwear for NUs

Temporary: provides safe ambulation, pressure reduction, can use when total contact is not an option (inserts, padded AFOs, walking shoes)

Permanent: ½ in longer than longest toe

Burn Injury

Goal is to achieve full wound closure in <21d (decreases risk of hypertrophic scarring)

Comfort dressing (painful and more painful once skin buds appear), metabolic (reduction in evaporative cooling to maintain moist), protection against microorganisms, debridement of eschar

Scar Tissue

Contract 24hrs a day until met with opposing force

Dermis

Elastin (gives ECM of CT elasticity and decreases with age)

Collagen (resists stretching forces)

Ground substance (GAGs that form into proteoglycans) (chondroitin 4-sulphate is smallest % of GAGs but is 6x more present in burn scars than in normal skin) (chondroitin is found normally in bone)

Remodeling phase

Type 3 collagen laid down during proliferation replaced by type 1 by collagenases (reabsorbed)

Breakdown > production = flat pliable scar

Breakdown < production = hypertrophic scar

All components of dermis are affected by magnitude and direction of stress applied to the scar (wolfe’s law) - scars need stress to remodel properly

Mature scars are 80% as strong as og tissue (rete pegs and dermal papillae are lost)

Vascularity and cellularity diminish and scar becomes less red and flattened

RFs for hypertrophic scarring

Prolonged healing time

Burn depth

TBSA

Infection

Race, age, gender, location

Thin skin grafts

Hypertrophic Scars

Red (increased vascularity, hyperemia id scar process is active)

Rigid, raised, painful, pruritis, peaks at 3-6m after injury

Scar Massage

Promotes collagen remodeling

Helps decrease itching and desensitizes the tissue

Provides moisture and pliability

Pressure must be hard enough to make scar blanch (3-4x day) (circles, vertical, horizontal, pinch and roll)

Pressure garments for scars

Controls collagen synthesis by limiting BF and force applied

Encourages realignment of collagen bundles present

Must be fit snugly, distal to proximal for 23hrs a day; must apply sun block prior

For long healing wounds, grafted wounds, children, dark skin, vascular support is needed

Exercise for scars

Stretching to the point of blanching for grades 1,2 (post-op/inpatient) and 1-4 for matured scars

Stg and endurance → beneficial for stg, power, body mass, aerobic capacity