Dressed for Success! An Introduction to Wound Dressings

Table of Contents Instructions...... 2 Introduction & Objectives. 2 Introduction to Wound Dressings.. 3 Case Presentations Self Study 12 Dressing Reference Chart... 22 Post-Test.. 27 Seminar Evaluation 29 1

Introduction Clinicians involved in wound care today are faced with many challenges. Choosing an appropriate dressing from the immense and ever-growing list of products available is not the least of these challenges. With new and improved products being introduced at such a rapid rate, it is virtually impossible to keep up. This course, instructed and written by Jamie V. Birmingham, PT, CWS, was designed to provide the clinician with the knowledge and tools needed to choose an effective and appropriate wound dressing. This home study course is intended for educational and instructional purposes only. It is the responsibility of each clinician to use their best clinical judgment and to address each patient on a case by case basis according to their individual and unique circumstances. Instructions To maximize your learning experience, please complete the following steps in this sequence: 1. Read Dressed for Success! text. 2. Perform case presentations-self study. 3. Review supplementary information. 4. Complete the post-test. Fax: (407) 578-8626 Mail: 9857 Montclair Circle Apopka, FL 32703 Certificates of Completion and Continuing Education Credit Anyone scoring an 80% or higher on the post-test will be awarded a certificate of completion. If you do not successfully complete your test you will be notified and may retake it. Please call if you have any questions, and please check with your state board to determine state-specific CEU requirements and home-study eligibility. There will be no refunds for home-study courses. Objectives Upon completion of this home-study program, the participant will be able to: Identify the various categories of wound dressings and list their characteristics and functions. Identify special considerations for each category of wound dressing and describe how it may impact their use. Choose an appropriate wound dressing when given pertinent details about a patient and the patient s wound. 2

Why Use Moist Wound Dressings? Historically, many wounds were left open and allowed to progress through the natural process of healing. After initial damage, the body responded through vasoconstriction and clot formation to establish hemostasis, thereby preventing further blood loss. Depending on the extent of tissue damage, a covering of devitalized tissue might develop. Continuous exposure to air and some exposure to sun acted as a drying agent to decrease the likelihood of infection. Epidermal migration occurred slowly under the scab or devitalized tissue. So, if all of this occurs naturally, why would you use wound dressings? Although there are times when dressings are unnecessary, early research into moist wound healing revealed some clear advantages. When kept continuously moist, wounds were found to have an increased speed of epidermal migration and the resulting scar had improved cosmetic outcomes. A moist environment was also found to assist in autolytic debridement and minimize pain. In addition, covering the wound also minimizes or prevents outside contaminants from entering the wound bed. Lastly, covering a wound was also found to provide thermal protection, promoting optimal blood flow to the wound bed and the immediate surrounding tissue. An important point to consider is that there are times when moist wound healing could be considered a contraindication. There are some situations where the risk of infection outweighs the benefits of moisture. These situations are usually in the presence of distal lower extremity wounds due to the increased likely hood of peripheral vascular disease and/or neuropathy. These conditions will reduce the effectiveness of normal immune function at the level of the cutaneous tissue and increase the risk for infection. Because dry tissue is less likely to become infected, it is generally considered to be the safer, more conservative approach. The Function of Dressings A wound dressing may serve many functions; however, its main purpose is to provide an environment that is conducive to healing. Before a clinician can begin to choose an appropriate dressing, he or she must first have an understanding of how wounds heal. Wound Closure Generally speaking, wound closure requires the depth of the wound bed to fill with granulation tissue, the wound edges to contract and allow the epidermal cells to migrate across the surface of the wound for closure to occur. If the wound bed is dry or necrotic tissue is present, the epidermal cells will migrate at a slower rate or not at all, causing wound closure to be delayed. Conversely, if the wound bed is clean and moist, cellular migration can occur more rapidly, therefore speeding up the rate of healing. Although moisture is beneficial to the wound bed, if intact skin is exposed to excessive moisture for extended periods of time, it becomes more susceptible to injury. Therefore, the cardinal rule when 3

choosing a wound dressing is to keep the wound bed moist and the surrounding intact skin dry. How to Choose a Dressing Many studies have been conducted to determine the most effective way of providing this optimum moist healing environment. There is no single dressing that is appropriate for every wound. There is also no wound that requires only one particular dressing. Usually, a number of dressings could be used with relatively equal success. So, how do you choose just one? Many wound dressings have numerous functions, such as absorption, flexibility, permeability, insulation, and ability to adhere. By answering a few questions about the wound, the list of choices can be considerably narrowed. (See Table 1) Table 1 Question How much drainage is there? Where is the wound located? Can the patient tolerate adhesives? Who will change the dressing? Is cost an issue? How deep is the wound? Is the patient compliant? Is the wound infected? Considerations Absorption Flexibility Ability to adhere Ease of application, Frequency required Cost, Frequency required Wound fillers Comfort, Ability to adhere Permeability Choose a Dressing Rather than attempting to memorize individual products, dressings can be divided into categories. One very common way of categorizing dressings is according to their structural makeup. In other words, they are frequently categorized by what they are rather than what they do. To provide the most complete and useful understanding of dressings, they will be described here first by structural category and then detail their functions, best uses, advantages, and disadvantages. Dressing Classification According to Structure Gauze Dressings Gauze dressings are made of a cotton or synthetic fabric that is absorptive and permeable to water, water vapor, and oxygen. Gauze dressings may be further subdivided into the following categories: all purpose, roll/wrapping, packing/debriding, non-adherent and impregnated. Furthermore, gauze can be either woven or non-woven and can be used dry or moist. All-purpose gauze is generally inexpensive. 4

Gauze is permeable to water and if allowed to dry, it may adhere to and desiccate the wound bed. Wet-to-dry dressings are often used for mechanical debridement, although, upon removal, the adherence is non-selective and healthy tissue can be removed along with necrotic tissue. Because this is unnecessarily painful and often destructive, wet-to-dry dressings are not recommended. Continuously moist gauze can provide a moist wound healing environment, however, the frequency of dressing changes required to assure that the dressing does not dry out often makes this an unfeasible option. All-purpose gauze could effectively be used over a primarily closed wound or sutures for protection and insulation, or as an inexpensive secondary dressing. A primary dressing is one that is located directly on the wound. A secondary dressing is used over the top of the primary dressing for added absorption, padding, insulation, or simply to stabilize the primary dressing in place. Primary dressing: A dressing located directly on the wound Gauze in the form of rolls or wraps is most commonly used as a secondary dressing, providing stabilization to the primary dressing as well as padding, insulation, and added absorption. The variety of forms, shapes, and sizes of gauze also make it useful for packing large wounds. Although the high permeability of gauze is often considered a drawback, it may be the dressing of choice in the event of an infection, as occlusion would be contraindicated. Gauze also comes in a variety of non-adherent and impregnated forms. Non-adherent means that it is resistant to adhering to the wound bed. Nonadherent gauze may be dry, woven, or non-woven gauze that is covered with a non-adhering layer, or may be impregnated with a substance that resists adherence to the wound bed. To be impregnated simply means that something has been added. Products may be impregnated with one or more of the following substances: Oil emulsion, petroleum, saline, scarlet red, sodium chloride, water, xeroform, hydrogel, and zinc. The degree of absorption and permeability of each of these products depends on what substance it has been impregnated with, and how much has been added. For example, if a sponge of gauze has been saturated with petroleum, this would make this dressing highly impermeable to oxygen and water and would virtually eliminate its absorptive capabilities. This dressing would also be less likely to dry out and adhere to the wound bed. Secondary dressing: A dressing used for added absorption, padding, insulation, or stabilization over the primary dressing. 5

Alginates Alginates are non-woven, fibrous dressings manufactured from certain types of seaweed. This dressing is known for its absorptive capabilities and is best used on wounds with moderate to large amounts of drainage. Alginates should never be used on dry wounds, as they will only cause further desiccation. When mixed with wound drainage, the alginate reacts to form a gel-like substance, therefore maintaining a moist wound environment. Alginate dressings come in the form of sheets and ropes. Sheets are used primarily over more superficial wounds and ropes can be used for packing wounds with depth. Because alginates are non-woven, a secondary dressing is required to secure them in place. Alginates have a relatively high permeability to oxygen, water, and water vapor. This, however, can be altered by choosing a secondary dressing that is less permeable. For example, if maintaining moisture in a moderately exuding wound is desired, a more occlusive secondary dressing, such as a semi-permeable film, could be used. Semi-Permeable Films Semi-permeable films are clear, non-absorptive, polymer-based dressings that are permeable to oxygen and water vapor, but impermeable to water and large molecule bacteria. Because they have no absorptive qualities, film dressings should not be used on wounds with moderate to heavy drainage, unless being used as a secondary dressing over an absorptive primary dressing. If used on light or non-exuding wounds, semi-permeable films can usually be left in place for up to a week. Because they are transparent, these dressings have the unique feature of allowing visualization of the wound bed without removal. In the event that fluid accumulates beyond the borders of the wound bed, risking maceration of intact skin, the dressing should be removed. Most film dressings also have strong adhesive properties, and they should not be used on very fragile skin. Caution should be used upon removal as skin tears can occur. Because they are very thin and adhesive, film dressings can also be difficult to apply. Some products come with a framed, peel off backing, making them more user-friendly. Because of their occlusive nature and their transparency, film dressings are quite useful when used to promote autolytic debridement. Autolytic debridement occurs when an occlusive dressing is used to cover a wound and allows devitalized tissue to self-digest by the action of enzymes present in wound exudate. Because the wound can be easily observed for signs and symptoms of infection without removal, the dressing can often be left in place for longer periods of time, allowing maximum debridement to occur. Foam Dressings Foams are sponge-like polymer dressings that may or may not be adherent. Some have adhesive covering the entire dressing, some have a border of adhesive and some have no adhesive at all. Although foam dressings 6

vary in the level of absorption, they generally absorb moderate to heavy amounts of drainage. Therefore, foams are not recommended for wounds with little or no drainage as they can dry out the wound bed. Thicker foam dressings provide higher levels of absorption, padding, protection, and insulation to the wound. These features and their non-adherence to the wound bed make them useful under compression dressings for weeping wounds. In terms of moisture vapor permeability, foam dressings vary from highly permeable to completely impermeable. Large pore foams with no backing are highly permeable to moisture vapor, while foams with backings can be semipermeable to impermeable, depending upon the nature of the backing. Hydrogel Dressings Hydrogels are water-based, non-adherent, polymer dressings that may have some absorptive qualities. These dressings come in the form of amorphous gels, hydrogel sheets, and impregnated gauze. Hydrogel dressings are best used on wounds with minimal to no exudate as they can provide moisture to the wound bed. They are also useful for softening necrotic tissue prior to sharp debridement or to promote autolytic debridement. The amount of hydration varies from one product to another and some hydrogel sheets can dry out if left on a dry wound for too long. Absorption also varies from one product to another and some can absorb minimal amounts of drainage. To avoid maceration of surrounding tissues, hydrogel sheets can be cut to fit the wound bed. Amorphous gel serves primarily as a wound filler and a secondary dressing is required to keep it in place. Hydrogel dressings are cool and have the ability to conform to the wound surface. These qualities can be soothing to painful and sensitive wounds. Hydrocolloid Dressings Hydrocolloids are highly adhesive, moldable wafers made primarily of carboxymethylcellulose, gelatin, and/or pectin. They are produced in many shapes, sizes, and thicknesses. A clinician can determine which particular product would be most appropriate by considering factors such as wound location and amount of drainage. For example, a superficial sacral wound with minimal drainage may benefit most from a thin, heart-shaped hydrocolloid. Placed on the body as an upside down heart, the crevice of the heart accommodates for the gluteal fold. Hydrocolloid dressings usually have a water-proof backing and are impermeable to oxygen, water, and water vapor. Due to their strong adhesive properties, hydrocolloids adhere to the surrounding intact skin, preventing outside wound contamination. These dressings absorb minimal to moderate amounts of drainage and they react with moisture in the wound exudate to form a gel, thereby maintaining a moist wound environment and preventing adherence to the wound bed. 7

Hydrocolloid dressings can often be left in place for up to seven days. They are not recommended for wounds with heavy drainage, sinus tracts, or infections. They are best used on clean wounds with low to moderate drainage or on necrotic, non-infected wounds to promote autolytic debridement of slough or eschar. Hydrocolloids often leave a foul smelling residue in the wound bed. This residue is a normal byproduct and should not be confused with infection in the absence of other signs and symptoms of clinical infection. (see Table 2) Signs and Symptoms of Infection Purulent exudate Odor Erythema Warmth Tenderness Edema Pain Fever Elevated white cell count Table 2 Collagen Dressings Collagen is a fibrous insoluble protein found in connective tissue, including skin, bone, ligaments, and cartilage. It is the most abundant protein found in the body. Collagen is naturally present and necessary to every stage of normal wound healing. A collagen dressing initially acts as a hemostatic agent and continued use appears to promote the development of new tissue and aids in the debridement process. The collagen used in wound dressings is usually extracted from bovine, porcine, or avian sources. Dressings are produced in the form of powders, gels, pads, and ropes. In the proper form, collagen is highly absorptive, absorbing 40-60 times its weight in fluid. Collagen acts as a primary dressing and requires a secondary dressing to secure it in the wound. Compression Dressings The presence of edema can significantly impair the process of wound healing. Edema management is an important component of a successful wound management program. Wounds occurring in the lower leg, especially the gaiter area (proximal to the ankle and distal to the knee), are often due to the effects of chronic venous insufficiency. Compression is an important component in the treatment of these types of wounds. Compression dressings come in a variety of forms, including elastic bandages, stockings, non-elastic wraps and multi-layer systems. Some factors to consider when choosing the appropriate compression regimen are: 1) degree 8

of insufficiency, 2) patient s functional level and compliance, 3) frequency of dressing changes required, and 4) amount of drainage. Compression dressings should provide adequate amounts of pressure in a graduated fashion. These dressings vary in the skill level required for application and some can be harmful if applied inappropriately. Because of the complex nature of edema management and the high risk for complications, full coverage of this topic is beyond the scope of this program. Prior to applying any compression dressing, package inserts should be read thoroughly, including manufacturer s application instructions, precautions, and contraindications. Compressions dressings should never be applied in the presence of arterial insufficiency. If presented with this type of patient, additional training specific to edema management is highly recommended. Hydrofiber Hydrofiber dressings are non-woven, fibrous, highly absorbent dressings composed of carboxymethylcellulose. Although similar in appearance to alginates, hydrofiber dressings have a unique ability to quickly absorb fluid vertically rather than laterally. This vertical absorption may be advantageous by preventing fluid from coming in contact with surrounding skin, thereby preventing maceration. These absorption dressings are indicated for moderately or highly exuding wounds. Wound Contact Layers Wound contact layers are thin, non-adherent sheets that are placed in the wound bed to prevent dressings or other materials from coming in contact with or adhering to wound tissue. They are thin and flexible to conform to the shape of the wound bed, yet they are porous to allow drainage to pass through and be absorbed by the overlying dressing or other absorbent material. Composite Dressings Composite dressings are simply a combination of two or more physically distinct components into one. For example, one common composite dressing is a combination of semi-permeable transparent film and an absorptive layer, such as a non-adhesive foam or non-woven gauze. Rather than using a semipermeable film as a secondary dressing over a foam or gauze primary dressing, a composite dressing will have the two components combined into one distinct dressing. Composite dressings can come in many shapes and sizes, combining two or more of the previously mentioned categories. Often, composites are described as being adhesive, non-adhesive, or island dressings. Adhesive dressings have an adhesive coating over the entire surface of the wound dressing that contacts the wound surface. Generally the adhesive will not stick to a moist wound surface, only to the surrounding intact, dry skin. As the name indicates, non-adhesive dressings have no adhesive, and therefore will require a secondary layer or dressing to secure it in place. These dressings may be 9

necessary for patients with adhesive allergies or fragile skin. Island dressings generally have a central non-adhesive island with a surrounding adhesive border. Topical Antimicrobials All wounds are suspected of being contaminated with a variety of pathogens. In small numbers, these pathogens do not interfere with wound healing. However, excessive bioburden can slow down or even halt healthy cell production, indicating the presence of clinical infection. Severe cases can even cause worsening of the wound, damage to surrounding tissue or even death. Topical antimicrobials are intended to reduce the amount of potentially harmful organisms on the wound surface without harming healthy cells or preventing healthy cell production. Two such antimicrobial agents are topical silver and cadexomer iodine. Topical silver has been found to be an effective broad spectrum antimicrobial in vitro. Silver is generally delivered via impregnated dressings and every category of dressing discussed so far can be purchased in silver impregnated form. Cadexomer iodine has been found to be non-cytotoxic to healthy epidermal cells yet effective against a broad spectrum of potentially harmful organisms manufactured in the form of gels or pads. These products provide sustained release of iodine over time to reduce bioburden and absorb slough, debris, and exudate from the wound. Odor Control Some dressings or topical applications are designed to reduce wound odor. These dressings often contain charcoal or other ingredients that interact with wound drainage resulting in odor control. Enzymatic Debriding Agents Enzymatic Debridement is the topical application of proteolytic substances (enzymes) to break down devitalized tissue. This method of debridement may be chosen when the patient cannot tolerate other methods such as sharp or surgical debridement. It is important to read the manufacturer s instructions, as some enzymes may be incompatible with certain ingredients in wound cleansers, dressings or topicals. Some wounds may require sharp debridement to crosshatch thick eschar prior to application of enzyme. Additionally, some products may be contraindicated in infected wounds. Supplemental Products Skin sealants and protectants generally form a protective layer between the skin and dressings, adhesives or external moisture such as wound exudate, urine, and feces. There are a wide variety of these products available and they come in such forms as wipes, sprays, gels, and ointments. It is important to read the product instructions, especially when using over irritated or broken skin. 10

Tapes Tapes are often required to secure dressings in place. They come in a wide variety of forms, such as rolls, sheets, patches, and in many shapes and sizes. Tapes also come in a variety of materials, such as cloth, silk, plastic, and paper. They can be flexible or rigid, occlusive, or semi-permeable, and they may even offer some absorption. Some tapes may also be impregnated to offer soothing properties to compromised skin. When choosing a tape, some factors to consider are location, frequency of dressing changes, and condition of surrounding skin. Adhesive removers Adhesive removers may be used to ease the removal of tapes or adhesive dressings. They generally come in the form of wipes though some come as sprays or in bottles. Proper Application The effectiveness of a wound dressing is greatly dependent upon proper application. If applied carelessly, a dressing is likely to have decreased effectiveness, and possibly even damaging effects. Clinicians should always read the manufacturer s instructions on the package insert prior to applying any dressing for the first time. The package insert generally gives a product description and instructions for use, including indications, contraindications, precautions, and directions for application and removal. It should not be assumed that just because two dressings fall into the same category or look the same that they are indicated for the same wounds or applied and removed in the same manner. Case Presentations Self Study The following self-study will feature five wound scenarios. These presentations will allow you to develop problem solving skills and enable you to choose appropriate wound dressings for various types of wounds. You will also be challenged to appropriately modify your choices as the wound characteristics change. Please read the following case presentations and note your dressing choices in the spaces provided below. Instructor s notes are on the following pages. 11

Case Presentations Self Study Case Presentation #1 Ms. Lewis Patient: Ms. Lewis Age: 73 History: S/P Acute CVA, 6 weeks ago. Status: Due to her unstable condition, the patient spent most of the past six weeks in bed in intensive care. She is now considered medically stable. Functionally, however, she requires total assistance for all mobility and ADL s. She is incontinent of bowel and bladder. Wound Classification/Location: Stage IV pressure ulcer over her sacrum. Wound Measurement: 5.3 cm long x 1.8 cm deep with undermining of 3.1 cm at 12:00 and 1.2 cm at 3:00. Wound Composition: The wound bed is 75% yellow slough and 25% meaty red granulation tissue and is producing moderate amounts of clear yellow drainage. There is no notable odor. Surrounding Area: Tissue is intact and clear. Patient sensitivity: Ms. Lewis complains of minimal pain upon palpation of the wound and surrounding area. What dressings would you choose for this patient? Some factors to consider before choosing a dressing are: The wound has depth and undermining (need to eliminate dead space/wound filler) Moderate amounts of drainage (absorption) Location sacrum/ Patient requires total assistance (ease of application/frequency of dressings changes) Incontinence (permeability) Primary Dressing? Secondary Dressing? Rationale? Other options? 12

Case Presentations Self Study Case Presentation #1 Ms. Lewis - Instructor s Notes What Dressings Would You Choose for This Patient? In this case, an alginate was chosen as the primary dressing. The alginate, loosely packed, provides high absorption, generally allowing once daily dressing changes and eliminates dead space. The secondary dressing of semi-permeable film secures the alginate in place and provides an occlusive barrier, keeping moisture in and urine and feces out. The transparency of the film dressing also allows visualization of the alginate and the dressing can be left on until the alginate becomes visibly saturated. Leaving the dressing in place longer supports autolytic debridement of yellow slough. Precautions Transparent films are sometimes difficult to apply, and due to their high adherence, they can irritate and damage surrounding tissue upon removal. These complications can be decreased or eliminated by using a skin prep sealant on the surrounding tissue prior to applying the film and using an adhesive remover for dressing changes. The film can also be stretched upon removal, to more readily release the adhesive. To increase ease of application, use a product that comes with a windowed border and have an assistant available while applying while applying the dressing to position the patient. Other Options Another choice for the primary dressing could have been hydrofiber or collagen. If the transparent film proves to require too frequent dressing changes due to saturation, the secondary dressing choice could have been hydrocolloid or foam. Both hydrocolloid and foam dressings allow additional absorption and are available with occlusive backing to keep out urine and feces. Some precautions would be that a foam dressing may provide absorption too quickly and dry out the wound, where a hydrocolloid s high adhesive properties (higher than transparent film s) may damage surrounding tissue if changed too frequently. Some hydrocolloids and foams show strike-through (discoloration on the outer surface when saturated), signaling when to change the dressing and allowing them to be left on for up to seven days. Primary Dressing? Secondary Dressing? Rationale? Other Options? Alginate semi-permeable film see above Primary dressing: hydrofiber or collagen Secondary dressing: hydrocolloid or foam 13

Case Presentations Self Study Case Presentation #2 Ms. Lewis Six Weeks Later Name: Ms. Lewis (Six weeks later) Age: 73 History: CVA Status: Requires minimal to moderate assistance of one person for bed mobility, transfers and gait for ten feet with a rolling walker. She continues to have bouts of incontinence two to four times per day. Wound Classification/Location: Stage IV pressure sore over her sacrum. Wound Measurement: Her wound now measures 3.5 cm long x 2.8 cm wide x 0.4 cm deep, with undermining of 0.8 cm at 12:00. Wound Composition: The wound bed is 100% granulation tissue and is producing minimal amounts of clear yellow drainage. Surrounding Area: Tissue is intact and clear. Patient sensitivity: Ms. Lewis complains of an increase in pain, moderate to severe, with palpation and with pressure in sitting or supine. Should you continue with the current dressing or make a change? Some factors to consider are: Decreased drainage Increased pain Primary Dressing? Secondary Dressing? Rationale? Other options? 14

Case Presentations Self Study Case Presentation #2 Ms. Lewis Six Weeks Later - Instructor s Notes What Dressings Would You Choose for This Patient? In this case, the primary dressing was changed to an amorphous hydrogel and the secondary dressing of semi-permeable film remained the same. The hydrogel is cool and soothing, possibly providing some pain relief and also has some absorptive qualities. The transparent film will allow continued protection from urine and feces. Other Options Another choice may have been to continue with the alginate as a primary dressing. Moistening the alginate with normal saline prior to application would prevent drying out the wound bed, but this probably would not have provided any pain relief. The secondary dressing could also have been changed to a hydrocolloid or a hydrogel sheet. The hydrocolloid is appropriate for wounds with low to moderate drainage, however, the patient has done well with transparent film and changing to a hydrocolloid may risk irritation of surrounding skin. A hydrogel sheet is appropriate for wounds with low drainage but may macerate the surrounding tissue. Primary Dressing? Secondary Dressing? Rationale? Other Options? changed to amorphous hydrogel semi-permeable film see above Primary dressing: continue with alginate, pre-moistening Secondary dressing: change to hydrocolloid or hydrogel sheets 15

Case Presentations Self Study Case Presentation #3 Mr. Donnoly Name: Mr. Donnoly Age: 53 History: Venous hypertension, strong pedal pulses and Doppler studies show good arterial blood supply to his right leg and foot. Patient s right leg presents with moderate edema. Status: Patient lives at home alone and is independent with gait, transfers and ADL s without assistive devices. Wound Classification/Location: Mr. Donnoly presents with four wounds on his right leg, specifically, the medial and posterior right calf. The wounds have been present for three months. Wound Measurement: The four wounds vary in size with the smallest measuring 1.2 cm long x 0.4 cm wide and the largest measuring 2.3 cm long x 1.5 cm wide. Wound Composition: Superficial; wound beds are red and granular. They are producing heavy amounts of clear, yellow drainage. Surrounding Area: Surrounding skin and wound edges are macerated. Patient sensitivity: Mr. Donnoly has no complaints of pain. He has had no previous treatment, as he hoped the wounds would just go away on their own. What dressings would you choose for this patient? Some factors to consider are: Heavy amounts of drainage (absorption) Venous insufficiency/edema (need for compression) Large area (size of dressing) Skin macerated (absorption and adherence) Primary Dressing? Secondary Dressing? Rationale? Other options? 16

Case Presentations Self Study Case Presentation #3 Mr. Donnoly - Instructor s Notes What Dressings Would You Choose for This Patient? In this case, a non-adhesive foam dressing was chosen as the primary dressing, secured in place by an elastic compression dressing. The foam dressing provides high absorption and protection, even under compression. The contact layer won t adhere to the wound bed or surrounding tissue, preventing further damage and allowing easy removal. An in-depth discussion of compression dressings is beyond the scope of this course, and as previously mentioned, this course is not intended to cover edema management. However, there are numerous other choices, including non-elastic compression dressings, garments/devices, multi-layer compression dressings, and compressive tubular bandages. Other Options Other choices for the primary dressing could have been alginate, collagen, hydrofiber, or a specialty absorptive dressing. Each of these could have variable absorptive capabilities under compression dressings. Primary Dressing? Secondary Dressing? Rationale? Other Options? non-adhesive foam elastic compression dressing see above Primary dressing: alginate, collagen, hydrofiber, or specialty absorptive dressing Secondary dressing: non-elastic compression dressings/ garments/devices, multi-layer compression dressings, and compressive tubular bandages. 17

Case Presentations Self Study Case Presentation #4 Ms. Davis Name: Ms. Davis Age: 82 History: Ms. Davis s pertinent medical history includes severe osteoarthritis with multiple joint contractures, dementia of the Alzheimer s type and incontinence of bowel and bladder. Status: Patient is a resident of a long-term care facility. Functionally, she requires moderate assistance for bed mobility and transfers and she is nonambulatory. Wound Classification/Location: She presents with a Stage III pressure ulcer on her left greater trochanter. Wound Measurement: The wound measures 3.0 cm long x 2.6 cm wide x 0.2 cm deep, with no undermining. Wound Composition: The wound is producing moderate amounts of thick, cloudy, gray, foul smelling drainage. The wound bed is 100% gray slough. Surrounding Area: Surrounding tissue is intact but presents with induration, erythema, and warmth. Patient sensitivity: Ms. Davis is unable to express symptoms verbally secondary to advanced dementia but her body temperature and blood cell count are normal. What dressings would you choose for this patient? Some factors to consider are: Signs and symptoms of infection (permeability) Location of the wound/ incontinence (permeability/ adherence) Moderate amount of drainage (absorption) Primary Dressing? Secondary Dressing? Rationale? Other options? 18

Case Presentations Self Study Case Presentation #4 Ms. Davis - Instructor s Notes What Dressing Would You Choose for This Patient? In this case, an alginate was chosen as the primary dressing, using 4 x 4 standard gauze as a secondary dressing to secure the alginate in place and to provide additional absorption as necessary. The dressing was to be changed daily or more often if dressing becomes soiled or saturated. Other Considerations The wound is demonstrating signs and symptoms of localized infection. The clinician should ensure that the wound is being effectively cleansed and debrided. If the signs and symptoms of infection continue after two weeks of optimum cleansing, consider a two-week trial period of a topical antimicrobial. If the wound continues not to respond or if the patient begins to show signs of systemic infection, the physician may wish to perform a culture and initiate systemic antibiotics. Another consideration in this case is the possibility of irritation and damage to surrounding tissue from adhesives in the tape used and the frequent dressing changes required. Some steps that will help to prevent this are to use a skin sealant prior to applying tape to the skin and using adhesive remover to decrease trauma upon removal. One additional consideration is the complication of incontinence. If urine or loose stool presents a problem, steps should be taken to control them. A catheter may need to be used temporarily and medication may be indicated to resolve diarrhea. Other Options Other choices for primary dressing could have been hydrofiber, foam, or gauze. Other choices for secondary dressing could have been a foam dressing without any backing, as a backing would be occlusive and therefore contraindicated for an infected wound. Due to the frequency of required dressing changes, gauze would be more cost effective. If odor is problematic, an odor control dressing could be chosen. Primary Dressing? Secondary Dressing? Rationale? Other Options? alginate gauze see above Primary dressing: hydrofiber, foam, gauze Secondary dressing: foam dressing without backing 19

Case Presentations Self Study Case Presentation #5 Mr. Jarrard Name: Mr. Jarrard Age: 92 History: Mr. Jarrard s pertinent medical history includes COPD with steroid dependency and early senile dementia. Status: Patient is a resident of a long-term care facility. Functionally, he requires minimal assistance for transfers and gait with a rolling walker for functional distances. Wound Classification/Location: He presents with a skin tear of unknown origin on his right forearm. Wound Measurement: This triangular-shaped, partial-thickness skin tear measures 4.1 cm long x 2.3 cm wide. Wound Composition: The wound is producing minimal amounts of clear, yellow drainage. The wound bed is 100% bloody red granular tissue. Surrounding Area: Surrounding tissue is thin and shiny, with overall poor skin integrity secondary to steroid dependency. Patient sensitivity: Mr. Jarrard has no complaints of pain. What dressings would you choose for this patient? Some factors to consider are: Minimal clear drainage (absorption) Poor surrounding skin integrity (adherence) Location forearm/ Mild dementia (protection) Primary Dressing? Secondary Dressing? Rationale? Other options? 20

Case Presentations Self Study Case Presentation #5 Mr. Jarrard - Intstructor s Notes What Dressings Would You Choose for This Patient? In this case, a non-adhesive thin foam was chosen as the primary dressing, secured in place with an elastic tubular bandage as the secondary dressing. A foam dressing provides some protection to external trauma and the contact layer will not adhere to the wound bed, preventing any further direct trauma upon removal of the dressing. A thin foam will absorb minimal drainage and some products show strike through when saturated, alerting the clinician that it is time to change the dressing. The elastic tubular bandage is used to secure the primary dressing, as adhesives could cause further skin tears upon removal. Other Options Other choices for primary dressings could have been a hydrogel sheet or a wound contact layer. The hydrogel sheet can absorb minimal amounts of drainage but it is more difficult to keep in place without adhesives. the wound contact layer would allow an absorptive dressing such as gauze to be used on top without risking adherence to the wound bed or surrounding fragile skin. Primary Dressing? Secondary Dressing? Rationale? Other Options? non-adhesive, thin foam elastic tubular bandage see above Primary dressing: hydrogel sheet or wound contact layer 21

Dressing Options (This is for educational purposes only - Not intended to be an all-inclusive list) Type of Dressing Characteristics/Functions Best Uses Products/Manufacturers Non-adherent and impregnated gauze Prevents adherence to tissues May absorb minimal drainage Clean, granulating wounds Telfa, Xeroform / Kendall Adaptic / Johnson&Johnson Alginates Semi-Permeable Film Dressings Foams A non-woven absorptive dressing manufactured from seaweed. Come in sheets and ropes. Clear, adherent, non-absorptive, polymer-based dressing that is permeable to oxygen and water vapor but not to water A sponge like polymer dressing that may or may not be adherent Wounds with moderate to heavy drainage and uneven or tunneling wounds Non-infected shallow wounds with minimal drainage AlgiSite / Smith & Nephew Kaltostat / ConvaTec Sorbsan / Mylan Bertek Tegaderm / 3M Opsite / Smith & Nephew To promote autolytic debridement of slough or eschar Moderate to heavily draining wounds Lyofoam / ConvaTec PolyMem / Ferris Mfg. Corp. Collagens Collagen containing products derived from bovine, porcine or avian sources. Come in many forms such as powders, pastes and sheets. Minimal to heavily draining wounds depending on product absorption Non-healing wounds Mepilex / Molnlycke Promogran Matrix / Johnson & Johnson Stimulen / Southwest Technologies 22

Wound Contact Layers Dressed for Success! Non-adherent sheets intended to protect wound tissue from direct contact with other dressings or materials Fragile and/or painful wounds Mepitel / Molnlycke Restore / Hollister Dressing Options (cont.) (This is for educational purposes only - Not intended to be an all-inclusive list) Wound Veils / Smith & Nephew Type of Dressing Characteristics/Functions Best Uses Products/Manufacturers Hydrogels Hydrocolloids Water-based Come in amorphous gel, sheets, strands or impregnated gauze Hydrocolloids are highly adhesive, moldable wafers made primarily of carboxymethylcellulose, gelatin, and/or pectin Wounds with minimal or no drainage To donate moisture To soften wounds prior to sharp debridement Clean wounds with low to moderate drainage To promote autolytic debridement of slough or eschar in shallow, noninfected wounds SoloSite / Smith & Nephew Saf-Gel / ConvaTec Hypergel / Molnlycke RepliCare, Cutinova Hydro / Smith & Nephew DuoDERM / ConvaTec Hydrofiber Varies per product and Manufacturer Moderate to heavily draining wounds Aquacell, Versiva / ConvaTec 23

Dressing Options (cont.) (This is for educational purposes only - Not intended to be an all-inclusive list) Type of Dressing Characteristics/Functions Best Uses Products/Manufacturers Odor Control Impregnated with material such as charcoal. Designed to control wound odor. Odorous wounds CarboFlex / ConvaTec Restore / Hollister Antimicrobials Topicals intended to reduce the number of bacteria in the wound Infected wounds or wounds with risk of infection Iodoflex, Iodosorb / Smith & Nephew Aquacell Ag / ConvaTec Compression Dressings Intended to provide graduated compression to reduce edema and improve venous return Wounds due to venous disease with adequate arterial circulation Contraindicated with impaired arterial circulation (products vary, check with manufacturer) Acticoat 3, Acticoat 7 / Smith & Nephew SetoPress, SurePress, UNNA-FLEX / ConvaTec Profore, Profore Lite / Smith & Nephew Comprilan, Gelocast / BSN - Jobst 24

-SAMPLE - Wound Dressing Protocols SAMPLE- Choose dressings according to the following wound characteristics unless otherwise ordered: Wound Type Dressing Choices Dressing Change Frequency Dry to minimal drainage/superficial Dry to minimal drainage/deep Moderate to heavy drainage/superficial Moderate to Heavy Drainage/Deep Primary dressing: Transparent film -or- Hydrocolloid Primary dressing: Hydrogel (amorphous, impregnated gauze or sheet) -or- Petroleum impregnated dressing Secondary dressing: Hydrocolloid -or- Transparent Film Primary dressing: Hydrogel(amorphous or impregnated gauze) Secondary dressing: Hydrogel sheet -or- Transparent film -or- Hydrocolloid Primary dressing: Composite (ie: Versiva, CombiDERM) -or- Hydrofiber (Aquacell) -or- Calcium Alginate -or- Foam Dressing Secondary dressing(if needed): Composite (ie: Versiva, CombiDERM) -or- Foam Dressing -or- Transparent film -or- Hydrocolloid Primary dressing: Hydrofiber (Aquacell) Calcium Alginate Secondary dressing: Composite (ie: Versiva, CombiDERM) -or- Foam Dressing -or- Transparent film -or- Hydrocolloid Change dressing every 7 days or as needed to maintain moist wound bed. Change required when clinically indicated such as saturation (indicated by strikethrough) or broken seal(dislodged dressing) Change dressing every 3 days or as needed to maintain moist wound bed. Change required when clinically indicated such as saturation (indicated by strikethrough) or broken seal(dislodged dressing) Change dressing every 3 days or as needed to maintain moist wound bed. Change required when clinically indicated such as saturation (indicated by strikethrough) or broken seal(dislodged dressing) Change dressing every 3 days or as needed to maintain moist wound bed. Change required when clinically indicated such as saturation (indicated by strikethrough) or broken seal(dislodged dressing) Change dressing every 3 days or as needed to maintain moist wound bed. Change required when clinically indicated such as saturation (indicated by strikethrough) or broken seal(dislodged dressing) 25

Post Test Name: Credentials/Degree: Address: City/State/Zip: Daytime Phone: Evening Phone: E-Mail: Read the following questions and circle the most appropriate answer. Be sure to mail or fax this test to receive credit and your certificate. 1. What is the cardinal rule when choosing a wound dressing? a. Allow permeability to oxygen, water, and water vapor. b. Keep the wound bed and surrounding intact skin dry. c. Dressing must be adherent and flexible. d. Keep the wound bed moist and the surrounding intact skin dry. 2. Which of the following statements about alginate dressings is false? a. Alginates are manufactured from seaweed. b. Alginates are best used on clean wounds with minimal exudate. c. Alginates can be used on infected wounds. d. Alginates usually require a secondary dressing. 3. Which of the following dressings promote autolytic debridement? a. Hydrocolloids b. Transparent films c. Gauze d. A and B e. All of the above 4. What one major advantage do transparent films have over other dressings? a. They will not adhere to surrounding tissues. b. They are easy to apply and remove. c. They allow for visualization of the wound. d. They absorb varying amounts of drainage. 5. Which of the following would not be used as a secondary dressing? a. Gauze b. Transparent film c. Alginate d. Foam 26

Post Test Cont. 6. Which of the following statements about foam dressings is true? a. They are non-woven, fibrous, absorptive dressings. b. They will not dry out the wound bed. c. They can be used under compression dressings. d. They form gel when mixed with exudate. 7. Stating that a dressing is impregnated means that: a. It doubles in size when fluid is added. b. It is vacuum-packed. c. One or more substances have been added. d. It is reusable. 8. Which of the following statements about hydrogel dressings is false? a. They are cool and soothing to painful wounds. b. They may provide absorption c. They come in the form of amorphous gels, sheets, and impregnated gauze. d. They are best used on wound with heavy drainage. 9. What is one advantage of hydrocolloid dressings? a. They can be left in place for up to seven days. b. They absorb large amounts of exudate. c. They allow visualization of the wound bed. d. They reduce odor in the wound bed. 10. Which dressing does the following statement describe? These can leave a residue in the wound bed which may be foul-smelling and is often confused with infection. a. Collagen b. Alginates c. Hydrogels d. Hydrocolloids 11. What is a precaution when using hydrogel dressings? a. They can macerate surrounding tissue. b. They have non-selective adherence to the wound bed. c. They can be painful. d. They should not be used on necrotic wounds. 12. Alginate dressings are indicated for: a. Wounds with minimal drainage. b. Uneven or tunneling wounds. c. Wet-dry mechanical debridement. d. Skin tears. 27

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