Basic Wound Treatments Sean Craig, RN BSN, CWCN Wound Program Coordinator Alexandria, LA VA Medical Center

OBJECTIVES Describe factors to consider when selecting a dressing Identify commonly used dressings Select appropriate dressings based on wound assessment Describe the advantages and disadvantages of different dressing types

“I do wound care.”

What am I supposed to do now? How many of you feel like a monkey with a math problem when you are presented with a chronic wound? Not really sure of which direction to take? Don’t feel bad, this can be a confusing matter. I want to help make it a little simpler for you.

V. Vascular status. – (ABI, Venous Doppler, V Vascular status? – (ABI, Venous Doppler, Consult vascular specialist) O Off load – (pressure on boney prominences) I Infection – (Treat infection, biopsy wound) D Debride – (Remove any devitalized tissue after vascular status is established)

Factors to Consider Prior to Selecting a Wound Treatment What is the causative factor What is the goal of the treatment Is the wound bed wet or dry Is the wound infected Does the wound have an odor

Factors to Consider Prior to Selecting a Wound Treatment Is there dead tissue in the wound bed Is there dead space in the wound bed Where is the location of the wound Is the selected treatment manageable for staff and patient (Pain, time, ability) What is the cost of the treatment

Dressings and Treatments Wound Cleansers Alginates Hydrofibers Contact Layers Foams Gauze Hydrocolloid Hydrogel Specialty Absorptive Transparent film ** Some of these dressings must be special ordered and may not be available at all facilities Antimicrobials Collagens Debriding agents Skin substitutes/grafts Skin sealants Moisture barrier ointments Negative Pressure Wound Therapy Composites

Wound Cleansers Solutions used to clean and irrigate debris from wound bed Optimum irrigation pressure is 4-15 PSI Spray from CarraKlenz 35cc syringe with 19 angiocath

Antiseptics Povidone iodine, ¼ strength Bleach, Acetic Acid, Hydrogen Peroxide. Cytotoxic to bacteria as well as WBC and fibroblasts Use with caution short term for microbial control and odor control.

Bleach solution Is a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in this solution, is a strong antiseptic that kills most forms of bacteria and viruses. For wound management, use as an irrigant, cleanser, or the wetting agent for a wet-to-moist dressing ; 0.25% strength Protect surrounding intact skin with a moisture barrier ointment or skin sealant as needed. Used to prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure ulcers. It is also used before and after surgery to prevent surgical wound infections. Controversial among wound care providers

Alginates Made from seaweed Absorptive Non-adhesive, non-occlusive, and conforms to wound bed.

Alginates Indications: Contraindications: Moderate to heavy exudate Hemostasis with minimal bleeding Promotes autolysis Change frequency based on manufactures guidelines Contraindications: 3rd degree burns Dry wounds

Hydrofibers Soft sterile pads or ribbons Carboxymethylose fibers that turn into a gel when moistened and conform to wound bed. Maintains moist wound bed.

Hydrofibers Indications: Contraindications: Advantages: Exudating wounds Moisten dressing and apply to dry wounds Contraindications: Patients with sensitivity to dressing components Advantages: May remain in place for 7 days Available in silver Will not create a foreign body if left in wound

CONTACT LAYERS Protect fragile skin or underlying skin grafts. Non-adherent layer that will not damage new epithelial tissue. Allows wicking of exudate and changing secondary dressing without disturbing wound bed.

Contact Layers Soft porous non-adherent silicone Allows exudate to pass to secondary dressing May be left in place for up to 14 days depending on condition of wound Allows decreased primary dressing change If you see this dressing on a wound check orders before removing Can be cut to size.

Contact Layers: Petrolatum Gauze Occlusive dressing Will not adhere to wound bed. Maintains moisture Some are yellow with a bacteriostatic action May trap heavy exudate underneath causing maceration.

Contact Layers Primary dressing made of porous cellulose acetate impregnated with petroleum. Prevents secondary dressing adherence Prevents pooling of exudate. Can be cut to size.

FOAM: Polyurethane foam with cleansing agent that is activated with exudate and slowly released to clean the wound bed. Glycerin keeps wound moist, reduces odor, increases comfort. Keeps wound moist and wicks extra moisture away. Looses Wick property when saturated. Use as a primary dressing only. (no enzymes, antimicrobials) can be used for excessive drainage Do not clean wound bed between dressing changes. May adhere to wound bed. ***Photo from Patricia Seemann, BSN, WCC. WOCN 40th Annual Conf.

Foam Soft foam with absorptive capacity May combine with enzymes and antimicrobials. (excludes silver foam) Used for partial and full thickness wounds with exudate. Silicone backing keeps dressing from adhering to wound bed

Foam Methylene Blue /Gentian Violet provide broad-spectrum bacteriostatic protection against a variety of microorganisms including MRSA and VRE. Approved for use on all types of wounds except third degree burns Must be moistened with NS squeezed out and secured to the wound bed with an appropriate secondary dressing Provides gentle debridement Provides odor control Change every 1 to 3 days; may require more frequent change with infected wound, indicated by the dressing changing color from blue to white. Available in Pharmacy, Physician order

Hydrocolloid Elastomeric, adhesive, and gelling agents Adopted from ostomy products Absorbs minimal exudate and forms a gel keeping wound moist. Autolytic debridement May have an odor with removal, do not confuse with infection Do not use in wounds that require monitoring more than 2 times a week Avoid with neutropenic patients, unless pallative

Hydrogel Water or glycerin based gel or sheets that provide moisture to wound bed Softens necrotic tissue and keeps wound bed moist Not for heavily draining wounds Will not adhere to wound. May macerate periwound skin Daily dressing changes

Absorptive Dressings Highly absorbent multi-layered cellulose dressing with non-adherent wound contact layer. Air permeable backing Some may be cut

Transparent film Polyurethane with porous adhesive layer that allows gas and moisture vapor transmission (semi-occlusive) Preventative as primary (barrier film) Secondary dressing for wounds. Do not use as a primary dressing for skin tears. Autolytic debridement

Antimicrobials Absorbs slough and exudate Iodine is absorbed and gel absorbs exudate turning white when deactivated Active up to 72 hours Do not use on patients with thyroid disorders

Antimicrobials: Silvers Antimicrobial effects Many types: foams and gels Not compatible with petroleum and deactivates enymes. Remove prior to MRI May stain tissues

Debriding Agents: Collagenase Enzyme that digests collagen in necrotic tissue. Does not effect healthy collagen. May be mixed with bacitracin to optimize PH. Do not mix with silvers. Slow acting Change daily

Debriding Agents: Honey Keeps wound moist Low PH and high osmotic activity Aids in autolytic debridement Decreases odor May have antimicrobial effects Used as a primary dressing/non-adherent Can be left in wound bed for up to 7 days May increase wound exudate the first few days of use

Composites Dressings made up of a combination of products Provide multiple functions (Bacterial barrier, absorptive layer, adhesive border) See manufacturers’ recommendations May adhere to wound bed Requires intact peri-wound skin May be used as primary or secondary dressings Appropriate for minimal to heavy exudate, granulation, or necrotic tissue

Border Dressings Non-traumatic adhesive, Allowing for routine skin assessments and removal without skin trauma because of the silicone technology An occlusive outer covering Shape that covers the sacrum and separates the gluteal folds. Prevents friction between the gluteal skin folds Absorbs exudate/moisture Providing a barrier between the bed surface and the skin for patient positioning, reduces pressure/friction Resisting minor fecal incontinence due to the occlusive outer layer. Recommended areas of use: Sacral wounds caused from pressure, friction or shear; prevention. Manufacturer's suggested wear time: Up to 7 days.

Border Heel Self-adherent - no tape needed Shaped to fit heels – no need to cut or adapt/ may also be used on elbow, shoulders Non-traumatic silicone backing, Minimize pain and trauma at dressing changes Manages exudate and decreases maceration Decreases pressure, shear, and friction to area of decreased soft tissue. Can remain in place for several days depending on the condition of the wound Can be removed and replaced for assessment without losing its adherent properties Continue to use heel relief boots.

Dressing removal- silicone Adhesive releaser Easily and rapidly releases dressings or appliances adhered to skin Helps minimize trauma with “no touch” removal Helps minimize skin stripping when removing tape

Products to assist with repositioning, offloading, and moisture balance Turn and reposition sheet Heel Relief boot waffle cushion

Dress this Wound

Dress this Wound

Dress this Wound

Dress this Wound

Dress this Wound

Dress this Wound

Dress this Wound

V. Vascular status. – (ABI, Venous Doppler, V Vascular status? – (ABI, Venous Doppler, Consult vascular specialist) O Off load – (pressure on boney prominences) I Infection – (Treat infection, biopsy wound) D Debride – (Remove any devitalized tissue after vascular status is established)

References Baranoski, S. & Ayello, E.A. (2004). Wound treatment options. In Wound Care Essentials: Practice Principles (127-156). Philadelphia, PA: LWW. Rolstad, B.S.& Ovington, L.G. (2007). Principles of Wound Management. In Bryant,R.A. & Nix, D.P. (eds) Acute & Chronic Wounds: Current Management Concepts (391-426). St. Louis, MO: Mosby Elsevier.