Dressing Selection Flashcards
Primary dressing function
facilitate wound healing through debridement, antimicrobial, and moisture balance maintenance
Secondary dressing function
anchor primary dressing, protect the wound from mechanical forces, manage edema
Dressing selection
primary: based on wound bed; secondary: based on patient’s activity level
Passive dressing function
absorb drainage, cover to prevent contamination
Interactive dressing function
provide antimicrobial agents, provide growth factors, promote lysis of necrotic tissue
Bioactive dressing function
stimulate the migration and mitosis of cells by the introduction of live cells or by providing collagen
wet to dry dressings
No longer considered standard of care
Unacceptable means of mechanical
debridement; painful for the patient
Detrimental to wound healing by
destroying healthy granulation tissue with removal
Has limited use in acute- and long-term care settings (CMS Pressure Ulcer Guidelines in F-Tag 314)
transparent films: composition
Thin polyurethane membrane with adhesive acrylic layer
transparent films: indications
Autolytic debridement
Secondary dressing
Anchor IV catheters
impregnated gauze: composition
Mesh with petrolatum, with/without bismuth tribromophenate
impregnated gauze: indications
Flat, dry partial thickness wounds
Secondary dressing
hydrocolloids: composition
Adhesive inner layer
Gel-forming absorbent layer
Occlusive or semi-occlusive outer layer
hydrocolloids: indications
Shallow or flat wounds with minimal drainage
hydrogels: composition
Organic polymers with 30% to 90% water content
hydrogels: indications
Dry wounds for autolytic debridement
Over tendon, muscle, bone to prevent desiccation
foams: composition
Soft open-cell sheets of polyurethane
With or without adherent backings
With or without adhesive borders
foams: indications
Wounds with heavy exudate Flat wounds (donor sites, skin tears, surgical incisions)
calcium alginates: composition
Calcium or calcium & sodium salts Derived from seaweed Processed into a dry fiber that becomes a gel when it interacts with exudate May be hemostatic on some wounds Absorbs 5-15 times weight
calcium alginates: indications
draining cavity wounds
cellulose (hydrofiber): composition
Sodium carboxymethyl-cellulose spun into fibers
Absorbs exudate and becomes a gel
Maintains a moist wound environment
Absorbs 25 times weight
cellulose (hydrofiber): indications
Wounds with heavy exudate
Either flat or cavity
X-cell (xylos, inc): composition
3 layers of cellulose impregnated with normal saline
With or without PHMB
X-cell (xylos, inc): indications
Flat wounds with min exudate
Painful wounds
STSG donor sites
Venous/vasculitic wounds
Honey: composition
Carbs, protein, vitamins
Enzyme inhibine=>hydrogen peroxide and gluconolactone (antibacterial)
honey: indications
Partial thickness burns
Wounds with odor
Wounds with eschar
collagen: composition
Collagen harvested from bovine, porcine, or avian collagen
Processed into 100% collagen or into a collagen matrix with alginate
collagen: indications
Clean, granulating wounds to facilitate cell migration to the wound bed
collagen: contraindications
Infected wounds
Non-viable tissue
Patients allergic to porcine or bovine products
allograft: composition
Harvested cadaver skin
Acellular freeze-dried
Contains basement membrane with collagen, elastin, proteoglycans, and vascular structures
Biological scaffold for dermal/epidermal regrowth
allograft: indications
burn therapy and other clean, full-thickness wounds
living skin equivalents: composition
Neonatal fibroblasts in a collagen or nylon-like mesh
Apligraf, Dermagraf, Transcyte
living skin equivalents: indications
Clean granulated wounds as a temporary wound to promote closure or to protect while waiting for skin graft
topical antimicrobials purpose
To restore a balance between bioburden and local immune system
types of topical antimicrobials considered “best practice”
Ionic silver dressings Available in a variety of dressings Cadexomer iodine Iodosorb, Iodoflex Polyhexamethylene biguanide compound (PHMB) XCell antimicrobial AMD gauze Acetic acid washes only for pseudomonas
silver dressings wound healing actions
Destroy broad spectrum of bacteria by blocking cell respiration, destroying cell membrane and allowing cytoplasm to leak (respiration, replication, repair processes are disabled)
Decrease excessive matrix metalloproteinase (MMP) activity by decreasing zinc levels
cadexomer iodine: composition
Macrospherical, hydrophilic, biodegradable beads of cadexomer starch with 0.9% iodine in paste or ointment
cadexomer iodine: indications
Partial thickness burns
Draining wounds with bacteria present
cadexomer iodine: contraindications
Patients with iodine sensitivity or allergy
dressings to avoid
Povidone iodine (Betadine) Used as skin disinfectant Can be cytotoxic for granulation tissue Acetic acid Effective against pseudomonas Use as a wash only, not as a dressing Dakin’s solution (infected, necrotic wounds only) Contains sodium hypochlorite Retards deposition of collagen Hydrogen peroxide Toxic to fibroblasts No antibacterial effects May be used to dissolve clots (Rodeheaver, Ratliff)
dressing selection should be based on these
Wound healing phase Tissue in the wound bed Amount of drainage Presence of microbes Patient activity level Goals for wound healing
tools to guide dressing selection
The Red/Yellow/Black color system (Marion Labs)
Classification by grade, stage or depth
Wagner/UT -grade
NPUAP -stage
PTW/FTW -depth
Selection based primarily on exudate & presence of devitalized tissue
Solutions Algorithms www.guideline.gov
Selection driven by Clinical/Physiologic Need
Dressing Decision Tree (Broussard)
inflammatory phase dressing selection
antimicrobials, debriding agents, absorbent fillers
proliferative phase dressing selection
Fillers, foams
Hydroactive dressings
Hydrogels, biologicals
remodeling phase dressing selection
silicone-backed foam, scar therapy
DIME paradigm
Debridement, Inflammation/infection, Moisture balance, Edges
DIME: Debridement
gels, films; enzymes
DIME: inflammation/infection
antimicrobials, alginates
DIME: Moisture
absorbent fillers, hydroactive dressings, hydrogels
DIME: Edges
collagen, xeroform
dressing selection based on tissue type (colors)
Black (eschar) Gels, films, enzymes Yellow (fibrous, slough) Enzymes, cellulose, alginates, foams Red (granulation) Gels, cellulose, foams, hydroactive dressings
dressing selection: moderate to copious drainage
cellulose, foams, alginates
dressing selection: minimal to moderate drainage
cellulose, foams, alginates, hydrocolloids, hydroactive dressings
dressing selection: scant to minimal drainage
thin foams, hydrocolloids, hydroactive dressings, hydrogels
indications for antimicrobial dressings
Failure to heal (may be first sign of bacteria)
Serous, purulent, or hemorrhagic exudate
Foul odor
Small areas of yellow or brown slough on wound bed
Fragile granulation tissue that bleeds easily
Surrounding skin pain, warmth, and swelling (cellulitis)
Increased size or new adjacent wounds (infected deeper structures) (Sibbald)
goals for wound healing
Wound to advance in healing phase Full closure by secondary intention Prepare for surgical closure Manage drainage or odor for palliative care Caregiver or patient to be independent in changing dressing No signs of clinical infection
secondary dressing application
Begin distally and progress to joint above the wound.
Wrap in spiral or figure 8 depending on the amount of edema/vascular status- Do not encircle a limb with tape -
Use conforming gauze on dry skin.
Apply tape to gauze or elastic wrap only; avoid tape on skin.
Secure dressing sufficiently for patient functional level
flat wound dressing application
Select dressing appropriate for wound bed.
Select dressing that extends beyond any involved periwound skin.
Apply dressing so that it touches all of the wound bed.
Avoid any dead space between dressing and wound surface.
Apply secondary dressing so that it is adhered at any folds or crevices.
For ‘at risk’ skin, consider a barrier film-let dry before taping/applying dressing
dressing removal
Take the skin off the tape, not the tape off the skin.
Roll/Pull parallel to the skin.
Roll/Pull in the direction of the hair.
Use adhesive tape remover/saline soaked sponge.
Avoid alcohol products on inflamed skin
Minimize Discomfort and Skin damage
fragile skin
Avoid any adhesives on fragile or insensate skin (including patients with diabetic neuropathy.)
For ‘at risk’ skin, consider a barrier film/lotions/creams
Avoid adhesive transparent films.
Avoid holding extremities to move patient.
dangers of picking wrong dressing
Delay healing Increase pain Cause dessication or maceration Increase cost of care Decrease quality of life
5 goals of topical care
Optimization of the moist environment Wound stabilization, manipulation, pressure reduction & edema control Activation of wound environment Bioburden control, infection prevention Quality of life improvement
Macerated wound margins - goals and product to use
goal: protect wound margins; product: Non-sensitizing Moisture barriers: Zinc oxide Dimethicone Petrolatum Dressing Barriers: Films Hydrocolloids NPWT*
moderate to heavy drainage - goals and products
goal: absorb drainage; products: Alginates Hydrofibers Foams Absorptives NPWT* Pouching
non to minimally draining wounds - goals and products
goal: maintain moisture; products: Hyrdogels Hydrogel gauze Saline gauze Film dressings Hydrocolloid Non-adherent
dry or dessicated wounds - goals and products
goal: hydrate wound; products: Hydrogel gauze
Hydrogel
Saline gauze
cavernous, undermined, tunneled wound goals and products
goal: fill "dead" or negative space; products: Gauze Packing Gauze packing strips Hydrofiber strips Alginate Rope Hydrogel gauze Hydrocolloid paste Cavity Strand (Polymer) NPWT*
edema - goals and products
goal: reduction and control; products: Compression Bandaging Dynamic Static Segmental pumps Graduated compression stockings
unrelieved pressure - goals and products
goal: pressure reduction/relief; products: Offload foot/heel
“Football” dressing
Specialty devices
Support surfaces
Overlay
Replacement Mattress
Cushionsgranulated static/stalled wound - goals & products
goal: biologic support; products: Growth factors Apligraf Dermagraft Oasis/Matristem Allograft
failure to heal - goals & products
goal: enhance tissue growth; products: MMP inhibitors Hyaluronic acid Maltodextrin Collagen NPWT* Polyhydorgenated ionogen Oxidized regenerated cellulose Trolamine sodium alginate
necrotic - goals & products
goal: remove non-vital tissue; products: Debridement Autolytic-eg, hydrocolloid Mechanical- eg gauze Larval Enzymatic- collagenase
malodor/quality of life -goals & products
goal: odor control; products: Activated Charcoal
Iodosorb/Iodoflex
Silver Dressings
Gentian Violet/Methylene
blue PVA foam
Metronidazole
Maltodextrin NF
Dilute Antiseptic solutionspain/quality of life goal & products
goal: pain reduction/control; products: Siliconized dressings
Hydrogels
Impregnated gauze
Non-adherent contact layers &
dressings
Compression bandages
Topical analgesics (eg Lidoderm®)
