Types of Dressings Flashcards
What are 4 major factors that influence wound healing?
- High pressures or contusions
- Excessive exudate
- Infection (Bacteria)
- Desiccation (Drying Out)
Factors that need to be addressed…
Color
Depth
Exudate
Infection
Protection
Fragility
What is the Red-Yellow-Black System?
is way that therapists can classify healing or non-healing wounds and allow for the appropriate decisions regarding the successful achieving proper wound closure.
Red: Indicates granulation tissue, reactivity, repair, remodeling.
Yellow: Slough or infection (treat it)
Black: Necrosis (Get rid of it)
What are the different kinds of exudate?
Serous: Water-based with immune cells
Serosanguinous: Above but a tinge of blood
Hemorrhagic/Blood: Actively bleeding
Purulent: INFECTION
What are Semipermeable Films and what are they used for?
•1-2 inch transparent-semipermeable sheets with adhesive outer edges
Film dressings allow for
- visualization
- maintain a moist wound bed
- impermeable to microorganisms.
These are used for minor burns and simple injuries and NOT used for deep or infected wounds.
Wound Profile:
- Color: Pink or Red
- Depth: Unbroken skin to superficial partial thickness only
- Exudate: Minimal exudate or dry
- Infection: NOT infected
- Protection: friction or shear
- Fragility: Periwound intact
- Clinical Pearl: Visualization, Can be used as 2nd dressing
What are Hydrocolloids used for?
•Simple occlusive wafer sheets that are adherent to the surrounding tissues.
Hydrocolloids dressings
- prevent the passage of microorganisms
- absorb exudate
- conform to body shape
- maintain a moist environment
- does not require a secondary dressing.
Hydrocolloids are used for wounds that are small and superficial with minimal drainage. Wounds that are treating with a HC are superficial burns, superficial leg ulcers, and pressure ulcers.
Wound Profile:
- Color: Pink or Red, black or slough
- Depth: Superficial Partial Thickness
- Exudate: Minimal exudate
- Infection: NOT infected
- Protection: Light pressures
- Fragility: Peri-wound intact
- Clinical Pearl: Can leave behind yellowish residue, cant see underneath**
What are Hydrogels used for?
Amorphous or sheet-like wafers that are non-adherent and have absorptive qualities. They need something else to hold it in place!
•Hydrogel dressings are ideal because they can
donate moisture to dry wounds
- absorb exudate
- comes in different forms (amorphous and sheet)
- Non-adherent
- Promotes Autolytic Debridement
- Hydrogels are used for wounds that are dry and typically partial to full thickness. (arterial insufficiency ulcers, deep full thickness wounds)
Wound Profile:
- Color: Pink or Red, black or slough
- Depth: Superficial partial to Full Thickness
- Exudate: Dry to Moderate exudate
- Infection: Not infected or Infected (Amorphous GEL Only)
- Protection: Light pressures
- Fragility: Peri-wound intact
- Clinical Pearl: Can pack wounds (amorphous)
What are Foams used for?
•Non-stick, semipermeable foam padded dressings with adhesive Hydrogel dressings
Foam dressings
- absorb moderate to high exudate
- maintain a moist environment
- provide a healthy wound temperature (insulation)
- provide cushioning (padding)
- doesn’t adhere to the wound bed.
- contour the body
- Foams are used for wounds that are moderate to heavy draining, need contouring, and protection.
Wound Profile:
- Color: Pink or Red
- Depth: Superficial partial to Full Thickness
- Exudate: Moderate to Heavy exudate
- Infection: No, Not infected if used alone
- Protection: Excessive or repetitive pressures
- Fragility: Peri-wound intact
- Clinical Pearl: No Necrosis / Protect from Contusion
*TYPICALLY PAIRED WITH HYDROGELS OR SOMETHING IMPREGNATING IT
What is gauze used for?
- Woven translucent fabric with high absorptive capacity and multiple forms of utilization
- Gauze is not ideal because
- It adheres to the wound and can create a wet to dry situation causing pain and damaging healthy tissue (consider purpose)
- It can desiccate the wound bed delaying the healing process
- It is permeable to bacteria and water which can place the patient at risk for infection.
- Gauze dressings are ideal because they can absorb high levels of exudate and can be used on infected wound impregnated with an antibacterial agent. (silver nitrate)
Wound Profile:
- Color: Pink or Red, Slough, Or Eschar (Not Thick)
- Depth: Superficial partial to Full Thickness
- Exudate: Moderate to Heavy exudate
- Infection: No, Not infected wounds unless impregnated
- Protection: Light pressures
- Fragility: Periwound intact
- Clinical Pearl: Heavy Drainage / Impregnate Your Gauze
What are alginates used for?
- Calcium based flexible fibers with high absorptive capacity
- Alginates dressings
- absorb high levels of exudate
- conform to body shape
- provide moist environment (autolytic debridement)
- does not adhere to the wound
- Alginates are used for wounds that are large cavity wounds such as leg ulcers, pressure wounds and donor sites. These dressings can also be used for infection and SHOULD NOT be used for wounds that are dry or have thick, black eschar.
Wound Profile:
- Color: Pink or Red, Slough, Black
- Depth: Superficial partial to Full Thickness
- Exudate: Moderate to Heavy exudate
- Infection: Infected or Not Infected
- Protection: Excessive or repetitive pressures
- Fragility: Periwound intact
- Clinical Pearl: No minimally draining wounds or wounds with thick eschar
What is tunneling vs undermining?
- Tunneling
- Also called ”sinus tracts” channels that extend from a wound into and through subcutaneous tissue or muscle
Undermining
- Multidirectional extension of subcutaneous tissue underneath intact skin damage that
- Caused by
- Infection
- Ischemia or cell death
- Weakened wound bed (lack of nutrients)
- Shear
How do you asses undermining/tunneling?
- Tunneling (Q-tip method)
- Place Q-tip into tunnel as far as possible until a gentle resistance is felt
- Pinch the Q-tip stick with your thumb and index fingernails at the break of the skin
- Pull out the Q-tip and measure from the Q-tip head to the point where you are pinching the Q-tip stick. This is the tunnel depth.
- Undermining (Q-tip method & Clock Method)
- Measure using Clock Method
- Head is 12 o’ clock
- Feet are 6 o’ clock
