Wound Dressings Flashcards
Dressings Goals
Maintain moist wound bed Protect surrounding skin Control exudate Fill dead space Protect wound from environment Allow gas exchange so O2,H20,CO2 can pass through dressing Maintain normal thermia Impermeable to microorganisms Non-traumatic with removal Maintain correct ph
Moist Wound Healing
Traps endogenous enzymes to facilitate autolytic debridement Preserves endogenous growth factors Reduces patient pain complaints Reduces hypertrophic scarring Faster healing
Protect Surrounding Skin
Use skin protectants at wound borders to prevent maceration
Make sure dressing adequately controls drainage.
Avoid aggressive adhesive, especially on fragile skin
What dressing to use to on extremity to protect surround skin?
circumferential dressing
What dressing to use to on abdomen to protect surround skin?
abdomen Montgomery straps can be left in place to avoid excessive skin trauma
Moisture barriers
Ointments or creams
Prevents peri-wound rashes/skin breakdown
Can apply to macerated skin
Moisturizers
Key component of basic skin care
Help restore barrier function of epidermis
Maintain/restore skin hydration
Avoid those with perfume or alcohol (possible skin reaction)
Apply to intact skin
Petrolatum may penetrate best
Ointments are more occlusive than creams or lotions
Too Moist
Maceration- skin becomes fragile and susceptible to colonization
May increase wound size
Increased chance of infection
Protect wound from environment
Adequate padding to prevent trauma
Adequate coverage to prevent exposure to contaminates
Adequate layers/absorption to prevent strike through drainage
Allow gas exchange
Adequate permeability to allow O2,H20,CO2 transfer
Impermeable to microorganisms
If strike through drainage occurs, allows conduit for bacteria
Insure adequate coverage to prevent environmental exposure
Non-traumatic with removal
Insure dressing can be removed without trauma to granulation tissue
Also important for pain control
What does maintaining the wound bed temperature at 98 degrees do?
mytotic activity increases increasing the proliferative response up to 108%.
What happens when the wound bed cools?
cellular activity drops dramatically
What does warmth stimulate?
adequate perfusion of tissue
Classes
Semipermeable Transparent Films Hydrogels Hydrocolloids Foams Absorptive Dressings/Alginates Gauze Other specialized dressings
What are semipermeable film dressings?
Thin sheets of transparent polyurethane with adhesive backing
What do semipermeable film dressings allow?
Allow visualization of wound bed Permeable to water vapor, O2, CO2 Highly elastic and conformable Keeps wound moist Protects against shear
What do semipermeable film dressings stop?
Impermeable to bacteria and water
Non- absorptive/non insulating
What are semipermeable film dressings used on?
Used on clean wounds
May use as secondary dressing
May leave in place > 5-7days
What should semipermeable film dressings not be used on?
Infected wounds
Wounds with moderate to heavy drainage
Patients with fragile skin
Semipermeable Film Dressings Precautions/Contraindications:
Skin sealant may be needed to protect periwound
Must maintain good edge seal
Semipermeable Film Dressings Common uses:
Superficial or partial-thickness wounds Skin tears Donor sites Areas of friction Abrasions Over IV catheters to allow bathing/whirlpool Over wounds for ultrasound treatments
Benefits of Semipermeable Film Dressing
Moisture-retentive dressing Encourages autolytic debridement Reduces friction, protects against shear Allows visualization of wound bed Waterproof Cost less over time
Limitations of Semipermeable Film Dressing
Adhesive may traumatize periwound upon removal Cannot use on highly exudating wounds Can be hard to apply Should not use on infected wounds Will not adhere to wet or oily skin
Hydrogels
Amorphous gel, sheet (Polymer gel with backing), or impregnated gauze
Gels are wound fillers and require secondary dressing
What comprised hydrogels?
30-90% water or glycerin-based
Some have adhesive borders
How long do hydrogels last?
up to 3 days
What are hydrogels used for?
Used to maintain adequate wound moisture
Used over abrasions, donor sites, and partial thickness burns
Non-adherent, reduces heat in burns, soothing
Can be used as coupling medium for US
What can hydrogels absorb?
small amounts of exudate and facilitate autolytic debridement
What are hydrogels permeable to?
gas and water
What should hydrogels not be used on?
Heavily draining wounds
Infected wounds
Sheet Hydrogels:
Precautions/Contraindications
Absorb fluids slowly
Skin sealant may be needed to protect periwound
Hydrogel sheets
Minimally/moderately exudating wounds Blisters/abrasions/skin tears Burns (thermal and radiation) Donor sites Mastitis To decrease pressure/shear or provide padding in casts
Hydrogel amorphous
Add moisture to wound bed
Soften eschar
Coupling agent for ultrasound
Benefits of hydrogel
Moisture-retentive dressing
Encourages autolytic debridement
Non- or minimally adherent
Limitations of hydrogel
May dehydrate
Cannot use on highly exudating wounds
Generally require secondary dressing
Should not use on infected wounds
What are hydrocolloids?
Contain hydrophilic colloidal particles with a strong film or foam adhesive backing to create a relatively occlusive dressing
What do hydrocolloids do?
Create an effective barrier against urine, stool
React with wound moisture to absorb or create a gel that maintains a moist wound bed
Wide range of absorptive abilities within this class
What do hydrocolloids react with?
wound moisture to absorb or create a gel that maintains a moist wound bed
Dressing residue may appear purulent and malodorous
Hydrocolloids and periwound?
Adhesive may be traumatic if delicate peri-wound skin
Hydrocolloids:
Precautions/Contraindications
Bleeding or heavily draining wounds Infected wounds Dry wounds, arterial ulcers, third-degree burns, or wounds with minimal drainage ( may aid in increasing wound moisture if surrounding skin is stable enogh) Wounds with exposed tendons/fascia Patients with poor skin integrity Caution on immunocompromised patients
Common uses of hydrocolloids:
Partial- to full-thickness wounds
Granular or necrotic wounds
Minor burns
Venous insufficiency ulcers
Pressure ulcers including special shapes for sacral and coccygeal ulcers
On peri-wound as an attachment for adhesive tape
Benefits of hydrocolloids:
Moisture-retentive dressing Encourages autolytic debridement Provide thermal insulation Waterproof Absorb moderate amounts of drainage Impermeable to urine, stool, bacteria Provide moderate absorption
Limitations of hydrocolloids:
Adhesive likely to traumatize peri-wound May roll in areas of friction Should not use on infected wounds Leaves residue in wound bed May cause hypergranulation (too much moisture)
Semipermeable Foams:
Permeable to gas but not to bacteria
Provide thermal insulation
Absorbent
How long can semipermeable foams last?
Can last up to 7 days depending on exudate
Polyurethane foam
Hydrophilic wound side
Hydrophobic outside
Some have semipermeable film backing
Shape of semipermeable foams:
Conform to irregular surfaces
Provide padding (protection)
Keeps wound moist
Non-adherent)
Semipermeable Foams:
Precautions/Contraindications
No specific contraindications
Make sure there is adequate moisture
Protect peri-wound skin if there is excessive moisture
Semipermeable Foams Common Uses:
Minimally to heavily exudating wounds Donor/ostomy sites Minor burns Granulating or slough-covered partial- to full-thickness wounds Neuropathic ulcers Venous insufficiency ulcers
Benefits of semipermeable foams:
Moisture-retentive dressing Encourage autolytic debridement Provide thermal insulation Provide cushioning Absorb moderate amounts of drainage Available with and without adhesive
Limitations of Semipermeable foams:
Adhesive may traumatize peri-wound
May roll in areas of friction
Should not use on infected wounds unless changed daily
What are alginates?
Salts of alginic acid from marine brown algae and giant kelp
React with serum and wound exudate to form a hydrophilic gel to provide a moist wound environment
Absorbs 20x its weight
What do alginates require?
Require secondary dressing
Characteristic of alginate?
Highly absorbent, used on highly exudating wounds
Engineered hydro-fibers (Aquacel) are 30% more absorptive and non-wicking
Alginates:
Precautions/Contraindications
Full-thickness burns (third degree) Dry or minimally draining wounds Wounds with exposed: Tendon Joint capsule Bone
Common Uses of Alginate:
Highly exudating wounds
Venous insufficiency ulcers
Tunneling wounds
Swabs to probe, fill, measure wound depth
Benefits of Alginate:
Encourages autolytic debridement Highly absorbent Infected and uninfected wounds Biocompatible Nonadherent
Limitations of Alginate:
Require secondary dressing
Use with extreme caution with exposed deep tissue to prevent desiccation
Should change daily on infected wounds
Kinds of gauze dressing:
woven (cotton)
nonwoven (synthetic, more absorbent)
Characteristics of gauze dressing:
Highly permeable
Relatively nonocclusive
Finer weave/smaller pores decrease wound bed trauma
Air permeable, allows drying of wound (such as for wet to dry mechanical debridement)
Primary or secondary dressing
Inexpensive for one-time or short-term use
Gauze Dressings:
Precautions/Contraindications
May require more force for removal
May leave residue or lint
If dehydrates, will adhere to wound bed
Roll gauze should be applied at an angle, snugly but without tension
Telfa dressings are reserved for superficial, nondraining wounds
Gauze Dressings Common Uses
Infected and noninfected wounds
Wounds of all sizes, shapes, depth, or etiologies
Wounds requiring packing
Wounds requiring frequent dressing changes
Highly exudating wounds
Benefits of Gauze:
Universally available
Low one-time cost
Can use on infected and uninfected wounds
Can use alone or with other dressings/topical agents
Can add more layers to increase absorption
Provides cushioning
Roll gauze keeps adhesives off patients’ skin
Limitations of Gauze
Costly over time May adhere to wound bed May leave particulate matter in wound bed Highly permeable Require more frequent dressing changes
What can mesh gauze dressing be impregnated with?
petrolatum bismuth zinc hydrogel saline
Petrolatum
Vaseline gauze/Adaptic- non-adherent to protect granulation, can be used as a secondary dressing to increase occlusiveness.
Bismuth
Scarlet red, Xeroform- were thought to promote epithelialization, unsure if chemicals may actually impede healing. If they become dry can be traumatic to remove
Characteristics of impregnated gauze dressing?
Nonadherent contact layer
Require a secondary dressing
Increase occlusiveness of a gauze dressing
Dressings with bismuth
Cytotoxic to inflammatory cells
May cause inflammatory response in patients with venous insufficiency ulcers
Iodine-impregnated gauze
Cytotoxic
Only mildly antimicrobial
Common uses
Impregnated Gauze Dressings
Granulating wounds Epithelializing wounds Wounds with exposed tendons Wounds that bleed easily Burns
Benefits of
Impregnated Gauze Dressings
Decrease wound bed trauma with dressing changes
Decrease pain of dressing change
May increase occlusiveness of gauze dressing
Limitations of
Impregnated Gauze Dressings
More costly than plain gauze
Require secondary dressing
May present a barrier to keratinocyte migration
Have minimal absorptive capabilities
Other dressings:
silver dressings hyper-osmolar dressing hyaluronic acid charcoal honey collage composite dressing tissue adhesive
Silver dressings-
decreases microbial load against gram+ and gram-, antifungal, inactivates enzymatic debriders
Hyper-osmolar dressing example
Mesalt- Heavily draining/infected wounds- by osmosis draws out exudate
Hyaluronic acid
“natures moisturizer” enhances granulation
Charcoal
Controls odor
Antimicrobial Wound Dressings
Silver or cadexomer iodine
Incorporated into all classes of dressings
Broad-spectrum antimicrobial
Decrease wound bioburden
Antimicrobial Dressings:
Precautions/Contraindications Silver:
Blue-black wound bed discoloration
Monitor for signs of hypersensitivity/ADR
Do not moisten with saline
When can you not use antimicrobial silver?
Can’t use with electrical stimulation ??
Remove before MRI
Not for neonates
Cytotoxic, may delay re-epitheliailization
Antimicrobial Dressings:
Precautions/Contraindications Cadexomer iodine
Sensitive to iodine
Thyroid disease
Large cavity wounds (Need to monitor dosage to avoid toxicity)
Antimicrobial Dressings Common Uses:
Partial- and full-thickness chronic wounds Donor sites Burns Venous insufficiency ulcers Neuropathic foot ulcers Pressure ulcers: heavily colonized Traumatic wounds
Benefits of Antimicrobial Dressings
Broad-spectrum antimicrobial
Available in wide variety of dressing classes
Adhesive and nonadhesive forms
May be primary or secondary dressing
Consider for heavily colonized pressure ulcers
Limitations of Antimicrobial Dressings
Paucity of research
High cost
Honey-Impregnated Dressings
Leptospermum, also known as Manuka honey
Purported Ways to Improve Healing
Antimicrobial
What to consider with Honey-Impregnated Dressings?
Consider to control wound bioburden
Consider to control wound odor
What does honey impregnated dressings stimulate?
May stimulate growth factors
Stimulates angioblasts, fibroblasts, monocytes
What does honey impregnated dressings control?
Reduces inflammation and edema
Osmotic action controls drainage
Collagen
Provide an extracellular framework for multi-cellular animals
Primary protein present in the skin, providing strength and structure
Present in the reticular layer of the dermis providing the skin with its strength, interwoven with elastin to provide flexibility
Collagen Dressing
Minimal exudates Can use on infected wounds Partial and full thickness Need to watch for allergic reaction Stimulates cells to proliferate Hemostatic Attracts fibroblasts and macrophages Increases tissue strength Decreases effect of MMP’s Can be from any source
Kinds of collage dressing:
Sheets, ropes, and pad dressings
Gel, paste, powder, or particles
What is collagen dressing used for?
Consider for nonhealing category/stage III or IV pressure ulcers
Partial- or full-thickness wounds
When is collagen dressing contraindicated?
if sensitive to collagen
Collagen Purported Ways to Improve Healing
Stimulates macrophages, angioblasts, keratinocytes, platelets
Protects growth factors
Provides scaffolding for cell proliferation/migration
Maintain moist wound environment
May encourage balance between MMPs and TIMPs
Inner contact layer of composite dressing:
Nonadherent
Prevents wound bed trauma
Middle layer of composite dressing:
Absorbs moisture, wicks, maintains moist wound bed
Hydrogel, semipermeable foam, hydrocolloid, or alginate
Outer layer of composite dressing:
Bacterial barrier
Commonly a semipermeable film
Tissue Adhesives
Skin glues
Primary wound closure without staples or sutures
Use on acute linear wounds without tissue loss
Must protect wound from tension early on
Function of Primary Dressing:
Direct contact with wound
Antimicrobial
Non-adherent/non-traumatic
Maintains moisture balance
Function of Secondary Dressing:
Over primary dressing Can provide Protection Cushioning Absorption Occlusion
The Future of Wound Management:
Growth Factors
Cytokines, interleukins, colony-stimulating factors
Growth-promoting substances that enhance cell size, proliferation, or activity
In humans, wounds treated with certain growth factors improved significantly more than wounds treated with a placebo
What are growth factors limited to?
Limited to chronic wounds that are recalcitrant to traditional interventions
Extremely costly
Biosynthetic Dressings and Skin Substitutes
Derived from natural tissues
Retain the skin’s natural barrier properties
Encourage autolytic debridement
Help create healthy granular wound bed
Skin Grafts:
Provide skin coverage
Wounds with extensive surface areas
Large full-thickness burns
Chronic wounds
Types of skin grafts:
Allograft, xenografts, autografts
Drawbacks of skin grafts:
Limited supply
Very costly
Short shelf life
Possible cultural/religious concerns
Indications for skin substitutes:
Nonhealing, uninfected partial- and full-thickness ulcers
Burns
Traumatic wounds
Skin substitutes:
No immune response
Temporary or extended wound coverage
Used in highly specialized areas of wound care, such as burn clinics
Skin Substitutes Types:
Alloderm Apligraf Biobrane Dermagraft Epicel GRAFTJACKET Integra Transcyte
Draining
Absorb moisture
Protect the surrounding wound from maceration
Nondraining
Provide moisture
Prevent evaporative fluid loss
Since moisture will be added to the wound, a skin sealant should be used to protect periwound
Granular and Nondraining
Healing as expected
Protect granulation tissue
Obtain/maintain moist environment
Protect surrounding tissue
Dressing options for granular and nondrainig:
Gauze, impregnated gauze
Transparent film
Hydrogel
Dressing options for granular and draining:
Gauze
Alginate
Semipermeable foam
Hydrocolloid
Granular and Draining
Observe for infection
Protect granulation tissue
Absorb exudate
Protect surrounding tissue
Necrotic and Nondraining
Soften eschar
Remove eschar
Obtain/maintain moist environment
Protect surrounding tissue
Debridement options for Necrotic and Nondraining
Surgical
Sharp
Enzymatic
Autolytic*
Dressing option for Necrotic and Nondraining
Gauze, impregnated gauze
Transparent film
Hydrogel
Hydrocolloid
Necrotic and Draining
Observe for infection
Absorb exudate
Remove eschar
Protect surrounding tissue
Debridement options for Necrotic and Draining
Surgical
Sharp
Enzymatic
Autolytic*
Dressing options forNecrotic and Draining
Gauze
Alginate
Semipermeable foam
Hydrocolloid*
Wound Infection
Should avoid occlusive dressings
Rebandage daily
Good dressing options for wound infection:
Gauze
Alginate
Semipermeable foam
Small wound
gauze or moisture-retentive dressings
Large wound
gauze dressings
Deep wound:
lightly fill to prevent abscess formation
Tunneling:
gauze dressings and frequent dressing changes
Objectives of Comprehensive
Wound Management
Granular wound bed Moist wound bed Warm wound environment Manage infection Eliminate dead space Protect peri-wound Enhance patient’s ability to heal
Bandaging Procedure:
Wounds with Dead Space
Packing material should be confined to
wound bed
Use sterile instruments and packing materials to fill wound
Leave a wick
Dressings for hands:
If a large wound or infected, use roll gauze
Figure-eight wrapping
Minimize bandage bulk to allow use of extremity
Dressing for Arms and Legs:
Nonadherent dressings if poor skin integrity or significant body hair
Secure with roll gauze, self-adherent elastic wraps, or elastic netting
Dressing for Trunk
Secure with roll gauze, an elastic netting vest, or both
Use short-stretch compression wraps with caution to allow adequate respiration
Large wounds, consider a burn vest
Montgomery straps
Dressing for ankle/foot:
Can bandage like hand wounds May drain more, so may need more absorptive dressing Ensure adequate room for footwear Consider temporary footwear Consider assistive device
