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05.03 Wound Care – Selecting a Dressing

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Overview

  1. Types of Wound Healing
    1. Primary Intention
      1. Clean wound
      2. No tissue loss
      3. i.e. Surgical incisions (suture/staples)
    2. Secondary Intention
      1. Tissue loss (i.e. trauma)
      2. Allow granulation
    3. Tertiary Intention
      1. Delayed closure or grafting
      2. Often includes debridement

Nursing Points

General

  1. Purpose of Dressings
    1. Slow/stop bleeding
    2. Prevent infection
    3. Absorb drainage
    4. Debridement
    5. Reduce psychological stress

Assessment

  1. Wound Assessments
    1. Exudate type/amount
    2. Wound characteristics
    3. Need for debridement
    4. Need for pressure
    5. Risk for infection
  2. Special Considerations
    1. Moisture
      1. Too moist = infection
        1. Need to pull moisture away from wound bed
      2. Too dry = can’t heal
        1. Need to keep moisture in wound bed
    2. Bleeding
      1. Mild/moderate – use a hemostatic dressing or packing
        1. i.e. Surgicel
    3. Gauze wrapping
      1. Pressure dressing
      2. Hold another dressing in place
      3. Circumferential wounds
      4. large/awkward wounds

Therapeutic Management

  1. Classification of Dressings
    1. Alginates
      1. Calcium alginate → chemical reaction with exudate → gel
      2. Maintains moisture
      3. Best for wounds with heavy exudate
    2. Antimicrobials
      1. Silver / Iodide
      2. Full dressing or strips for packing.
      3. Silver dressings require moist environments
    3. Films
      1. Thin, elastic, transparent
      2. Provide a barrier
      3. NOT absorptive
      4. Superficial – skin tears, etc.
    4. Foams
      1. Provides moisture retention while providing cushion
        1. i.e. wounds over bony prominences
      2. May be too drying
      3. Not recommended for heavy exudate
    5. Hydrocolloids
      1. Sheet or gel
      2. External = semiperm
      3. Internal = hydrophilic (absorptive)
      4. Can stay on many days
      5. Abrasions, post-op wounds, partial thickness wounds/burns
    6. Hydrofibers
      1. Similar absorptive properties to Alginates
        1. Less risk of maceration due to moisture trapping
    7. Hydrogels
      1. 95% water
      2. Increase natural moisture in wound bed
      3. Promotes autolytic debridement
      4. Best for wounds containing eschar
    8. PMDs (Polymeric Membrane Dressing)
      1. External = semipermeable
      2. Internal = hydrophilic polyurethane membrane
      3. Thicker dressing for more exudate
      4. Enhance debridement
      5. Improve healing
      6. Prevent infection
  2. Choice of Dressing by Wound Type
    1. Deep
      1. Alginates
      2. Hydrofibers
      3. Hydrocolloids
      4. PMDs
    2. Eschar
      1. Hydrogels
      2. Hydrocolloids
      3. PMDs
    3. Exudate
      1. Alginates
      2. Hydrofibers
      3. Foams
      4. PMDs
    4. Granulating
      1. Hydrocolloids
      2. Hydrogels
      3. PMDs
    5. Infected
      1. Antimicrobials
    6. Slough
      1. Hydrogels
      2. Hydrocolloids
      3. Wet to Dry
    7. Superficial
      1. Films
      2. PMDs

Nursing Concepts

  1. Tissue/Skin Integrity
  2. Nursing Skills
  3. Infection Control

Patient Education

  1. If going home – must educate on wound care orders.
    1. Highly recommend they return-demonstrate before discharge
  2. Signs of infection to report

Reference Links

Study Tools

Video Transcript

In this lesson, I just want to run through a few key things to think about when you’re selecting a dressing. A lot of times you’ll have very specific wound care orders, but sometimes we need to use our nursing judgment on how to choose an appropriate dressing based on the wound.

The first thing we need to look at is there is multiple different types of wound healing and wound closures. So one of the things we need to know about our ruined is how we are managing the healing of the wound. The first type is primary intention. This is a clean wound with no loss of tissue and the edges tend to be approximated. The best example of this is a standard surgical incision that gets closed by sutures or Staples or even glue. The second type is secondary intention. This is where there has been some sort of loss of tissue or it is a jagged wound of some sort. A great example of this is any kind of trauma to the tissue. The goal with secondary intention healing is to allow the wound to granulate before we actually fully close the wound. We may actually let it completely granulate on its own instead of forcing closure with some sort of device like sutures or Staples. And the Third Kind is tertiary intention. This is when we actually intentionally leave a wound open. We do this either because we’re going to provide a graft to close it with or we’re just going to wait and close it later. This happens a lot with exploratory laparotomies, when we open up a patient’s abdomen. We tend to leave it open for a few days to allow any kind of swelling or drainage to decrease before we close the abdomen all together. This could also be a large pressure ulcer or other wounds that requires debridement. So we’ll leave the would open so that we can continue to debride as needed before the wound closes.

Let’s just review the purpose of using dressings for our wounds. It could be to slow or stop some sort of bleeding. there’s a specific dressing type that can actually help with this which we will talk about in just a second. We also want to make sure that we prevent infection in our wounds by providing a barrier between the wound and the outside world. Dressings can also help to absorb drainage and provide debridement for wounds with eschar or slough that needs to be removed. And lastly wound dressings can actually help to reduce psychological stress because the patient doesn’t have to look at the wound itself.

There’s a few things are going to want to assess on your wound before you determine what kind of dressing that you need. First is is there any exudate or drainage and how much is there? What does our wound look like? Is there eschar or slough? Is it dry? Is it granulating? All of those things help us pick a dressing. We also need to know if we’re going to need debridement or to provide pressure. And of course we want to determine how high the risk of infection is in this wound because we may need to use an antimicrobial dressing option.

Before I talk about the specific dressing types I want to just give you a couple different considerations when it comes to choosing dressings. One is regarding your moisture. A general rule to keep in mind is that we never want a wound to be too moist or too dry. If you have an extremely moist wound bed it’s going to be a breeding ground for bacteria. Therefore we want to dry the wound out of it and remove the moisture. This means that the dressing itself is going to be wet when you remove it. Good examples would be simple dry cause Foams or alginates. If your wooden bat is too dry, then of course you want to keep it moist because if it’s too dry it’s not going to granulate and heal. So we could use things like a wet to dry dressing, a hydrocolloid, or a hydrogel. Just remember, not too dry and not too wet.

Now remember I talked about specific dressing to use for bleeding. If you have a wound with mild to moderate bleeding, you can use something called surgicel. It looks like a little mesh, sometimes in squares and sometimes in strips. You just apply it directly to the wound bed and it actually causes the wound to clot and provides hemostasis. Of course if you have an arterial bleed or severe bleeding you’re going to need to use some other options.

Another thing to remember is that we can always use a gauze wrap around other dressings or other wound care techniques. We especially use gauze wraps when we need to do pressure dressings or to hold another dressing in place. We’re also going to use gauze wraps for a circumferential wounds that go all the way around an extremity or a finger, order for a large or awkward loons that we can’t necessarily tape a dressing to.

Now I want to just quickly talk about the most common types of dressings that you’re going to see in a clinical setting. I didn’t talk about standard dry gauze here because, well, it’s just gauze. Hydrogel balls are 95% water. The benefit of hydrogels is that they actually increase the natural moisture in the wind bed and it allows for what’s called autolytic debridement, which means the body’s own hormones and enzymes come in to debride any dead tissue. These are fabulous for wounds with eschar. Hydro colloids can either be in a sheet or a gel they have a semi-permeable membrane on the outside and a hydrophilic layer on the inside. Remember hydrophilic means it attracts moisture. So this is good for a wound that needs moisture kept in it, like abrasions and partial thickness wounds. These dressings can stay on for usually 2 to 3 days before needing to be changed. Alginates have something in them called calcium alginate which actually reacts with the drainage and forms a gel. So it draws moisture away from the wound bed but keeps the wound from drying out too much. I’ll jene’s are fabulous for wounds that have a lot of drainage. Hydro fibers are really similar to alginates in that they absorb heavy drainage. However one of the risks of alginates is that all that moisture gets trapped and it can actually cause maceration of the healthy tissue. Hydro fibers have less risk of that maceration oh, so they’re a great option if we start to see that complication.

Foam dressings as you can imagine are highly absorptive they absorb so much moisture into the foam itself. The benefit of a a foam dressing is that you get moisture attention while also providing cushion. So foam dressings are fabulous for wounds that are over bony prominences. The only problem is they may be too drying until we’re not really recommending them for wounds with heavy exudate. PMDs or polymeric membrane dressings are kind of like a jack of all trades. They have a semi-permeable membrane on the outside and a hydrophilic membrane on the inside. They also come in multiple thicknesses, so you can use a thicker dressing if you have more drainage. They’re great for enhancing debridement, improving healing, and preventing infection. As you’ll see on the next slide you can use a PMD for almost any type of wound. Simple films, like a tegaderm, are thin, elastic, transparent dressings. The whole purpose of a film is simply to provide a barrier, they are not absorptive. These are great for superficial, non-draining wounds like skin tears. And lastly we have antimicrobial dressing like silver or iodide dressings. They could be full dressings or simply strips that you can pack into a wound. One thing you need to know here is that silver dressings require moist environments, so you wouldn’t use them on a dry wound.

So really quickly just to summarize what types of wounds require what types of dressings let’s go through seven of the most common types of wound characteristics. For superficial wounds like we said a simple film or even a PMD works wonderfully. For wound with eschar which is stick dead tissue, sort of like a third degree burn, we would use a hydrogel, A hydrocolloid, or a PMD. For wounds with lots of drainage, we could use alginates, Hydrofibers, foams, or PMDs. Or ones that are already starting to heal and show granulation tissue, we’d focus on hydrocolloids, hydrogels, or PMD’s. For wounds that need debridement because of slough, we use hydrogels or hydrocolloids, as well as wet to dry dressings. Deeper wounds will use alginates, hydrofibers, hydrocolloids, or PMD’s. And infected wounds will require antimicrobial dressings like silver or iodide impregnated dressings.
I know that’s a lot of information, so let me just boil it down to a few key points to Remember When selecting a dressing. Consider the wound characteristics what’s going on with your wound itself? Is there drainage, is there slough? then think about the goals, what are we trying to accomplish? Do we need to debride it? Are we dealing with an infection? As you go through this process make sure you’re working closely with your wound care nurse. They are specially trained On choosing dressings. It’s especially important to collaborate with them if you can tell that the wound is changing or healing and needs a different type of dressing. Always verify your wound care orders, sometimes they don’t have any specific directions, so you want to use your nursing judgment. And finally always make sure you’re looking for complications like maceration to the skin around the wound, reactions to the dressing itself, or possible infection in the wound.

Make sure you check out all the resources attached to this lesson, including the video guide, which will have these slides you can download, as well as the rest of our wound care skills videos. Now, go out and be your best selves today. And, as always, happy nursing!!

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