Dressing selection at it’s finest… By Aleatha Myers, RN, CWCA July 2016

Dressing Selection There are many different types of dressings available out there. There is rarely “One True Dressing” for a wound.

Functions of Wound Dressings Create a moist environment A moist environment: Facilitates all three phases of wound healing Traps endogenously produced enzymes to facilitate autolytic debridement Preserves endogenously produced growth factors Increases fibroblast proliferation and collagen synthesis Reduces patient pain complaints Results in a more cosmetically appealing scar If wound is too wetneed absorbent dressing If wound is too dry  dressing should donate moisture

Functions of Wound Dressings (cont.) Provide Thermal Insulation – wound must kept be 37-38 degrees for proper healing Provide a barrier to microorganisms Protect exposed nerves and decrease pain Eliminate dead space to prevent premature wound closure Remove debris, necrotic tissue and foreign material Provide adequate gas exchange between the wound and the environment

Categories Wound dressings are divided into two categories: Primary Dressing: comes into direct contact with the wound. Ex: bandaid Secondary dressing: placed over a primary dressing for increased protection, cushioning, absorption or occlusion

Why use Moisture Retentive Dressings instead of Gauze???? 1- Lower moisture vapor transmission rate 2- Lower infection rates by: *Serve as a bacterial barrier *Impermeable to stool and urine *Facilitate neutralization of microorganisms *Facilitate removal of necrotic tissue 3- Trap wound fluid rich in enzymes, neutrophils, growth factors and macrophages in the wound bed. 4- Comfort – protect nerve endings and reduce pain

5- Healing: * Moisture Retentive dressings lead to faster wound healing through stimulation of: a. granulation tissue formation b. collagen synthesis c. epithelialization 6- Debridement (autolytic) –usually within 12-96 hours 7- Protection 8- Temperature maintenance 9- Usability 10- Cost – may cost more that gauze but need fewer dressing changes

Categories of Wound Dressings Gauze Impregnated gauze Films Hydrogels Foams Hydrocolloids Alginates Antimicrobials

Gauze Woven gauze (cotton) Nonwoven gauze (synthetic, more absorbent) Least occlusive dressing available-highly permeable Gauze with finer weave and smaller pores minimizes risk to the wound bed May promote desiccation in wounds with minimal exudate unless used in combination with another dressing or topical Can be used as a primary or secondary dressing Inexpensive – used for one-time or short-term use

Gauze (continued) Common uses: Dressing of choice for: Infected and non infected wounds of any size, shape, depth or etiology Although they may not be the best choice of dressing, they can be modified to be safe with any wound Dressing of choice for: Frequent dressing changes Decreased cost Infected wounds being treated with enzymatic debriders Wounds requiring packing Patients with fragile skin (roll gauze used to secure dressing)

Gauze (cont.) Precautions/contraindications: Woven gauze may require more force to remove Woven gauze may leave residue or lint in the wound bed causing granuloma formation or prolonged inflammatory response Will adhere to the wound bed if allowed to dry out Roll dressings should be applied at an angle without tension Telfa Dressings are reserved for superficial, nondraining wounds.

Gauze dressings available here

And more gauze….

Impregnated Gauze Mesh gauze dressings impregnated with petroleum, oil, bismuth or zinc Used as a contact layer and require a secondary dressing Nonadherant Mildly increase the occlusiveness of a standard dressing Potentially improve dressing’s ability to maintain a moist wound environment

Impregnated gauze (cont.) Common uses: Wound contact layer on granulating wound bed In combination with a secondary dressing Used with or without a topical agent such as hydrogel or antimicrobials Prevents exposed tendons/tendon sheaths from dehydrating or adhering to a dressing

Impregnated gauze (cont.) Precautions/contraindications: Dressings with Bismuth (Xeroform) are cytotoxic to inflammatory cells and may cause inflammatory response in patients with venous insufficiency ulcers Bismuth has mild antiseptic and antibacterial qualities Iodine impregnated gauze are cytotoxic and only mildly antimicrobial

Impregnated gauze dressings – at UMHS Xeroform (petrolatum and 3% bismuth) Oil emersion gauze Vaseline gauze

Films Thin flexible sheets of transparent polyurethane with an adhesive backing Permeable to water vapor, O2, and CO2 but not permeable to bacteria and water Few absorptive properties (moisture retentive) Allow visualization of wound bed Conform to body contours Should be applied w/out tension or wrinkles May be left in place for 5-7 days Should not be used for wounds with moderate to heavy drainage

Films (cont.) Common uses Superficial wounds, lacerations, abrasions Partial thickness wounds, sutured wounds and donor graft sites Granular wounds and yellow slough-covered wounds Amorphous hydrogel covered by film can be used to soften eschar covered wounds May be used in areas of friction Because they are waterproof they may be used to cover IVs or dressing to allow for bathing

Films (cont.) Precautions/contraindications Will not adhere to wet or oily skin Must maintain a good edge seal -- If a channel or wrinkle forms they must be changed To prevent maceration, use a skin sealant Do not maintain the ideal warm temperature needed for optimal wound healing Should not be used on infected wounds

Hydrogels 80% to 90% water or glycerin based wound dressings available in sheets, gels or impregnated gauze. Absorb a minimal amount of fluid Donate moisture to dry wounds Permeable to gas and water Less effective bacterial barriers than semipermeable films or hydrocolloids May dehydrate easily (esp. water based versions) May decrease pain – feel cool Almost non-adhesive, requiring a secondary dressing

Hydrogels (cont.) Common uses Minimally or moderately draining wounds (sheet versions) Superficial or partial-thickness wounds (ex: abrasions, skin tears, blisters, donor sites, burns..) Effective at softening eschar Precautions/contraindications Should not be used on heavily draining wounds Absorbs fluid slowly Should not be used no infected wounds Skin sealant should be used to protect periwound skin from maceration

Hydrogels we have here… Well, we don’t have a sheet hydrogel at this time, but I am working on that…  DuoDerm Gel can be used as a hydrogel of sorts to fill dead spaces, moisturize dry wounds and soften eschar (we do have this)

Foams Polyurethane foam with a hydrophilic wound side and an hydrophobic outside Permeable to gas but not bacteria Provide thermal insulation Comes in adhesive and nonadhesive forms, with or without borders Less likely to cause trauma upon removal Easy to apply Good for use on pressure ulcers -- redistribute pressure to the area

Foams (cont.) Common uses Wounds with minimal to heavy exudate Granulating or slough-covered partial thickness wounds Donor sites, ostomy sites, minor burns, diabetic ulcers and venous insufficiency ulcers Precautions/contraindications Not indicated for dry or eschar-covered wounds Not indicated for arterial ulcers Not ideal for heel ulcers or areas of high friction Skin sealant should be used to protect the periwound Do not have the flexibility of alginates to address significant depth, undermining or sinuses

Hydrocolloids Contain hydrophilic colloidal particles (gelatin, pectin, cellulose) with a strong film backing Moisture retentive dressing-considered the most occlusive of the moisture retentive dressings Vary in absorptive abilities Absorb fluid slowly by swelling into a gel-like mass

Hydrocolloids (cont.) Provides thermal insulation Impermeable to water, O2 and bacteria DuoDerm, is an effective barrier against stool, urine, MRSA, hepatitis B, HIV-1 and pseudomonas Residue often remains after removal and must be rinsed from the wound with dressing changes

Partial and full thickness wounds Granular wounds Hydrocolloids (cont.) Common uses: Partial and full thickness wounds Granular wounds Necrotic wounds (used to promote autolysis) Minor burns and venous insufficiency ulcers

Hydrocolloids (cont.) Precautions/contraindications Not appropriate for bleeding or heavily exudating wounds * Contraindicated in infected wounds * Use with caution on immunocompromised patients Should not be used on dry wounds, arterial ulcers, third degree burns or wounds with minimal drainage Should not be used on wounds with exposed tendons/fascia Has been associated with hypergranulation and should be discontinued at first sign of it. Use skin sealant on periwound skin

Alginates and Hydrofibers Alginates: salts of alginic acid extracted from brown seaweed and converted into calcium/sodium salts Kaltostat Hydrofiber: made from sodium carboxymethylcellulose – interchangeable with alginates. Aquacel

Alginates and Hydrofibers (cont.) React with serum and wound exudate to form a hydrophilic gel to provide moist wound environment May trap bacteria which can be washed away with dressing changes Highly permeable and non-occlusive, requiring a secondary dressing Hydrofibers: Individual cells trap moisture, creating an occlusive gel when wet are highly absorbent but more expensive than alginates

Alginates and Hydrofibers (cont.) Common uses: Absorb up to 20 times their weight in exudate Moderately to highly exudating wounds Partial and full thickness wounds (venous insufficiency ulcers, pressure ulcers, diabetic ulcers, burns) Can be used on granular or slough covered wounds Ideal for infected wounds -- as primary dressing Dressings must be changed daily Not indicated for dry or minimally draining wounds

Alginates and Hydrofibers (cont.) Available in three forms: Sheets (to absorb drainage) Ropes (to fill tunnels, cavities or undermining) Alginate tipped applicators (to probe wounds, perform swab cultures and measure wound depth) Precautions/contraindications: Not recommended for 3rd degree burns Not for use no wounds with exposed tendon, joint capsule or bone Skin sealant should be use on periwound skin

Antimicrobials – Silver Silver is an antiseptic agent that has been incorporated into all classes of dressings Proven antimicrobial activity against MRSA, VRE, yeast, mold and a large number of gram+ and gram- microorganisms and aerobes Dressings containing silver may: Be primary or secondary Be adhesive or non-adhesive Vary in absorptive capabilities Release of silver ions in the wound can result in blue-black coloration

Silver (cont.) According to the International Consensus on the Appropriate Use of Silver in Wounds (2012): Silver dressings should not be used in the absence of localized, spreading or systemic infection, unless there are clear indicators the wound is at high risk of infection or re-infection. Recommended to use antimicrobial dressings for 2 weeks and then re-evaluate. Once the bioburden is under control and the wound is improving, a non-antimicrobial dressing should be considered.

Silver (cont.) Dressing must be in contact with the wound bed Silver dressing require a Doctor’s order Saline cannot be used with silver because it deactivates the silver Dressing must be in contact with the wound bed Remove silver dressing if pt. is to undergo MRI Again, discontinue once bioburden is controlled and the wound healing progresses, or if no improvement in wound status is seen after 2 weeks of use.

Silver (cont.) Precautions: Silver dressings should be used with caution in epithelializing or granulating wounds due to cytotoxicity There is little research to support silvers effectiveness against biofilms NO evidence that silver is effective in the presence of slough or necrotic tissue No evidence that silver helps prophylactically in healing uninfected wounds Silver dressings cost a lot more than standard moisture retentive dressings

Hydrofera Blue…………… Contains Crystal Violet and Methylene Blue These substances have bacteriostatic properties, including effectiveness against many organisms including MRSA and VRE Open cell foam allows for removal of wound exudates and inhibits growth of microorganisms on the foam for up to 7 days Color of the foam will “blanch out” as uptake of exudate occurs Comes in sheets and ropes (used for packing tunneling, or undermining wounds)

Hydrofera Blue (cont.) Intended for use on complicated wounds Approved for all wounds except full-thickness wound (burns) Promotes self-debridement of necrotic tissue and odor control (through prevention of growth of odor causing bacteria on the sponge) Clinically it has been effective in reducing hypergranulation tissue, as well as flattening out epibole HFB Classic -Initial dressing changed after 24 hours and then q 2-3 days Must stay moist – cover with film dressing (Tegaderm)

What else?? Lets talk about….. Sealants Sure-Prep No Sting Skin Barrier Has no alcohol, hence the “No-sting” Lays down a protective barrier on the skin to: Decrease friction Repel moisture Prevent tape tears Should be used on all periwound skin and under tape Applied q 1-3 days, depending on what you are using it for Marathon Skin Protectant Stronger skin barrier than Sure-prep Applied q 3-5 days Can be used to seal linear skin tears closed Special order, dispensed by Skin Care Team leaders

Mepitel One Porous wound contact dressing Adheres to healthy skin only, not moist wound beds. Serves as a primary dressing that stays in place up to 14 days for undisturbed wound healing. Secondary dressing used to absorb drainage and can be changed without causing pain to the patient. Transparent for easy inspection of the wound Areas of use: Skin tears Surgical incisions Blistering Venous and arterial ulcers Partial and full thickness grafts Skin abrasions Second degree burns Lacerations Diabetic ulcers

Salt impregnated dressings Mesalt – gauze impregnated with NaCl Absorbs exudate bacteria and necrotic material Stimulates the cleansing of wounds Low potential for skin irritation and allergy Areas of use: Heavily draining or infected wounds in the inflammatory phase Deep cavity wounds Pressure ulcers Surgical wounds Changed daily Contraindications/precautions Should not be used on dry wounds with low level of exudate Should not be used on exposed tendon or bone

Salt impregnated dressings (cont.)….. Hypergel – 20% NaCl solution in gel form Softens eschar and draws drainage and debris from the wound The high concentration of NaCl gel creates a hypertonic environment that hydrates and facilitates natural debridement of necrotic tissue. Intended for softening and removal of both moist and dry eschar Apply daily in a dime thick layer directly on necrotic tissue Requires a cover dressing Essential to protect periwound skin with skin prep

Moisture barriers Comfort Shield Barrier wipes Calazime Has 3% dimethicone to heal damaged skin Has lotion and barrier in the wipe Should be used after cleaning of incontinence has been completed with the no- rinse Foam Cleanser Calazime Contains 20% Zinc and Menthol Used for severe cases of Incontinence Associated Dermatitis Applied in a dime thick layer (Operative word there is “thick”) Only the top layer is to be removed when cleaning off stool or urine and then more is reapplied Obtained from distribution when needed

**Prevents cracking, callus, and flaking Moisturizers – used to maintain moist strong skin **Prevents cracking, callus, and flaking Not for use on overly saturated skin Reapply at least twice a day, more if skin is very dry Adhesive removers/releasers These are used to prevent skin tears with removal of tape or hydrocolloids

Silver impregnated fabric Common use: Used to wick moisture away from skin folds Kills bacteria and yeast growing in the folds When it becomes too moist it can be laid out to dry and reused for up to 5 days Precautions: Expensive Can’t be washed without removing the silver in the fabric Should not be used at the same time as antifungal creams or powders

REMEMBER THE BASICS When encountering a wound, or an area of skin breakdown, it is important to……

Final thoughts… There are hundreds of different wound care products available out there. The ones mentioned in this presentation are representative of the main types being used and of what we have available here at UMHC. It is advisable that an order be written for any of the dressings mentioned as that is a sure way for dressings to be applied appropriately. Any dressing with a medication included (ex: Silver) must have a Physician’s order.

Final thoughts…cont… As the Skin Care Team representative in your units it is important that you understand the dressings available and why they are, or are not, appropriate. If a dressing is being used on your patient, it is important to assess for the dressing’s effectiveness. If no change, for the better, is noted in two weeks, or if the wound has worsened, it may be time to re-evaluate. Let your doctors know…. Communicate  Document thoroughly…… this includes pictures, measurements and descriptions.

UMHC Skin Care Team Give Aleatha or Penny a call if you need a second or third opinion. We love to help you grow in your role as the SCT representative in your area. We are all part of TEAM. Remember that. You are very appreciated! Thank you!