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

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

3. 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

4. Functions of Wound Dressings (cont.)
Provide Thermal Insulation – wound must kept be 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

5. 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

6. 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

7. 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 hours 7- Protection 8- Temperature maintenance 9- Usability 10- Cost – may cost more that gauze but need fewer dressing changes

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

9. 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

10. 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)

11. 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.

12. Gauze dressings available here

13. And more gauze….

14. 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

15. 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

16. 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

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

18. Films
Thin flexible sheets of transparent polyurethane with an adhesive backing
Permeable to water vapor, O2, and CO 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

19. 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

20. 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

21. 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

22. 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

23. 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)

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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.

36. 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.

37. 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

38. 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)

39. 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)

40. 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

41. 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

42. 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

43. 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

44. 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

45. **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

46. 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

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

49. 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.

50. 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.

51. 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!