Wound Treatment

Learning Objectives #

Upon completion of this module, the student will:

1. understand the etiology of pressure ulcers.

2. be able to understand and distinguish between the different stages of pressure ulcers.

3. master the risk factors associated with pressure ulcers.

4. master the initial treatment and management for basic pressure ulcers.

5. understand complex treatment of pressure ulcers.

6. master when to advise the WOCN.

Treament of Wounds #

By the end of this unit, you will:

• Master the principles of wound assessment and management
• Differentiate between different products and identify wound care products available at Vancouver Coastal Health Authority.

Principles of Wound Management #

The principles of wound management assist in guiding assessment and treatment. The principles should be considered and followed prior to commencement of therapy. A non-healing wound or even wound deterioration may be the result if the principles of wound management are not considered.

There are three principles of wound management. The first is to identify and treat or eliminate causative factors. For example if the wound is caused by pressure, remove or try to reduce the pressure. If the wound is infected, treat the infection with antibiotics. The second principle of wound management is to provide systemic support for wound healing. Providing nutritional support is an example of providing systemic support. The third principle is to apply appropriate topical therapy. In other words, appropriate dressing selection. 

Along with considering the principles, determining a desired & achievable patient outcome or goal needs to be known. 

For example, if the wound is not healable, everyone involved needs to be aware of this.

Topical Therapy #

An easy acronym to help guide your choice in an appropriate dressing for wounds is ‘idipamop’. It is used at Emory University in their wound education program.

• I -identify and treat infection
• D -debride necrotic tissue
• I -insulate wound
• P -pack dead space
• A -absorb excess exudate
• M -maintain moist wound environment
• O -open wound edges
• P -protect wound and periwound skin

Wound Assessment #

Also guiding dressing selection is the wound assessment, which includes:

• Anatomical Location
• Size – measure length, width, depth
• Wound base
• Wound edges
• Exudate
• Maceration
• Odor
• Periwound skin
• Undermining/sinus tract
• Pain

Another consideration when choosing an appropriate dressing is the age of the wound. For non-healing wounds re-evaluate treatment. Also consider other contributing factors such as:

• infection
• inadequate nutrition
• trauma

If you suspect infection in a chronic wound, look for obvious deterioration of the wound,

• Increase (or change) in pain,
• Increase (or change) in exudate
• Increase (or change) in odor
• Increase (or change) in erythem
• Edema
• Elevated temperature

Wound Dressing Selection #

Dressing selection is based on wound assessment and an identified healing goal. 

Consider the “category” and “function” – what is the form the dressing comes in and what does the dressing do. 

Dressing Categories #

There are many different categories of dressings. These include: 

• Transparent films
• Hydrocolloids
• Hydrogels
• Hydrofibers
• Alginates
• Foams
• Gauze
• Impregnated gauzes
• Non-adherent impregnated gauzes
• Absorbents
• Antimicrobials
• Composites

It is easiest to think of the different types of products based on their function. Such functions include:

• Hydrating
• Moisture retentive
• Absorbent
• Antimicrobials
• Niche (specialty function products) or composite (layers) 

Dressing selection is based on the needs of the wound. Wounds require a moist, not wet, environment in order to heal. When selecting a dressing, keep in mind that it’s all about moisture – managing the moisture. Therefore, if the wound is dry, add moisture; if the wound is wet, manage or absorb the moisture. Moist wound healing is the Golden Rule. The exception to this is when the goal of therapy is contraindicated based on the wounds ability to heal. For example, if the wound is on an ischemic foot and the goal was to keep the wound dry and free of infection, adding moisture to a wound that does not have adequate systemic support, in this case blood flow, will likely lead to infection and wound deterioration.

Examples of Topical Therapy #

These are just examples of some of the products used. Keep in mind that every company usually has their own brand name for each category.

Hydrating #

Hydrating products include hydrogels. Examples are Intrasite Gel and Duoderm Gel Hydrogels are for dry wounds. Use includes:

• Hydro gels add moisture to a dry wound
• Assisting in maintaining a moist wound environment
• Acts as an autolytic debrider by promoting the action of proteolytic enzymes
• Application amount should exceed 5 mm
• Requires a secondary dressing
• Becomes less viscous at body temperature therefore observe for maceration of surrounding skin due to excessive moisture.

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Moisture Retentive #

Transparent Films

Transparent films are generally used for minor abrasions & friction. They are not recommended for use on fragile skin. They should also be avoided for use to keep other types of dressings in place, for example foam dressings. Transparent films are considered to be one of the most occlusive dressings available and thus, when applied over top of a dressing that is in place to absorb, it interferes with that function.

Use includes:

• Maintains a moist wound environment;
• Waterproof;
• Prevents bacterial penetration;
• Non-absorbent;
• Skin Protection.

To remove, stretch the dressing horizontally.

Hydrocolloids

Common examples of hydrocolloids are Tegasorb and Duoderm.

Hydrocolloids are generally used for stage I & II with minimal exudate. Hydrocolloids are considered occlusive thus they assist in maintenance of a moist wound environment. Hydrocolloids are not recommended for use on heels unless a thorough vascular assessment of the lower limbs rules out peripheral vascular disease.

Hydrocolloids may be left on for up to seven days or maybe changed as frequently as every two days.

Uses include:

•  The moist wound environment, promotes autolytic debridement;
•  Has minimal absorptive qualities;
•  Able to stay on for 2-7 days therefore decreasing the risk of bacterial contamination while maintaining thermo-insulation;
•  Bacteria is unable to penetrate the dressing;
•  Dressing should overlap the intact skin by 3-4 cm;
•  Surrounding skin may need to be shaved to secure adherence;
•  Adherence is improved if hydrocolloid is warmed to body temperature.

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Absorbent #

Alginates

Absorb moderate to heavy amount of exudates. Examples include Kaltostat and Melgisorb.

Use includes:

• Comes in fibrous pads and requires a secondary dressing
• Primary ingredient is derived from seaweed
• Is bio-degradable, and thus is not necessary to remove every single fibre
• Due to the absorption of exudate, provides a moist wound environment thus promoting autolysis
• Layering provides increased absorption
• Some have hemo-static qualities
• Do Not use on full thickness burns or dry/non-exudating wounds

Hydrofiber

Aquacel is a hydrofiber. “Absorbs 33% more than most alginates,” (Bryant, 2000, p.119). When Aquacel becomes wet, it turns into a transparent gel.

Use includes:

• For moderate to large amounts of exudate
• Provides a moist wound environment with the use of an occlusive dressing
• Turns into a gel when moistened
• May be left on wound for 2-3 days thus providing thermo-insulation
• If surrounding skin becomes macerated, increase frequency of dressing changes

Impregnated Gauze

Mesalt is an example of a hypertonic impregnated gauze. It is impregnated with saline. It is used for yellow sloughy wounds. Mesalt needs to be ‘fluffed’ prior to use to be more efficient, as well it should avoid touching intact skin as it will irritate the healthy skin. Use includes:

• Requires a secondary dressing
• The saline draws the exudate from the wound
• Requires changing a minimum of every 24 hours.

FoamsFoam dressings are used moderately draining with fragile skin. Examples include Mepilex Border, Allevyn and Biotane.

Uses include:

• Absorb via wicking action
• Have a non-adherent surface
• Provide for a moist wound environment, depending on the drainage
• Provide thermoregulation
• Foams should overlap 2.5 cm of surrounding intact skin.

Specialty Pads

Exu-dry is an absorbent dressing used for heavily exudating wounds. It also has a non-shearing side; this is the side that must touch the wound bed to be absorbent.

Antimicrobials #

Silver Dressings

Silver has antimicrobial properties. Silver dressings come in absorbent and non-absorbent dressings. Examples of non-absorbent are Acticoat Burn and Actisorb. Examples of absorbent silver dressings are Aquacel Silver and Acticoat absorbable.

Acticoat Burn use includes:

• Must be moistened in sterile water as opposed to saline as saline inactivates the silver
• Must be kept moist either from wound drainage or by misting with sterile water every 12 hours
• Requires a cover dressing
• Deposits silver into the wound bed
• Requires a change every 3 days
• Acticoat Absorbable and Aquacel Ag
• Do not require moistening with sterile water
• Used for moderately to heavily exudating wounds
• Aquacel Ag does not deposit silver into the wound bed

Flamazine or Silversulfadiazine

Flamazine is a topical cream that is used primarily for burns but is also used for areas that require moisture and an antimicrobial property.

Use includes:

• Used for large partial and full thickness wounds, (usually burns) that are infected or are as a prophylactic measure due to the patients compromised immunity
• Best if applied to gauze first and then applied to the wound
• Requires once daily changes
• Maintains a moist wound environment
• Requires removal with saline prior to next application and may be painful or uncomfortable
• Contraindicated in patients with sulpha allergies

Iodine

Iodosorb is an antimicrobial. It is a slow release cadomer iodine. It is used when an antimicrobial effect is required. It is effective in fighting MRSA. The ideal wound has minimal to moderate drainage and requires some debriding.

Use includes:

• Easies if applied or buttered on gauze then applied to the wound bed
• May be applied to gauze packing and then packed into the wound
• Goes on dark and then turns a pale yellow when it is time to change
• Precautions include those with severe renal disease and hyperthyroid disease (see package insert)

Proviodine is also an antimicrobial. It is also used to stabilize non-healable wounds, especially heel ulcers.

Use includes:

• Does not require a secondary dressing
• Allow to dry otherwise it can stick to sheets or socks
• May be painful if sensation is intact
• Not recommended for use with iodine allergies.

Niche or Composite Dressings #

Niche

Non-adherent Dressings

Mepitel is a non-adherent dressing. Another name brand similar to this is Adaptic. They are primarily made out of silicone and thus do not stick to the open wound. They are used for fragile wound bases.

Uses include:

• Requires a secondary dressing
• Weave structure allows the practitioner to clean and apply a topical treatment (if required) without removal of dressing
• May leave on wound for 7 days
• Due to its non-adherent qualities, the secondary dressing does not stick to the open wound thus avoiding subsequent trauma to the wound

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Composite Dressings

Composite dressings are dressings that have layers.

Alldress is a composite. It is used for lightly exudating wounds. It is also the dressing of choice over Hydro gels.

Carboflex and Carbonet are also composites. They are used for odorous wounds such as malignant wounds.

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Skin Protectants #

Skin Prep

Skin preps are skin barriers. Name brands include Skin Prep, and Cavilon No Sting. No Sting which does not contain alcohol and can be used on open skin without stinging. Skin barriers are used to protect periwound skin from maceration and/or from tape tears.

Use includes:

• Helps maintain seal around adhesive dressings and stomas
• Allow to dry before covering

Ointments

Proshield Plus Ointment is also a skin barrier and is used to protect the periwound skin from maceration. Other brand names include Unisalve, and Triple Care.

Summary #

To summarize:

• Prevention is your primary focus
• Assessment is the key for your treatment choices
• Treatment is based on: wound assessment, an identified healing goal (healability) and the form and function of dressings

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Investigations

• Glucose profile: Fasting
• Blood Sugar: 7.5 mmol / L
• HbA1c: 8 %

Current Orders:

• Control of vital signs q8h
• Blood glucose before meal and HS
• wound culture stat
• Daily wound dressing change, cleansing the pressure ulcer with a normal saline solution, removing all necrotic tissue, and applying a moisture barrier ointment to the wound bed. Using hydrocolloid dressings
• Acetaminophen 500 mg q8h PRN, considering 2mg hydromorphone PO, PRN before dressing
• Registered dietician consult
• Insulin glargine 10 unit HS and insulin Lispro sliding scale
• lisinopril 5 mg PO, q Am
• Occupational Therapists consult

Material Resources     

Select an item from the list below to download.

• Bibliography 3

https://lms.can-health.org/content/36/text/bibliography3.pdf

This is a bibliography that you can use for further reading.

• Print Version of Module 3

https://lms.can-health.org/content/36/text/Module_3_print_version.pdf

This is a printable version of the content on this webpage. Beware, it is a large file.