Lotions, Potions and Lotions, Potions and Dressings – What do I DO?Dressings – What do I DO?
Anna Braden, BSN, RN, CWOCN
ObjectivesObjectives
Have a basic understanding of skin and wound assessment
Have an understanding of basic dressing selection guidelines based on assessment
Have a basic understanding of product categories
AnatomyAnatomy
EpidermisDermisSubcutaneous tissueFascia, Muscle, Bone
Injury
Hemostasis:• Coagulation• Platelet aggregation
Platelets
Inflammation:•Macrophages•Neutrophils•Granulocytes
•Debridement•Resistance to infection
•Neovascular growth•Granulation
Collagen lysis Collagen synthesis
Maturation: remodeling
Healed wound
Proliferation
Epithelialization Proteoglycansynthesis
Contraction
Wound Wound HealingHealing
Wound Care: An Incredible Visual! Pocket guide, 2009
Wound healingWound healing
Wikipedia, the free encyclopedia
Wound HealingWound Healing
Partial Thickness ◦Epidermis, dermis
Full Thickness ◦Can be shallow or deep◦Subcutaneous tissue◦Fascia, Muscle
Factors affecting wound Factors affecting wound healinghealing
Skin AssessmentSkin Assessment
ColorTextureTemperatureTurgorOdor Sensations
Wound AssessmentWound Assessment
1. Location – anatomic landmarks2. Size including
a. Underminingb. Tunneling/sinus track
3. Wound bed appearance4. Exudate
a. Amount & characteristics
5. Odor6. Pain7. Peri wound skin
Infection? – Yes or No?Infection? – Yes or No?
Contamination
Colonization
Critical Colonization
Infection◦Local vs systemic◦Elevated Glucose in diabetics◦Pain in neuropathic extremity
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 270-273
Skin ProductsSkin Products
AntimicrobialEmollientHumectantPreservativeSkin protectantSurfactant
DimethiconePetrolatumZinc Oxide
◦ <25% = creamy◦ >25% = pasty
Dressing Selection – 1Dressing Selection – 1stst Basic Basic RuleRuleDry
shallow/superficial wound
= Need to ADD moisture
Dry deep/cavity wound
= Need to ADD moisture= Need a Filler in order to pack
undermining/tunneling areas= Need a Cover dressing
Wet shallow/superficial wound
= Need to wick/absorb moisture
***Peri wound skin: Protective barrier film***
Wet deep/cavity wound
= Need to wick/absorb moisture= Need a Filler to pack undermining/tunneling areas= Need a Cover dressing
***Peri wound skin: Protective barrier film***
Then Dressing SelectionThen Dressing Selection
Goes on based on:◦ Does the wound need to be debrided?
Mechanical, enzymatic, autolytic
◦ Is there an infection present?◦ Does the wound bed remain moist or is
it drying up?◦ Do the wound edges need to be
opened?◦ Is the wound bed being protected from
injury, trauma etc.?◦ Is the wound being insulated?
“A dry cell is a dead cell”
ProductsProducts
Terms:◦Primary dressing◦Secondary dressing◦Filler ◦MVTR – Moisture-Vapor Transmission Rate◦Epidermal stripping
Products - Antimicrobial Products - Antimicrobial Antiseptics, iodine, honey, hydrofera blue,
mupirocin ointment, silver Indications:
◦ Partial or full thickness wounds◦ Critical colonization, infection◦ Odorous wound
Primary or secondary dressing Advantages:
◦ Provides broad range of antimicrobial or antibacterial activity
◦ Reduces infection◦ Prevents infection
Disadvantages:◦ Silver - May cause staining◦ May cause stinging or sensitization◦ Nanocrystalline Silver – inactivated by saline
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 292
Products – Calcium Products – Calcium alginatealginateCalled usually ‘alginate’Polysaccharide derived from brown
seaweedPartial or full thickness woundsPrimary dressing/filler
◦Usually needs a secondary/cover dressing
Highly absorbent – moderate to heavily draining wounds
Converts to a viscous/hydrophilic gelHemostatic propertiesChange as needed – usually every
24-48 hoursBryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 292
Products - CharcoalProducts - Charcoal
Activated carbon◦Absorbs toxins and wound degradation
productsIndications:
◦Malodorous wounds◦Fecal fistulas
Apply as a ‘filter’ for odor controlIf absorbing drainage, need to
change when saturated
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 292
Products – Collagen Products – Collagen Enhances deposition of collagen fibersChemoattractant to granulocytes & fibroblastsBioresorbableHemostatic propertiesProcessed from bovine or porcine sources Indications:
◦ Full-thickness wounds with or without depths◦ Noninfected wounds◦ Minimal to moderate amount of drainage
Apply to wound base◦ Requires a secondary/cover dressing
Packaged as gels, alginates, sheets, powdersContraindicated in bovine sensitivites
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 292
Products - CompositeProducts - Composite
Combine distinct dressing components into a single dressing◦Absorptive part is different than alginate,
foam, hydrocolloid, hydrogelBacterial barrierPartial or full thickness wounds
without depthDry to heavy drainage – depending
on dressing componentsPrimary or secondary dressingCan be used with topical medications
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293
Products – Contact layerProducts – Contact layerProtects the wound from direct
contact with other agents/dressingsConforms to wound shapePorousIndications:
◦Partial or full thickness wounds with or without depth
◦Infected wounds◦Donor sites◦Split-thickness skin grafts
Not intended to be changed with every dressing change
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293
Products – Fiber gellingProducts – Fiber gelling
Hydrofiber Moderate to heavy drainageConverts to gel - “snot”-like
appearancePartial or full thickness woundsUsually needs a secondary
dressing
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293
Products - FoamProducts - Foam
Absorptive and non-adherentIndications:
◦Partial or full thickness wounds with or without depth
◦Moderate to heavily drainageContraindicated with dry escharFrequently used as a secondary
dressing after medication and/or primary dressing
If used as primary dressing, apply appropriate secondary dressing
Change every 24 hours or as neededBryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293
Products - HydrocolloidProducts - Hydrocolloid Contains gel-forming agents
◦ Forms a gelatinous mass Impermeable to contaminants = reducing risk of
infection Promotes autolysis Indications:
◦ Partial or full thickness wound with or without depth◦ Minimal to moderate drainage
Avoid acutely infected wounds and dry eschar Use cautiously in diabetics Low MVTR Change every 3-5 days as needed Select dressing 1-2” larger than the wound Use light pressure of hands to allow body heat
promote adhesion
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 294
Products - HydrogelProducts - Hydrogel
Adds moisture to dry wound bedNon-adherent Little or no absorptionCool & soothingVarious formulations:
◦Gel, sheets, impregnated gauze, with silver
Apply according to instructionsUse appropriate secondary dressing
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293
Products – Transparent Products – Transparent filmfilmIndications:
◦Shallow partial thickness◦Dry to minimal drainage = nonabsorbent
Low MVTRCan promote autolysisCreates “second” skinApply without tension/stretchingAllow for 1-2” border around woundUse skin sealant around wound edgesNot for infected woundsChange every 4-7 days or as needed
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 293
Products – MedicationsProducts – Medications Collagenase/=Santyl
◦ Enzymatic debrider Collagenase derived by fermentation of Clostridium histolyticum
◦ Need physician order◦ Need some ‘contact’ with moist wound bed
Around edges or cross-hatching by physician ‘Xenaderm’ = BCT
◦ Balsam Peru◦ Castor oil
Improve epithelialization Protective covering Aids in reduction of pain
◦ Trypsin – mild debrider Dakin’s solution
◦ 1/16 strength – odor control◦ 1/25 strength – pseudomonas infection
Metronidazole/Flagyl◦ Crushed - odor control
Thomas Hess, C. Clinical Guide to Skin and Wound care. 2013, 7th Edition, p 557-559
Peri wound protectionPeri wound protectionPrevent epidermal stripping
◦Avoid tapes if possible◦Roll gauze, tubular stockinette,
Montgomery straps◦Skin sealants
Maceration◦Skin sealants◦Zinc oxide◦Re-evaluate current dressing and/or
frequencyInfection
◦Candidiasis Crusting technique with antifungal powder
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 300-301
Special Consideration:Special Consideration: Palliative Wound Palliative Wound
CareCareS = Stabilize the woundP = Prevent new woundsE = Eliminate odorC = Control painI = Infection prophylaxisA = Advanced absorbent wound dressingsL = Lessen dressing changes
Haas. M.L., Moore-Higgs, G.J. Principles of Skin Care and the Oncology Patient.2010. p 105.
DocumentationDocumentation
Today – EMR/Electronic Medical Record◦Order◦Assessment◦Actual dressing change◦Teaching
Must meet certain criteria for reimbursement
Accurate and consistent◦Monitoring◦Legal
Bryant, R., Nix, D. Acute & Chronic Wounds. Current Management Concepts. 2012, 4th Edition, p 300-301
Presentwoc.com
Worldwidewounds.com
ReferencesReferencesBryant, R., Nix, D. Acute and Chronic
Wounds. Current Management Concepts. 4th Edition. 2012.
Hass, M.L., Moore-Higgs, G.J. 2010. Principles of Skin Care and the Oncology Patient, p 105,
Milne, C.T., Corbett, L.Q., Dubuc, D.L., Wound, Ostomy, and Continence Nursing Secrets, Questions and Answers Reveal the Secrets to Successful WOC Care. 2003
Thomas Hess, C. Clinical Guide to Skin and Wound care. 7th Edition. 2013.
Wound Care: An Incredibly Visual! Pocket Guide. 2009. Wound healing, p 21.
Questions?