Managing a patient with a chronic, nonhealing

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1 Confused about all the wound care products on the market today? Not sure which ones are best for a given patient and wound? This article will help you make smart dressing choices. CAROL CALIANNO, RN, CWOCN, MSN Wound, Ostomy, and Continence Nurse Specialist Jeanes Hospital Temple University Health System Philadelphia, Pa. Managing a patient with a chronic, nonhealing wound can be one of the toughest challenges you face. It goes beyond knowing what type of wound the patient has. You also need to consider what caused the wound, why it won t heal (including any patient comorbidities that are standing in the way), and what you can reasonably do to jump-start healing. No small task indeed. Because selecting the right dressing for the job can be the most puzzling aspect of wound management for many nurses remember, there are over a thousand topical products on the market today in this article I ll focus on the categories of products that are available and why you might use them. Future articles will tackle other aspects of the wound management equation. Getting down to business The following information is intended as a broad description of general product catefast fact When choosing a dressing, consider the: cause of the wound condition of the wound bed amount of drainage presence of infection depth of the wound. The optimal situation Choosing the right dressing for any type of chronic, nonhealing wound will depend on the cause of the wound, the condition of the wound bed, the amount of drainage, the presence of infection, and the depth of the wound. In general, the optimal dressings should: provide adequate tissue hydration to support cell viability without overhydrating the wound bed protect the wound bed from trauma and contamination promote the skin integrity of the surrounding tissue. Knowing right from wrong So how do you know which dressing is right for your patient? This article presents an overview of the categories of dressings that are available. A key point for you to remember is that not all dressings in a product category perform the same; in fact, indications and contraindications may vary from product to product in the category. An indication for a specific wound type doesn t mean that a product is right for every wound of that type, however. For example, a pressure ulcer that s clean, shallow, and granulating with minimal drainage will have different dressing needs than a deep, undermined pressure ulcer with large areas of necrosis. Advocates of a performance-based approach to selecting wound dressings meaning that the dressing should be chosen for its suitability for a particular wound suggest that several questions should be answered before any dressing is applied: What does the wound need? What does the product do? How well does it do it? What does the patient need? What s available? What s practical? For more on this approach, see Answering Questions about Performance. 50 Nursing made Incredibly Easy! September/October 2003

2 gories. The product examples given are representative of the category; the list is not intended to be allinclusive. Remember, you re responsible for reviewing product inserts and for understanding how to safely apply any wound care product you re using. Alginates Alginate dressings are nonwoven fibers derived from seaweed; some may have additives such as collagen. They re used for autolytic debridement and to absorb up to 20 times their weight in exudate. Alginates can be used on infected if the infection is being treated systemically and nonocclusive secondary dressings are used. Exudating with slough Fill dead space and debride sloughing Full-thickness burns Sensitivity to alginate, collagen, or other additives Heavily bleeding Dry Comfeel SeaSorb (Coloplast) Kalginate (DeRoyal) Kaltostat (Conva- Tec) Maxorb (Medline) Sorbsan (Bertek) Collagen dressings Collagen dressings promote the deposit of newly Wound with slough A wound covered in slough may be a candidate for autolytic debridement with a dressing, like an alginate or a hydrocolloid. September/October 2003 Nursing made Incredibly Easy! 51

3 Need to fill dead space? A collagen might do the trick. formed collagen in the wound bed. These dressings come in pad, gel, and particle forms. They can be used in deep to fill dead space, absorb exudate, and provide a moist environment. A secondary dressing is usually required. Tunneled or cavity with drainage Partial- and full-thickness Partial-thickness burns Wounds with dry eschar Sensitivity to additives FIBRACOL PLUS (Johnson & Johnson) Kollagen-Medifil (BioCore Medical Technologies) Composite dressings These combination dressings are designed to provide the multiple properties of two or more products in a single dressing. Most composite dressings have an adhesive border Tunneled wound A tunneled wound may be more extensive than it first appears. Alginates or collagen dressings can be used to fill the dead space. Primary or secondary dressing Minimal, moderate, or heavy exudate, depending on the composition Partial- and full-thickness If occlusive, contraindicated for untreated infected Sensitivity to composite materials (polyurethane, alginates, or adhesives) Not intended for use over a cavity wound; dead space must be filled May be contraindicated for heavily Answering questions about performance A performance-based approach to selecting wound dressings is guided by the answers to six basic questions. Here s how you find the answers: Q: What does the wound need? A: A thorough assessment of the wound and periwound skin, initially and at each dressing change, will tell you what the wound needs. Look at the size of the wound, the type of tissue in the wound bed, the quality and quantity of drainage, the condition of the periwound skin, and the microbial status. Q: What does the product do? A: Review marketing materials, data from controlled clinical trials and in vitro evaluations, the product package insert, and the material safety data sheet. Q: How well does the product perform? A: This may be difficult to answer because there are so few head-to-head evaluations of products. Besides reviewing data from any randomized controlled clinical studies, also look at objective lab comparisons to gauge relative product performance. Q: What does the patient need? A: A comprehensive medical and psychosocial evaluation will help determine any underlying cause or systemic factor that needs to be corrected first and any patient issues that should be addressed. Q: What s available? A: This question refers to availability of specific products, payment for products and services, and cost-effectiveness of the products relative to the patient s specific health care plan and the health care setting where he s being treated. Q: What s practical? A: Take into consideration the overall plan of care and the goals of wound treatment. How complicated is the product to use? Will it be applied and removed by a health care provider, a family member, or the patient? Adapted from Ovington, L.: Wound Care Products: How to Choose, Advances in Skin & Wound Care. 14(5): , September/October Nursing made Incredibly Easy! September/October 2003

4 Got a lot of exudate? Steer clear of wet-tomoist gauze dressings. draining, full-thickness burns, and with exposed tendon, muscle, or bone; review product inserts for more information Alldress (Mölnlycke Health Care) Covaderm Plus (DeRoyal) Stratasorb (Medline) TELFA Adhesive Dressing (Kendall 3M Tegaderm + Pad (3M Health Care) Foams Absorbent dressings made of polyurethane, foam dressing may be waterproof and bacteria-proof. Some foams are nonadherent and require a secondary dressing. Moderate to heavily exudating Provide thermal insulation and moist wound environment Secondary dressing to provide additional absorption in deep wound; use with packing Can be used under compression dressings to absorb heavy drainage Wound with maceration The macerated periwound skin is the result of selecting a dressing that couldn t absorb the wound s heavy exudate. Dry Partial-thickness with minimal exudate Wounds with exposed muscle, tendon, or bone Arterial ischemic lesions Allevyn (Smith & Nephew) Cutinova Thin (Smith & Nephew) Flexzan (Bertek) Lyofoam (ConvaTec) Mepilex (Mölnlycke Health Care) PolyMem (Ferris Manufacturing Corp.) TIELLE and TIELLE PLUS (Johnson & Johnson) Gauze dressings Gauze dressings are commonly used, although they may not be the best choice. For more on gauze dressings, see Gauze: The Controversy Continues. Dry gauze dressings Surgical First 24 hours after sharp debridement to limit bleeding Absorb exudate and wick drainage Fill dead space Secondary dressing Protect dry gangrene area that can t be debrided Wounds that require a moist environment Pain and bleeding of viable tissue Wet-to-dry gauze dressings Absorb exudate and wick drainage Fill dead space Debride moist necrotic Wounds that require a moist environment warning! Foam dressings aren t the right choice for dry, like arterial ischemic lesions. September/October 2003 Nursing made Incredibly Easy! 53

5 Wound not healing? You may need to rethink the plan of care. Granulation tissue A granulating wound should be protected from reinjury. Hydrocolloids or hydrogels may be a good choice. fast fact Wounds dressed with gauze are at greater risk of infection than those covered with a moisture-retentive dressing. Partial-thickness Pain and bleeding of viable tissue Wet-to-moist gauze dressings Infected Absorb exudate and wick drainage Fill dead space Debride necrotic Highly exudating Severe maceration of surrounding tissue Hydrocolloids Adherent, occlusive dressings that are nonpermeable to water vapor and oxygen, hydrocolloids prevent outside contamination if they re intact. The hypoxic environment created by occlusion is ideal for our bodies to trap wound fluid on the surface of the wound without drying out. Remember, cells get their oxygen from the local capillary beds, not from the outside atmosphere. This moist environment stimulates cells such as keratinocytes, fibroblasts, and macrophages to clean up the wound bed and release growth factors. These growth factors, in turn, stimulate new tissue production and development of new blood vessels to supply the repaired skin. Most hydrocolloid dressings are self-adhesive pads; a few come in paste form. Wounds with minimal to moderate exudate Wounds with slough or granulating Partial-thickness Protect intact skin Infected Wounds with sinus tracts Deep cavity Heavily exudating Wounds with friable surrounding skin Full-thickness burns Comfeel Plus (Coloplast) DuoDERM (ConvaTec) Exuderm (Medline) Restore (Hollister) 3M Tegasorb (3M Health Care) Hydrogels These dressings, also called polymer gels, are primarily used to maintain a moist wound environment and can be used in with minimal exudate. Amorphous gels and gel sheets cool wound surfaces; they re soothing, comfortable, and help reduce pain. Some sheet forms have an occlusive backing and shouldn t be used in infected. Abrasions, minor burns, and other partial-thickness Radiation injuries (must be approved by the radiation oncologist if treatment is ongoing) Maintain moist environment in healing Donor sites Superficial and partial-thickness burns Hydration and autolytic debridement of nonviable tissue Moderate to heavily exudating 54 Nursing made Incredibly Easy! September/October 2003

6 Gauze: The controversy continues Does your facility routinely use gauze as a primary dressing to cover? It may be time to reconsider. Time-honored research has shown that a moist wound environment speeds healing. Gauze dressings can t provide this optimum environment. In fact, they may impede healing by allowing moisture in the wound bed to evaporate, which reduces the local tissue temperature and triggers physiologic reactions that impair healing (such as vasoconstriction and hypoxia). Gauze dressings can t keep bacteria out of the wound, making dressed with gauze more susceptible to infection than covered with moisture-retentive dressings. Studies have found higher infection rates when gauze dressings were used 7.1% in one study, compared with 2.6% for covered with moisture-retentive dressings. Patient comfort is a major issue. With wet-to-dry gauze dressings, typically used to mechanically debride necrotic tissue from the wound, the gauze is moistened with normal saline, placed in the wound bed, then covered with dry gauze. The moistened gauze dries, sticking to the necrotic tissue. This tissue is pulled out when the dressing is removed. The problem is healthy tissue is also removed, causing reinjury and significant pain for your patient. In theory, a wet-to-moist gauze dressing should reduce problems because the dressing is supposed to be remoistened periodically until removal. In practice, though, wet-tomoist gauze may become wet-to-dry if the gauze dries out before it s remoistened with normal saline. This, too, can cause reinjury, pain, and delayed healing. Finally, maintaining wet-to-moist gauze dressings is labor intensive. The dressing must either be changed several times a day or remoistened to prevent it from drying out. That takes extra time that you probably don t have. And when your time is factored into the equation, gauze dressings cost your facility more than pricier moisture-retentive dressings that are changed less often. Adapted from Ovington, L.: Hanging Wet-to-Dry Dressings Out to Dry, Advances in Skin & Wound Care. 15(2):79-84, March/April Infected, if the dressing is occlusive Fungal Full-thickness burns Over a cavity wound (sheet hydrogels); dead space must be filled : Amorphous hydrogel IntraSite Gel (Smith & Nephew) NU-GEL (Johnson & Johnson) Normlgel (Mölnlycke Health Care) WOUN DRES (Coloplast) 3M Tegagel (3M Health Care) : Sheet hydrogels Aquasorb (DeRoyal) Elasto-Gel (Southwest Technologies) Vigilon (Bard Medical) Nonadhering dressings Designed to provide a surface that won t stick to the wound bed, these dressings are generally used as primary dressings. They require a secondary cover or wrap to secure them. Impregnated gauze dressings are impregnated with petrolatum or antibacterial or bactericidal compounds. Nonimpregnated gauze has a nylon or polyurethane covering that doesn t adhere to the wound bed. Skin grafts and donor sites Abrasions and lacerations Reduce bacterial proliferation in superficial wound Heavily exudating Sensitivity to antibacterial or bactericidal compound ADAPTIC (Johnson & Johnson) AQUAPHOR Gauze (Smith & Nephew) September/October 2003 Nursing made Incredibly Easy! 55

7 fast fact Don t use a transparent film if the patient has fragile, easily damaged skin it could make things worse by causing the skin to tear. Scarlet Red Ointment Dressing (Kendall Vaseline Petrolatum Gauze (Kendall Xeroform Petrolatum Gauze (Kendall Odor-absorbent dressings These dressings have an encapsulated layer of activated charcoal that absorbs exudate and neutralizes odor. They can be used in combination with other dressings to absorb heavy exudate and to minimize wound odors. Neutralize odors in necrotic Provide comfort and palliative care for terminally ill patients with draining Infected or noninfected with moderate drainage Dry, superficial CarboFlex (ConvaTec) Lyofoam C (ConvaTec) Odor Absorbing Dressing (Hollister) Transparent adhesive films Also called MVP (moisture vapor permeable) dressings, transparent adhesive films maintain a moist wound environment by trapping moisture on the wound surface. They re impermeable to bacteria and contaminants. Superficial Wounds with minimal exudate Protection of intact skin Moderate to heavily exudating Friable (fragile) surrounding skin that can tear or bruise with little pressure or tension; even removing a thin transparent dressing can lift off the dermis and cause damage Wounds with sinus tracts Full-thickness BIOCLUSIVE (Johnson & Johnson) OpSite (Smith & Nephew) Suresite (Medline) 3M Tegaderm (3M Health Care) A nurse s work is never done So now you have a better idea of how to determine which dressing is right for your patient. But your job isn t done. Once local wound care and other interventions have been initiated, you ll need to regularly reassess your patient s progress. Generally, if the wound isn t showing signs of improvement in 2 weeks, the plan of care should be reassessed and changed as needed. Continuing patient education and encouragement are essential, especially during a long healing process; patients can understandably become discouraged and depressed. If possible, involve the patient s family and community support systems to relieve anxiety and help with the healing process. Guiding your patient down the path to healing success may seem daunting, given all the variables that go into wound healing. But by understanding the types of dressings available and their indications and contraindications, you re on your way to making a big problem more manageable. Learn more about it Bergstrom, N., et al.: Treatment of Pressure Ulcers. Clinical Practice Guideline, No. 15. Rockville, Md., U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Publication No , December Hess, C.: Clinical Guide: Wound Care, 4th edition. Springhouse, Pa., Springhouse Corp., Hess, C.: Product Update 2002, Advances in Skin & Wound Care. 15(6): , November/December Ovington, L.: Wound Care Products: How to Choose, Advances in Skin & Wound Care. 14(5): , September/October Panel for the Prediction and Prevention of Pressure Ulcers in Adults: Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline No. 3, Rockville, Md., U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Publication No , May Wound, Ostomy and Continence Nurses Society: Guideline for Management of Wounds in Patients with Lower Extremity Arterial Disease. Glenview, Ill., Wound, Ostomy and Continence Nurses Society, Nursing made Incredibly Easy! September/October 2003