Making the Most of your Dressing Products Catherine Hammond CNS/CNE

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1 Making the Most of your Dressing Products 2013 Catherine Hammond CNS/CNE

2 What do you need in your dressings cupboard? 2

3 Skin tear 3

4 4

5 Lack Confidence in Selecting Dressings? 5

6 Appropriate Use of Product Avoid wasting precious resources 6

7 Some of the older more traditional treatments

8 Providing The Right Environment

9 Holistic Wound Management Determine the underlying cause Assess blood supply Consider comorbidities Educate patient Patient comfort Control factors affecting healing Promote independence Provide optimal wound environment Prevent recurrence 9

10 Creating the ideal wound environment 10

11 What is Wound Bed Preparation? Creation of an optimum wound environment = Tissue management = Inflammation/infection control = Moisture balance = Epithelial (edge) advancement Falanga, V. (2004). Wound bed preparation: science applied to practice. EWMA Position Document: Wound Bed Preparation in Practice. London. MEP Ltd. 11

12 Products Made Simple Antimicrobials for high bacterial Donate Moisture TIME Absorb Moisture Protection

13 Products Made Simple Antimicrobials Donate Moisture TIME Absorb Moisture Protection

14 Products Made Simple Antimicrobials Silver dressings Cadexomer iodine Iodine Honey Absorb Moisture Alginates Hydrofibre Foams Absorbent pads TIME Donate Moisture Hydrogels Hydrocolloids Protection Films Foams Silicone Fine woven tulle

15 Patient 1 What will you include in your history? 15

16 Patient 1: Assess the wound 16

17 What is Wound Bed Preparation? Creation of an optimum wound environment = Tissue management = Inflammation/infection control = Moisture balance = Epithelial (edge) advancement Falanga, V. (2004). Wound bed preparation: science applied to practice. EWMA Position Document: Wound Bed Preparation in Practice. London. MEP Ltd. 17

18 Patient 1: Define aim of treatment? Select your products/treatment 18

19 Products Made Simple Antimicrobials Silver dressings Cadexomer iodine Iodine Honey Absorb Moisture Alginates Hydrofibre Foams Absorbent pads TIME Donate Moisture Hydrogels Hydrocolloids Protection Films Foams Silicone Fine woven tulle

20 Biofilm Biofilm bacteria less susceptible to immune defences Resistance to antimicrobial agents Increase in gene transfer between bacteria

21 Iodine based products Cadexomer iodine Reduces bacterial load Slow release Non-toxic to fibroblasts Absorbent Do not use on dry wounds, on pregnant women or pts on lithium Caution when used in renal failure or thyroid disease

22 Silver products Broad spectrum bactericidal Penetrates superficial tissue Do not use on nonviable tissue Appropriate use to reduce resistance

23 Gamma irradiated Moist environment Antibacterial Osmotic action Odour control Low adherence to wound bed May cause stinging Can result in maceration Honey

24 Polyhexamethylene Biguanide Added to some dressings foam and gauze Very effective with pseudomonas (PHMB) 24

25 Sharp Debridement Local protocols Skill and knowledge of health professional Local anaesthetic Pain control Equipment Lighting Contingency for problems Follow-on treatment

26 Patient 1: 19 days later Reassess the wound and describe what is happening at a cellular level What product would you select now and why? 26

27 Alginate Calcium & Sodium salts from brown seaweed Exchange sodium for calcium ions forms gel Cut to fit wound to avoid maceration Firm stays in one piece Soft dissolves Do not use on low exudating wounds

28 Hydrofibre Woven hydrocolloid Hydrophilic Vertical wicking moist wound, remains dry on surrounding tissue Forms gel on contact with exudate Do not use on low or non exudating wounds

29 ? May Still Need Antimicrobial 29

30 30

31 Patient 1 Describe what is happening at a cellular level What dressing would you select? 31

32 Polyurethane or silicone foam Semi permeable O² and water vapour Absorbs exudate Impermeable to fluid and bacteria Provides padding for protection Do not use on heavily exudating wounds Foams

33 Low adherent dressings Finely woven gauze Allows exudate to pass through dressing Reduces adherence Example - Adaptic

34 Management of Wound Margins 34

35 Patient 2: Post Excision Melanoma Day 1 Day 2

36 Day 3 Day 4

37 Day 5 Day 6

38 Day 7 Day 10

39 Day 14 Day 18

40 Six weeks

41 Products Made Simple Antimicrobials Silver dressings Cadexomer iodine Iodine Honey Absorb Moisture Alginates Hydrofibre Foams Absorbent pads TIME Donate Moisture Hydrogels Hydrocolloids Protection Films Foams Silicone Fine woven tulle

42 42

43 Moisture Balance Control underlying cause eg heart failure Control bacterial burden Dressing products to wick exudate away Frequency of dressing change Protect surrounding skin 43

44 44

45 Protective Barrier Wipes/Remove Wipes 45

46 Hydrofibre Woven hydrocolloid Hydrophilic Vertical wicking moist wound, remains dry on surrounding tissue Forms gel on contact with exudate Do not use on low or non exudating wounds

47 Alginates Calcium & Sodium salts from brown seaweed Exchange sodium for calcium ions forms gel Cut to fit wound to avoid maceration Firm stays in one piece Soft dissolves Do not use on low exudating wounds

48 Capillary wicking dressing:vacutex Primary dressing May require non-adherent contact layer Cut to size of wound Caution with pressure ulcers Do not use on dry wounds 48

49 Using Secondary Dressings 49

50 Products Made Simple Antimicrobials Silver dressings Cadexomer iodine Iodine Honey Absorb Moisture Alginates Hydrofibre Foams Absorbent pads TIME Donate Moisture Hydrogels Hydrocolloids Protection Films Foams Silicone Fine woven tulle

51 Dry necrotic tissue

52 Insoluble polymers approx 70-90% H²O Donates moisture to wound Can absorb small amount exudate Permeable to moisture vapour and O² Hydrate dry eschar Do not use on highly exudating wounds Hydrogels

53 Hydrocolloids Flat, occlusive dressing Forms gel over wound Impermeable to water vapour and O² Used to rehydrate dry necrotic wounds Provides moist environment Caution with infected wounds

54 Gamma irradiated Moist environment Antibacterial Osmotic action Odour control Low adherence to wound bed May cause stinging Can result in maceration Honey

55 Film Semi-permeable polyurethane Impermeable to fluids or bacteria Permeable to O² and water vapour Flexible Allows visual checks Monitor for maceration and foliculitis

56 Contraindications to Debridement Ischaemia immune response healing response If dry eschar leave intact and refer for urgent vascular review

57 Iodine based products Povodone iodine solution Useful to reduce bacteria and keep wounds dry eg. Mummified necrotic wounds Reduces bacterial load Release not sustained Toxic to fibroblasts

58 58

59 Biological Debridement Larvae from Lucilia sericata Protect surrounding tissue using hydrocolloid Apply larvae 5-8 per cm² Cover with wound veil secured at edges Cover with absorbent pad Change outer pad PRN Larvae can be left in situ 48 to 72 hours

60 Case Study Mrs J 63 year old women Recently became widow 5 year history Necrobiosis Lipoidica affecting right pretibial region Recurrent cellulitis

61 Case Study Mrs J Necrobiosis labodica Bronchitis Hysterectomy Hypertension Cellulitis Past smoker

62

63

64

65

66 Wound Cleansing Points to consider: Sterile vs non sterile Water or saline Other solutions Additives to water Temperature Technique Morison, M., Ovington, L. & Wilkie, K. (2004). Chronic Wound Care. Philadelphia. Mosby. 66

67 Care of the surrounding skin

68 Management of Eczema Remove irritant/allergen Wash in water Moisturize Cotton tubular gauze bandage Zinc paste bandages Topical steroids Dermatologist Patch testing Cameron, J. (1998). Contact sensitivity in eczema in leg ulcer patients. In N. Cullum & N. Roe. Leg ulcers nursing management: A rresearch-based guide. Bailliere Tindall. London

69 Bandaging Techniques 69

70 LaPlace s Law Related to Compression Bandaging Limb circumference Width of bandages Number of layers Tension of bandages Thomas, S. (2003). The use of the Laplace equation in the calculation of sub-bandage pressure. EWAJ. 3(1)

71 Topical Negative Wound Therapy

72 72

73 Expected outcomes Wounds should reduce by 25% in 4 weeks Venous leg ulcers should heal with compression within 12 weeks Wounds that do not meet this criteria should be referred to the Specialist Wound Management Service Margolis, D., Allen-Taylor, L. Hoffstad, O. et al. The accuracy of venous leg ulcer prognostic models in wound care systems. Wound Rep Regen. 12,

74 What do you need in your dressing Main products for everyday use? Products will in small amounts? Need to order in as required? When do you refer on to other services? cupboard? 74

75 How do you make your case? 75

76 Evidence based guidelines

77 77

78 78

79 References Daunton, C., Kothari, S., Smith, L. & Steel, D. (2012) a history of materials and practices for wound management. Wound Practice & Research. 20(4), Hurlow, J. & Bowler, P. (2009). Clinical experience with wound biofilm and management: A case series. Ostomy Wound Management. April Percival, S. & Bowler, P. (2004). Biofilms and their potential role in wound healing. Wounds, 16 (7), Phillips, P., Wolcott, R., Fletcher, J. & Schultz, G. (2010). Biofilms made easy. Wounds, 1(3),1-6 Ramundo, J. & Gray, M. (2008). Enzymatic wound debridement. WOCN, 35(3), Sibald, G., Goodman, L., Woo, K. et al. (2011). Special considerations in wound bed preparation. Wound Healing South Africa.4(2), Smith, f. Dryburgh, N. Donaldson, J. & Mitchell, M. (2011). Debridement for surgical wounds (review). The Cochrane Collaboration. Issue 5. Sweeney, I., Miraftab, M. & Collyer, G. (2012). A critical review of modern and emerging dressings used to treat exuding wounds. International Wound Journal, 996),

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