Lynn Peterson RN, CWOCN discusses a framework for wound bed preparation, lists main indications for common dressing categories, as well provide the tools to help select the appropriate topical therapy for common wound care problems.
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TAPE STARTS – [00:00]
Speaker: Good afternoon. The presentation that I am going to do is utilizing basic wound management products. So it's basically topical management. I am going through best practice as it relates to topical management of wounds. Okay, that’s my disclosure. I do work for 3M. The objectives and so the overall goal of topical therapy is to create a local environment that supports healing through appropriate cleansing and dressing selection. And that's what I am going to go through. So key considerations of your dressing selections. Of course, we want to pick the best type of wound dressing that's going to provide that moist wound healing environment. We all know that but there is other key considerations that you need to take into consideration. So what is the woundology and we have been talking pretty much about that the whole day. You need to know what your wound etiology is so that from that you can figure out what else is going on. If you have a pressure ulcer, pressure injury and you don't remove the pressure, it really doesn't matter what dressing that you put on it. Same thing for diabetic foot ulcers or venous leg ulcers. If you don't know the etiology as fixed the contributing factors it's not going to matter what kind of dressing that do put on. What are the goals for the patients? So in evaluating that what are their goals? Is it a palliative care patient and they simply want to keep that wound free of infection and have no pain or is the goal healing? All of those are considerations for what's the correct type of topical management to use.
The characteristics of the wound. So what's the exudate level? Do you have very minimal amount of drainage and you have a very dry wound bed and so therefore you need to add moisture to that wound bed or do you have copious amount of drainage and you need to choose the right kind of dressing or the right kind of technology that's going to manage that level of drainage. The tissue type. Dr. McGuire did a great job of talking throughout the different tissue types and as well as Heather and Pamela. Do you have dry, necrotic type tissue? Do you have beautiful granulation tissue? What's the type of tissue that's there that also will be used to determine what kind of dressing you are going to use. And the presence of infection. And then the last thing to consider is the frequency of dressing changes. What environment are these patients in. If they are in home care, is there a caregiver that can be taught how to change that dressing and you aren't going to necessarily -- what you don't want to do is pick a dressing and say I am going to leave this on for the whole week just because patients can't come back into the clinic or home care can't go back out and there is no caregiver. All dressings need to be chosen based on the characteristics of the wound and the dressing characteristic. So those are all key considerations. Other components of that whole best practice wound care include cleansing. Always have to cleanse the wound. The wounds needs to be cleansed every single time that dressing is changed. Periwound skin protection. To protect that wound from adhesive trauma, protect it from moisture, protect it from other characteristics that might be happening. Also filling and eliminating dead space or wound depth. I am going to be going through all of these but with that if you have a tunnel, it's filling that area so that the moisture or the exudate that's in the bottom of that tunnel can be wicked out to help that area to close.
You know if there is dead space that needs to be filled and finally what's your covered dressing that you are going to choose to manage that level of exudate? So this is in regards to cleansing and cleansing should be done like I said with every dressing change and it is to remove the bacteria and debris without harming any tissue that's there, any healthy tissue that's growing in. It does need to be done with each change. You do want to use low pressure irrigation of a 4 to 15 PSI, then you can accomplish that a couple of different ways. You can use a 35-mm syringe with a 19-gauge catheter or also there is many manufacturers on the market that have commercial wound cleansers available and oftentimes whatever device they are using or whatever container they are using, that's formulated to provide that correct PSI, so you aren't going to damage the wound bed when you are using that preparation. Non-infected wounds can be cleansed with saline, potable water or tap water, commercial cleansing solutions like I said. And then in regards to infected or critically colonized wounds, there are preparations that are available as anti-septic solutions and antimicrobial agents, different types of solutions or products with surfactants that are in them and we all know that some of these different products here will be cytotoxic. It comes with what makes up that particular cleanser or that particular antiseptic or antimicrobial but the thing is that we don't want to use if longterm. You use it for no more than 14 days, very short term, usually no more than 14 days and discontinue it when the wound starts to improve.
When that wound start to improve, go back to using the saline or potable water or cleansing agent that you were using before. So you use it to deal with the challenge and then move on into the next safe cleansing arena. So periwound skin protection is next. So you always want to do periwound skin protection. Periwound skin protection, like I said, is going to help prevent any type of medical adhesive skin related injury. How many of you are familiar with MARSI? Just a few. So MARSI is a big initiative that's out that we don't want to do harm to periwound tissue. So when you take off any type of adhesive products where it would be tape, IV dressings, wound care dressings, negative pressure wound therapy, drapes, whatever the case might be, you want to use a periwound skin protectant first when you put that down so that when you are removing that adhesive dressing or adhesive dressing tape whatever it might be, you aren't injuring the skin when you are removing it. You are actually removing that barrier film or that skin protectant that you are using and not causing harm to that wound. Some of the different barriers that are on the market, [indecipherable] [07:27] alcohol-free barrier film. It's a liquid that actually lays down a film on that periwound tissue and again it's going to protect the skin from any kind of adhesive trauma and also from any exudate that might overflow onto the skin from any other drainage that's there. There are moisture barrier ointments that are available but when you think about how you are going to treat your wounds, those protectants might contain dimethicone. They may have petroleum base to it. They might have a zinc paste to it.
When those are put down, your wound care dressing may not adhere as well as they would without those products. So those are some things that you need to think about if you are deciding what's the best product to use for periwound skin management. With zinc, a lot of the zinc paste preparations that are available, they are thick, they are messy, they are more difficult to put on and to spread and they are more difficult to cleanse and they may cause more trauma to the skin, more damage to the skin trying to cleanse them off than it would to choose a different type of preparation. I did homecare for the majority of my clinical life and we used what I saw used was a solid way for skin barriers for areas of skin that were really broken down, especially from like the negative pressure wound therapy drapes where the skin was just raw because of just the amount of times that needed to be changed and we would line that with the skin barrier and then we would tape to the skin barrier. The solid way for skin barriers would stay in place and that would be your taping platform. So that's another option for that as well. And then another very critical piece is to learn proper adhesive removal. So if you are using a lot of tapes, if you are using a lot of film bordered type dressings, have the manufacturers come in and do a taping in service on how to actually apply the tape and how to remove that tape so that you are not causing any kind of skin damage when you take it off. Work with your manufacturer to learn how to appropriately apply that dressing and also remove that dressing and that's probably one of the biggest tips that I can give you for the periwound skin protection. So eliminating dead space. Like I said, we want to gently fill any dead space so that the wound healing that's going on will be from the bottom up and it won't close in and end up leaving an area that is leaving the whole or leaving some dead space there or tunnel that covers over and you will end up with an abscess.
So you want to loosely fill any space with packing material. You packing material could be an absorbent fiber like an alginate or hydrofiber. It could be gauze tape. There are many different products that can be used to pack those areas, but again you don't want to heavily pack the areas because too tight can actually cause pressure on that tissue and so you want to just loosely fill it to allow the breathability and allow that healing to take place. And then remember that dressings are designed to improve wound healing time. If we are using the right kind of product and seen that wound continue to progress, that will shorten that time of healing. They are made to absorb blood and tissue exudate. They are made to minimize pain associated with application and removal. Again, that trauma that can happen when you remove those products. If you have a wound bed that's drying out and you are using, let's say you are putting an hydrofiber in it or an alginate in it, it's too dry for that type of environment. That will cause a lot of trauma when it's taken out. They are also designed to absorb and control odor and reduce injury to the periwound skin. So as we look at dressing selection, like I said, you want to determine which type of dressing based on the characteristics of your wound and based on the functionality of that dressing and as you can see there is different categories that the dressings can fit into. So there is some that are on the market to help with pain and protection. Particularly, the silicone dressing that came out and there is more and more that are coming on the market.
They are less likely to cause pain upon removal than an adhesive dressing is. They are gentle, they are easy to remove and patients really like them. If you go to dry to light amount of drainage, there you might be using a transparent film, a hydrogel. A hydrogel is going to be donating fluid back into that dry wound bed that then is going to facilitate that moist wound healing environment. And then you also have the composite dressings or Island dressings. Those are dressings that just manage minimal amount of drainage. You have low to high draining. You have moderate-to-high and excessive bio-burden. For today, we are going to talk about the moderate-to-high and the excessive bio-burden. Those are the categories that I am going to focus on. They are the ones that are most often used for the lower extremity and just due to also limited time. So first are the absorbent fibers. So absorbent fibers are made to be used with wounds that have moderate-to-high or copious amount of drainage. They are primary dressing. They go down on the wound and they always will require secondary dressing or a cover dressing such as foam or super absorber or transparent film or something else that's going to hold them in place. They can be used for partial thickness and full thickness wounds but the most important thing is that you have wounds that are moderate-to-high drainage. You don't want to use these on the wound that has very minimal drainage. It will just contribute to desiccating that wound or drying that wound bed out. They can be used for autolytic debridement. So they are great choice for autolytic debridement in which you can put the absorbent fiber in and cover it up with a transparent film. That will create an environment that will start that autolytic debridement process. So if you are not in need, if there is no infection there, you are not in need to have really fast debridement going on, an absorbent fiber is a great product to choose to do that.
They also can be used on infected or non-infected wounds and they can last in the wound up to seven days. How often you change them is going to depend upon the characteristics of your wound and how much drainage you have there. So we have two different types of absorbent fibers. We have calcium alginate dressing and then we also have the hydrofiber dressings. So the calcium alginate dressings are derived from brown seaweed. They are soft. They are non-woven. I am sure you have seen them either in rope style, so they are long and they can then be fit down into a tunnel or into undermining area. They also come in just a flat sheet and will fit over, let's say, for instance shallow venous leg ulcer that has got a lot of drainage, that can actually be fit right on there. They come plain or they also are impregnated with antimicrobial type of material and they might have silver in them or another antimicrobial product. The calcium alginates have the mild hemostatic properties. So they can be used like post-debridement where you have got some bleeding going on or also if you are dealing with the patient that has got really friable tissue and you just take off a dressing and it starts to bleed. An alginate might be a really good choice there because it helps with that hemostatic properties. As I said, they do require a secondary dressing and the dressing change frequency is going to depend on the amount of exudate. So when you put that in and you cover it with -- let's say, you cover it with a foam dressing. If you are seeing on day 3 that foam dressing is saturated, it's time to change it and then you change it all. So you would take off your foam dressing, you would take out the calcium alginate what's left there and then you would clean the wound and start it all over again.
Also with calcium alginate dressing, they can come in two varieties. They can be either a high integrity, which means that they basically keep the integrity up the properties that they have. They don't gel down. They stay in fibrous form and the other form that you can have is once that the way that the ions, the sodium and the calcium ions work with the exudate. They gel down and so when it gels down in order to remove that, you are going to have to irrigate it out. Sometimes in home health that can mean, you can take the dressings off and let them get in the shower and that can clean the area. Otherwise, you would clean it with your cleansing agent per choice. In the rope, a lot of times what you can see with the rope is that you can literally just take that out in one piece. Now, whether you want to choose to use a calcium alginate down all the way deep into the tunnel, as a clinician I never did that. I choose not to put something all the way down into the wound that I wouldn't be able to see the base and know that I got it all back out again. So I used to put them in very small narrow wounds or undermining areas but I wouldn't put it down in to a deep, deep wound. Also with the high integrity or the high gelling, some manufactures just have one or the other and there is other manufactures that have both to try to meet your needs of what you want. So they hydrofiber dressings, so the calcium alginates were from brown seaweed. Hydrofiber dressings are composed of sodium carboxymethylcellulose or CMC. They are highly absorptive and they will actually melt down into a gel. They are also available in a sheet or ribbon and with some of the hydrofiber dressings that are on the market, they have had a thread or string, or I was trying to figure out exactly what the name of that is, but they have something that has been sewn into that rope for higher integrity and strength.
So that if they do put that all the way down into a deeper tunnel, they know when they pull it out, it's all going to come in one because of that piece of fiber or string or thread that they have had sewn into them. They also will come into a plain or in antimicrobial foam. Again, they manage moderate-to-high exudate levels and your dressing change is still going to depend upon your exudate level and they are contraindicated for dry wounds, dry eschars and third-degree burns. So the next category is foam dressings and foam dressings used to be indicated for use for moderate-to-high drainage and now because of lot of manufacturing changes that have been going on, they now a lot of them are indicated for use on low-to-high draining wounds. Foam dressings are polyurethane foams. They are breathable. Some of them are just a single-layer foam and they have nothing over the top. And so therefore they are really breathable and they can dry out easily. And others might be multiple layers that are all stack together to manage all that exudate that's going on and they are covered with a transparent film. And then that transparent film provides a barrier to outside contaminants and also it helps with the breathability of that dressing. For those that are composed that way, that's where you get the ability to ether put them on a low draining wound or high draining wound because what happens is that based on the technology that's built into those foam dressings, if it's a low draining wound, the breathability or the evaporation that happens is low. So it's not going to dry that wound bed out.
But if it's a real high draining wound, then the breathability of that dressing because of the technology will be higher and it's going to help to reduce the risk of maceration. So you have to talk with your manufacturer, figure out what's the technology that's build into that particular foam and they can tell you the level of that that will actually handle. Foam dressings can be used as a primary or secondary dressing. If you don't have any other product that you are using it with and it goes down right on the wound, then it's going to be your primary dressing. They can be plain or they can silver. Again, you want to check with your different manufacturers to find out what is built into their types of foams. We do know that with the foam dressings, you can have border and the border you might see an acrylate type of border, which would be like a film that has adhesive on it. It's a regular acrylate type of adhesive that's on it. We also now have a lot of silicone dressings that are out in the foam style. Also we have non-adhesive or non-bordered and with those, you may not have anything at all. It might just be the foam. It might have film over the top. It's just a foam and some of them also have silicone that has been coated on to it and that goes down against the wound and onto the skin. So you are going to see lots of different types of the foam dressing. They also come in different sizes and they come in different shapes. One other thing that I mentioned when I first started is that I went around and I put several different dressings in the middle of the table. We tried to get a mix from different manufacturers to the best that we would, take a look at those and hopefully they can just give you some ideas as I am going through the different categories. The last design that you might see with the foam dressing is a fenestrated.
So a fenestrated foam has -- I had a picture, it might be in my next slide here. Down here on the bottom, you have this is a fenestrated foam, so that's used for trachs, it goes around tubes, gastric tubes, PEG tubes that kind of stuff to manage any moisture that might be draining around that tube and protect the skin at the same time. Indications for use for foam dressings, partial and full-thickness wound. Again, it could be low to high draining. Know what the capacity of that wound dressing is. They are great to use underneath compression wraps but what you want to use under compression would either be your non-bordered or silicone non-bordered. Because of the tissue type that's involved with the venous leg ulcers, it wouldn't be good to put that acrylate adhesive dressings down because it could very much cause more trauma when you take it off. The wear time is going to depend upon the amount of drainage that you have. They can be left on uninterrupted to seven days but oftentimes they may need to be changed once or twice a week because they are saturating through and they won't manage anymore drainage and it's time to change it. Super absorber dressings and we are seeing a lot of super absorber dressing on the market as well. There is many different manufacturers that have these. This as far as dressing category, we will manage the largest amount of drainage that there is. Some of these have a wound contact layer that goes over the dressing and sits on the wound to help prevent trauma, to help prevent maceration from occurring but there are super absorbing cores is what they have and so they have highly absorptive fibers. Some are powdered, some are crystals or gels, some are like a diaper technology and if any of you have been around the newest diapers that are out it's just this technology that grabs all that fluids that's there and just locks it in place.
So it can't go back down onto the wound bed and also they stay very low profile. So they are great to use with high-to-copious amounts of drainage, underneath a compression garment, possibly a pressure injury or even the surgical wound that has dehisced. Most of the super absorber dressings have to be secured in place with like a gauze wrap or compression wrap possibly tape or some other kind of platform to keep them in place because I think I just saw one that now has a silicone border but the majority of them do not and you will need to secure it with something. So antimicrobial dressings, so they will decrease the bacterial burden. They are an antimicrobial substance that is used to control or decrease the bio-burden. They can be used for partial thickness, full-thickness wounds. They can be help with odors with the wound because of the way that they absorb the exudate and help to control that odor. They need to be used on highly contaminated or infected wounds. There are different categories for these two. You have your silver antimicrobial dressings. You have the cadexomer iodine, the PHMB dressings and then also antimicrobial absorbent wound dressing. So ionic silver dressings, so these are antimicrobial dressings. Again, we are seeing these very -- over and over every manufacturer seems to have some kind of silver dressing. They might be with the foams. They might be an alginate. They might be in a gel. They might be in a powder. They are just all different types of substrates that they are put into. They have controlled release of the ionic silver. The way that a lot of them work is that the silver is not necessarily deposited into the wound or onto the wound base.
What happens is that the exudate goes into what are the substrate is. Let's say it's a foam dressing and then the sliver becomes active and it can either lyse the cells. It can suffocate the cells. There is three different mechanisms of action that the ionic silvers actually can have to kill that bacteria or help to control and decrease the microbial contamination that's in that wound bed. The dressings require moisture so that silver can dissolve. So you want to make sure that whatever you are using, it's not used on a dry wound bed. If it's, you need to make sure that there is something underneath that that has fluid that's there [indecipherable] [26:48] But most of the time if you have a highly contaminated wound bed, you are going to have a lot of exudate. So you don't generally have to worry about it being too dry. When the signs of local infection are under control, you want to discontinue the use of the dressing. So I think we saw the pendulum go one way where silver dressings were used and used and used and nobody discontinued them. So you might have a silver dressing on a wound for 30 days and then it came back the other direction and wasn't being used enough and now really what you should be doing is using the silver dressing for maybe about two weeks, reexamine what's going on with your wound bed if that's not working. If nothing has changed, do the assessment through all the parameters that we talked about earlier today and figure out what's going on in that wound bed, why is this not working and if it has worked, discontinue the silver and go back to using your basic wound treatment dressings. Cadexomer iodine is a sustained release of iodine.
The iodine is encapsulated in a starch-like material and then as that starch comes into contact with the wound exudate then that iodine is released down into the wound bed. It's active against MRSA, staph aureus, many other relevant pathogens. It can work very well with moderate-to-high exuding pressure injuries and other injuries. I actually use this in my practice one time, probably more than one time but I had a pressure injury that was at least a stage 3 or stage 4 in it was full of necrotic or non-viable tissue and I put that on and it came back two days later and it was totally clean. It kind of blew my mind. It's like oh, what happened because I had never seen that before. So it is a very effective antimicrobial that can be used. The wear time will be dependent on the amount of exudate and the dressing characteristics and you don't want to use this product if your patient is allergic to iodine. Polyhexamethylene biguanide or PHMB is another product that's out there. This one binds to bacteria cells membrane and it literally causes a structural change that kills the bacteria. It is effective against a wide range of pathogens. It's widely available in a solutions and gels and dressings. We have seen it in gauze sponges. We have seen it in gauze. It's in cleansing solution form, so it's an effective barrier to bacterial contamination and the contraindications for this would be adverse reactions to PHMB or chlorhexidine. The antimicrobial absorptive wound dressings, there are some out here on the table that I put in the middle. Their trade name is Hydrofera Blue. They are the only one that's on the market that has this.
It's a polyvinyl alcohol or PVA sponge with organic pigments. It's got methane blue in it and Gentian Violet and it's an antiseptic. So you need to make sure that this dressing is kept moist and before removing and as needed. And it's only the things that kind of goes across the board. If you have ever put anything on a wound and the wound dried out while you were using it, make sure that you hydrate that wound or irrigate that wound good to moist in that backup so that we're not causing any trauma when you are removing it. And then honey-based dressing. There was a honey-based dressing that's also on your table there. They promote a moist wound healing environment. They also can promote autolytic debridement. They reduce inflammation and they actually decrease the wound pH and when they are decreasing the wound pH that decreases the bacterial load. So as you can decrease the characteristics of that wound then you will have a change in the tissue. They are available in a calcium alginate gel sheets, hydro gel paste form. They can be left in place for up to seven days and again the dressing change frequency is going to depend upon wound characteristics and the amount of exudate that you have. And then also there are adjective or advanced therapies. So if all of the other wound, topical wound management principles aren't working, then you should start to look at the adjunctive type of therapy. So negative pressure wound therapy, ultrasound, E-stim, hyperbaric oxygenation. Note that there are -- I don't have time to go into any of those today, but they are available out there but they should be used if the traditional things aren't working and your wound isn't advancing. So that was a lot in a little bit of time. And I actually have the next segment as well. So any questions or should I just keep on going?
TAPE ENDS - [32:18]