There are a multitude of dressings to choose from and selecting the right one is crucial to promoting healing, as the wrong dressing can significantly hinder a wound from healing. A good understanding of how wounds heal, the dressings available and how they work should enable nurses to make an appropriate selection. The final article in the series is about wound complications and how to deal with them.
Citation: Hampton S Selecting wound dressings for optimum healing. The healing process is complex and not entirely understood, but it occurs in stages, as discussed in part one of this series Brown, In order to heal quickly and cleanly, wounds need an optimum healing environment at all these stages.
Nurses can achieve this by selecting and applying the right dressing at the right time Hampton and Collins, Dressing selection is fraught with complications and there are numerous dressings to choose from. Local wound care formularies contain the most economic and clinically effective products and are useful tools for non-specialist nurses.
However, if the products in the formulary are not assisting with wound healing, even though modifiable factors associated with delayed healing have been optimised, such as nutrition, pressure relief, anaemia and venous hypertension, nurses should contact a specialist tissue-viability nurse TVN for additional advice and support. Nevertheless, as a quick guide, most wounds will heal using appropriate dressings from a selection of six types. These can be referred to as the six As of wound care.
No single dressing will manage all the many nuances within a wound and although two dressings may fall into the same category, their performance characteristics and clinical indications may vary Green, Current research indicates that bacterial growth is a contributing factor when wounds become chronic Davis et al, ; Donlan and Costerton, Bacteria can also be the source of malodour in wounds Hampton, a ; this is a significant issue for patients, caregivers and health professionals, and should always be appropriately addressed Fleck, The odour is caused by volatile agents that include short-chain organic acids produced by anaerobic bacteria Moss, The type of bacteria present can sometimes be identified from odour alone, such as Pseudomonas aeruginosa, which has a distinctive, sweet smell.
When managing a malodorous wound, it may be necessary to use a dressing that absorbs the volatile molecules being released Thomas, When they adhere to damp surfaces, bacteria have the ability to build a biofilm — a community or colony of bacteria that have encased themselves in a slimy film. The film provides a physical barrier to antimicrobials, mechanical removal and the immune response Woods et al, Microbial biofilms are implicated in both the infection of wounds and failure of infected wounds to heal Percival et al, It is vital to remove these colonies and the best method for this is debridement.
Wound complications and infections are discussed further in part six of this series. Debridement, whereby dead tissue is removed from the wound, is an important aspect of wound management — it prevents the formation of biofilms and infection in the wound. Specialist nurses trained and assessed as competent in debridement, doctors and surgeons may undertake sharp debridement with a scalpel or curette at the bedside, or surgical debridement in theatre.
Maggot therapy is widely used for debridement. Sterile larvae are placed on the wound surface and produce an enzyme that breaks down the biofilm so that the bacteria can be removed. Maggots have been found to be effective in surgical wounds infected with MRSA and many other wound types Beasley and Hirst, , and tissue oxygenation is measurably increased during maggot therapy Wollina et al, However, they are not as effective for wounds infected with pseudomonas.
Debrisoft is a new product that has been shown to remove devitalised tissue National Institute for Health and Care Excellence, Versajet is also an excellent choice for debridement but is often only available to surgeons and TVNs due to cost and training issues. Proteases are naturally produced enzymes that act on proteins by breaking them down into peptides and amino acids. In wound healing, the major proteases are the matrix metalloproteinases MMPs , which are extremely important for healing in acute wounds.
However, in chronic wounds, there is an overproduction of MMPs and the increased proteolytic activity is known to damage the wound bed, degrade the extracellular matrix and cause peri-wound skin problems Romanelli et al, Immune cells produce the MMPs in response to the inflammatory process during healing and also in response to infection; reducing bacteria in a wound can therefore reduce the MMPs that are creating poor wound-healing conditions.
Since proteolytic activity is sensitive to pH, another way to reduce it is to create a more acidic environment Hampton, b. The pH of chronic wounds has been measured as 7. Antibacterial and interactive dressings change the wound pH Hampton, b , generally lowering it to a more acidic and wound-friendly level.
The dressing must support a moist environment as drying of the wound bed increases pH, making the wound more alkaline Australian Wound Management Association, As noted above, many types of dressings will reduce wound bacteria, debride and promote an ideal healing environment.
They include: honey, PHMB, Zorflex, Sorbact, silver, iodine and highly absorptive dressings, all of which have been shown to reduce bacterial load. These dressings can also reduce chronic proteolytic activity and lower the pH in the wound.
Silver has bactericidal properties and was used in the past to prevent or manage infection in its solid form for example, placing silver wire in wounds ; as a solution for example, using silver nitrate solution as a cleanser ; and more recently, as creams or ointments containing a silver-antibiotic compound called silver sulfadiazine International Consensus, Today, the silver component of dressings may appear as a coating on one or both surfaces elemental or nanocrystalline silver , within the structure of the dressing or a combination of these International Consensus, How the silver then interacts with the wound will differ, as with some dressings it will deposit on the wound bed, whereas in others it will remain in the dressing, where it will act on the bacteria that is absorbed.
All antimicrobials should be used for a maximum of two weeks. Honey is another effective remedy for healing wounds. It has been found to be an excellent wound dressing with multiple bioactivities that work to expedite the healing process.
Honey debrides wounds rapidly, replacing slough with granulation tissue; it also promotes rapid epithelialisation and absorption of oedema from around the ulcer margins Al-Waili et al, However, not all types of honey are equally effective: sensitivity-testing using non-standardised honeys has shown that their antibacterial potency varies greatly Cooper and Molan, It is thought that manuka honey, which is derived from the tea tree plant, has more potent antibacterial properties.
Significant antibacterial activity can be maintained easily when using any medical honey as a wound dressing, even on heavily exuding wounds. Impregnated gauze iodine is therefore useful as a surface protection but not necessarily for deeper and colonised wounds. Cadexomer iodine produces a sustained release of iodine into the wound over a hour period and is therefore more useful for deeper chronic and colonised wounds; it will continue to destroy bacteria until it turns white.
Hydrogel sheets can be extremely useful in absorbing fluid and keeping the wound bed moist. Use on: venous ulcers, wounds with tunneling, wounds with heavy exudate.
Pros: highly absorbent; may be used on wounds that have infection present; are non-adherent; encourage autolytic debridement. Cons: always require a secondary dressing, may cause desiccation of the wound bed, as well as drying exposed tendon, capsule or bone should not be used in these cases. Composite , or combination dressings may be used as the primary dressing or as a secondary dressing. These dressings may be made from any combination of dressing types, but are merely a combination of a moisture retentive dressing and a gauze dressing.
Use on: a wide variety of wounds, depending on the dressing. Other dressings available on the market include dressings containing silver or other antimicrobials , charcoal dressings and biosynthetic dressings.
It is likely that as your experience with wounds grows, you will find success using a small variety of wound care products of different types that are readily available to you. You may occasionally need to use other dressings for special situations or wounds recalcitrant to healing.
It is important to understand how dressings from each category affect the wound bed and which wounds you should not be using particular dressings on. In short, know your dressing categories and become familiar with a few dressing types from each category to create your own collection of go-to dressings to suit most wounds.
Sources Baranoski, S. Wound and skin care: Choosing a wound dressing part 1. Nursing ; 38 1. Myer, B. Wound Management: Principles and Practice. Pearson Prentice Hall. Upper Saddle River, New Jersey. The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc.
Last month I introduced you to the concept of how being a wound care professional is often a lot like being a detective. In a recent survey, we asked our WoundSource Editorial Advisory Board members what outdated wound care practices they continue to see in the field. Depending on what health care setting clinicians work in, there are specific guidelines, policies, and procedures that may impact standard of care View the discussion thread.
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However, metronidazole gel 0. Charcoal dressings eg, CliniSorb, CarboFLEX can also be used to reduce odour, but some are only suitable for use as a secondary dressing. Additionally, charcoal dressings can stick to wounds if they are allowed to dry out, causing substantial trauma when removed. Iodine dressings are contraindicated in hypersensitive patients, pregnant or breastfeeding women and those with thyroid disorders or renal impairment. T3 and T4 levels should be monitored.
Iodine can alter lithium levels. Examples include povidoneiodine sheets Inadine and cadexomeriodine paste Iodoflex or powder Iodosorb. When silver dressings come in contact with exudates, silver an antibacterial and antifungal is released. Although expensive, these dressings are effective and are useful as a supplement to systemic therapies, which may have difficulty reaching therapeutic levels in the wound bed especially for patients with poor vascular perfusion.
Avoid in patients with silver allergies and use with caution in renally impaired patients since silver can accumulate over time. Sterilised honey dressings maintain a moist healing environment, eliminate odour, stimulate new tissue growth and aid debridement. Granulation tissue is a fragile mixture of proteins and polysaccharides linked together with collagens to form a highly vascular gel-like matrix with a characteristic red appearance.
Granulating wounds must be kept warm and moist and exudates must be managed. The size, shape and amount of exudate in a granulating wound can vary considerably.
Low-depth wounds should be protected with a low- or non-adherent dressing or a hydrocolloid. Occlusive hydrocolloids are particularly effective because they create a hypoxic environment, which promotes granulation. If exudate is heavy, alginates can be used. Dressings should be changed as infrequently as possible to prevent damage to the fragile wound bed.
For deep cavity granulating wounds, a polyurethane foam dressing eg, Allevyn, Lyofoam, Tielle can be used to pack the wound. These usually consist of foam or foam chips enclosed within a soft flexible pouch to allow entry of exudates.
It is important not to overpack the wound because this can cause wound distortion leading to ischaemia, necrosis, cosmetic defects and patient discomfort. Granulation continues until the base of the wound cavity is almost level with the surrounding skin. At this point, the wound begins epithelialisation. In the final stage of wound healing, epithelial cells advance in a sheet across the wound, starting at the wound margins before meeting in the middle.
The length of time this process takes depends on the extent of tissue damage. This process does not tend to produce large quantities of exudate. The aim for this stage of healing is to keep the wound moist until it closes. Superficial wounds can be managed easily with hydrocolloids or one of the semipermeable dressings mentioned previously.
It should be remembered that this tissue is still delicate, so care should be taken to avoid trauma when changing the dressings. Other dressings useful in the final stages of healing include soft silicone dressings eg, Mepitel , knitted viscose preparations eg, N-A dressing, Tricotex and nylon sheet dressings eg, Tegapore. Remember to check for nylon, silicone or viscose allergies. Whichever dressing is used, the wound should be monitored regularly for signs of infection or deterioration.
Thanks to Claire Richardson senior staff nurse , Barbara Topley tissue viability sister and Jane Marshall directorate pharmacist for the department of medicines for older persons for their comments and review of this article.
Articles in the series have been commissioned from independent authors who have summarised useful clinical skills. Access provided by.
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