Adkins, Carrie L. RN, BSN, CWOCN
Editor's Note: This author has been a Certified Wound, Ostomy, Continence Nurse (CWOCN) for 3 years and prior to this, worked as a home healthcare nurse for numerous years. In the transition to becoming a CWOCN, the complexity of chronic wounds in the home care setting was recognized. The clinician's knowledge of properly identifying wounds and appropriateness of wound care products within her organization is a challenge. As a new CWOCN, the nurse was also able to identify the need for consultation with a CWOCN because of this complexity and the many products available.
In home healthcare, clinicians are responsible not only for educating patients and their caregivers about wound care, but also considering the cost of dressings, the number of visits by clinicians, the cleanliness of the home environment, and the ability of the patient and his or her caregivers to manage wounds at home. Although all of this is important, the most important consideration is to match the wound with the most appropriate dressing for the wound. Although clinicians may be familiar with certain wound-care products, it is also extremely important to read product inserts before using a dressing, as the guidelines frequently change (Bryant & Nix, 2007).
When assessing a wound, the clinician must first identify the type of wound. Although the technology of wound care has advanced, it cannot change all the factors that contributed to the development of the wound, such as chronic pressure and uncontrolled diabetes. For wounds to heal and progress, contributing factors such as pressure, chronically elevated blood glucose, infection, and viability of wound tissue need to be addressed before topical treatment is applied. Some of these factors can be resolved by dressing choices and may assist with fighting infection and debridement of nonviable tissue.
Most wounds heal with proper wound moistness. According to Barbara Dale (2011) in her article “Say Goodbye to Wet-to-Dry Wound Care Dressings,” research over the past 50 years repeatedly shows that wounds heal faster and stronger when moist wound healing principles are used. If a wound is very wet and has a large amount of exudate, it needs to “dry out a little.” If a wound bed is very dry, moisture needs to be added. Many patients want their wounds to “air out” and do not understand that it is essential to have a moist wound environment for healing to occur. If the wound cells are too dry they will dehydrate and “die”; if the wound cells are too wet, they will “drown.” Wound tissue that is dry is much more prone to infection, scarring, and pain (Bolton, 2007).
Overview: Product Considerations
There are many wound care–specific products. According to BCC Research, the wound care industry in 2010 was a 2.0 billion dollar market (BCC Research, n.d.). Wound care products vary in price and it is important to consider all factors when choosing an appropriate product, not just the price. These factors include home environment, ability of caregiver or patient to perform wound care, amount of exudate from wound, cleanliness of wound, and type of wound. Wound care manufacturers seem to come out with new products daily, which makes it difficult to keep up with “the newest product.” In this article, the most common dressing choices are listed alphabetically. There are numerous brand names for specific wound care products, but only the generic name or category will be described. Clinicians may refer to a detailed resource manual from 2012, “Wound Source,” which is a reference that names all brands and products for each category of dressings (Kestrel Health, 2012).
Wound Dressing Categories
Alginates are primary dressings (dressings placed in direct contact with wound bed) that are composed of brown seaweed (Swezey, 2011). Often called calcium alginate, there are numerous manufacturers with many different names; be cautious, they may not all use the term Alginate. Drainage is absorbed by an ion exchange to form a gel, which then conforms to the shape of the wound (Bryant & Nix, 2007). These dressings are useful for wounds with moderate-to-heavy drainage; they can absorb up to 20 times their weight. They also promote homeostasis in minimally bleeding wounds, as well as assist with autolytic debridement (Swezey, 2011). Alginate is a good replacement for a dry gauze dressing such as those that might be used in a wet-to-dry dressing (wet-to-dry is always changed daily if not twice per day). Wet-to-dry dressings are no longer recommended for use. Readers are referred to the article “Say Goodbye to Wet-to-Dry Wound Care Dressings: Changing the Culture of Wound Care Management Within Your Agency” by Barbara Dale and H. Denise Wright, published in this journal in July/August 2011.
Tips for Using Alginate Wound Dressings
* Alginates come in the forms of sheets, ropes, and ribbons.
* Use for moderate-to-high draining wounds.
* Apply multiple layers, if exudate is heavy.
* Educate the patient that the “gel” is normal and not a sign of infection.
* Cover with a secondary dressing (this is the secondary dressing that is over top of the primary dressing, which is intact with the wound bed).
* Consider ribbon or rope for tunneling and undermining.
* Pack loosely into wound.
* Change dressing when drainage is visually coming through secondary dressing.
* Moisten and irrigate wound with normal saline if dressing is adhered to wound bed, before removing it.
* A wound with a dry wound bed.
* A wound with a third-degree burn (Bryant & Nix, 2007).
* Do not moisten dressing prior to placing in wound bed.
Antimicrobials are topical dressings or products used for wounds that are not healing because of infection, or wounds that are at high risk for infection. The advantage of antimicrobial dressings is a longer wear time; they can be left in place for several days. They are also the dressing of choice for a patient who is unable to change his or her own dressing, or for a patient who has an unclean living environment. Some may feel that these are expensive dressings, but they are cost-effective when used as recommended. This is because fewer supplies are used, fewer clinician visits are needed if daily dressings are ordered, and often healing time is shortened. This is one of the only categories with subsets: iodine, leptospermum honey, and silver.
Iodine-Based Antimicrobial Dressing
These dressings work by slowly releasing iodine, while at the same time absorbing drainage from the wound. These dressings can last up to 72 hours (Hess, 2008). They come in the form of a paste or gel.
Tips for Using Iodine-Based Antimicrobial Dressing
* Change the dressing at least three times per week or when the color of dressing goes from brown to yellow or gray (Hess, 2008).
* Leave the wound slightly moist when applying dressing (Hess, 2008).
* Sensitivity to iodine.
* Use with caution in patients with thyroid problems.
* Not for use with pregnant or nursing mothers (Hess, 2008).
Honey dressings are made from a medical grade honey; the honey is impregnated into the dressing. The honey is not in a raw honey form. The popularity of these dressing is on the rise and is in part because it can be used for wounds with several different characteristics. In addition to the antimicrobial properties, honey dressings also support moist wound healing, debridement of nonviable tissue, odor control, anti-inflammatory properties, and can help minimize scar formation (Chang, 2009). Honey is available in creams, gels, ointments, alginates, hydrocolloids, and even contact layers (this will be discussed later in this article).
Tips for Using Honey Antimicrobial Wound Dressings
* Use a secondary dressing with all forms of honey wound dressings.
* Dressing can be left on up to 7 days; do remove if exudate come through secondary dressing (Pieper, 2009).
* Ensure all honey is washed out of the wound with normal saline or soap and water with dressing changes.
* Allergy to bees, honey, or sensitive to bee stings.
* Do not use on dry necrotic wounds (Chang, 2009).
Silver Antimicrobial Dressing
Silver dressings are the largest category of antimicrobial dressings. They have antimicrobial activity against an extensive range of aerobic, anaerobic, gram-negative, and gram-positive bacteria, yeast, fungi, and viruses (Tomaselli, 2006). The different forms of silver are supplied as alginates, foams, gauzes, hydrocolloids, contact layers, combinations with hydrogels, creams, powders, and collagens.
Tips for Using Silver Antimicrobial Wound Dressings
* Some brands of silver alginate state the dressing can be changed every 21 days; this can explain cost savings with using less wound care supplies.
* Inform the patient that silver dressings such as silver alginates may turn a grayish-green color when wet.
* Change the dressing when saturated no matter what form of silver being used.
* Read each manufacturer insert for application and “wear time”; all silver dressings are different.
* Instruct patient to notify clinician before getting an x-ray, radiation, or any medical treatment; a physician may not want dressing on during a test, as it may interfere with results.
* Some staining on skin or tissue can occur due to silver that may darken or add a blue hue to the skin, which is temporary (Tomaselli, 2006).
* Do not use with enzymatic debrider agents, as it may inactivate them.
* Do not use with bleach solutions.
* Patient sensitivity to silver or sulfa drugs.
* Even though some brands of silver alginate antimicrobial dressings allow the dressing to remain intact for up to 21 days, regular wound assessment is important. The wound should be assessed at least weekly.
Consider using a collagen-based dressing for wounds that just do not seem to heal or wounds that have stalled or have not progressed toward a healing goal. Collagen dressings help the wound heal by stimulating the collagen fibers, for new tissue and blood vessel growth (Brett, 2009). They are made of cowhides and or tendons, or porcine collagen (Bryant & Nix, 2007). Collagens are absorbent and provide a moist wound environment. They can stay in place up to 7 days, depending on the manufacturer. Collagens come in the form of gels, sheets, pads, powders, and particles. Some manufactures combine collagen with silver or alginate to make a combination dressing.
Tips for Using a Collagen Wound Dressing
* Read the manufacturer insert; most collagens do not need to be removed from the wound bed with the next dressing change.
* Use collagen as the primary dressing and top with a secondary dressing such as dry gauze.
* Clean the wound bed with normal saline prior to the dressing change, if the wound bed is dry you may need to add normal saline to the collagen or to the wound bed; this will cause slight “gelling” of the collagen.
* If the dressing is a sheet or pad, cut to fit the shape of the wound bed.
* Check with the patient on cultural or religious beliefs: they may not agree with using bovine or porcine products.
* Wounds with a large amount of exudate.
* Do not use on third-degree burns.
* Not for use on active vasculitis (per most manufacturers contraindications). Check with physician first.
* Collagen sensitivity.
Composite Wound Dressings
Composites are dressings where two dressings are combined into one. These can increase the ease for patient use. An example of a composite dressing would be a foam island composite dressing. This is a foam dressing with a tape or adhesive border.
Advantages of Composite Wound Dressings
* Can be used as either a primary or a secondary dressing.
* Choose a composite dressing if dressing change process is complicated and difficult for the patient and caregivers.
* Instead of using a foam dressing topped with a dry dressing and tape, use a foam island composite dressing.
Contact Layer Wound Dressings
Contact layer wound dressings are a solution for dressings that are painful to change and traumatic to the tissue of the wound bed. They are nonadherent single-layer dressings applied directly to the wound base. Drainage comes through the woven or mesh-like material, allowing it to be absorbed by the secondary dressing (Bryant & Nix, 2007). Contact layers have the ability to stay in place for 1 week, which can be cost-effective. These are usually transparent so that you can assess the appearance of the wound bed. Some manufactures incorporate silver or medical-grade honey into the contact layer adding protection to wounds that are at a high risk for infection.
Tips for Using Contact Layer Wound Dressings
* Use with wounds that have a painful dressing removal.
* Use under Negative Pressure Wound therapy for “stuck foams” or painful removal.
* Clarify with the physician if the contact layer is to stay in place for 1 week and the secondary dressings be changed accordingly.
* Use with wounds that have friable tissue and bleed easily with dressing changes.
* Not for use in the tunnel of a wound (a tunnel is a tracking that extends from the wound to surrounding tissue; one cannot usually see the end of the tunnel).
* Do not use with evidence of thick wound exudate.
* Some manufacturers contraindicate their use of contact layer dressing in patients with third-degree burns.
Foam Wound Dressing
Foam wound dressings can be used on a wide variety of wounds. They are made of an absorbent sponge-like material that provides thermal insulation as well as a moist wound-healing environment. Foams are used for light-to-moderate draining wounds, and can be primary and/or secondary dressing. The various forms include pads, sheets, ropes, rolls, and pillow cavity dressings. Some manufacturers have formulated different shapes for heels, elbows, coccyx, and more. Some foams come with cleansers, silver, and contact layers incorporated into them.
Tips for Using Foam Wound Dressings
* Read all manufacturers guidelines; some foams have a special border that shows when dressing is saturated.
* Do not leave on heavily draining wounds for extended periods of time without checking wound because saturation may cause maceration to periwound skin.
* With many manufacturers, foam dressings are contraindicated for use on third-degree burns (ReliaMed, 2007).
Hydrofera Blue Foam Dressing
Hydrofera Blue Foam is a brand name, but this dressing is the only type of its kind—a bacterostatic foam. Hydrofera Blue Foam dressing is applied differently than the other foam dressings because it needs to be hydrated to work effectively, while still absorbing moderate-to-excess amount of drainage. This is an absorptive foam made of Hydrofera polyvinyl alcohol sponge, methylene blue, and crystal violet. This foam inhibits growth of bacteria such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci (Wounds, 2011).
Tips on Hydrofera Blue
* When applying this dressing, moisten with normal saline or sterile water and then ring out the excess. Do not use tap water.
* It is important to change the dressing every 1 to 3 days.
* The dressing should not dry out completely; instruct the patient to rehydrate the dressing with saline or sterile water.
* When the dressing color turns from blue to white, it needs to be changed (Hydrofera, 2012).
Hydrocolloid Wound Dressings
Hydrocolloid dressings generally consist of a semipermeable film coated with an absorbent mass of sodium carboxymethylcellulose, pectin, or gelatin (Rivera & Wu, 2011). They are a very versatile dressing that are appropriate for stage I and stage II pressure ulcers, partial- and full-thickness wounds, and light to moderately draining wounds. Hydrocolloids can be used on clean wounds as well as wounds that need debridement. When placed on a wound with necrotic tissue, autolytic debridement can occur (Rivera & Wu, 2011). These dressings come in the form of gel, paste, and wafers. They come in various shapes and thicknesses.
Tips for Using Hydrocolloid Wound Dressings
* Warm the dressing in your gloved hands prior to application for better adherence.
* Stretch corner of dressing parallel to skin for easier removal.
* Tape down edges if cut from a larger piece to avoid rolling.
* Dressing should set on at least 1 in. of intact skin for better adherence.
* Instruct the patient that when this dressing is removed it may look “gooey” such as a consistency of honey or pudding; this is a normal part of autolytic debridement.
* Some hydrocolloids need changing one time a week; others up to three times per week. This depends on manufacturer guidelines and exudate amount from a wound.
* Infected wounds.
* Heavily draining wounds.
* Wounds with tunnels.
* Wounds with bone or tendons showing.
* Fragile periwound skin.
* Third-degree burns.
Hydrogel Wound Dressing
Hydrogel wound dressings are primarily composed of water. These dressings can hydrate and maintain a moist wound bed as well as liquefy necrotic tissue (Rivera & Wu, 2011). Hydrogels come in tubes, dry sheets, and moist gel sheets. These are ideal for a wound with a necrotic or dry bed because they can soften the necrotic tissue in the wound bed, which promotes easier removal of the necrotic tissue. Some have additives such as alginate, which can assist with minimal absorption of exudates, whereas others have silver added to them. Hydrogels are also appropriate for skin tears and first- and second-degree burns.
Tips for Using Hydrogel Wound Dressings
* Cleanse the wound with soap and water or normal saline (depending on physician order) when changing the dressing, flushing out existing hydrogel.
* Read the product insert; some hydrogels require daily dressing changes, whereas others are every 3 days.
* Cut hydrogel sheets to size of the wound because periskin can become macerated.
* Use skin protectant around the wound to help prevent maceration.
* Cover with a secondary dressing.
* Keep dressing in refrigerator for a “cooling” effect to help with pain.
* Highly exudating wounds.
* Third-degree burns.
Miscellaneous Wound Dressings
There are many miscellaneous dressings that do not fall in a specific category. We briefly explain what they are and how they can be used here.
* Specialty Absorptives: these are for highly exudating wounds. These dressings are often used as a secondary dressing for a wound with large amount of exudate. Abdominal gauze pads are a familiar specialty absorptive.
* Sodium Impregnated Gauze
* Available in ribbons and sheets.
* Daily dressing changes are required.
* Good for “cleaning out a wound.”
* Absorbs minimal-to-moderate amounts of drainage.
* Petroleum Impregnated Gauze
* For skin tears, burns, skin grafts and donor sites, as well as no-stick dressings.
* Often used for healthy, pink, granulating wounds.
* Use in a single layer; a double layer can block drainage from leaving the wound.
* Leave in place on a burn or skin graft and dried edges are trimmed off.
* Iodoform Gauze
* Packing strips that are used for tunneling wounds.
* Helps control bioburden and absorb drainage.
* Change at least daily.
* Liquid Skin Protectants
* Sealant that are made with polymer and solvent; with or without alcohol (Hess, 2008).
* Used under adhesives to prevent epidermal stripping.
* Used on incontinent associated dermatitis.
* Available as wipes, sprays, swabs, and applicators.
Available in many different forms:
* dry gauze,
* packing gauze, and
* roller gauze.
Gauzes are primarily used as a secondary dressing or historically as a “wet-to-dry dressing packing.” Wet-to-dry dressings are no longer recommended because dry dressings can cause damage to healthy tissue from nonselective tissue debridement, which can damage newly granulating tissue and may cause pain on removal (Dale & Wright, 2011; Rivera & Wu, 2011). Do not remove dry dressings; moisten if necessary.
* Used primarily for intravenous dressings and secondary cover dressings.
* When removed the skin is at high risk for tearing, so do not use on fragile skin or over skin tears.
* Do not use with moderate to highly exudating wounds.
Negative Pressure Wound Therapy
Negative pressure wound therapy (NPWT) is often referred to as a “Wound Vac.” Although it is not a wound care dressing per se, NPWT is widely used in home care. M. W. Kaufman and D. W. Pahl report in their article, “Vacuum-Assisted Closure Therapy: Wound Care and Nursing Implications,” statistics comparing NPWT and saline-soaked gauze. In the article, they compared 1,032 Medicare home healthcare patients and 84 nursing home patients who all had Stage III and IV pressure ulcers on their trunk or trochanter. The home healthcare patients were treated with NPWT and low air loss beds; the nursing home patients were treated with saline-soaked gauze and low air loss mattresses. The home care patients had a healing time of 97 days at a cost of $14,546, whereas the nursing home patients had a healing time of 247 days and at a cost of $23,465 (Kaufman & Pahl, 2003). The purpose of this therapy is to accelerate wound healing by removing excess drainage, promoting granulation tissue, and maintaining a moist wound environment (Bryant & Nix, 2007). Components of the NPWT include the dressing, the suction tubing, containment system, and pump. The various forms of dressings include a black- or silver-based porous foam, a dense white foam that is moist or needs to be moistened by saline, or antibacterial gauze. After the wound is filled with the foam or gauze, a transparent dressing covers and suction is connected. The advantages for home healthcare patients are that it is a portable pump, the dressings are changed two to three times per week by home care clinicians, and it is a closed system giving the clinician control of a clean dressing change, regardless of the home environment.
Tips for NPWT
* Negative pressure allows better perfusion to the wound bed; remember a lack of drainage is not indicative of a problem.
* Explain dressing procedure to the patient as it can seem overwhelming.
* NPWT system needs to be “running” 24 hours a day, either plugged in or by using battery power.
* Apply white moist foam or appropriate contact layer over exposed bone or tendon.
* Use with caution on a patient with clotting disorders or on blood thinners.
* Make sure fistulas have been explored before using NPWT. If the fistula tracks to an organ use of negative pressure applied can be very dangerous.
* Document a sponge count for each dressing change (there have been cases of lost sponges in wound).
There are significant safety issues with the use of NPWT. The U.S. Food and Drug Administration (2011) discusses contraindications and information: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm244211.htm?utm_campaign=Google2&utm_source=fdaSearch&utm_medium=website&utm_term=negativepressurewoundtherapyproblems&utm_content=1
* Untreated osteomyelitis.
* Exposed vessels or organs.
* Malignant wounds.
* Black eschar unless specifically ordered by physician.
* Do not allow black foam to lay on unprotected skin.
Wounds demand complex care, thinking and, at times, may need to be referred to a wound care expert. There are many types of wound care products available for wound care management. The challenge for many clinicians is knowing what type of dressing is appropriate for the various types of wounds. Clinicians provide an important connection in the physician–patient relationship in home care and especially in wound therapy.
So what happened to the 85-year-old patient mentioned in the opening of this article? What type of products did we use and why? Because of the patient's unclean environment, a silver alginate was chosen for his venous ulcers. The silver helped with the infection, and a composite gauze dressing was used as a secondary dressing. On the stage 2 pressure ulcers, a hydrocolloid was used. Nursing visits for this patient were scheduled at two times per week and all the dressings were contained, which helped with the patient's environment and healing.
Wound care is an increasingly important part of the role of the home care nurse. The critical thinking needed for the choosing of the best products based on the assessment should help patients and organizations support improved care and outcomes. In addition, the complexity of the patients and wounds may demand the experience of a WOC nurse or a CWOCN.
Mr. Adams is an 85-year-old home healthcare patient whom you have just admitted to your agency. His primary diagnosis is chronic venous stasis ulcers and multiple Stage II pressure ulcers. You find that his home environment is not very clean, and he lives alone. Physician orders include a visit to the patient to recommend wound care management, including the dressing. As home healthcare nurses know, we must first obtain the order from the physician before performing wound care. This patient has neuropathy from diabetes in his hands and feet, and you fear he will not be able to perform any wound care on himself. You ask yourself what dressing is appropriate for these wounds, and should I consult our certified wound, ostomy, continence nurse?