Wound Dressing Material Moist Wound Healing Wound

Development of Today’s
Wound Dressing Products
World War I
Tree bark and egg yolk were been used
Tulle gras dressings were developed as a
low-adherent dressing.
Carbolic acid was found to have cleansing
effect, so Eusol, and Dakin’s solution had
been introduced.
Wound Dressing Material
Tang Siu Fong Anna
NS (Stoma-care)
Kwong Wah Hospital
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Moist Wound Healing
Moist Wound Healing
In a moist environment exudate
bathes the wound bed with
nutrients, and many modern
dressing materials are designed to
maintain moisture.
George Winter (1927-1981)
 Zoologist
 Research 1962
 Published 1971
Dry Wound Healing
Under dry conditions the bed of an open
wound rapidly dries out and forms a scab
made up of dead and dying cells.
New epithelial cells migrate down
underneath to find a moist area, the
healing phase was extended
 Investigated wound healing in cutaneous wounds in the domestic pig.
He later became interested in wound dressings and worked on
covering wounds in an experimental model (using the pig) and
observing healing rates.
 Winter observed that wounds covered with an occlusive dressing had
healed faster than wounds left open to air (Winter 1962) 1.
 It was from this work that the principles of moist wound healing
were developed.
3
Wound Management Strategies
Factor Affecting Wound Healing
Nutritional
Status
Local Wound
Condition
Elimination
Absorbing drainage (exudate)
Removing necrotic tissue
Preventing or controlling infection;
Age
Medication
Patient
with
Wound
Wound environment
Body
build
Moist
Protecting
Chronic Illness /
Immuno Status
Oxygenation /
Circulation
Stress
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5
The wound from further injury by
Excessive wound exudate,
Inappropriate wound dressings
Infectious bacteria
6
Clinician Competencies for
Dressing Selection 2
Wound Care: Debridement
Conduct a wound assessment to identify wound characteristics
and treatment options
Mechanical debridement
Autolytic debridement
Enzymatic debridement
Surgical debridement
Know the principle of wound care
Know the characteristics of an ideal dressing
Be able to differentiate among the different types of dressing
Consider patient’s healthcare coverage, financial abilities, factor
in cost and clinical benefit when selecting products
Attend conference, seminar, and self-study to keep abreast of
the latest treatment, technique and products
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Principle of Wound Care
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Ideal Dressing
Baranoski S (1999)
Seaman (2002) provided a nursing perspective of
criteria for an ideal wound dressing:
The “MEASURES” acronym
Minimize trauma to wound bed
Eliminate dead space
Assess and manage the amount of exudate
Support the body’s tissue defense mechanism
Use non-toxic wound cleansers
Remove infection, debris, and necrotic tissue
Environment maintenance
Surrounding tissue, protect from injury and bacteria invasion9
Classification of
Dressing Products
•
•
•
•
•
•
•
Non-adherent / Capable of protecting the wound
from further trauma / Insulating Thermally /
Impermeable to bacteria / Non-toxic and nonallergenic
Capable of maintaining a high humidity at the
wound site while removing excess exudate
Comfortable and conformable
Requires infrequent dressing changes
Cost-effective
Long shelf-life
Available both in hospital and in the community
Primary dressing
 Dressings that direct contact to the wound
bed
Secondary dressing
Dressings that cover a primary dressing or
secure a dressing in place
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Healing in a Dry Environment
DELAYS the Healing Process
Contact layer
is a single layer of a woven net act as a low adherence material
when applied to wound surface Hess CT (2006)
Dehydration
Pain
 Apply direct to the wound acts as a protective interface
between the wound and the secondary dressing
 They are often mixed with ointment, cream, and topical
products
Hess CT (2006) Clinical Guide: Wound Care, 5th Ed. Philadelphia: Lippincott Williams & Wilkins
Bacteria
Permeable 3
Adhere to
the wound
 The main purpose is to allow exudate to pass through the
contact layer and into the secondary dressing
DAILY DRESSING CHANGE !!!
Cause damage to
newly formed
tissue and bleeding
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Why are Gauze Dressings still be used
Gauze Dressing
Have a long tradition
Readily available and inexpensive,
Easily tailored to fit the wounds
Unaware of and confuse the healthcare
providers by the broad alternative dressing
products and their characteristics
Reduced wound temperature (up to 10°C
below normal) 4
results in
local vasoconstriction,
hypothermia,
impaired leukocyte mobility and phagocytic efficiency
Hypoxia, increase affinity of hemoglobin for oxygen
Ovington LG (2002) Hanging Wet-to-Dry Dressing Out to Dry, Advances in Skin &
Wound Care 15(2):79-84.
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Non-adherent
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Emollient dressings
Impregnated with an emollient
Composed of Synthetic Materials
e.g. Jelonet is a fine mesh gauze impregnated with paraffin.
To remain lightly adherent or non-adherent
while maintaining a moist wound surface.
Offer minimal to no absorption; exudate
absorption can be provided by a cover
dressing.
The usual frequency for dressing changes is
no more than once per day.
It can be classified into:
•Non-impregnated
•Non-adherent gauze
•Impregnated
•Soaked gauze with antimicrobial /antiseptic agents
•Vasaline /paraffin (emollient dressing)
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Emollient dressings
Benefit
 Fragile tissue protective layer
 Soothing effects (prevent the wound from
drying)
 Prevent adherence and pain
Indications:
 For superficial exudating wound
 For burn, radiation injuries
 Skin grafts, donor sites
 Use postoperatively in plastic surgery
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Emollient Dressing
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Film Dressing
** Adhesive, polyurethane
materials **
Impregnated
 Alldress
 Melolite
 Mepitel
 Adaptic
 Tegapore
 Telfa
 Jelonet
• No absorptive capacity
• Semi-permeable to gases and
water vapor
• Promote autolysis
• Transparent, allow easily wound
inspection
• Conform to body contour
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Film Dressing
Film Dressing
 Do not use on exudating wounds and
 Change the dressing when fluid reaches the edge of
the dressing, or the seal is broken
 Contraindicated for
 exudative wounds
 wounds with tracts, and
Indications:
 Superficial or shallow ,
minor burns, lacerations
 Apply on eschar for
autolysis
 Securing catheter sites,
drainage tubes and over
sutures
 As a secondary dressing
 should not be used in infected wounds
 Should be used cautiously on wounds with friable
peri-wound tissue
 Avoid creating either tension or wrinkles when
applying the dressing
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Hydrocolloids
Film Dressing
Examples:
 Bioclusive




Flexifix opsite
Mefilm
Opsite
Tegaderm
**Elastic adhesive wafer
containing
Hydrophilic Film
hydroactive or hydrophillic
Film Spray
(absorbent) particles
such as karaya, pectin and gelatin,
mixed with a hydrophobic (repellent)
polymer
Film Roller
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Hydrocolloid Wafer
Hydrocolloids
 Hydrocolloids were firstly be named as
stomahesive, which was used to protect the
peri-stoma skin. It was subsequently found
that they improve the healing of excoriated
skin
 To interact with wound exudates, it forms a
gel-like substance which can facilitate autolysis
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Hydrocolloids
Hydrocolloid Paste or Powder
Apply hydrocolloid powder or granules
underneath the wafer improves absorption.
The paste or powder is used in a deeper
ulcer or cavity, these products convert to a
gel-like substance when contact with wound
exudate.
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Advantages
•Absorb light to moderate wound exudate
•Promote autolysis
•No adhesion to newly growth tissue
•Painless removal
•Less dressing change
•Water and bacteria permeable
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Hydrocolloids
Hydrocolloids
 Change the dressing
Indications:



Wound with light to
moderate exudate
- Skin tears
- Lacerations
- Pressure ulcers
- Second degree burns
- Surgical wounds
3 to 7 days, or
before it reaches its maximal absorption, or
before it reach within 1 inch of the edge
 May be cut to fit different wound areas, such as
heel, elbow
 As a primary or secondary dressings
 May have an odor during dressing change
 Flush out any residue with saline
 Tape the dressing edges may prevent it from rolling
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Hydrogels
**A type of polymer that expands in water**
Packing: - Gel sheet / Amorphous gels
乾的傷口怎麼辦 ?
Advantages:
- Create optimal moist environment
- Autolytic debridement
- Soften necrotic tissue
- As a filler
- Transparent
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Hydrogels
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Hydrogels
Indications:
 It mixed with other
Ingredients, such as
Alginates, Collagen, or
Starch to enhance greater
absorptive capacity
 Macerate periwound area
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Gel sheet
 Superficial secondarydegree burns
 Superficial necrotic
wounds
 Superficial wound with
light exudate
Amorphous gel
 Stage III or IV wound
with no or minimal
exudate
 Slough or eschar for
autolytic debridement 37
Hydrogel
 Do not use it on intact or heavily exudating
wounds
 Change dressing on daily based
大量滲液的傷口怎麼辦 ?
 Some gel may easily evaporate
 Some gel sheet may last for several days
 Protect the surrounding skin with a skin
sealant, spray or ointment
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Calcium Alginates Dressings
Alginate 成份 (Laminaria hyperborea葉柄 )
Calcium alginate dressing
blood / exudate
Ca++
Haemostasis
Laminaria hyperborea 褐藻
葉柄: 含較多 Guluronic acid
葉片: 含較多 Mannuronic acid
藻酸塩吸收滲出液並形成凝膠
Na+
Na+Alginate (gel-formed)
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Calcium Alginate Dressings
Properties
 Provide a hemostatic properties
 Trauma-free removal
 Can absorb exudate up to 20 times of their weight
 Apply an occlusive cover dressings can enhance
absorptive capabilities
 Various products a/v for tunneled, undermined or
draining wounds
Alginate
 Cost-effective if used appropriately
Gauze
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Calcium Alginate Dressings
Disadvantages:
Calcium Alginate Dressings
Indications
Require a moisture retentive covering to
avoid drying out
 Stage II to IV wounds
 For wound with heavy
exudate
 For wounds with slough,
necrotic tissue, bleeding
or cancerous wounds
Gel formation may be confused with
infectious wound bed
Loose texture may leave fiber residue
Contraindications




Dry wounds
Eschar covered wounds
Surgical implantation
Third-degree burns
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Hydrofiber
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Hydrofiber
Mixed with sodium carboxy-methylcellulose, which
interact with wound fluid or exudate to form a gel-like
substance
Highly absorbent
 Gel-state property keeps wound moist
can facilitate autolytic effect
 Locks in fluid and bacteria
 Controls the lateral spread of fluid
 Contours to the wound bed
SHOULD NOT be used
on a dry wound bed, on third-degree
burns, or for heavy bleeding
Carboxy-methylcellulose
is a cross-linked polymer
- absorbs exudate
- maintains moisture
- provides stability
- provides shape
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Foam Dressing
A+ B
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Foam Dressing
Foam Dressing
Indications:
Polyurethane based with a heat- and pressure- modified
wound contact layer 5
 Moderate to heavy exudating
wound
 Prophylactic protection over
bony prominences or friction
areas
 Skin tears, donor sites under
compression wraps
 If used on infected wounds,
need daily change 6
Benefit
 Hydrophilic properties allow for absorption of
exudates
 Act as a secondary dressings to provide
additional absorption of excess body secretions
 The second generation of foam are available
Heel ulcer with medium exudate
Do not use on dry eschar wound, it may cause
desiccation to the wound bed
with ionic silver
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Highly Absorbent Dressing
I. Garment
Foam Dressing
 See package insert for use on infected wound
 Can be kept for up to 7 days, depends on the absorption
capacity of each product
 Cut-to-fit to different wound size
 Correct pattern tracing to fit the wound bed
 Skin sealant, wipe can be used to prevent maceration
 Non-adhesive border be secured by taping or
wraps
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Highly Absorbent
Dressing
II. Pouch
 For heavily wound
exudate / fistula
management
 Tailor-made pouch for
large abdominal fistula
 Pouch is connected to
drainable system for
high output fistula
已經感染的傷口怎麼辦 ?
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Impregnated dressing :
(For disinfection and infection control)
Dressing
for
Infected Wound
 Antiseptics





Salt (hypertonic)
Chlorhexidine
Silver
Povidone Iodine
Cadexomer Iodine
Antibiotics
 Fusidic Acid
 Metronidazole
 Framycetin
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Saline Impregnated Dressing
(Hypertonic Saline Gauze)
Saline Impregnated Dressing
(Hypertonic Saline Gauze)
 Apply hypertonic saline gauze such as Mesalt
in dry state to wound
 Dressing absorbs exudate until it being
diluted and reached to an isotonic state
 May damage new or fragile tissue if drainage
is minimal
 May be painful for sensitive patient
 Evaluate for alternate products if exudate
decreases
Indications:
 For heavy exudating wound
 For debridement of slough
 For infected wounds
Example:
Mesalt
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Ringer’s Solution Impregnated Dressing
Antimicrobial Dressings
(Tender Wet Therapy)





Continuous wound cleansing
Take up wound exudate
Trap micro-organism
To avoid trauma during removal
Provide moist environment for
promoting autolytic debridement and
wound healing







Benefit :
Moisture and electrolytes
of Ringer’s solution
stimulate cell proliferation
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Antimicrobial effect against bacteria and provide a
moist environment for healing.
The active ingredients may be silver ions, cadexomer
iodine, or poly-hexamethylene biguanide, which are
locked inside the dressing
Anti-inflammatory
May staining of wounds
Toxicity
Do not replay the need for systemic antibiotic therapy
Variety of forms: transparent dressings, gauze, island
dressing, forms, and absorptive fillers
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Antimicrobial Dressings:
Silver Impregnated Dressings
Antimicrobial Dressings:
Silver Impregnated Dressings
Mesh Ag+
Allevyn Ag
S&N
Forms Ag+
Nanocrystalline Ag+ (10¯
Alginates Ag+
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Antimicrobial Dressings:
International Consensus:
Dressing Contain Iodine
Appropriated Use of Silver Dressing in Wounds
 Antimicrobial
 Modulates local pH – lower pH
Follow the standard wound care for infected
wounds, wounds at high risk of infection or
re-infection
inactivates harmful proteases
 Desloughing
 Exudate Management
Silver dressing used for an initial two week
“Challenge” period, then reassess the wound,
patient, and management approach
Povidone Iodine
0.9% Cadexomer Iodine
http://www.woundsinternational.com/pdf/content_10381.pdf
Iodosorb ointment
Iodosorb dressing
Iodosorb powder
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IODOSORB
Action of Iodine ion
smith&nephew
Mode of Action
Inactivates harmful proteases
which are causative of prolonged
inflammation and reduced
fibroblast proliferation Cullen et al (2002)
Iodosorb
Wound Bed
Concentration Gradient
I2
I-
I2
Can lower the pH level of the local
wound environment by ion exchange
0.9% Iodine immobilised in
cadexomer is slowly release from
the cadexomer to an iodine free
environment in the presence of
exudate (the wound)
(Smith & Nephew data on file report 0410020)
Cullen B, Smith R, McCulloch E, Silcock D, Morrison L (2002) Mechanism of action of Promogran a protease
modulating matrix for the treatment of diabetic foot ulcers, Wound Repair Regen, 10(1): 16-25
Iodine
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The Iodine (I 2) will move
across a concentration
gradient until an equilibrium
is established between
Iodosorb and the wound bed
Protein/Organic materials
I
-
Once in the wound bed, the I 2
will convert to - as it kills micro organisms. When all the I 2 has
been converted to I there will
be a noticeable colour change
which will indicate that it is time
to change Iodosorb.
Antimicrobial Dressings:
Charcoal Dressing
Dressing Contain Iodine
Indications
 Chronic wound and moderate
to highly exuding wounds
 Leg ulcers (arterial /venous
/DM)
 Pressure ulcers
 Wounds with slough,
infections or in risk of
infection
Contra-indications
 Iodine sensitivity
 Sever impaired renal
function
 Past Hx of hyperthyroidism
 Thyroid disorders
 Patients on Lithium
 Pregnant & lactating women
 Children under 12 years of
age
Advantages:
Charcoal for rapid cleansing of
infected wounds
Silver added enhance anti-bacterial
effect
Disadvantages
Avoid direct contact to wound exudating
soaked dressing may inactivate the odorabsorbent effect
Require security seal
Allergic reaction
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Charcoal Dressing
Examples:
Actisorb Plus
CarboFlex
Carbonet
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Composite Dressings
 Combination of several products, e.g. hydrocolloid and
alginates; foam, charcoal and alginates
 Dressings are designed to provide multiple functions
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Larval Therapy (Biosurgery)
Composite Dressings
 Easy to apply
 Be careful when it be used in fragile skin
 May adhere, and remove the dressing with
caution
 May facilitate mechanical or autolytic
debridement
 May be used on infected wound and with topical
products, see package insert
Description
 Sterile larvae (maggots) supplied for use in wound management
are those of the common green bottle Lucilia sericata. When
applied to the wound they are only about 2-3 mm long, but once in
place they produce powerful proteolytic enzymes that degrade
and liquify necrotic tissue which they ingest as a source of
nutrient. Under favourable conditions, larvae rapidly increase in
size, reaching 8-10 mm when fully grown.
 As well as removing slough and necrotic tissue, larvae combat
odour and infection by ingesting and killing bacteria present in
the wound. It has also been reported that the use of larvae may
reduce wound pain and stimulate the formation of granulation
tissue.
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Maggot Therapy
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Larval Therapy (Biosurgery)
Indications
 Sterile larvae can be used in the treatment of many types
of sloughy, infected or necrotic wounds including leg
ulcers both venous, and arterial, pressure sores, burns,
and ulcerated areas on the feet of diabetics.
Contra-indications
 Larvae should not be applied to wounds that have a
tendency to bleed easily, or be introduced into wounds
that communicate with the body cavity or any internal
organ. They should also not be applied close to any large
blood vessels.
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Growth Factors
Honey
 Proteins (polypeptides)
 Traditional treatment for multiple drugresistant organisms e.g MRSA
 Worthless but harmless substances
 Make the smell of discharge less offensive
 Primarily found in platelets and macrophages
 Platelet-derived growth factor (PDGF) is widely recognized
Molan (2001)
 Limitations:
 Quality control in honey production
 Sensitive to pollen
 Lack of evidence base in therapeutic effects and
chemical properties of honey
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 Two main types
 Single growth factors manufactured thro recombinant DNA
technology
 Multiple growth factors retracted from human platelet
 Found to be efficacious in the management of diabetic ulcer and
in granulating wound
McAleer JP et al (2006) Use of Autologous Platelet Concentrate in a Nonhealing Lower Extremity Wound,
Advances in Skin & Wound Care 19(7):354-62.
Negative Pressure Wound Therapy
Ultraviolet Light
NPWT principles
Ultraviolet light B (UVB)
 To provide a moist , protected
environment
 Reducing peripheral oedema
around the wound
 Stimulate circulation to the
wound bed
 Decreasing bacterial
colonization
 Increasing the rate of tissue
formation and epithelialization.
 As adjunct therapy in infected
wound
Conner-Kerr et al (1999)
 Inducing an inflammatory reactions, stimulating the growth
of granulation tissue, and promoting break down and
elimination of dead tissue from the wounds
Ultraviolet light C (UVC)
 Wave length 200nm to 290nm
 Most often used in the treatment of chronic wounds
 Is capable of killing bacteria, or ulcer infected with MRSA
Thai et al (2002)
Eastman (2001)
Conner-Kerr et al (1999) UVC reduces antibiotic-resistant bacteria in vitro, Ostomy / Wound Management, 45:84.
Thai T et al (2002) Ultraviolet Light C in the Treatment of Chronic Wounds with MRSA: A case study, Ostomy/Wound
Management 48 (11):52-60
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NICE
for Dressing Decision Making
Ayello & Sibbald (2008)
Is there and Necrotic Tissue needs to be debrided?
Is the wound Infected or Inflamed?
Do the specific wound Characteristics, such as
location, need to be considered?
Is there any Exudate, if so, how much, and what is
the color and consistency?
Adapted from Ayello EA and Sibbald RG (2008) Wound Care Essential: Practice Principles, 2 nd Ed, Lippincott,
Ch. 9: 143-144.
Necrotic tissue, slough, eschar
Key Information
Caution
 Wet-to-dry dressings are a nonselective mechanical
debridement
 Limited use of wet-to-dry
dressing as a debridement
method
 Autolytic debridement of tissue
is best accomplished with
hydrogels, hydrocolloids, and
alginates dressing
 Some dressings can not be used
to necrotic wounds, check with
the manufacturer for any
contraindication
 With dressing stimulated
autolytic debridement, watch
for secondary infection, and
remove unwanted slough when
dressing change
 Removal of non-viable tissue is
an important step in preparing
the wound bed for healing
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Infection / Inflammation
Characteristics
Key information
Caution
Key information
Caution
 Consider using antimicrobial
dressing (for example, silver,
iodine)
 Not all dressings can be used in
infected wounds, check with the
manufacturer
 Select and assess a dressing
based on location of the wound
such as the use of conformable
dressings for hard-to-fit areas
 Change dressing while it soaked
with urine or stool
 Infected wounds may require
more frequent dressing changes
 Waterproof dressings may be
used for incontinence is an issue
 If patient consider wound pain,
dressings may promote comfort
and pain release
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 Different dressings can remain
in place for different lengths of
time, check with the
manufacturer for recommended
frequency for dressing changes
 Avoid dressings that may
increase or contribute to wound
pain and consider systemic pain
management strategies
86
Wound Care Decision
Algorithm
Exudate
Infection
Antimicrobials
Key information
Caution
 Match the absorbency of the
dressing (none, low, moderate,
heavy) to the amount of exudate
from the wound
 Surrounding skin needs to be
protected from wound drainage.
Search for the cause of the
excessive exudate and the need
to correct the cause. Exudate
may be an indicator of infection
 Assess surrounding skin to
evaluate for maceration
Wound /Ulcer
Granular
Necrotic
Partial and Full-thickness/stage II
Non-drainage
Transparent
Hydrogel
Hydrocolloid
Composite
Growth factor
Gauze (moist)
Draining
Foam
Calcium alginate
Hydrocolloid
Composite
Collagen
Gauze
Full-thickness / Stage III / IV **
Non-drainage
Transparent
Hydrogel
Hydrocolloid
Gause (Moist)
Tissue-engineered skin substitutes
(after debridement)
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Drainage
Foam
Collagen
Calcium
alginate
Gaze
Composite
** debridement
88
Adapted from Baranoski S, Mclntosh A, Barkauskas C and Galvan L, (2001) Lecture, Symposium on Advances in Skin and Wound Care, Dallas, Tex.
Conclusion
Point-of-care
 If the wound is dry, add moisture. If the wound has drainage,
absorb it. If the wound has necrotic tissue, debride it
1. Treat the whole person, not only treat a wound
2. Principle:
 Wound dressing should be changed to meet the characteristics
of the wound bed
 Define aetiology of wound
 Control factors that affect wound healing
 Select appropriate wound dressing products
 Read and understand the information in the package insert
before using a wound care product
a. Maintain a moist wound healing environment
b. No one dressing is appropriate for all types of wounds
c. Wound assessment is recommended
 Plan wound healing maintenance to prevent recurrence
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References
1. Winter GD (1962), Foundation of the Scab and the Rate of Epithelialization of Superficial Wounds in
the Skin of Young Domestic Pigs, Nature, 193:293-94.
2. Baranoski S (2005), Wound Dressings: A Myriad of Challenging Decisions, Home Healthcare Nurse
23(5): 307-317.
3. Lawrence JC (1994) Dressing and Wound Infection, American Journal of Surgery 167 (suppl. 1A)
4. Thomas S (1990) Wound Management and Dressing, London: The Pharmaceutical Press.
5. Hess CT (2006) Clinical Guide: Wound Care, 5th Ed Philadelphia: Lippincott Williams & Wilkins.
6. Seaman S (2002) Dressing Selection in Chronic Wound Management , Journal of the American
Podiatric Medical Association 92(1):24-33.
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Thank You
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