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Wound products
- 1. Dr. Clare Fenwick, 2010
- 2. Dr. Clare Fenwick, 2010 Aim of wound dressings Heal, prevent infection and manage exudate Protect wound and surrounding tissue Reduce pain and minimise client distress Maintain wound temperature Manage potential or actual haemorrhage Manage wound odour Immobilise an injury
- 3. Dr. Clare Fenwick, 2010 Product selection Wound aetiology Wound location Wound exudate Product life span Cost factors Availability
- 4. Dr. Clare Fenwick, 2010 Wound Bed Preparation Cleansing techniques Debridement Sharp Surgical Mechanical Enzymatic Autolytic Biodebridement (maggots)
- 5. Clare Fenwick Griffith University Gold Coast 2010 Sharp Debridement
- 6. Clare Fenwick Griffith University Gold Coast 2010 Surgical debridement using waterjet hydrosurgery Pre-operative Intra-operative
- 7. Clare Fenwick Griffith University Gold Coast 2010 Mechanical debridement
- 8. Clare Fenwick Griffith University Gold Coast 2010 Enzymatic Debridement
- 9. Clare Fenwick Griffith University Gold Coast 2010 Autolytic Debridement
- 10. Clare Fenwick Griffith University Gold Coast 2010 Biodebridement
- 11. Dr. Clare Fenwick, 2010 Cleansing techniques Clean versus sterile technique Normal saline and tap water are OK Hand washing is essential to reduce infection Dirty hand & clean hand Wound field concept
- 12. Dr. Clare Fenwick, 2010 Clean and dirty hand Dressing Equipment clean dirty
- 13. Dr. Clare Fenwick, 2010 Wound Field concept Dressing Equipment
- 14. Dr. Clare Fenwick, 2010 Dressing & Exudate None – Low Films Hydrogels Low – Mod Hydrocolloid Mod – Heavy Alginates Hydrofibre Foams
- 15. Dr. Clare Fenwick, 2010 Wound products Inert non stick dressings Film dressings Foam dressings Hydrogel dressings Hydrocolloid dressings Alginate dressings Hydrofibre dressings Zinc dressings Nanocrystalline Silver dressings Cadexomer Iodine Vacum assisted closure Manuka Honey
- 16. Clare Fenwick Griffith University Gold Coast 2010 Inert non stick dressings Gauze Paraffin tulle dressings (Jelonet®, Bactigras®) Non-paraffin, non-tulle, woven products, (eg Adaptic®, Inadine®) Non stick dressings (eg Melolin®, Cutilin®) Combine Primary dressing Protective low absorption dressing Application: Clean wound base Place shiny side of dressing to wound. May require soaking if exudate strikethrough has occurred. Contraindications/Possible Side effects: Harsh debridement of the wound bed if exudate dries Limited use as a primary dressing Dries out the wound bed Non Adherent Dressings
- 17. Clare Fenwick Griffith University Gold Coast 2010 Film dressings Product names include Opsite Flexigrid® Opsite Post-Op® Tegaderm® Polyskin® Primary and secondary dressing Low exudating wounds, protective dressing. Application: Clean wound base Prepare periwound area with a protective barrier wipe. Apply adhesive side to wound and remove outer layer. Adhesive strongest in first 24 hours, can remain for 7 days. Observe for maceration, remove if this occurs. Contraindications/ Possible Side effects: Do not apply to infected wounds or if allergic to tapes If not removed correctly can be traumatic to the wound bed . NB Green sided Opsite is for wounds, orange sided Opsite is for vascular access devices Film Dressing
- 18. Clare Fenwick Griffith University Gold Coast 2010 Foam dressings Product names available Allevyn® Allevyn Adhesive® Allevyn Cavity® Cavi-Care® Primary and secondary dressing Light/mod/highly exudating wounds, protective dressing, cavity wounds Application: Clean wound base Read packaged for insertion side (patterned or shiny side up) Sheet foam left insitu up to 7 days (24 hours if infected) Cavity foams left insitu up to 14 days (daily washing of foam if infected) Contraindications/ Possible Side effects: Avoid covering with occlusive dressings. Avoid wounds dressed with antibacterial solutions. Foam Dressing
- 19. Clare Fenwick Griffith University Gold Coast 2010 Hydrogel dressings Product names available Solugel® Intra site® Gel Solosite® Gel Clear-Site® Duoderm® Gel Aquaflo® Primary dressing Sloughy or necrotic wounds requiring chemical debridement. Lightly exudating wounds, hydrate dry wounds. . Application: Clean wound base Coat wound base with at least 5 mm gel. Apply sheet directly to wound base. Can remain insitu up to 3 days Requires a secondary dressing Contraindications/ Possible Side effects: Remove if patient complains of burning or discomfort. Can cause maceration if too much is applied. Don’t use on highly exudating wounds or blind sinuses Hydrogel Dressing
- 20. Clare Fenwick Griffith University Gold Coast 2010 Hydrocolloid dressings Product names available Duoderm Extra Thin® Duoderm CGF® Duoderm® Paste Comfeel Plus Transparent® Comfeel Plus® Contour Dressing Comfeel Plus® Pressure Relieving Dressing Comfeel® Paste Comfeel® Powder Primary and secondary dressing Sloughy wounds requiring autolytic debridement, low/moderate exudating wounds. Application: Clean wound base, wipe periwound with barrier wipe Warm product in hands to activate adhesive Place adhesive side to wound. Leave at least 2 cm border around wound. Can be left insitu up to 7 days, dependant on exudate level. Dressing becomes opaque when due for change Contraindications/ Possible Side effects: Do not apply to infected wounds or if client is allergic. Remove if patient complains of discomfort. Hydrocolloid Dressing
- 21. Clare Fenwick Griffith University Gold Coast 2010 Alginate dressings Product names available Kaltostat® Algoderm® Sorbsan® Curasorb® Kaltocarb® Primary dressing Medium to heavy exudating, bleeding, sloughy or infected wounds. Application: Clean wound base Lightly pack or line the wound, product swells with exudate. Avoid pre-moistening the product. Discontinue use if the dressing remains dry. Can be left insitu up to 4 days, dependant on exudate level. Requires a secondary dressing, do not use an occlusive dressing Contraindications/ Possible Side effects: Do not use on dry wounds as it dehydrates the wound bed Calcium Alginate Dressing
- 22. Clare Fenwick Griffith University Gold Coast 2010 Hydrofibre dressings Product names available Aquacel Primary dressing: Medium to heavy exudating or infected wounds Application: Clean wound base Line the wound base with product Cover with a secondary dressing. Can be left insitu up to 7 days, dependant on exudate level. Contraindications/ Possible Side effects: Heavily infected wounds require Hydrofibre impregnated with Silver. Do not use in people allergic to hydrocolloids Hydrofibre Dressing
- 23. Clare Fenwick Griffith University Gold Coast 2010 Nanocrystalline Silver dressings Product names available Acticoat® Aquacel Ag® Actisorb plus® (charcoal) Primary dressing: Infected wounds (150 pathogens including MRSA and VRE), burns, donor and recipient sites. Application: Clean wound base Moisten product with sterile water, daily if not enough exudate Cut to wound size and shape, apply blue side down Cover with a secondary dressing. Can be left insitu up to 7 days, dependant on exudate level. Contraindications/ Possible Side effects: Do not use on people going for a Magnetic Resonance Imaging Do not use in people allergic to silver Nanocrystalline Silver Dressings
- 24. Clare Fenwick Griffith University Gold Coast 2010 Zinc dressings Product names available Steripaste® Viscopaste® Flexidress® Gelocast® Primary dressing Sloughy wounds, epithelialising wounds and to protect limbs at risk of skin tears or degloving. Application: Cut length as required, usually 3-4 times the size of the wound Fold to make a patch and place over wound. Requires a secondary dressing. Can be left insitu up to 7 days. Contraindications/Possible Side effects: Allergy to zinc Zinc Paste Dressings
- 25. Dr. Clare Fenwick, 2010 Other Dressings Wound Honey Cadexomer Iodine Vacum assisted closure (VAC) (see lecture)
- 26. Dr. Clare Fenwick, 2010 References Carville, K. (2005). Wound Care Manual. Western Australia: Silver Chain Foundation. Ellis, T. (2002). Wound bed preparation- a wound management imperative. Woundcare Network(10), 1-4. Myers, B. A. (2008). Wound Management Principles and Practice (2nd ed). New Jersey: Prentice Hall.
Notas del editor
- AIM of WOUND DRESSINGS Heal, prevent infection and manage exudate Protect wound and surrounding tissue Reduce pain and minimise client distress Maintain wound temperature Manage potential or actual haemorrhage Manage wound odour Immobilise an injury
- PRODUCT SELECTION Wound aetiology – What caused the wound? Wound location – How will a dressing stick there? Will it slide off? Will it cause constriction? Wound exudate – How much exudate is there? Do I need to hydrate the wound? Product life span – How long can I leave this on? How does the dressing let me know that it is ready to be removed? Is the wound infected? Cost factors – Is it cheaper to use another product? Availability – Do we have this in stock? Is it easy to get?
- WOUND BED PREPARATION Purpose of wound bed preparation is to, Remove necrotic load Necrotic tissue harbours bacteria and presents a physical barrier to cell migration. The wound can remove this necrosis but it is timely and there is a risk of infection. Removal of the necrotic load by debridement and wound protection will accelerate healing. Remove bacterial load 1 000 000 per gram tissue bacterial load will interfere with healing. Bacteria will compete for nutrient and oxygen supply. Bacteria will also produce endotoxins reinitiating the inflammatory process. Both process will stall the wound healing, preventing the move form inflammatory to proliferation stage. Treatment will be systemic to topical antibiotics or other topical agents such as silver-based dressings, Cadexomer iodine or pure Manuka honey Optimise exudate levels High exudates result in maceration of the peri wound. Reducing necrotic and bacterial loads will reduce exudate levels. Meanwhile the exudate must be managed by foams, hydrofibre dressings, alginates and hydrocolloid powders. Remove cellular burden and correct biochemical imbalances The wound’s underlying aetiology needs to be addressed if healing is to occur. For example, if it is a venous ulcer then compression bandaging will aid in restoring venous return.
- Surgical debridement uses scalpels, lasers, scissors or high pressure waterjets in a sterile environment to remove necrotic tissue or foreign material or debris. A physician or surgeon will perform this task. This is the last resort other less invasive debridement methods should have been attempted first. Best Uses Wounds with a large amount of necrotic tissue. In conjunction with infected tissue. Advantages: Fast and selective Can be extremely effective Disadvantages: Painful to patient Costly, especially if an operating room is required
- Mechanical debridement is a forceful removal of devitalised tissue, foreign material or debris. Methods used are wet to dry dressings, scrubbing, hydrotherapy, and some wound cleansing products. A medical officer or surgeon will perform this task. It is a painful procedure and non selective, it will take good tissue with the bad. Best Uses: Wounds with moderate amounts of necrotic debris Advantages: Cost of the actual material (ie. gauze) is low Disadvantages: Non-selective and may traumatize healthy or healing tissue Time consuming Can be painful to patient Hydrotherapy can cause tissue maceration. Also, waterborne pathogens may cause contamination or infection. Disinfecting additives may be cytotoxic.
- Enzymatic debridement allows exogenous products to remove devitalised tissue such as proteolytic (breaks down proteins comes from animal products and plant products such as papaya and pineapple), fibrinolytic (breaks down fibrin) and collagenase (breaks down collagen comes from king crabs and some bacteria). A nurse or medical officer with the appropriate training can perform this task. Contraindicated if wound is deep exposing any bone, vessel, ligament, nerves or tendons. There are no licensed enzymatic debriding agents in Australia Best Uses: On any wound with a large amount of necrotic debris. Eschar formation Advantages: Fast acting Minimal or no damage to healthy tissue with proper application. Disadvantages: Expensive Requires a prescription Application must be performed carefully only to the necrotic tissue. May require a specific secondary dressing Inflammation or discomfort may occur
- Autolytic debridement allows endogenous (wound exudate) enzymes to devour necrotic or sloughy tissue. This is achieved by keeping a warm, moist wound environment. A nurse or medical officer with the appropriate training can perform this task. It is also virtually painless for the patient. Autolytic debridement can be achieved with the use of occlusive or semi-occlusive dressings which maintain wound fluid in contact with the necrotic tissue. Autolytic debridement can be achieved with hydrocolloids, hydrogels and transparent films. This technique is contraindicated in infected wounds. Best Uses: In stage III or IV wounds with light to moderate exudate Advantages: Very selective, with no damage to surrounding skin. The process is safe, using the body's own defence mechanisms to clean the wound of necrotic debris. Effective, versatile and easy to perform Little to no pain for the patient Disadvantages: Not as rapid as surgical debridement Wound must be monitored closely for signs of infection May promote anaerobic growth if an occlusive hydrocolloid is used
- CLEANSING TECHNIQUE Clean procedures and dressings are for areas that are already loaded with bacteria such as nasogastric insertion, the gut is full of bacteria or wound dressings, wounds have a bacterial load Sterile procedures and dressings are reserved for areas that have no bacterial load such as insertion of a urinary catheter or accessing a central venous catheter. Consider, is it safe to transfer bacteria from one area such as the skin to another area such as the urinary bladder. What would happen; sepsis. Research suggests that there is no significant increase in wound infection or wound colonisation when normal saline or tap water is used during wound cleansing. Antiseptics are no longer favoured as a wound cleansing agent as some will destroy epithelizing tissue and can be deactivated by the presence of pus. However some antiseptics are still used for specific wound care such as MRSA and pseudomonas colonisation Hand washing is the single most effective intervention to prevent the spread of infection (Hollinworth & Kingston 1998) Showering postoperative wounds does not increase infection. Research suggests allow 48 to pass then shower. Chronic wounds can be showered with no increase in bacterial load Wound Field concept, this is concept where we acknowledge that the wound is contaminated with microbes, and anything not of the wound such as yourself or foreign matter should not be introduced. Dirty hand & clean hand is still used actively within a sterile environment however it is loosing favourability in the ward and community environment. This technique has been based on historical significance rather than research based.
- CLEAN AND DIRTY HAND The clean/dirty hand technique is when the dressing area is considered to be separate of the wound. The clean hand can only operate over the area of the dressing field. The dirty hand is allowed only over the wound area. Neither hand should cross the imaginary fence line. At this fence line cleaning product is passed to the dirty hand which cleans the wound. The product is discarded and the dirty hand returns to the fence line for more cleaning product from the clean hand Considering that wound care is now requiring wound irrigation the clean/dirty hand concept is becoming impractical and outdated.
- WOUND FIELD CONCEPT Infection occurs when an imbalance of normal flora numbers occurs and the body’s normal defences cannot confine or control them. A wound is considered infected if there is 100 000 (105) organisms per gram of tissue (Carville, 2001), a wound is contaminated if levels are lower than this The wound field concept is based upon the theory that the contaminants of the person and their wound will not further infect the wound. Only items introduced will cause further infection such as a sneeze across the wound bed or your clothing touching the wound. The wound field concept is an alternative to the clean/dirty hand theory.
- MANAGING EXUDATE WITH DRESSINGS None – low use films and hydrogels Low – moderate use hydrocolloids Mod – Heavy use alginates, hydrofibre and foams
- INERT NON STICK DRESSINGS Gauze Paraffin tulle dressings (Jelonet®, Bactigras®) Non-paraffin, non-tulle, woven products, (eg Adaptic®, Inadine®) Non stick dressings (eg Melolin®, Cutilin®) Combine Primary dressing Protective low absorption dressing Application: Clean wound base Place shiny side of dressing to wound. May require soaking if exudate strikethrough has occurred. Contraindications/Possible Side effects: Harsh debridement of the wound bed if exudate dries Limited use as a primary dressing Dries out the wound bed
- FILM DRESSINGS Opsite Flexigrid® Opsite Post-Op® Tegaderm® Polyskin® Primary and secondary dressing Low exudating wounds, protective dressing. Application: Clean wound base Prepare periwound area with a protective barrier wipe. Apply adhesive side to wound and remove outer layer. Adhesive strongest in first 24 hours, can remain for 7 days. Observe for maceration, remove if this occurs. Contraindications/ Possible Side effects: Do not apply to infected wounds or if allergic to tapes. If not removed correctly can be traumatic to the wound bed NB Green sided Opsite is for wounds, orange sided Opsite is for vascular access devices
- FOAM DRESSINGS Allevyn® Allevyn Adhesive® Allevyn Cavity® Cavi-Care® Primary and secondary dressing Light/mod/highly exudating wounds, protective dressing, cavity wounds Application: Clean wound base Read packaged for insertion side (patterned or shiny side up) Sheet foam left insitu up to 7 days (24 hours if infected) Cavity foams left insitu up to 14 days (daily washing of foam if infected) Contraindications/ Possible Side effects: Avoid covering with occlusive dressings. Avoid wounds dressed with antibacterial solutions.
- HYDROGEL DRESSINGS Solugel® Intra site® Gel Solosite® Gel Clear-Site® Duoderm® Gel Aquaflo® Primary dressing Sloughy or necrotic wounds requiring chemical debridement. Lightly exudating wounds, hydrate dry wounds. Application: Clean wound base Coat wound base with at least 5 mm gel. Apply sheet directly to wound base. Can remain insitu up to 3 days Requires a secondary dressing Contraindications/ Possible Side effects: Remove if patient complains of burning or discomfort. Can cause maceration if too much is applied. Don’t use on highly exudating wounds or blind sinuses
- HYDROCOLLOID DRESSINGS Duoderm Extra Thin® Duoderm CGF® Duoderm® Paste Comfeel Plus Transparent® Comfeel Plus® Contour Dressing Comfeel Plus® Pressure Relieving Dressing Comfeel® Paste Comfeel® Powder Primary and secondary dressing Sloughy wounds requiring autolytic debridement, low/moderate exudating wounds. Application: Clean wound base, wipe periwound with barrier wipe Warm product in hands to activate adhesive Place adhesive side to wound. Leave at least 2 cm border around wound. Can be left insitu up to 7 days, dependant on exudate level. Dressing becomes opaque when due for change Contraindications/ Possible Side effects: Do not apply to infected wounds or if client is allergic. Remove if patient complains of discomfort.
- ALGINATE DRESSINGS Kaltostat® Algoderm® Sorbsan® Curasorb® Kaltocarb® Primary dressing Medium to heavy exudating, bleeding, sloughy or infected wounds. Application: Clean wound base Lightly pack or line the wound, product swells with exudate. Avoid pre-moistening the product. Discontinue use if the dressing remains dry. Can be left insitu up to 4 days, dependant on exudate level. Requires a secondary dressing, do not use an occlusive dressing Contraindications/ Possible Side effects: Do not use on dry wounds as it dehydrates the wound bed
- HYDROFIBRE DRESSINGS Aquacel Primary dressing: Medium to heavy exudating or infected wounds Application: Clean wound base Line the wound base with product Cover with a secondary dressing. Can be left insitu up to 7 days, dependant on exudate level. Contraindications/ Possible Side effects: Heavily infected wounds require Hydrofibre impregnated with Silver. Do not use in people allergic to hydrocolloids
- NANOCRYSTALLINE SILVER DRESSINGS Acticoat® Aquacel Ag® Actisorb plus® (charcoal) Primary dressing: Infected wounds (150 pathogens including MRSA and VRE), burns, donor and recipient sites. Application: Clean wound base Moisten product with sterile water, daily if not enough exudate Cut to wound size and shape, apply blue side down Cover with a secondary dressing. Can be left insitu up to 7 days, dependant on exudate level. Contraindications/ Possible Side effects: Do not use on people going for a Magnetic Resonance Imaging Do not use in people allergic to silver
- ZINC DRESSINGS Steripaste® Viscopaste® Flexidress® Gelocast® Primary dressing Sloughy wounds, epithelialising wounds and to protect limbs at risk of skin tears or degloving. Application: Cut length as required, usually 3-4 times the size of the wound Fold to make a patch and place over wound. Requires a secondary dressing. Can be left insitu up to 7 days. Contraindications/Possible Side effects: Allergy to zinc
- Other Dressings Cadexomer Iodine Vacum assisted closure (VAC)
- REFERENCES Carville, K. (2001). Wound Care Manual. Western Australia: Silver Chain Foundation. Ellis, T. (2002). Wound bed preparation- a wound management imperative. Woundcare Network(10), 1-4. Myers, B. A. (2004). Wound Management Principles and Practice. New Jersey: Prentice Hall.