A few weeks ago I introduced you to the concept of how being a wound care professional is often a lot like being a detective (read series introduction post here). This blog post is going to start our “cases.” I decided, in keeping with the theme, to write it up similar to what you would see in a court document. For each case, remember the key objects:
Application of multiple dressings with contradictory therapeutic actions resulted in delayed wound healing.
The patient is a 65-year-old man who presented with a stage 3 pressure ulcer/injury to the left ischial tuberosity. He has a history of an anoxic brain injury, is non-verbal, and is unable to move himself. The family reports that the ulcer started after a prolonged car trip. He has a colostomy and a suprapubic catheter. The wound is dry, with minimal exudate, and the periwound skin is fragile and has a slight amount of contact dermatitis. The tissue in the wound bed is mostly adhered slough, with a small amount of granulation tissue. He is being cared for by his family members, who refuse to use any type of bordered foam dressing or hydrocolloid type dressing. Dressings being used included a hydrogel applied directly to the wound base. This dressing is covered with a silver hydrofiber and covered with an absorbent pad, which is secured with cloth tape. The patient has been using this dressing based on information found by “googling.”
The main issue with this case goes back to the basics of wound care—appropriate dressing selection to maintain a moist wound healing environment. Starting at the beginning, what is the pathophysiology of this wound? It is a pressure injury/ulcer secondary to immobility and total care. The patient does have a gel cushion in his wheelchair and has been limiting sitting to one-hour intervals three times a day for meals. Next, look at what they have been trying and what has not been working. The family states that they started using the hydrogel because the wound was too dry. They then added the hydrofiber because it was silver and would help with bacteria, and finally, they added the absorbent pad to collect drainage and “pad” the wound.
Guilty of misuse of advanced topical dressings.
In this case, the patient and his family were using dressings based on what they had found on the Internet.
Based on the evidence, let’s look at what could have been done differently. When deciding on dressing selection, look at the needs of the wound.
Dressing selection based on exudate level is important. As we discussed previously, creating a moist wound healing environment is of utmost importance. Often I like to think of moisture management like “Goldilocks.” We don’t want it too dry or too wet; we want moisture to be just right.2 When looking at the mechanism of actions related to the dressings that the patient was using, you can see why this combination was perhaps not the best choice.
Hydrogels add moisture to a wound bed and are hydrophobic, meaning they add moisture to the wound bed.3 Hydrofibers (if placed on dry) are designed to wick fluid away from the wound bed and are hydrophilic, meaning they pull moisture into them.3 The wound also showed no signs of increased bioburden or infection, so the use of silver would not be indicated. Based on the current state of the wound, the patient’s condition, and the dressing mechanisms, the patient was transitioned to a hydrogel sheet that was changed daily, and the periwound skin was treated with a cyanoacrylate skin protectant. As the wound progressed through the phases of healing, he was transitioned to a petroleum-impregnated gauze dressing, and eventually the wound went on to heal.
About the Author
Emily Greenstein, APRN, CNP, CWON, FACCWS is a Certified Nurse Practitioner at Sanford Health in Fargo, ND. She received her BSN from Jamestown College and her MSN from Maryville University. She is certified as an Adult-Gerontology Nurse Practitioner through the American Academy of Nurse Practitioners. She has been certified in wound and ostomy care through the WOCNCB for the past 8 years. At Sanford she oversees the outpatient wound care program, serves as chair for the SVAT committee and is involved in many different research projects. She is an active member of the AAWC and currently serves as co-chair for the Research Task Force and Membership Committee. She is also a working member of the AAWC International Consolidated Diabetic Ulcer Guidelines Task Force. She has been involved with other wound organizations and currently serves as the Professional Practice Chair for the North Central Region Wound, Ostomy, and Continence Society. Emily has served as an expert reviewer for the WOCN Society and the Journal for WOCN. Her main career focus is on the advancement of wound care through evidence-based research.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.