By the WoundSource Editors
Chronic wounds pose an ongoing challenge for clinicians, and there needs to be a clearer understanding of the pathophysiology of wound chronicity and treatment modalities available.
By Lydia A Meyers RN, MSN, CWCN
A wound care patient is a person with an open area that is not healing. I hear wound care patients referred to as: the pressure ulcer, the hip wounds, the one that has legs that always smell like urine, the amputee that is going to lose the other leg, the non-compliant with the chronic wound, the drug addict. Where in nursing did we lose that perspective of the person behind the disease or illness? These are people with wounds that require our best effort in order to heal. They need our loving care, our education, and our assurance that all will be well.
A young patient that had found the wrong path became so addicted to drugs and alcohol that she did not realize she had fallen. In the injury, she broke her leg and was found to have been laying on it for a long period of time. She was taken to the hospital completely out of her mind and very close to death. Her blood work showed many combinations of drugs, and of course she was labeled as that "drug addict that deserves what she has gotten." Her course of medical care was very extensive since she had compartment syndrome and the leg had to be opened up completely.
It is difficult for wound care patients to have a positive view about themselves with the public so consumed with outward appearance. Even after sometimes years of recovery, the patient has scars left behind and if the wound care has been substandard, those scars can be terrible looking and greatly impact the patient's self-image and lifestyle. There are misunderstandings about the types of wound dressings that should be used on a wound patient. There are doctors, physical therapists and nurses trained in wound care that truly do not understand how dressings work or do not base their dressing selections on the levels of healing. Often times, one important element is forgotten in selecting dressings to heal a wound: the person who has the wound.
The biggest part of choosing a dressing is knowing your patient. Is the patient non-compliant? Are you looking at what is best for that person's lifestyle? A patient having to work for a living will need a different type of offloading than a person who is not working. The patient who wants to write a book will need a different way to compress his legs than the patient who sits watching television all day.
The next part of the art of choosing a dressing is wound assessment. Look at all facts of the wound including:
This assessment will help you to decide where the wound is at in the healing process and if the edges need opening up. What type of dressing will create moist wound healing? A dressing that promotes a wound environment that is not too moist or too dry. A dressing that is not changed daily, allowing the cells to move in the normal body temperature. A wound bed that is allowed to move through the healing cycle, and remained covered with heal quicker with less chance of infection. According to Baranoski (2011), a daily dressing or a twice daily dressing decreases healing time and increases infection rates by 50%. A wound bed that is allowed to move through the healing cycle while remained covered with heal quicker with less chance of infection.
Dressing choices include: transparent film, hydrocolloid, hydrogel, composite, growth factor, gauze, foam, calcium alginate, collagen, cellular and/or tissue-based tissue products, compression dressings, contact layers, and negative pressure wound therapy dressings. There is no way to know each and every dressing, since new ones come on the market daily, but having a resource available, like WoundSource, will help make the decision easier.
The wound and the dressing need to be assessed every two weeks to assure the wound is progressing. For example, a wound in hemostasis has different needs than a wound that is epithelizing. An infected wound will need a different dressing than a wound that is in the inflammatory stage. A wound with a large amount of bioburden will need to be debrided and most often sharp debridement is the best for rapid removal.
A wound care nurse can carry a few dressings that will provide the best of moist wound healing for a majority of wounds. Negative pressure wound therapy (NPWT) can be used on many wounds. The dressings and supplies for NPWT can be be ordered by the manufacturer providing the device.
One basic dressing for wound care nurses to have is a foam dressing which provides good wicking power. This wicking pulls the drainage away from the wound, preventing maceration. Most foams are able to remain in place for 2 to 7 days, depending on the wound bed and the amount of drainage. Foams can be primary or secondary dressings depending on the needs of the wound.
Calcium Alginate Dressings
The next dressing you should have handy is a calcium alginate that will allow for moderate to large amounts of drainage. It is best to use this type of dressing on venous insufficiency ulcers or stage III or stage IV pressure ulcers. The dressing comes with or without antimicrobial silver. Each manufacturer has its own formulation, but all are primarily made from seaweed. Calcium alginate dressings are best kept in place for 2 to 4 days. It also needs a secondary dressing such as a foam or abdominal dressing.
The next dressing to consider carrying is a hydrogel. Hydrogel dressings can be used for many different kinds of wounds. It helps in autolytic debridement when the use of other kinds of dressings can cause break down of good healthy tissue. This dressing can be left on for 2 to 3 days depending on what is needed by the wound. If using for autolytic debridement, you can use a hydrocolloid with it to promote the breakdown of the tissue. If using to create a moist wound bed, then a foam will help to create that environment.
Negative Pressure Wound Therapy
The last dressing that is often used and most friendly to home care is negative pressure wound therapy dressings. These are changed 3 times per week. The company that is being used to supply products is dependent on the contract with the insurance, hospital or ability of the patient to pay the co-payment for device treatment. Black foam is good choice to make with NPWT as it creates an ideal wound healing environment.
The patient with the leg injury went to heal with the use of negative pressure wound therapy and eventually a skin graft, a course of treatment that required great assessment, re-assessment and patient education. The patient, with support from her health care team and family, was able to find her way, not using drugs anymore and continued her progress towards mental, physical and spiritual health.
The proper dressing at the proper time will help to create a good healing environment and promote wound healing. A thorough assessment of the wound and patient will help to assure the proper dressing is being used at the proper time, and ongoing re-assessment will assure the wound will progress appropriately. Wound care is patient care, not just caring for the area that needs healing.
Sharon Baranoski, Elizabeth A. Ayello PhD RN APRN BC CWOCN. Wound Care Essentials, Practice Principles. Lippincott Williams & Wilkins; 2011.
About the Author
Lydia Meyers RN, MSN, CWCN has been a certified wound care nurse for over 15 years with experience working in home healthcare, extended care facilities, hospice care, acute care, LTAC, and wound clinics. Her nursing philosophy to "heal wounds as quickly as possible" is the guiding force behind her educational pursuits, both as a teacher and a student.
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., its affiliates, or subsidiary companies.