Covering

• Wounds, once covered, should be exposed as infrequently as possible. Reasons for exposing a wound include: Observation for complications, Removal of excess exudate, Removal of dead tissue, Removal of drains or sutures, Treatment of local infection

• For a discharging wound the dressing must be changed often enough to avoid contamination of its surface. However, dressings should always be carried out with minimum disruption to the healing wound, and it should be remembered that antiseptics may damage healing tissue as well as killing bacteria. The dressing of a wound should not be carried out within 30 minutes of dusting or bed making.

Criteria for Choosing a Dressing

1. maintains a moist environment at the wound bed (the only exceptions are peripheral necrosis secondary to arterial disease)

2. able to control (remove) exudate. A moist wound environment is good; a wet environment is not beneficial

3. does not stick to the wound and cause trauma on removal

4. protects the wound from the outside environment

5. aid debridement if there is necrotic or sloughy tissue in the wound. (With exception of ischaemic wounds)

6. keep the wound close to normal body temperature

7. acceptable to the patient

8. cost-effective

9. Diabetes – choose a dressing that will allow frequent inspection

Wound Cleansing

• Normal saline is the treatment of choice for most wound cleansing as it is isotonic so does not donate or withdraw fluid from the wound

Tissue types

• Hard black eschar: Hard black /brown appearance. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.. Objective: to rehydrate eschar and reduce risk of infection. Dressing options: Hydrogel Hydrocolloid

• Black wet necrotic wound: Black, green, yellow wet tissue. Malodourous. Objective: Hydrate to assist removal of devitalised tissue, remove slough to enable wound to granulate, prevention of infection, odour and exudate management, protection of surrounding skin using barrier. Dressing options: Hydrogels, Hydrocolloids, Hydro-fibre, antimicrobials (with caution and TVN advice), larvae therapy (TVN advice only). Exception: Due to the increased risk of infection and amputation, necrotic lesions on feet should be left dry until a full foot assessment has been performed.

• Yellow sloughy wound: Yellow/green/black slough. Wet and possibly malodorous. Objective: Remove slough to encourage wound to Granulate, Prevention of infection, Odour and exudate management, Protection of surrounding skin using barrier. Dressing options: Hydrogels/hydro-fibre with foam secondary dressing, Hydrocolloid, Antimicrobial dressings (TVN advice), Larvae therapy (TVN advice only)

• Red granulation tissue: Red colour with visible granulation buds. No slough or discoloured tissue. Objective: Maintain a moist wound healing environment, Encourage granulation tissue, Reduce exudate. Protect from infection and trauma. Dressing options: hydro-fibre/alginate Foam secondary dressing. If cavity present; Hydro-fibre to loosely fill the wound to encourage granulation tissue, will also aid autolytic debridement if sloughy, V.A.C (TVN assessment only), Hydrocolloid for superficial wounds.

• Epithelial tissue: Pink, fragile tissue. Objective: Reduce friction and maintain skin integrity. To continue to encourage new tissue and allow final stage of healing. Dressing options: Hydrocolloid

• Hyper-granulation Tissue - is believed to occur as a result of an extended inflammatory response. Granulation usually occurs in an orderly, if occasionally, slow manner in the majority of wounds, in others it can become disorganised resulting in the production of a protruding mass of granular tissue, which appears to inhibit wound closure. This ‘over-granulation’ can be unsightly and distressing to patients, as well as posing a management challenge to clinicians.

• Skin tears: The epidermis (outer layer of the skin) is separated from the dermis (inner layer of the skin), or both the dermis and the epidermis are separated from the underlying tissue. Tears can be simple such as a linear injury, or be more complex, with include tissue loss haematoma and bruising. Skin tears mainly occur on the arms and legs, but can occur on any area that is knocked or scraped. Description: A skin tear usually occurs in the elderly or those with fragile skin, as a result of a knock or vigorous washing and drying of the skin. Objectives: Control bleeding. Cleanse wound with saline to remove any debris present. If possible and the flap is viable gently ease the skin flap back in to place. Encourage moist wound healing environment. Dressing options: Non adhesive silicone based dressing with foam secondary dressing. (It is important to avoid harsh adhesive dressings). Light retention bandage

• Infected Wounds: Before commencing any topical or systemic therapy, swabs should be taken for culture and sensitivity. Where wounds are only colonised or have superficial local infection present, topical antimicrobials may be used. Antibiotic therapy is generally not required or prescribed for wound colonisation alone, if there is evidence of spreading cellulitis. Antiseptic dressings, for example, those impregnated with silver or iodine may be helpful for wounds infected or heavily colonised with MRSA and their use should be considered if appropriate for the wound type. Superficial MRSA wound colonisation may occur without undue complications or delayed wound healing. Antibiotic applications should be avoided, since they can lead to the emergence of resistant organisms and cause sensitisation. In particular, agents that are also used systemically (e.g. gentamicin, fusidic acid) should only be used on the authority of a Microbiologist or Dermatologist)

  • Colonised: Multiplications of organisms with, as yet, no host reaction. Positive swab/biopsy. Objectives: Prevent Infection, Reduce bacterial numbers, Prevent bacterial proliferation

  • Critically Colonised: Sufficient organisms present to interfere with healing but not invading surrounding tissue, therefore no inflammation. Characteristics: Pain, excess exudate, Dull, dark red granulation tissue, wound is static and delayed healing. Objectives: Reduce bacterial numbers, Prevent bacterial infection, Remove barriers to healing

  • Clinically Infected: Deposition and multiplication of bacteria with host reaction. Characteristics of infection: Pain, Erythema, Inflammation, Pyrexia, Pus, Odour, Heavy exudate, Non-healing. Objectives: Resolve deep infection using systemic antibiotics, Reduce bacterial numbers, Treat symptoms Prevent septicaemia, Remove Barriers to healing. In cases of clinical infection, systemic antibiotics must be used. When assessing a wound, check for signs of a spreading infection: Pyrexia, Localised heat and swelling around the wound margins, Pain, Friable wound bed, pus, green slough and offensive odour may be present

Dry dressings

• Dry dressings: When you think of wound dressings, this is probably the first thing that comes to mind. Dry dressings are gauze pads that lie under rolled gauze and tape – and the category also includes your standard bandages. You may have this type of dressing, which is intuitive and simple for most people to take care of and change, for wounds that are relatively dry themselves. If your dressing sticks to your wound bed, pour a little saline solution over the area to help it come off without pain.

• Wet-to-dry dressings: Keeping the wound area moist is very important in certain types of wound care. For wounds that need this, particularly wounds that need to be debrided, sometimes providers will use wet-to-dry dressings. This involves soaking gauze or cotton in saline and putting it on the wound. As the sponge dries, it will dry out the wound around it as well, helping to debride it. If you need to use this type of dressing at home, be careful with your hygiene, as it doesn’t protect against outside contaminants as well as some other types of dressings.

• Foam dressings: Foam dressings are padded to protect the wound and keep everything moist. Generally, they’re useful for pressure ulcers in the early stages because they protect the entire area from being rubbed further. Mostly, these are self-adhesive, so report any pain around the wound site to your practitioner.

• Hydrocolloid dressings: Just like wet-to-dry dressings, hydrocolloid dressings assist in wound debridement. They also keep the wound moist for healing and keep oxygen out. They are not recommended for wounds that are already infected, but they’re very useful for wounds at high risk of infection. They are long-term dressings that can be used for up to a week unless they get saturated with discharge before that point.

https://www.rch.org.au/clinicalguide/guideline_index/Wound_dressings_acute_traumatic_wounds/

https://www.thewaltoncentre.nhs.uk/uploadedfiles/FOI/Wound%20care%20formulary.pdf