WOUND CARE, DRESSING AND BANDAGING

OBJECTIVES• To learn the principles of wound care in terms of assessment and management• To learn bandaging techniques

Wound Care and DressingOBJECTIVES

• To identify the optimal wound healing environment• To learn the different types of wounds• To identify the most appropriate type of wound dressings to promote wound healing of different types of wounds• To learn how to do a conservative surgical debridement for necrotic tissues• To learn how to do simple wound irrigation

Wound Care• Wound care is more than a dressing.• It is a total approach to the assessment and management of the person with a wound.• Wound management consideration– Prevent further trauma to wound– Correct nutritional and fluid status– Promote comfort and reduce pain– Prevent maceration of skin– Treat systemic illness– Promote optimal wound healing environment• Optimal wound healing environment– Remove necrotic tissue – Eliminate wound infection and protect from bacterial invasion– Prevent irritation to wound and surrounding skin– Maintain wound temperature at 37°C– Choose appropriate wound dressing materials, maintain moist wound surface to promote granulation– It is important that necrotic tissue and slough are removed as it provides an ideal breeding ground for bacteria• Debridement of Devitalized Tissue• Bacterial Reduction• Moisture Balance• Dry wounds– Wounds in which the skin is intact or in which the skin edges are approximated – Wide mesh gauze is most commonly used; protects the wound and allows free circulation of air through the dressing. Moisture from the skin can evaporate and the dressing remains dry.• Raw wounds– Chronically draining wounds– Wounds left open due to infection or contamination

Definition of Terms• Drainage/exudates – the fluid produced by a wound, which may contain serum, cellular debris, bacteria, leukocytes, pus or blood• Erythema – an inflammatory redness of the skin caused by engorged capillaries

• Eschar – non – viable wound tissue that is characterized by a dry, leathery, black crust• Fistula – an abnormal passage between two organs or between organs and skin• Granulation – the formation of soft, red, fleshy projections during the healing process in a wound not healing by primary intention, consisting of capillarie ssurrounded by fibrous collagen.• Maceration – softening of a tissue as it is soaked in fluid• Necrosis – cell or tissue death; non – viable tissue easily recognizable as black or brownish in appearance• Pressure ulcer – wounds that are the clinical manifestation of localized tissue death due to lack of blood flow in areas under pressure.• Stage I– Persistent redness on intact skin even after relief of pressure• Stage II– Superficial loss of skin or blister formation• Stage III– Loss of subcutaneous tissue with shallow cavity• Stage IV– Loss of subcutaneous tissue with deep cavity, may expose muscle, bone or tendon• Undermining – a tunneling effect or pocket under the edges of a wound that is caused by the pressure gradient transmitted from the body surface to the bone.• Wound assessment chart – a written record of the wound and its progress

Wound care and assessment• Obtain patient’s consent before the treatment/ procedure.• Obtain patient’s profile and history relevant to the wound– Medications used– Medical condition– Social history– Mobility – Nutritional status– Incontinence– Allergies• Obtain latest laboratory results if any• Identify location of wound. Mark in the chart.• Identify type of wound– Pressure sore Stage I – IV – Malignancy– Traumatic – Others – Leg ulcer– Surgical– Burn– Sinus/fistula• For leg ulcers assess as to – Presence of paresthesia– Presence of claudication– Monofilament assessment– Presence of lesser toe deformities– Presence of charcot joints– Presence or absence of peripheral pulses– Presence of atrophic skin– Presence of atrophic/dystophic nails– Absence of hair– Capillary refill– Presence of varicose veins

– Temperature gradient on affected foot/leg• Take wound photo after obtaining patient’s consent or sketch wound in chart.• Measure the wound bed using wound measurement system. Use the unit centimeter. Take the length and width. For burns, use the Rule of Nines.• Measure the depth using cotton applicator. Use the unit centimeter. If there is necrotic tissue, wound depth cannot be measured.• Assess tissue status using percentage system.• Assess for the presence of undermining or sinus. If present, locate using the clock system of measurement. • Assess the peri - wound skin as to:– Presence of maceration – Presence of blisters

– Presence of hyperpigmentation – Presence of edema– Presence of eczema – Others– Dryness/ friability– Presence of erythema/cellulitis• Describe amount of exudates– None – Minimal – 5ml/24hours, minimal strikethrough marking on the surface of the inner dressing approximately <2cm in diameter– Moderate – 5 – 10ml/24hrs, strikethrough marking on the surface of the inner dressing approximately .2cm in diameter but not outside the dressing edge– Heavy – 10ml/24hrs, strikethrough marking on the surface of the inner dressing and outside the dressing edges• Note the presence of odor as this can be caused by infection, necrotic tissue or the use of certain dressing materials– None– Only present when dressing is removed (dressing may be the cause of the odor)– Fills the room – often indicates the presence of anaerobic bacteria• Assess for wound pain. Location, frequency and severity of pain can help determine the presence of underlying disease, effectiveness of analgesia and efficacy of local wound care i.e. dressing/cleansing methods– None– Only at dressing change - may indicate inappropriate choice of dressing or method of cleansing• Assess for wound pain. Location, frequency and severity of pain can help determine the presence of underlying disease, effectiveness of analgesia and efficacy of local wound care i.e. dressing/cleansing methods– Intermittent – pain may be influenced by position (e.g. arterial ulceration of lower leg)– Continuous - dressing regime and analgesia should be reviewed• Assess for clinical signs of infection• Assess need for wound debridement– Autolytic – selective as only necrotic tissue is liquefied achieved with hydrocolloids, hydrogels and transparent films– Enzymatic - chemical enzymes are fast acting products that produce slough of necrotic tissue. Can be selective or non - selective. • Assess need for wound debridement– Mechanical - allowing a dressing to proceed from moist to wet, then manually removing the dressing causes a form of non - selective debridement.– Surgical - sharp surgical debridement and laser debridement under anesthesia are the fastest methods of debridement. It is very selective since the surgeon has complete control over which tissue is removed and left behind. Can be done at the OR or bedside depending upon the extent of the necrotic material.

• Wound home instructions should be explained and given to patient and/or caregiver. Includes the ff:– Type of wound cleansing and dressing and how it should be applied– Frequency of changing– Compression therapy if applicable– Follow up care with the wound care clinic

Wound management• Debridement– Decreases potential for infection– Optimizes odor management– Enhances wound assessment• Debridement types– Surgical debridement – fastest way to remove necrotic debris– Enzymatic debridement – uses topically applied proteolytic enzymes to selectively degrade necrotic tissue• Debridement types– Autolytic debridement – slowest alternative– Mechanical debridement – non – selective

Surgical DebridementSurgical debridement

• Holding The Forceps: Hold the tissue forceps so that the 'blades' function as an extension to the thumb and index finger (the pencil grip).• Using the scalpel for debridement: The scalpel should also be held in the pencil grip. This allows the index finger/thumb joint to control the movements.• Using the scissors (Iris): If the scissors are curved, the concavity should face upwards. Rest the index finger at the joint to gain maximum control.• Bacterial reduction– Use of antiseptic lotions – hypochlorite solution, Povidone – Iodine, hydrogen peroxide• Most antiseptic lotions are toxic to fibroblasts, thus delay healing• Some lose their antiseptic effect in the presence of blood and pus• Some irritate surrounding skin• Antiseptics need to be in contact with bacteria for about 20 minutes to have killing effect• Ideal wound dressing– Keeps wound moist– Removes and debrides necrotic tissue– Prevents surrounding skin from maceration– Absorbs excessive wound exudates– Allows removal without causing trauma or pain– Protects from bacterial invasion– Maintains thermal insulation at 37°C

Wound dressing selection• Wound dressings – any material applied to cover a lesion or wound– Alginate – derived from seaweed which becomes a hydrophilic gel when in contact with wound secretions, providing a moist wound environment– Film dressing – vapour permeable, allow the passage of water vapor and oxygen but not water or microorganisms – Hydrogels – made of silicone and water, rehydrates wounds and provide moist wound environment– Hydrocolloids – interactive when in contact with wound exudates. Absorbs fluid and becomes a gel– Foam dressing – absorbent polyurethane foam

– Antimicrobial dressing – reduces bacterial burden and prevent further development of infection, maintains moist wound environment– Retention bandages and elastic stockinet – used to secure dressing in place– Micropore tape – used to secure dressing in place– Compression bandages – used in the management of venous ulceration– Hydrofiber – soft, sterile, hydrophilic non – woven sheets composed entirely of hydrocolloid fibers. It is used for management of exuding wounds.• After assessment of wound, choose a product ideal for wound healing– For necrotic tissues – hydrogel, semi – permeable film or low/non – adherent dressing or hydrocolloid for none to low exudates level. Alginate or hydrofiber for moderate to high exudate level.

– For necrotic digit – Cadexomer iodine to prevent increase in bacterial contamination and to control exudates or alginate to control moderate to high exudates.– For sloughy tissues – hydrogel and semi – permeable film/low non – adherent dressing or hydrocolloid for non to low exudates. Alginate with secondary absorbent dressing for moderate to high exudates.– For granulating tissues – low/ non – adherent dressing or hydrocolloid for none to low exudates. Alginate or hydrofiber with secondary absorbent dressing for moderate to high exudates.– For epithilializing tissues – low/ non – adherent dressing or hydrocolloid for none to low exudates. Alginate or hydrofiber with secondary absorbent dressing for moderate to high exudates.– For cavity wounds – hydrogel and semi – permeable film for non to low exudates. Alginate or hydrofiber with secondary absorbent dressing for moderate to high exudates.– For macerated wound edges – alginate or hydrofiber with secondary absorbent dressing.• Gauze dressing– Characteristics: cotton fibers– Usage• Wet to dry – mechanical debridement• Dry gauze – absorb exudates• Wet gauze – provide moist environment– Examples: Gauze, Melolin, Mesalt (hypertonic saline gauze)• ADV– Moderately absorbent– Economic– Autolytic effect if applied moist• DISADV– Adhere to wound and cause trauma when removed dry– Allow bacterial invasion– Unable to absorb excessive exudates– May macerate surrounding skin– Delay epithilialization• Transparent film– Characteristics: allow oxygen and water vapour to pass through but not bacteria or foreign body– Usage: For minimally exudating wounds; used as secondary dressing to maintain moisture and promote autolytic debridement effect– Examples: OpSite, Optiskin, Tegaderm• ADV– Permit constant observation– Minimizes pain

– Reduce surface friction– Protect, moisture retentive, semipermeable, reduce infection– Secondary dressing to keep moist dressing for autolytic debridement

• DISADV– Non – absorptive– May damge new and fragile skin– Not suitable for deep cavity when used on tis own• Impregnated Gauze dressing– Characteristics: chemical compounds or agents added to gauze material, some medicated and some non - medicated– Usage: for wound coverage and protection, initial dressing over skin grafts, donor sites in plastic surgery– Examples: Jelonet, Paratulle (non – medicated); Sofra – tulle (anti – infective with 1% Framycetin Sulphate); Bactigras, Serotulle (antiseptic, 0.5% Chlorhexidine Acetate)• ADV– Low adherent– Moisture retentive• DISADV– Need secondary dressing– Permeable to air and bacteria– Non – absorbent causing maceration of wound– Water vapour and exudates are trapped within the wound as they cannot pass through the paraffin• Foam dressing– Characteristics: non – adherent, highly absorbent– Usage: for Stage II to III surface to shallow wounds; heavily exudating wounds and overgranulating tissue– Examples: Allevyn, Lyofoam, Tielle• ADV– Absorb excessive exudate– Non – adherent – Moisture retentive– Protect from contaminant– May flatten overgranulating tissue• DISADV– Not suitable for dry wound• Hydrocolloid dressing– Characteristics: occlusive or semi – occlusive, interacts with wound exudate to form a soft gel like substance– Usage: Stage II or III pressure ulcers with moderate amount of exudates; has autolytic debridement effect– Examples: Algoplaque, Comfeel, Duoderm, Hydrocoll, restore, Tegasorb• ADV– Minimal to moderately absorbent– Non – traumatic on removal– Moisture retentive, thermal insulttion, water resistant– Bacterial barrier– Autolytic effect

• DISADV– Not transparent– Melt out effect– Occlusive smell and gel resemble pus residue

– Not recommended for infected wound or highly exudating wound• Lipido – colloid dressing– Characteristics: vaseline and hydrocolloid dressing– Usage: For superficial burn wound, trauma wound, pressure ulcer, skin grafts and donor sites– Examples: Urgotul• ADV– Moisture retentive– Allow drainage of exudate, prevent maceration– Non – adherent, no pain– No penetration or granulation cells– No residue fiber• DISADV– Need secondary dressing• Hydrogel dressing– Characteristics: consists both absorption power and give moisture by its high water content– Usage: Stage III or IV wound with no or minimal exudate, sloughor eschar, for autolytic debridement– Examples: Duoderm gel, Hypergel, Intrasite gel, Nu – gel, Suprasorb, Tegagel, Purilon Gel• ADV– Gel rinses off easily– Some with absorbent effect– Hydrate hard dry eschar– Autolytic effect• DISADV– Not suitable for highly exudating wound– Require secondary dressing– May macerate skin• Alginate dressing– Characteristics: composed of calcium and sodium to absorb excessive amount of exudate and has hemostatic effect– Usage: highly exudating wounds, Stge II to IV wounds, wounds with slough, necrotic tissue or bleeding, cancerous wounds– Examples: Fibracol, Kaltostat, Sorbalgon, Seasorb, Tegagen• ADV– Non – toxic – Fiber biodegradable– Highly absorbent moisture– Autolytic effect– hemostatic• DISADV– Not suitable for dry wound– Require secondary dressing• Moisture Balance– Use of non – irritant skin cleanser– Moisturizing cream– Protective skin barrier– Pressure ulcer preventive spray

Wound Irrigation• Wound irrigation– Promotes wound cleaning by creating hydraulic forces generated by the fluid stream.

– In order for the irrigation to be effective in cleaning the wound, the force of the irrigation stream must be greater than the adhesion forces that holds the debris to the surface of the wound.• Bacterial burden– Amount of bacteria colonizing the wound bed• Wound irrigation – The process of washing debris, drainage or exudates out of the wound to promote healing

Wound Irrigation• Step 1: Assess patient’s pain and premedicate if needed 30 minutes prior to the procedure• Step 2: Place a waterproof pad on the bed. Assist the patient onto the pad and place in a position that will allow fluid to flow through the wound.• Step 3: Clean hands and don clean gloves. Remove and discard old dressing.• Step 4: Assess the wound. Document findings.• Step 5: Prepare room temperature irrigating solution and syringe (20cc syringe and G23 needle).• Step 6: Change into clean gloves. Wear apron, gown or goggles if needed.• Step 7: Fill the syringe with irrigating solution and gently flush the wound. Hold the syringe approximately 1 inch above the wound bed to irrigate. • Step 8: Refill the syringe and continue to flush the wound until the solution returns clear and no exudates are noted.• Step 9: Dry the edges of the wound with sterile gauze.• Step 10: Assess the wound appearance and drainage and document.

BandagingOBJECTIVES

• To learn principles of bandaging• To learn some bandaging techniques

Bandaging

• Should be done neatly and carefully• Should be snug, but not too tight as to leave marks on the skin after it has been removed• Should remain firmly in place until it is time for the wound to be redressed• Amount of pressure should be merely sufficient to hold it in place• Bandage should be applied evenly without wrinkles• Use the widest bandage that will properly do the job– One – inch for fingers– 2 – inch for hand and head• An elastic bandage should not be stretched to its limit before it is applied or its becomes, in essence, a non – elastic bandage.• When used to wrap an extremity, the elastic bandage should be tightest at the distal end and looser as it is applied proximally.• An elastic bandage on the lower extremity must include the toes; otherwise the unbandaged limb distal to the elastic bandage will swell.• If pressure over a wound is required, additional dressings should be applied and bandage wrapped tighter.• Under such circumstances, the area must be examined at frequent intervals to ensure the pressure is not injuring the tissues.

Methods of Bandaging• Circular Bandage– Used over a tubular area like the arm

– Bandage is fixed by several turns about the part and it is then advanced by circular turns in the direction desired.– Each successive turn overlaps the preceding one by ½ to 1 inch• Figure of Eight– Used over joints, it is anchored at one end by making several turns about the limb below the joint.– The bandage is then carried obliquely across the joint and is again anchored above the joint by a complete turn.– The dressing is then carried obliquely across the joint to the lower part of the extremity and anchored by a complete turn.• Recurrent bandage– This is used in distal stump.– It can be used as a bulky dressing over the hand, any distal area, such as the finger, amputation stump or as ahead dressing.– The bandage is anchored by several circular turns and then, while one holds the bandage at the point where it is anchored, the direction is changed 90 degrees and the bandage is applied over the end and down to the other side of the anchoring bandage.– It is again anchored here and and the direction reversed back to the initial anchoring point.– The dressing is continued back and forth until adequate covering is accomplished.– The bandage is locked by a circular turn.• Reversed spiral bandage– This bandage is used for tubular structures of changing diameter such as the leg or forearm.– The bandage is fixed by two or three circular turns and then on each turn is rotated counterclockwise 180 degrees, creating a reverse spiral as it is advanced along the extremity.– This bandage is likely to slip and is unsuitable for use over joints.