Download using dimes© to your advantage

USING DIMES©
TO YOUR ADVANTAGE
By Kevin Y. Woo, Elizabeth A. Ayello and R. Gary Sibbald
Contents
D - Debridement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
I - Infection/Inflammation . . . . . . . . . . . . . . . . . . . . . . 5
M - Moisture balance . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
E - Edge/Environment . . . . . . . . . . . . . . . . . . . . . . . . . . 8
S - Support with Products, Services
and Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1
Treating Chronic Wounds
The assessment and treatment of chronic wounds is a daily
challenge. Clinicians need guidance on their wound care
journey as they move between care settings with financial
constraints, finite resources and the need to optimize
wound care.
DID YOU KNOW
DIMES© serves as
an easy framework
for planning and
implementing an
effective treatment
plan for chronic
wounds while
saving money
and using valuable
resources wisely.
What do DIMES have to do with chronic wound care?
DIMES© serves as an easy framework for planning and
implementing an effective treatment plan for chronic wounds
while saving money and using valuable resources wisely.
We all realize that preparation is the key to care. This is also
true in preparing wounds for healing. The wound bed
preparation (WBP) paradigm was created as a practical clinical
guide for the treatment of chronic wounds (see Figure 1).1,2,3
As always, the patient comes first. Start by addressing
patient-centered concerns, then treat the cause of the wound
before optimizing local wound care.
Figure 1
Wound Bed Preparation Paradigm
Person with Chronic Wounds
Treat
TreatCause:
Cause:
Local Wound Care
(e.g.
(e.g.vascular
vascularsupply,
supply,
edema,
edema,pressure,
pressure,shear)
shear)
Debridement of
Devitalized Tissue
Pressure
Redistribution
Infection
(superficial/deep)
Inflammation
Patient-Centered
Concerns: Pain
Including Pain
Moisture Balance
Edge – Non-healing Wound
Biological agents, growth factors, skin substitutes,
adjunctive therapies
Support with Products, Services and Education
To provide today’s wound care treatments
2
The initial components of local care are:
•
•
•
Debridement
Infection/Inflammation
Moisture balance
That gives us D-I-M. The E and S of DIMES stand for other
aspects of advancing stalled chronic wounds. The E (or
edge/environment) of non-healing wounds represents the
use of advanced active therapies to stimulate healing, while
the S stands for support products, services and education in
our wound healing bank. Remember: DIM before DIMES.4
As clinicians, you are constantly making decisions based on
data from answers to vital questions about your patients.
Some of these relevant questions relating to chronic wound
management are:
Questions relating to
Wound Management
3
1.
Patient-centered concerns: Is pain an issue? What are the
factors, including psychological, that might influence
wound healing? What factors can affect a patient’s adherence
to treatment?
2.
Cause(s) of the wound: What caused this wound?
Is the cause treatable or correctable?
3.
Local wound factors: First, think DIM! Is there necrotic
tissue that needs removal by some method of debridement?
Is there an undiagnosed infection or inflammation? Use the
“Goldilocks Phenomenon” to assess the moisture level of
the wound – is there too much or too little moisture?5
4.
DIM before DIMES: Is there anything else that can be done
to promote faster wound edge migration after local wound
care has been optimized? What else is needed to support
healing? This might include selecting products for stalled
chronic wounds from a tool kit of additional options
combined with patient education to strengthen partnerships
and promote adherence to treatment.
Start the wound-healing journey
Much has been published on the importance of accurate
wound diagnosis.6-9 You know that correcting the cause of the
wound is the first step in wound healing. The importance of
accurate wound diagnosis and correcting the cause as the first
step in wound healing has been explained in detail elsewhere.
Now it’s time to determine if the wound is expected to heal.
To determine the healability of a wound (Table 1), clinicians
must ascertain if:
•
•
•
Table 1:
Wound healability
The cause is treatable,
The blood supply is adequate and
The coexisting conditions or drugs do not prevent healing.
Wound
prognosis
Treat the
cause
Blood
supply
Coexisting medical
condition/drugs
Healable
Maintenance
Non-healable
Yes
No*
No
Adequate
Adequate
Usually
inadequate
Not prevent healing
+/- prevent healing
May inhibit healing
* Due to lack of adherence to treatment or lack of resources
The individualized patient concerns, wound healability (healable, non-healable or maintenance) and causes of wounds in
each situation will involve emphasis on pressure redistribution,
addressing the medical conditions as well as local wound care.
Moist interactive healing is contraindicated in non-healable
wounds. The care plan should include conservative debridement without cutting into living tissue and causing bleeding,
bacterial reduction and moisture reduction. When healing is
not immediately possible, such as in cases of uncontrolled
deep infection or where bacterial burden is more of a concern
than tissue toxicity, antiseptics are a good treatment option.10
Debridement
For wounds with the ability to heal, adequate and repeated
debridement is an important first step in removing necrotic
tissue. Eschar provides a pro-inflammatory stimulus inhibiting
healing while the slough acts as a culture media for bacterial
proliferation.11 Debridement may also help healing by removing
both senescent cells that are no longer capable of normal
4
DID YOU KNOW
In 2008, CMS will
only reimburse for
collagenase if it
qualifies under
Medicare Part D.
cellular activities and biofilms that shield the bacteria colonies.11
While sharp debridement is the quickest, this method might
not always be desirable due to pain, bleeding potential, cost
and the lack of clinician expertise. Autolytic debridement is
facilitated by modern moist interactive dressings. These
dressings provide a moist wound environment that enhances
the activities of all cells, including phagocytic cells and
endogenous enzymes that digest non-viable tissue or eschar.
Mechanical debridement utilizes saline wet-to-dry dressings,
but this method is often associated with local trauma and
pain. CMS has given clinicians a clear indication of its
rationale for recommending the limited use of mechanical
debridement with wet-to-dry dressings and even refer hospitals
to Tag F314 for direction about this aspect of care.
Polyacrylate debridement with the use of activated polymer
dressings is a valuable alternative to wet-to-dry dressings.
Enzymatic debridement using topical wound medications
(collagenase or papain urea) is another method for the removal
of dead tissue from the wound bed. Beginning in 2008, CMS
will only reimburse for collagenase if it qualifies under
Medicare Part D. Newer and emerging technologies to remove
wound bed eschar and slough include ultrasonic devices,
pulsating lavage and biological (maggot) therapy.12
Infection
All chronic wounds contain bacteria. The level of bacterial
damage may include contamination (organisms present),
colonized (organisms present and may cause surface damage
if critically colonized) or infected (deep and surrounding skin
damage). Wound infection is a clinical diagnosis based on
signs and symptoms rather than the presence or number of
bacteria obtained from a surface swab.
The risk of infection is determined by the number and nature
of invading bacteria as well as host resistance, as outlined in
the following equation:
Infection = Number of organisms
x Organism virulence
Host resistance
Host resistance is the most important factor in the equation.
This refers to the host immune response to resist bacterial
invasion and prevent bacterial damage.11,12 For example,
5
individuals with diabetes have at least a tenfold greater risk
of being hospitalized for soft tissue and bone infections of the
foot than those individuals without diabetes.11
Identification of infection as either superficial increased
bacterial burden or deep into the tissue helps guide clinicians
in deciding appropriate treatment. Wounds with increased
superficial bacterial burden may respond to topical
antimicrobials while those with deep infection usually
require systemic antimicrobial agents.
The mnemonics NERDS© and STONEES© have initials that
spell out the key signs categorizing the two levels of bacterial
damage or infection.13 Two or three of these signs should be
sought for the diagnosis in each level. If increased exudate
and odor are present, additional signs are needed to decide
if bacteria are superficial, deep or at both levels.
NERDS MNEMONIC
N
E
R
D
S
Non-healing wound
Exudative wound
Red and bleeding wound
Debris in the wound
Smell from the wound
© NERDS, Sibbald, Ayello, Woo
STONEES is an easy reminder of deeper infection. STONEES
sink to the bottom, or are the characteristics that you will find
when bacteria are deep within the chronic wound tissue or
have penetrated the surrounding skin. Early recognition of
infection is crucial to institute appropriate systemic treatment
and prevent further damage.
STONEES MNEMONIC
S
T
O
N
E
E
S
Size is bigger
Temperature increased
Os (probes to or exposed bone)
New areas of breakdown
Exudate
Erythema and/or edema
Smell
© STONEES, Sibbald and Ayello
6
There are many antimicrobial products available, and no one
product is going to be right for all patients.15-17 Silver needs to
have moisture for ionization and it is only the ionized form of
silver that is an effective antimicrobial agent (not appropriate
for non-healing or maintenance wounds). Clinicians need to
match appropriate product characteristics with the clinical
features of the wound bed.
As a reminder, do not use topical or systemic antibacterial
agents long-term without weighing the risks and benefits.
Discontinue antibacterial agents after the wound is in bacterial
balance unless the patient is prone to reinfection due to local
or systemic factors such as immune-compromise.
Surrounding tissue infection is referred to as cellulitis.
Classically, pain is associated with increased temperature,
edema and erythema. Cellulitis greater than 2 cm, on the leg
or foot of a person with diabetes, can be associated with
limb-threatening infection.14
DID YOU KNOW
The optimal use of
a silver dressing
requires the need for
decreased bacterial
burden (ionized
silver) combined
with the appropriate
moisture-balancing
dressing.
7
Systemic antimicrobial therapy depends on local best practice
recommendations and type of bacteria. In general, chronic
wounds are affected by gram-positive bacteria in the first
month. After that, both gram-negative bacteria and anaerobes
may invade the tissue as host resistance diminishes. The diagnosis of infection is made clinically and swab results are used
to identify organisms and their antimicrobial sensitivities.11
Use the Levine technique when taking swab cultures (see
callout box on following page).
The optimal use of a silver dressing requires the need for
decreased bacterial burden (ionized silver) combined with the
appropriate moisture-balancing dressing.
Moisture balance
Cells (fibroblasts and keratinocytes) and the various cellular
signals (growth factors, cytokines) all need the right amount of
moisture to move across the wound bed. Achieving moisture
balance is a delicate act. Too much moisture can damage the
surrounding skin, leading to periwound maceration and skin
breakdown.18,19 Conversely, too little moisture in the wound
environment can impede cellular activities and promote eschar
formation, resulting in poor wound healing. You cannot swim
in a dry pool, and neither can the cells! A moisture-balanced
wound environment is maintained primarily by “modern”
dressings with occlusive, semi-occlusive, absorptive, hydrating
and hemostatic characteristics, depending on the surface exudate and the need for moisture balance on the wound bed.
Edge/environment
Once DIM has been addressed, attention can be shifted to the
wound edge and DIMES. Wound edges tell an important story
about the wound’s healing journey. A non-healing wound may
have a cliff-like edge. Think of this as the stalled keratinocytes
piling up because they are incapable of moving forward. This
is in contrast to a healing wound with tapered edges like the
shore of a sandy beach. If the wound edge is not migrating
after appropriate wound bed preparation (debridement, infection/bacterial balance, moisture balance) and healing is stalled,
then advanced therapies should be considered. The first step
prior to initiating the edge effect therapies is a reassessment of
the patient to rule out other causes and co-factors.12 Clinicians
need to remember that wound healing is not always the primary outcome. Consider other wound-related outcomes, such
as reduced pain, reduced bacterial load, reduced dressing
changes and an improved quality of life.
Several edge effect therapies support the addition of missing
components: growth factors, collagen, fibroblasts or epithelial
cells or matrix components.12
TIPS!
There are other
products that
complement DIMES
but do not fit
into one of these
immediate categories. Therefore,
always consider the
“other” supportive
products that
complete the
treatment.
The Levine technique
This method relies on the swab being placed on a central
location – free of necrotic eschar and debris – in the wound
base. The swab is pressed firmly on the tissue to extract
exudate and then rotated 360 degrees. If the tissue is relatively
dry, the swab can be placed in the culture media prior to
taking the sample to increase the yield on culture.
Support with products, services and education
There are other products that complement DIMES but do not
fit into one of these immediate categories. Therefore, always
consider the “other” supportive products that complete the
treatment. For instance, for a patient with fragile skin, you
might choose an elastic net as a secondary dressing versus
tape. The secondary dressing is also important to the care plan.
Nutrition products are also part of treating the whole patient
and not just the hole in the patient.
8
Connecting the right product to the right application is critical. However, ongoing education is paramount to achieving
the best possible outcome. Education is not just for clinicians
so they know and use the latest evidence base in their practice,
but is essential for patient's and their families. Making sure
that patients and their families are taught the expected
outcomes and the plan to achieve them is vital for successful
wound treatment. Support with products, services and
education can make the right treatment plan even better.
DIMES helps heal chronic wounds
It’s important to understand DIMES not just an an acronym
but as a roadmap for practice. How can you use the guideposts
from DIMES to choose the right products, at the right time, for
your patients’ wounds? How can you arrive at the best outcome for the patient and get there in a cost-effective way? It’s
not always easy! Any journey, including treating chronic
wounds, can be lengthy. The right support and services are
vital in helping you reach your destination.
Education about the journey of healing helps clinicians avoid
costly detours from the healing path. By adopting an organized and consistent approach to care and incorporating the
DIMES components of wound bed preparation, the healing
journey can stay on track. We can help our patients reach the
destination of wound bed preparation in a safe – and less
costly – way.
Summary
In summary, the concept of wound bed preparation includes
the treatment of the whole patient before the hole in the
patient (treat the cause and patient-centered concerns).
Local wound bed preparation includes DIM (debridement,
infection/inflammation and moisture balance) before DIMES
(DIM plus advanced edge effect therapies for wounds with the
ability to heal). Support in the way of “other products,”
services and nutrition is also needed. Finally, always remember
that education is the scaffold for practice. Without it,
clinicians cannot advance practice and improve patient
wound healing outcomes.
9
References:
Sibbald RG, Williamson D, Orsted HL et al. Preparing the wound bed:
debridement, bacterial balance and moisture balance. Ostomy Wound Manage.
2000;46(11):14-22, 24-8,30-5;quiz 36-7.
Sibbald RG, Orsted H, Schultz GS, Coutts P, Keast D. International Wound
Bed Preparation Advisory Board. Canadian Chronic Wound Advisory Board.
Preparing the wound bed 2003: focus on infection and inflammation. Ostomy
Wound Manage. 2003;49(11):23-51.
Sibbald RG, Orsted HL, Coutts PM, Keast DL. Best practice recommendations
for preparing the wound bed: update 2006. Adv Skin Wound Care. 2007;
20:390-405.
Woo K, Ayello EA, Sibbald RG. The edge effect: current therapeutic options
to advance the wound edge. Adv Skin & Wound Care. 2007;20(2):99-117.
Ayello EA, Cuddigan JE. Jump start the healing process. Nursing Made
Incredibly Easy. 2003;1(2):18-27.
Canadian Association of Wound Care. CAWC Quick Reference Guide.
Available at: www.cawc.net/open/library/clinical/QRG2006E.pdf. Accessed
December 27, 2007.
Inlow S, Orsted H, Sibbald RG. Best practices for the prevention, diagnosis and
treatment of diabetic foot ulcers. Ostomy/Wound Manage. 2000;46(11):55–68.
Kunimoto B, Cooling M, Gulliver W, Houghton P, Orsted H, Sibbald RG. Best
practices for the prevention and treatment of venous leg ulcers. Ostomy/Wound
Manage. 2001;47(2):34–50.
Dolynchuk K, Keast D, Campbell K, et al. Best practices for the prevention and
treatment of pressure ulcers. Ostomy/Wound Manage. 2000;46(11)38–52.
Woo K, Etemadi, P, Coelho S, Sibbald RG. The use of betadine in nonhealing
wounds. Poster presentation. European Wound Management Association,
Glasgow, UK; 2007.
Landis S, Ryan S, Woo K, Sibbald RG. Infections in chronic wounds. In:
Krasner D, Rodeheaver G, Sibbald RG, eds. Chronic Wound Care: A Clinical
Source Book For Healthcare Professionals. 4th edition. Malvern, Pa: HMP
Communications; 2007:299- 321.
Kirshen C, Woo K, Ayello EA, Sibbald RG. Debridement: A vital component
of wound bed preparation. Adv Skin & Wound Care. Nov-Dec. 2006;19(9):
506-517;quiz 517-519.
10
Konig M, Vanscheidt W, Augustin M, Kapp H. Enzymatic versus autolytic
debridement of chronic leg ulcers: a prospective randomised trial. Journal of
Wound Care. 2005;14(7):320-3.
Sibbald RG, Woo K, Ayello EA. Increased bacterial burden and infection: the
story of NERDS and STONES. Adv in Skin & Wound Care. 2006;19(8):447-61.
Vermeulen H, van Hattem JM, Storm-Versloot MN, Ubbink DT. Topical silver
for treating infected wounds. Cochrane Database of Systematic Reviews.
2007;(1):CD005486.
Bergin SM, Wraight P. Silver based wound dressings and topical agents for
treating diabetic foot ulcers. Cochrane Database of Systematic Reviews.
2006;(1):CD005082.
Chambers H, Dumville JC, Cullum N. Silver treatments for leg ulcers: a
systematic review. Wound Rep Reg. 2007;15:165-173.
Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone
in infected pedal ulcers: A clinical sign of underlying osteomyelitis in diabetic
patients. JAMA. 1995;273(9):721-3.
Chaby G, Senet P, Vaneau M et al. Dressings for acute and chronic wounds:
A systematic review. Arch Dermatol. 2007;143(10):1297-1304.
11
WOUND CARE
ALGORITHM
Contents
Description of the Wound Care Algorithm . . . . . . . . . . 2
Necrotic Tissue Protocol . . . . . . . . . . . . . . . . . . . . . . . . . 3
Wound Cleansing Protocol . . . . . . . . . . . . . . . . . . . . . . 3
Primary Dressing Protocol . . . . . . . . . . . . . . . . . . . . . . . 4
Secondary Dressing Protocol . . . . . . . . . . . . . . . . . . . . . 5
Transparent Film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Hydrocolloid Dressing . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Hydrogel (Amorphous, Sheets and
Impregnated Gauze) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Alginate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Foam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Antimicrobial Dressings . . . . . . . . . . . . . . . . . . . . . . . . . 7
Secondary Dressings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1
Description of the Wound Care Algorithm
The mnemonic WOUND is a memory aid that will assist you
with wound assessment and also help you determine the type
of topical therapy to apply, based on the needs of the wound.
The five basic elements, along with a handful of questions and
protocols that focus on the details, will help you work through
the algorithm to make wound care successful for you and
your patients.
W - Is the wound healing? A partial-thickness wound should
show progress to complete closure in approximately two
weeks. A full-thickness wound should show signs of healing
within four weeks. If wound healing has stalled, in spite of
expert care, it may be time to add a collagen-based product to
“kick start” the healing.
O – Is there an optimal amount of moisture in the wound? A
wound that is draining or “wet” will need a product that can
manage the drainage. Consider the type of drainage and the
odor that is associated with the wound. A wound that is dry
or slightly moist requires a product that will donate moisture.
U – Understand the periwound skin. What is the condition of
the skin? Is the skin denuded, macerated or compromised in
some way? Evaluate the edema and pain associated with the
periwound skin. Consider using either adhesive prep wipes or
non-adhesive dressings.
N – Is there necrotic or viable tissue in the wound bed? A
wound that has necrotic tissue, whether slough or eschar,
must be debrided if debridement is consistent with the
patient’s overall goals. There are many options available for
debridement; choose the method that is most appropriate for
your patient. The best course of treatment for some wounds,
such as arterial insufficiency wounds, is to keep the wound
clean, dry and free from trauma and infection.
D – Does the wound have depth? The general principle is that if
there is depth, the depth must be addressed. A dressing that
will lightly fill, not pack, the wound bed is appropriate. If
the wound is flat, simply covering the wound with a dressing
that manages the fluid level is important.
The choices for treatment are based on a complete assessment
of the patient, expected healing time and the amount of
exudate in the wound bed.
2
Necrotic Tissue Protocol
Ye
s
Use TenderWet®
Cavity
Is the wound
Deep?
Start Here
No
s
Ye
Use TenderWet
Active
Is the tissue
necrotic?
No
Go to Cleansing
Wound Cleansing Protocol
Use MicroKlenz
s
Ye
Is there a concern
for bioburden?
No
Use Skintegrity®
3
Ye
s
Primary Dressing Protocol
Use:
Maxorb® Extra,
Optifoam® NonAdhesive
Is the Wound
Deep?
Ye
s
o
N
Use:
Hydrocolloid,
Optifoam,
Gentleheal®
Is the Wound
Draining?
Start Here
Ye
s
No
s
Ye
Use:
Skintegrity Gauze,
Skintegrity Gel
Is the Wound
Deep?
Is the Wound
Healing?
No
Ye
s
No
Use:
Hydrocolloid,
Suresite®,
Dermagel,
Skintegrity Gauze,
Skintegrity Gel
Use:
Maxorb Extra Ag,
SilvaSorb® Cavity,
Arglaes® Powder
Is the Wound
Deep?
No
s
Ye
Is the Wound
Draining?
No
s
Ye
s
Ye
Is the Wound
Infected?
Use:
Optifoam Ag,
Arglaes Island,
Arglaes Powder,
Maxorb Extra Ag,
SilvaSorb Sheet/
Perforated Sheet
Is the Wound
Deep?
Use:
SilvaSorb Gel,
Arglaes Powder
No
No
Use Collagen if the
Wound is Stalled
Use:
SilvaSorb Gel,
Arglaes Powder,
Arglaes Film
4
Secondary Dressing Protocol
s
Ye
Is the Periwound
Skin Intact?
Protect with:
Sureprep®,
Sureprep No-Sting
Use:
Stratasorb®,
Border Gauze,
Tape and Gauze,
SureSite
Ye
s
No
Protect with:
Sureprep No-Sting
Use:
Rolled Gauze,
Co-Flex®,
Stretch Net
Is the Wound on
an Extremity?
No
Protect with:
Sureprep No-Sting
Use:
Stretch Net,
Gentleheal
Transparent Film
Transparent films can be used as a primary or a secondary
dressing. As a primary dressing, they are ideal for a dry to
minimally draining wound. Transparent films help provide a
moist wound environment while helping to promote autolytic
debridement. Transparent films are a barrier to bacteria and
can be left in place for up to 7 days. They are available with
and without antimicrobial properties.
Hydrocolloid Dressing
A hydrocolloid is designed for use as a primary dressing,
coming in direct contact with the wound bed. It is used for
moist to moderately draining wounds. Hydrocolloids promote
a moist wound healing environment while facilitating autolytic debridement. Because of their physical barrier, they
help prevent infection and protect against bacterial invasion
in the wound bed. The dressing can be left in place for up to
7 days. Other dressing choices should be considered if the
5
dressing change frequency is greater than three times per
week because hydrocolloids are completely adhesive.
Hydrogel (Amorphous, Sheets
and Impregnated Gauze)
A hydrogel is a primary dressing that is designed to provide a
moist wound healing environment. In the amorphous form
it can be used to fill a defect, either alone or in an impregnated
gauze application. The sheet can be used for flat to shallow
wounds that need to be kept hydrated while providing gentle
or nonadhesive properties. Hydrogel dressings help with
autolytic debridement and offer antimicrobial properties.
When used appropriately, they can be left in the wound
bed for up to 3 days. Care should be taken when selecting a
secondary dressing to ensure that it does not wick or absorb
the water from the gel into the secondary dressing, resulting
in “drying-out” of the wound bed.
Alginate
Alginate is derived from seaweed and designed to absorb exudate in a wound. It subsequently becomes a gel and facilitates
autolytic debridement while creating a moist wound healing
environment. Depending upon the wet strength of the product, the alginate can either gently fill a wound or be placed
into undermining and tunneling. It can easily be irrigated out
of the wound bed at each dressing change. Depending on the
amount of drainage, the alginate can be left in the wound for
up to 5 days. If there is not enough drainage to gel the dressing, it may be left in the wound for a longer period of time, or
it may not be the right product for that wound. This product
also comes in an antimicrobial form.
Foam
These dressings are designed for use on a moderate to heavily
exudating wound. Foam dressings typically wick the fluid
up into the dressing. When used to manage large amounts of
fluid, they can help with autolytic debridement while maintaining a moist wound healing environment. These dressings
also provide antimicrobial properties. They can be used for
6
wound care as well as around percutaneous sites that may have
increased leaking, or secretions such as a tracheotomy, feeding
tube, and a G or J tube.
This type of dressing is not recommended for use as a secondary dressing; however, if it will help decrease the frequency of
dressing changes by managing more fluid it may be an appropriate choice.
Antimicrobial Dressings
These dressings come in many sizes and shapes. Their use or
design depends on their fluid-handling capabilities. They are
available as powders, films, foams, alginates, sheets, gels and
dressings to fill or cover a wound bed. After careful assessment
of the patient and their wound it may be determined that an
antimicrobial dressing is appropriate not only to manage
the bacteria in the wound, but as a prophylactic dressing as
well. The broad spectrum antimicrobial properties make these
dressings a good choice for chronic wounds, complex situations, patients with known drug resistance and those at risk
for further complications. The most common broad spectrum
antimicrobial added to dressings is silver; however, there are
others with cadexomer iodine and polyhexamethylene
biguanide (PHMB). These dressings are beneficial because
they maintain a moist healing environment, help with
autolytic debridement, and reduce surface bacteria in the
wound bed. They do not allow organisms to replicate, become
cellulitic, or advance to a limb- or life-threatening situation.
Secondary Dressings
Secondary dressings are designed to cover the primary
dressing. They should be chosen based on a similar wear-time
as the primary dressing. There are many additional characteristics to consider including its transparency, absorption, bacterial barrier, and waterproof properties. Other features may
include the ability to secure the dressing without the use of
adhesives. If the patient is not able to tolerate adhesion in the
periwound skin, alternatives should be addressed. This might
include a tubular elastic-type product that can be cut to accommodate several sizes, widths and diameters. An example
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might be a face mask, a pant or pant leg, or a vest. These
characteristics should all be considered based on the careful
assessment of the wound itself and the anticipated outcomes
or goals. Will the adhesion of the primary or secondary dressing be adequate to secure the dressing, or do other measures
need to be utilized?
The dressing should be selected based on a thorough assessment of the patient and the wound. It is expected that as the
wound is progressing through the phases of wound closure
towards healing; less absorptive products will be needed and
increased wear time should be expected. If the wound is not
progressing as expected in a seven to fourteen day time frame,
reassess the patient and wound to determine if there have
been changes and whether or not the wound has the ability
to close.
References:
Baranoski S, Ayello EA. Wound Care Essentials: Practice Principles.
Philadelphia, Pa: Lippincott, Williams & Wilkins; 2004.
Fleck CA. The well-dressed wound. Advance for Providers of Post-Acute Care.
January/February 2005.
Sibbald RG, Woo K, Ayello EA. Increased bacterial burden and infection:
The story of nerds and stones. Advances in Skin & Wound Care. October
2006:447-461.
Tomaselli N. The role of silver preparations in wound healing. JWOCN.
July/August 2006;33:367-380.
Ovington L. Hanging wet-to-dry out to dry. Home Healthcare Nurse.
August 2001;19(8).
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