Wound Assessment and Dressing Selection

Wound Assessment and Dressing

SelectionNoreen Campbell RN BScN MA IIWCC Lt CSW

TCS SystemsNorth Saanich, BC, Canada

Wound Healing Process

Hemostasisimmediate

InflammationDay 1-4

ProliferationDay 4-21

Epithelialisation

Maturation/RemodelingDay 21 - 2 years

Kane

Homeostasis – first 24 hours

‘Meat’

Inflammation 1-4 days

‘Mess’

Proliferation day 4 - 21

‘Full’

Fibrin, Collagen Bridge to Skin• Yellow, caramel like surface, pain• Granulation peeking, epithelial starting

6

Epithelialization

‘Baby skin’

Maturation/Remodeling up to 2 years

Well healed scar – always a scar…weaker tensile strength

• Normal• Hypertrophic

– With incision• Keloid

– Extends to normal tissue ‘stronger’

Potential for HealingIndividual assessment

Wound

Care

10

Tissue depth? Probe…

Infection• Heat• Redness• Swollen• Pain

– Not with neuropathy

– Blood Sugars elevated

11CULTURE

Cochrane Review 2011 water for cleansing

Infection: Assess Clean Wound • Wound

Cleansing– Potable tap

water– Saline– Boiled

cooled water• Mild soap

– Dove no dye or perfume

Wound Imperatives and Antimicrobials

Product Function Cost * CDA 020114Promogran Prisma is above with silver

MMP bindingON the wound “let it dance with the wound”

Promogran 28 sq cm $23.95 123 sq cm $55.95Prisma 28 sq cm $26.95

Iodosorb cadexomer iodine

Cochrane level support red. Infection, promote healing, but pain reports may limituse

Ointment $21.95 10 GmPaste $58.95not recommended

Inadine povidone iodine

Non-adherent sheets 9.5x9.5cm $2.30

Silver dressings Support of efficacy lacking Expensive 4x4” $18.95

Honey dressings Support of efficacy lacking Expensive $24.95 50gm

Canadian Diabestes Association Store – dodi.forbes@diabetes.ca

Eschar: risk infection and delay healingStable

• Black• Dry• Hard

Wet• Drainage• Marbling• Breakdown

Iodosorb + cast padding Inadine PHD

Autoamputation?

Debride

Debride Unstable Eschar• Drainage• Fluctuance

• Iodine produce will become paler with release of iodine

Debridement Advantage DisadvantageSurgical Fast Surgery, expensive,

pain, non-selectiveConservative Sharp Bedside, pain, Scope of practice

Skill Maggot Selective, disinfect

wound, stimulate healing

Ordering process, $120 treatment, dressing change 48 hours

Enzyme (Santyl) Selective $90-120 tube, weeks

Mechanical Wet to dry Saline Compresses Irrigation Shower

Non-selective Pain (wet to dry)Labour - compresses

Autolytic (natural) Moisture (gel)

Natural, selective Slow

16

MDT 4 days

17

What type of debridement?

18

92yo anesthetic riskTrauma scooter accidentInner thigh

Differentiation: drainage or allergy?

• Contact Dermatitis– pattern

• Sensitivity– Localized to

wound and product

• Drainage– Direction of

pooling

Blister: drain if risk expansion

20

Edge: Undermined, rolled edge

Packing – think ‘wicking’.

Dressing: think ‘Band Aid’‘protect, absorb, hold layers’

Function Product CostProtection Surface protection

Silicon (7 days) severe pain or fragile

Mepitel $11.50 4”x7”

Inadine (antimicrobial+) Inadine $2.30 4”x4”

Jelonet (petrolatum mesh) 10cmx40cm $3.50Tin 10 cm x 7M $36.00

Adaptic non-adherent $3.75 3”x8” 3pkg

Absorb Alginates – lowest absorb., sticks if insufficient exudate

Hydrocolloid Minimal exudate containment and hold

Do not recommend

There are no standards for stating performance of dressings (i.e. absorption). Standard for approval ONLY safety not efficacy.

Function Product CostFoam Rated high exudate but

generally <5ml 4”x4” protection layer built into dressing

Fragile skinAdhesive border strength varies and can damage skin, change when drainage at border

Mepilex 3”x3” $3.75Allevyn Gentle 3x3 $3.95Tegaderm 3.5”x3.5” $4.59**do not recommend unless dressing one week

Acrylic poor expensive Do not recommend

Absorbent Dressing

Classic Pads- incontinent pad 17x20cm can hold 750ml (stay dry)

10x20cm 3 $1.95Ultra 17x40cm 2 $3.00Classic super 50 $33.00

Gauze – chronic wound or > 48 hours Clean not Sterile

poor absorption Adequate cover dry gangrene

2x2” 200 $1.954x4” 200 $6.50Non-sterile clean package

Cast padding Holds dressings padding Protouch 17 rolls $17.59Single roll $1.50

Function Product CostTape – peal factor is tension to remove, adhesive is ability to hold

Fragile skin may strip or tear.

*consider skin strength**how many dressings***how frequentOrder of peal factorTranspore (3M) +++Kind Removal (3M) ++Mepitac silicon +

Transpore $1.65 roll

Kind Removal silicon roll $6.95

Mepitac silicon $11.50

Stockinet - TubiFastRoll or meter*

Blue normal limb adultYellow larger

Blue 10M $16.95*Yellow 10M $10M $23.75

Tubigrip elastic Size determines pressure – straight may constrict limb

Skin barriers If you need these the products are not appropriate

Steroids Good for immediate skin reactions i.e venous excema