Wound dressings

Attention

  • Do not use hydrogen peroxide
  • Do not swab wound with cotton wool
  • Do not let wounds dry out. Heal faster and better when kept moist — exception is dry gangrene
  • Use normal saline to clean wounds
  • Only use antiseptic solution if needed to wash dirty or infected wounds — chlorhexidine preferred
  • Syringe irrigate with normal saline or povidone iodine
  • Throw away
    • Chlorhexidine aqueous solution (water-based) 24 hours after opening
    • Chlorhexidine alcohol solution 7 days after opening

Remember:

  • If it is wet you need to control the exudate (ooze)
  • If it is dry you need to hydrate the wound only (except dry gangrene on toes)
  • Consider the whole person, the whole story
  • If in doubt — wound specialist consult

What you do

  • Before dressing wound —
  • Irrigate wound gently with normal saline
  • Use gauze to remove slough
  • When trimming wounds — remove smallest amount of skin/tissue possible
  • Do not trim wound if no foot and/or leg pulses — not enough blood for healing, a small cut while trimming may cause the wound to get worse
  • Select appropriate dressing — see Table 7.1 and How to manage and dress different types of wounds
  • Consider whether dressing
    • Protects wound from secondary infection
    • Provides a warm, moist wound healing environment
    • Can be removed without damaging wound
    • Removes drainage and debris
    • Is free from particles and toxic products
  • Cover dressing with crepe bandage to hide and protect wound if needed
  • Encourage person to shower every day, except where dressings can't be wet
  • Provide appropriate information so person/carer can help with wound care

Table 7.1 Wound dressings  

How to manage and dress different types of wounds

  • Do weekly tracing to make sure wound is healing (getting smaller)
  • If wound continues to improve — continue with same plan/dressing
  • If wound deteriorates or becomes bigger — reassess using TIME 
  • If wound continues to deteriorate — wound specialist or medical consult
Epithelising wounds — wounds that are healing over
  • Protect and encourage healing
  • Use a foam (eg Allevyn, Biatain) or film island dressing (eg Opsite, Asguard)
Granulating wounds — wounds with a red wound base — Figure 7.21

Figure 7.21  
  • Do not debride
  • High exudate — use calcium alginate (eg Algisite)
    • Cover with foam (eg Allevyn, Biatain)
    • OR exudate manager (eg Zetuvit, Mesorb)
  • Low exudate — use hydrogel (eg Solosite, Intrasite) to promote moist environment
    • Cover with secondary dressing that will keep in moisture (eg adhesive foam, hydrocolloid or film island dressing) — see Wound dressings table
Hypergranulation/overgranulation in wounds — wound tissue grows higher than skin level — Figure 7.22

Figure 7.22  
  • Remove overgranulation by debridement
    • Check if person is on anticoagulant therapy (eg warfarin, enoxaparin, rivaroxaban)
  • OR use caustic stick/silver nitrate stick to remove overgranulation
    • Apply paraffin to good skin for protection from nitrate stick
    • Then apply silver nitrate stick to overgranulation
  • OR use pressure pad
    • Cover wound with thick gauze pad
    • Strap firmly in place with strips of non-woven dressing (eg Fixomul)
    • Cut strips in downward direction to the box to get non-stretch weave
    • Apply strips by pulling firmly in different directions
Necrotic wounds — wounds with dry dead tissue — Figure 7.23

Figure 7.23  
  • Check aetiology (cause and circumstances) of wound first (eg diabetes)
  • Debride — but only if adequate pulses are present
    • Surgical debridement may be necessary  — with sharp instrument
  • Score thick necrotic tissue if necessary
    • Use scalpel to cut lines through top layer of thick eschar (dead tissue) to allow gel to absorb into dry hard tissue
  • Needs hydration — use a hydrogel dressing (eg Solosite, Intrasite)
    • If no signs of bacterial infection use film island dressing (eg Opsite, Asguard) or hydrocolloid (eg Comfeel, Duoderm) to speed up rehydration
  • Do not hydrate dry gangrene (black fingers or toes)
    • Paint with povidone-iodine (Betadine) and leave to dry — wound specialist/medical consult
Sloughy wounds — wounds with wet or dry sloughy tissue — Figure 7.24

Figure 7.24  
  • Need dressings that assist with autolytic (natural) debridement
    • Low exudate — use hydrogel (eg Solosite, Intrasite)
    • Moderate to high exudate — use hypertonic saline gauze (eg Mesalt, Curasalt). Do not use on painful wounds
    • High exudate — use calcium alginate (eg Algisite)
  • May need sharp debridement which will speed up healing by stimulating the inflammatory response
Infected wounds — Figure 7.25

*Do not use cadexomer iodine if under 12 years, pregnant or breastfeeding

Figure 7.25  
  • Need topical antimicrobial dressings — silver coated dressing (eg Acticoat) or cadexomer iodine* (eg Iodosorb)
    • Bite wounds/dirty, traumatic wounds — use silver coated dressing
    • Sloughy infected wounds — use cadexomer iodine*. Do not use silver coated dressing on thick slough
  • Do not use hydrocolloid (eg Comfeel, Duoderm) as a dressing cover
  • High exudate
    • Silver coated dressing (eg Acticoat) with calcium alginate (eg Algisite) over the top
    • OR for small wounds — cadexomer iodine* powder (eg Iodosorb)
    • Cover with foam (eg Allevyn, Biatain)  or exudate manager (eg Zetuvit, Mesorb) for absorbency
  • Low exudate
    • Sheet of silver coated dressing (eg Acticoat sheet) — moisten twice a day, or wet daily while showering
    • Cover with non-woven dressing (eg Fixomul)
    • OR for small wounds — cadexomer iodine* ointment (eg Iodosorb) and cover with adhesive foam (eg Allevyn, Biatain) or film island dressing (eg Opsite, Asguard)

Remember:

  • Silver coated dressing (eg Acticoat)
    • Broad-spectrum topical antimicrobial — works within 30 minutes
    • Has anti-inflammatory properties
    • Cannot debride thick slough or necrotic tissue
  • Cadexomer iodine (eg Iodosorb)
    • Do not use if under 12 years, pregnant, breastfeeding
    • Stimulates wounds that are not healing (static) or chronic
    • Reduces colonisation / bioburden of wounds
    • Cleans sloughy infected wounds
Colonised wounds that are not actively infected

Use an enzymatic gel (eg Flaminal)

  • Moderate exudate (eg Flaminal Forte)
    • Cover with adhesive foam (eg Allevyn, Biatain) or exudate manager
  • Low exudate (eg Flaminal Hydro)
    • Cover with adhesive foam (eg Allevyn, Biatain) or film island dressing (eg Opsite, Asguard)

Wounds with high bioburden — a lot of dead or necrotic (non-viable) tissue, offensive odour but not actively infected

  • Wash first with a wound anti-infective (eg Prontosan), rinse thoroughly with normal saline, then apply enzymatic gel (eg Flaminal)
  • OR wash with povidone-iodine for 2 minutes, rinse thoroughly with normal saline, then apply enzymatic gel (eg Flaminal) or cadexomer iodine (eg Iodosorb)
  • Povidone-iodine wash effective in reducing wound colonisation especially MRSA

Hydrocolloid dressing

(eg Comfeel, Duoderm)

  • For wounds with no or low exudate
  • Very good for friction burn/gravel rash. Change daily, it will lift out gravel you have not been able to remove

What you do

  • Leave on for 3–7 days — change daily to remove gravel
  • Change if there is leakage
  • Can use tape to hold onto skin if needed

Non-woven adhesive

(eg Fixomull, Hypafix, Mefix)

  • Use to hold dressings on or to protect healed burns from rubbing or friction (eg under bra straps)

Attention

  • Do not use if skin is fragile or broken 

What you need

  • Non-woven dressing

Also need for removal

  • Do not use Zoff adhesive remover
  • Use non irritating silicone based adhesive remover (eg Niltac, Remove)
  • If not available use oil — olive, vegetable, baby oil. Do not use peanut oil — potential allergic reaction
  • Plastic cling wrap
  • Bandage
  • Sink, bath/shower

What you do

  • Cut amount needed from roll, take off backing paper, put straight on healed burn/wound sticky side down
    • Do not overlap dressing by more than 2cm
    • Do not stretch dressing
  • To cover joint — bend limb, put along line of long bones
  • Explain to person/carer how to care for dressing
    • For first day — keep dry
    • If it gets wet — gently pat dry 
    • After first day — wash gently with ordinary soap and water twice a day, pat dry. Do not soak in water
  • Leave on for 5–7 days

To remove

  • Silicone based adhesive remover (eg Niltac , Remove or Brava) OR
    • Soak dressing all over in oil
    • Wrap in cling wrap and cover with bandage
  • Leave for 4 hours or more — can be left overnight
  • Wash gently in shower/bath, remove dressing

Silver coated dressing

(eg Acticoat)

  • Use for partial thickness burns at risk of infection, full thickness burns smaller than a 20 cent piece. See — Management of minor burns
  • For animal or human bite or dirty injury to reduce risk of infection
  • Coated with slow-release nanocrystalline silver. Keeps wound moist, kills bacteria, stops infection

Attention

  • Do not use if person allergic to silver
  • Water activates silver
  • Do not use saline or salt water, will stop silver working (deactivate)
  • Keep dressing moist not soaking

What you need

  • Sterile water or clean tap water
  • Silver coated dressing (eg Acticoat)
  • Scissors
  • Non-woven adhesive

What you do

  • Set up sterile dressing area
  • Cut piece of dressing a little bigger than wound
  • Wet dressing with sterile or clean tap water then gently squeeze out
  • Wait a few minutes to lessen stinging, then lay dressing on wound (blue side down for Acticoat)
  • Cover with non-woven adhesive
  • Tell person to wet dressing twice a day to activate silver. Do not use saline or salt water
  • Check every day but do not open dressing. Wash any exudate (ooze ) off dressing with clean or sterile water
  • Leave for 3 days

To remove

  • Wash in shower or with normal saline to loosen dressing
  • OR use commercial silicone based adhesive remover (eg Niltac)
  • Do not put oil on non-woven adhesive — not needed as only small amount in contact with healthy skin
  • Brown or silver colouring on unburnt skin is not harmful and will wash off