Wound care lectures

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Wound care lectures

  1. 1. Lecture 2. Wound managementproducts WOUND AND PAIN MANAGEMENT 3971 1 RALUCA DUCAR/ 3971NRS/ 2010-2011
  2. 2. LEARNING OBJECTIVES1.Understand the “TIME” concept in woundmanagement2.Discuss debridement as part of treatment plan.3.Identify signs of infection and discuss interventionsrelated measures.4.Discuss the benefits of maintaining moist woundenvironment.5. Describe the properties of the eight main categoriesof wound dressing. 2
  3. 3. 6. State indication, precautions and contraindicationsof the each of the wound dressings7. Discuss new advances in wound management(tissue adhesive, growth factors, biosynthetic dressing).8. Compare sterile with clean techniques for woundcare.9.Identify types of antiseptic agents used for woundcare 3
  4. 4. EXPECTED OUTCOMESBy the end of the session you will be able to: 1.Demostrate understanding of wound management principles related to “TIME” frame. (wound debridement, managing infection, keeping moisture wound environment) 2. Recognize types of antiseptic agents used for wound care 3. Differentiate between the 8 main types of dressings 4
  5. 5. 4.Demonstrate willingness to gain more knowledge related to advanced methods used in wound care (web search) 5. Apply learned principles of dressing techniques in clinical settings PREREQUISITES- MYERS (2008) chapters 5 ,6,7 (pp.70-155)- Potter,P.A.,Perry,A.G.,(2009).Fundamentals of Nursing.(7th ed).Mosby pp.1313-1321- Lecture handout 5
  6. 6. WOUND BED PREPARATION -WBPTo achieve an effective outcome, a wound should have:1. Well-vascularized wound bed2. Minimal bacterial burden3. Little or no exudate 6
  7. 7. WBP has 4 aspects1. Debridement2. Exudate management3. Bacterial imbalance resolution4. Undermined epidermal margin (Schulth et.al.2003) 7
  8. 8. FALANGA (2004) HAS UTILIZED THE WORK OFSCHULTZER ET AL. (2003) TO DEVELOP A FRAMEWORKCALLED TIME TO PROVIDE A COMPREHENSIVEAPPROACH TO CHRONIC WOUND CARE. T Tissue management ( non- viable) I Inflammation & infection control M Moisture Balance E Epithelial Edge advance 8
  9. 9. T-TISSUE MANAGEMENT PREDOMINAT TYPE OF NECROSISESCHAR SLOUGH FIBRIN HYPERKERATIN GANGRE OSIS NEHard Soft, soggy Soft, soggy Hard HardSoft, soggy Soft stringy Soft, Soft, soggy Mucinous stringyBlack/brown Yellow/tan Mucinous White/gray Black/brow yellow/whit nFirmly Firmly e Firmly attachedattached attached Firmly Attached Surrounds wound attachedAttached base Attached base base adges Loosely Loosely attached attached 9 clumps clumps
  10. 10. Tissue management Assessment for non viable tissue. Wound debridement is the principle intervention Is the removal of necrotic tissue, foreign material and debris from the wound bed (Myers, 2008) 10
  11. 11. T-TISSUE MANAGEMENTPurposes of debridement• Decrease bacterial concentration within the wound bed and the risk of infection.• Increase the effectiveness of topical antimicrobials.• Improve the bactericidal activity of leukocytes.• Shorten the inflammatory phase of wound healing.• Decrease the energy required by the body for wound healing.• Eliminate the physical barrier to wound healing.• Decrease wound odor. 11
  12. 12. Debridement options• Sharp or surgical• Autolytic• Enzymatic• Mechanical• Biosurgery or larval therapy 12
  13. 13. Sharp or surgical: involves using forceps,scissors, or a scalpel to selectively remove devitalizedtissue, from a wound bed. Fastest and most aggressive.Autolytic: uses the body’s own (endogenous)enzymes, including collagenase to digest necrotic tissueand macrophage to phagocytose debris by applying amoisture retentive dressing and leaving it in place forseveral days (Hydrocolloids, hydrogels, & alignates). 13
  14. 14. Enzymatic or chemical debridement: isthe use of a topical exogenous enzyme(collagenase, elastase, & fibrinolysin) toremove devitalized tissue.Mechanical: involves the use of force toremove devitalized tissue, foreign matter, anddebris. Nonselective debridement type thatincludes: - Wet-to-dry dressings - High Pressure wound irrigation - Whirlpool baths 14
  15. 15. Biosurgical or larval parasitic1. Mechanical movement loosen surface debris2. larvae secrete enzymes into the wound that break down necrotic tissue to a semi-liquid form3. Larvae ingest the dead tissue, leaving only the healthy tissue. 15
  16. 16. GENERAL DEBRIDEMENT INDICATIONSTHE RED-YELLOW-BLACK SYSTEMCOLOR WOUND BED TREATMENT GOALS DESCRIPTIONRED Pale, pink,beefy red Protect wound granulation tissue Maintain worm , moist environment Protect periwoundYELLOW Moist yellow slough Debride necrotic tissue Vary in adherence Absorb drainage Protect periwoundBLACK Thick ,black,adherent Debride necrotic tissue eschar, 16
  17. 17. GENERAL CONSIDERATIONS FORDEBRIDEMENT Wound characteristics- etiology, size, presence of infection, amount of necrotic tissue Patient’s general health, nutrition and other medical conditions (immunosuppression, thrombocytopenia) 17
  18. 18. I INFLAMMATION/ INFECTION 18
  19. 19. Specific Treatment Objectives for Infected wounds• To identify the infective organism.• To control and/or eliminate wound infection.• To remove devitalized tissue from the wound bed.• To cleanse the wound surface.• To absorb excess exudate production.• To protect the surrounding skin from the effects of maceration.• To control pain/discomfort. 19
  20. 20. HOW DO WE KNOW THE WOUND ISINFECTED? ASSESSMENT:- five cardinal signs of infection:R.C.T.D.F- Decline in wound status- Detect presence of silent infectinos- abcess Presence of biofilms with incresed bacterial resistance Wound cultures (tissue biopsy and swab cultures) 20
  21. 21. HOW DO WE TREAT AN INFECTEDWOUND? 1.Topical antimicrobial therapy- in order to provide an agent that destroys the offending organism - topical ointments or creams are applied to wound surface, penetrate the wound bed to the site of infection and inhibit bacterial growth - use of antimicrobial-impregnated wound dressings - use of silver as broad spectrum antimicrobial 21
  22. 22. Advantage of topical antimicrobial use is : -lower cost than systemic therapy and easeof application -it will decrease bacterial load if appliedproperly -they are applied direct to wound bed – betterto treat wounds with compromised circulationDisadvantage :- needs frequent application -sensitivity and allergic reactions - increased chance for microbes to becomeresistant 22
  23. 23. 2. ANTISEPTIC AGENTS(ACETIC ACID, Antimicrobial solutionCHLORHEXIDINE, HYDROGEN that preventsPEROXIDE, POVIDONE-IODINE) infection by killing microorganisms Previously were considered to reduce the rate of infection and speed wound repair Research showed that beside being broad-spectrum anti microbial, antiseptic agents are also cytotoxic to fibroblast, kerationcytes and neutrophyls ----------increse the duration of inflammatory response and delay epithelialization and wound contraction 23
  24. 24. Used to decrease bacterial growth on inanimate objectsReduce bacterial concentrations on intact skin- used assurgical scrubCan be used for short period of time on open wounds e.g. patients with bite from animals inthe farm can have short term use of povidone-iodinebecause this wounds are multimicrobial (Myers, 2008;p.104-113) 24
  25. 25. 3.SYSTEMIC ANTIMICROBIALTHERAPY Prescribed for patients with sepsis or deep space infections , alone or in combination with topical antibiotics Advantage –reduce bacterial load, better patient compliance with treatment Disadvantage- more frequent and severe adverse reactions, development of resistant stains 25
  26. 26. REVIEW: T- TISSUE MANAGEMENT DEBRIDMENT Sharp or surgical Autolytic Enzymatic Mechanical Biosurgery or larval therapy I- INFECTION/ INFLAMMATION 26
  27. 27. M M MOIST WOUND HEALINGTraditional theory says: “wounds should be kept dry andclean so that scab can form over the wound” Sussman,Bates-Jensen(2008)Practice shows that scab is a barrier to healing- because itinterferes with moving of epithelial cells- poor cosmeticresults and scarringThe wounds should be managed in a moist environment soepithelial cells will be able to moveMoist wound heals 3-5 times faster than dry wound becausemoist facilitates the three phases of wound healing process.Myers (2008) 27
  28. 28. The amount of moisture is not known exactly--a wound too dry will result in crust formation and will lack the enzymes and growth factors that facilitate healing-a wound that is to wet can delay healing because of the extra fluid around the wound which will produce maceration of tissue 28
  29. 29. DRESSINGS -FUNCTIONCreate a moist wound environment - if wound too wet-dressing will absorb the excessexudate - if wound too dry- dressing will donate moistureto itProvide thermal insulation maintain temp.37-38degrees C -this temp. increases oxygen saturation anddecreases hemoglobin’s affinity for oxygen. 29
  30. 30. -wound dressing should protect against infection- wound dressing should protect exposed nerveendings, decreasing the pain-provide hemostasis, edema control elimination of dead -dead space=void left by a wound cavity,undermining or tunneling---it must be avoided toprevent abscess formation and premature woundclosureProvide gas exchange between wound andenvironment 30
  31. 31. TYPES OF WOUND DRESSING PRIMARY DRESSING-Comes in direct contact with wound e.g.Band Eid SECONDARY DRESSING-Placed over primary dressing to improve protection e.g. Self-adhesive bandage placed over primary dressing 31
  32. 32. CLINICAL DECISION MAKING MOST APPROPRIATE WOUND CARE- 32
  33. 33. MOISTURE RETENTIVE DRESSINGMaintain an ideal wound healing enviromnentAre specialized synthetic or organic dressings that aremore occlusive than gauzeDescribes the ability of a dressing to transmitmoisture ,vapor and gases from wound toatmosphereHave a lower moisture vapor transmission rate thangauzeAllows patients to bathe, swim without contaminatingthe wound 33
  34. 34. Maintain wound temperature better than gauzeProtect the wound from trauma and infectionAre adhesive---there is no need for secondarydressingAre elastic and stay in place for 3-7 daysStimulate granulation tissue formation, collagensynthesis and epithelializationMain risk for using moisture retentive dressing INFECTION TRAUMA TO THE WOUND BED MACERATION OF SURROUNDING SKIN 34
  35. 35. 8 TYPES OF DRESSING1.GAUZE DRESSING2.IMPREGNATED GAUZE3.SEMIPERMEABLE FILMS4.SHEET HYDROGELS5.SEMIPERMEABLE FOAMS6.HYDROCOLLOIDS7.ALGINATES8.COMPOSITE DRESSINGS 35
  36. 36. 1.. GAUZE DRESINGS WOVEN GAUZE--made of cotton yarn or thread NONWOVEN GAUZE –-made of synthetic fibers pressed together (have grater absorbency) Loose weave gauze- aids in medical debridement but should not be placed over granulating tissue Gauze is highly permeable and nonocclusive and can be used as primary or secondary wound dressing 36
  37. 37. MULTILAYER GAUZE DRESSINGS- Outer nonocclusive layer ----allows gas exchange- Middle antisher layer ---------moves with the patient- Nonadherent contact layer—allows absorbtion of exudates, reduces moisture less risk for maceration ANTIMICROBIAL-IMPREGNATED GAUZE- The use of such products should be limited ----reduce the potential of developing resistant microorganisms 37
  38. 38. COMMON USESBoth infected and noninfected woundsLarge wounds or irregularly shapedPacking strips to prevent premature closure or keepaway exudates in tunneling or underminig woundsCAN BE USED ALONE OR IN COMBINATIONWITH ANTIBIOTICS, ENZYMES, GROWTHFACTORS, ALGINATES,SEMIPERMEABLE FOAMSOR FILMS 38
  39. 39. PRECAUTINONS /CONTRAINDICATIONS 1.woven gauze require more force to remove---- potential wound trauma 2.woven gauze may leave residue to which body will respond by forming granuloma rolled gauze should be applied snuggly but without tension---to prevent a tourniquet like effect Telfa dressing---nonadherent, little absorption , keeps wound exudates close to wound---maceration of tissue 39
  40. 40. 2IMPREGNATED GAUZE DRESSING Mesh gauze non adherent, moderate occlusive, Impregnated with petrolatum, bismuth, zinc Petrolatum impregnated gauze might facilitate wound healing by decreasing trauma during dressing Can be used as contact layer on granulating wound beds, combined with secondary gauze dressing Used to burn wounds because have pain free removal 40
  41. 41. PRECAUTIONS/CONTRAINDICATIONS Bismuth (from xeroform dressings) is cytotoxic to inflammatory cells-----cause increased inflammatory response (not advisable for pt with venous insufficiency ulcer) Iodine-impregnated gauze cytotoxic to human cells only mild antimicrobial 41
  42. 42. 3. SEMI PERMEABLE FILMSThin flexible transparent sheets with adhesive backingPermeable to water vapor, O2, CO2 but impermeableto bacteria and waterHave little absorptive capabilities , but are comfortablebecause of elasticityShould be applied without tension and wrinkles andcan stay in place for 5-7 daysShould NOT be used in cavity wounds or when heavydrainage is noted 42
  43. 43. •COMMONLY USED FOR SUPERFICIALWOUNDS (TEARS, LACERATIONS,ABRASIONS), INTRAVENOUS CATHETERSITES, AREAS OF FRICTION to prevent maceration ---apply on areas of intact skin-skin should not be oily or wet-if a channel or wrinkle forms----change dressing-NOT to be used on infected wounds 43
  44. 44. 4. SHEET HYDROGELS80-90% water or glycerin based wound dressingAbsorb minimum amount of fluid by swellingDonate moisture to dry woundsDecrease pain by cooling the wound bedAre permeable to gas and water---less effectivebacterial barrier 44
  45. 45. PRECAUTIONS/CONTRAINDICATIONS Are not able to absorb heavy drainage Are absorbing very slowly----should not be used on bleeding wounds Require secondary dressing : USE minimal or moderate draining wound -can be used within casts or splints to decrease pressure - Effective at softening eschar to facilitate autolytic debridment 45
  46. 46. 5. SEMIPERMEABLE FOAMSMade of polyurethaine, permeable to gas but notto bacteriahave high moisture vapor transmissionProvide thermal insulationEffective in treatment of stage II and III pressureulcer 46
  47. 47. - WOUNDS WITH MINIMAL AND HEAVYUSES EXUDATES -GRANULATING OR SLOUGH COVERED PARTIAL AND FULL THICKNESS WOUND -SEMIPERMEABLE FOAMS –USED IN DONOR SITES , OSTOMY SITES, MINOR BURNS, DIABETIC ULCER PRECAUTIONS-Not recommended in dry or eschar-covered wounds-not indicated for arterial ulcers---because of enhancing dryness- Not indicated for area of high friction—heel ulcers 47
  48. 48. 6.HYDROCOLLOIDSContain hydrophilic colloid particles like gelatin,pectin,Have various absorption abilitiesAbsolves exudates by swelling into a gel-likemassProvide thermal insulation to wound bedImpermeable to water, oxygen ,bacteria 48
  49. 49. Uses- indicated for partial and full-thickness wounds -can be used on granular and necrotic wounds -used on minor burns, and pressure ulcers Duo Derm- effective barrier against urine, stool, MRSA, hepaB,HIV and Pseudomonas Arginosa 49
  50. 50. 7. ALGINATES Contain salts of alginic acid from sea weeds and covered in calcium/sodium salts When placed on wound, it reacts with the serum and forms a hydrophilic gel Are highly permeable and non occlusive----require secondary dressing Stimulate macrophage activity Uses: highly draining wounds-partial and full-thickness wound-granular and eschar-covered wounds 50
  51. 51. PRECAUTIONS/CONTRAINDICATIONSNot recommended for use on full thickness burnsNot to be used on wounds with exposed tendon, jointcapsule, boneUse with moisture barer to protect periwound skinfrom maceration 51
  52. 52. 8. COMPOSITE DRESSING Multilayer dressing that can be used as primary or secondary wound dressings 3 layers 1. -inner contact-non adherent, prevents trauma to wound bed when dressing changes 2.-middle layer-absorbs moisture and keeps it away from wound bed to prevent maceration 3.-outer layer-bacterial barrier 52
  53. 53. SILVER DRESSING-silver is antiseptic-dressings may be primary or secondary, adhesive or non-adhesive-release of silver ions----blue-black wound discolorationNo evidence that silver is effective in presence of slough or escharSilver is cytotoxic to fibroblast 53
  54. 54. CHARCOAL DRESSING Key function of dressings is to control wound odor by absorbing odor producing gases released by bacteria---- --improve the quality of life for patients by allowing them to share with normal social activities 54
  55. 55. SUMMARYMANAGING EXUDATES WITHDRESSINGType of wound Optimal dressing0=dry Hydrogels, hydrocolloids, interactive wet dressings1=minimum exudates Hydrogels, hydrocolloids, semipermeable films, calcium alginates2= moderate exudates Calcium alginate, hydrofibre, hydrocolloid paste/powder, foams3=heavy exudates Hydrofibre dressings, foam sheets/cavity, wound/ostomy bags 55
  56. 56. WHEN CHOOSING TYPE OFDRESSING USED WE HAVE TOCONSIDER ALSO THESURROUNDING SKIN EDGE ,EPITELIAL ADVANCEMENT ESigns of epithelial (edge) advancement1. WB filled with granulating tissue.2. Epithelialization at the wound margins. 56
  57. 57. THE FOLLOWING QUESTIONSSHOULD BE ANSWERED PRIOR TOTHE CLEANSING OF ANY WOUND:1. What is the purpose of wound cleansing?2. What method of wound cleansing would be most appropriate?3. Does the wound require cleaning at each dressing change?4. What type of wound cleansing product would be most appropriate? 57
  58. 58. 1.THE PURPOSE OF WOUND CLEANSING: • Wound infection. • Excessive exudate. • Presence of foreign bodies, debris, eschar or slough. • A need to reduce contamination or devitalised tissue prior to suturing, in wounds healing by delayed primary intention (i.e. tertiary intention). 58
  59. 59. DECIDING TO CLEANSE A WOUNDSHOULD BE BASED ON THEFOLLOWING:• The size, shape and location of the patient’s wound.• The condition of the wound and stage of healing.• The availability and effectiveness of different methods of cleansing.• The availability and effectiveness of different cleansing agents.• The patient’s perceptions and needs 59
  60. 60. CLEANSING TECHNIQUE• Clean versus sterile technique• Use of Normal saline and tap water• Hand washing is essential to reduce infection• Wound field concept• Dirty hand & clean hand 60
  61. 61. IRRIGATION VS.SWABBINGSwabbing the wound surface of a woundmay mechanically dislodge loose,devitalised tissue but does not activelyremove pathogens from the wound.Irrigation under pressure is an effectivemethod of cleansing wounds that areinfected or heavily contaminated. Highpressure irrigation using a 30ml syringeand an 18-20G needle lowers the infectionrates in contaminated wounds. 61
  62. 62. STERILE VS.CLEAN TECHNIQUE Sterile technique -is defined as use of sterile equipment, ( gloves,wound dressing, instruments) in order to reduce exposure to microorganisms.-----------only sterile items may contact the pt’s wound,------------use of sterile gloves and sterile field------------meticulous set-up and maintenance of sterile field ( review table.6-8,p.117 text book) 62
  63. 63. Clean technique- procedures that reduce overall number of microorganisms-------------------hand, washing, sterile instruments-------------------use of clean gloves and maintenance of clean field-------------------use clean hand dirty hand dressing procedure (see table 6- 10,p.117,text book) 63
  64. 64. CONCLUSION OF RESEARCH- No difference in the rate of wound healing was found when comparing sterile with clean technique dressing-clean technique less expensive----clean technique----standard in wound management-sterile technique---reserved for wounds that require packing, severe burns, wounds of immunosupressed patients 64
  65. 65. CLEANING AGENTS Antiseptics Antibiotics Honey Saline 0.9% Tap water 65
  66. 66. ANTISEPTICS• Defined as a non-toxic disinfectant, which can be applied to skin or living tissues & has the ability to destroy vegetative compounds, such as bacteria, by preventing their growth.• If antiseptics are simply used to wipe across the wound surface, they will have little effect.• They need to be in contact with bacteria for about 20 min. before they actually destroy them.• They can applied in the form of soaks or incorporated into dressings, ointments, or creams. 66
  67. 67. LOTIONS - ANTISEPTICS1. Cetrimide2. Chlorhexidine3. Hydrogen Peroxide4. Iodine5. Potassium Permanganate6. Proflavine7. Silver8. Sodium Hypochlorite
  68. 68. LOTIONS - ANTISEPTICS1. Cetrimide• Useful for its detergent properties, particularly for the initial cleansing of traumatic wounds or the removal of scabs & crusts in skin disease.• It is mostly only used in ER for initial cleansing of wounds rather than a routine cleanser• Two dangers should be noted: - Skin irritation & sensitivity - Very easy to become contaminated by bacteria, especially Pseudomonas aeruginosa. (Dealey, 2005)
  69. 69. LOTIONS - ANTISEPTICS• It is available as a cream or as a lotion in combination with chlorhexidine. 69 (Dealey, 2005)
  70. 70. LOTIONS - ANTISEPTICS2. ChlorhexidineIt is effective against G-ve & G+ve.It could maintain its antimicrobial levels for a period of time when impregnated into a dressing.However, its efficacy is rapidly diminished in the presence of organic material such as pus or blood. 70 (Dealey, 2005)
  71. 71. LOTIONS - ANTISEPTICSIt is more suitable for disinfection & hospital hygiene rather than wound care 71 (Dealey, 2005)
  72. 72. LOTIONS - ANTISEPTICS3. Hydrogen Peroxide 3%• Effective against anaerobes• It loses its effect when comes in contact with organic material such as pus or cotton gauze.• Cytotoxic to fibroblast unless diluted to a strength of 0.003%. This dilution is not effective against bacteria. But, this dilution still inhibits keratinocyte migration & proliferation. (Dealey, 2005)
  73. 73. LOTIONS - ANTISEPTICSIt is no longer widely used as there is no evidence to demonstrate its efficacy & there are number of other more alternatives. (Dealey, 2005)
  74. 74. LOTIONS - ANTISEPTICS4. Iodine• Broad-spectrum antiseptic• Used in wound care as povidine iodine 10% which contains 1% iodine.• Used as a skin disinfectant & to clean grossly infected wounds.• Effective against MRSA. (Dealey, 2005)
  75. 75. LOTIONS - ANTISEPTICSDebate…?Lineaweaver et al. (1985) found that it is Cytotoxic to fibroblasts unless diluted to 0.001%, retards epithelialization & ↓ the tensile strength of the wound.However,Bennet et al. (2001) found that it significantly ↑ fibroblast proliferation slightly ↑ neodermal regeneration & epithelialization. (Dealey, 2005)
  76. 76. LOTIONS - ANTISEPTICS• In 2003, Selvaggi et al., have reviewed & appraised the role of iodine & concluded that povidine iodine is an effective antibacterial that is superior to other products & has no problems with resistance. Iodine should not be used for the patients with thyroid disease or those who are sensitive to the product. 76 (Dealey, 2005)
  77. 77. LOTIONS - ANTISEPTICSPovidine iodine is available in ointment, spray, & powder form & impregnated into dressings. Betadine 77 (Dealey, 2005)
  78. 78. LOTIONS - ANTISEPTICS5. Potassium Permanganate 0.01%• Used on heavily exuding wounds.• Generally, associated with leg ulceration.• Found in the form of tablets; to be dissolved in 4 L of water. (Dealey, 2005)
  79. 79. LOTIONS - ANTISEPTICS6. Proflavine• Has a mild bacteriostatic effect on G+ve, but no effect on G-ve.• It is available as a lotion 79 (Dealey, 2005)
  80. 80. LOTIONS - ANTISEPTICS7. Silver• Has a bactericidal effect on a wide range of bacteria (Dealey, 2005)Problem• It is extremely caustic, stains the skin black.• Prolonged use causes ↓Na, ↓K, & ↓Ca (Dealey, 2005)Solution• To overcome these problems → a cream, silver sulphadiazine, was developed → successful in controlling burn wound infections (Lansdown, 2004)
  81. 81. LOTIONS - ANTISEPTICSAvailable in 3 modalities:• Liquid (Silver Nitrate)• Cream (Silver Sulphadiazine)• Silver-coated dressing (Dealey, 2005)
  82. 82. LOTIONS - ANTISEPTICS8. Sodium HypochloriteOriginally used in the 1st World War.Have few beneficial effects & do much harm. (Dealey, 2005)
  83. 83. LOTIONS - ANTIBIOTICS• D’Arcy (1972) recommends that any antibiotic that is used systematically should not be applied to the skin. However, antibiotics that are not appropriate for systemic use may be developed for use on the skin or in wound care.• → creams, gels, ointments or impregnated dressings containing gentamicin, tetracycline, fusidic acid, or chlortetracycline. Should not be used as these antibiotics are used systematically (Dealey, 2005).• Mupirocin could be used for treatment of MRSA (Dealey, 2005)
  84. 84. LOTIONS - ANTIBIOTICS• A range of antibiotics is available in topical form.• There is considerable risk of sensitization to the patient as well as the development of resistance organisms.• Systematic antibiotics are the treatment of choice when treating infected wounds. (Dealey, 2005)
  85. 85. LOTIONS - HONEYHoney has been used in wound care since ancient times.Mole (1999) discussed the role of honey & its properties: Antibacterial action Deodirising action Debriding action Anti-inflammatory action Stimulation of wound healing Pain relief (Dunford & Hanano, 2004)
  86. 86. LOTIONS – TAP WATER• Is being used more frequently on wound areas already colonized such as wounds following rectal surgery of foot ulcer.• Using tap water to clean wounds did not differ from using sterile normal saline in respect of wound infection and healing rates. (Fernandez, Griffiths, & Ussia, 2002) 86
  87. 87. LOTIONS – SALINE 0.9%• The only completely safe cleansing agent & is the treatment of choice for use of most wounds.• It is used in conjunction with many of the modern products.• It is presented in sachets, small plastic containers, & aerosols. (Dealey, 2005)
  88. 88. REVISION OF DRESSING TYPES1. Inert non-stick dressings Gauze Paraffin tulle dressings (Jelonet®, Bactigras®) Non-paraffin, non-tulle, woven products, (e.g. Adaptic®, Inadine®) Non-stick dressings (e.g. Melolin®, Cutilin®) CombinePrimary dressing:• Protective low absorption dressing (Carville, 2005; Dealey, 2005)
  89. 89. DRESSING TYPES REVIEWApplication:• Clean wound base• Place shiny side of dressing to wound.• May require soaking if exudate strikethrough has occurred.Contraindications/Possible Side effects:• Harsh debridement of the wound bed if exudate dries• Limited use as a primary dressing• Dries out the wound bed (Carville, 2005; Dealey, 2005)
  90. 90. DRESSING TYPES REVIEW2. Film dressing Opsite Flexigrid® Opsite Post-Op® Tegaderm® Polyskin®Primary and secondary dressing:• Low exudating wounds, protective dressing. (Carville, 2005; Dealey, 2005)
  91. 91. Application:• Clean wound base• Prepare peri-wound area with a protective barrier wipe.• Apply adhesive side to wound and remove outer layer.• Adhesive strongest in first 24 hours; can remain for 7 days.• Observe for maceration, remove if this occurs.Contraindications/ Possible Side effects:• Do not apply to infected wounds or if allergic to tapes.• NB: Green sided Opsite is for wounds, orange sided Opsite is for vascular access devices. 91 (Carville, 2005; Dealey, 2005)
  92. 92. DRESSING TYPES REVIEW3. Foam dressings Allevyn® Allevyn Adhesive® Allevyn Cavity® Cavi-Care®Primary and secondary dressing:• Light/mod/highly exudating wounds, protective dressing, cavity wounds. 92 (Carville, 2005; Dealey, 2005)
  93. 93. Application:• Clean wound base• Read packaged for insertion side (patterned or shiny side up)• Sheet foam left insitu up to 7 days (24 hours if infected)• Cavity foams left insitu up to 14 days (daily washing of foam if infected)Contraindications/ Possible Side effects:• Avoid covering with occlusive dressings.• Avoid wounds dressed with antibacterial solutions. 93 (Carville, 2005; Dealey, 2005)
  94. 94. DRESSING TYPES REVIEW4. Hydrogel dressings Solugel® Intra site® Gel Solosite® Gel Clear-Site® Duoderm® Gel Aquaflo®Primary dressing:• Slough or necrotic wounds requiring chemical debridement.• Light/moderate exudating wounds, hydrate dry wounds. 94 (Carville, 2005; Dealey, 2005)
  95. 95. 5. Hydrocolloid dressings Duoderm Extra Thin® Duoderm CGF® Duoderm® Paste Comfeel Plus Transparent® Comfeel Plus® Contour Dressing Comfeel Plus® Pressure Relieving Dressing Comfeel® Paste Comfeel® PowderPrimary and secondary dressing:• Slough wounds requiring autolytic debridement, low/moderate exudating wounds. 95 (Carville, 2005; Dealey, 2005)
  96. 96. Application:• Clean wound base, wipe peri-wound with barrier wipe.• Warm product in hands to activate adhesive.• Place adhesive side to wound.• Leave at least 2 cm border around wound.• Can be left insitu up to 7 days, dependant on exudate level.• Dressing becomes opaque when due for change.Contraindications/ Possible Side effects:• Do not apply to infected wounds or if client is allergic.• Remove if patient complains of discomfort. 96 (Carville, 2005; Dealey, 2005)
  97. 97. WOUND DRESSINGS REVIEW6. Alginate dressings Kaltostat® Algoderm® Sorbsan® Curasorb® Kaltocarb®Primary dressing:• Heavily exudating, bleeding, slough or infected wounds. 97 (Carville, 2005; Dealey, 2005)
  98. 98. Application:• Clean wound base• Lightly pack or line the wound, product swells with exudate.• Avoid pre-moistening the product.• Discontinue use if the dressing remains dry.• Can be left insitu up to 4 days, dependant on exudate level.• Requires a secondary dressing.Contraindications/ Possible Side effects:• Do not use on dry wounds as it dehydrates the wound bed. 98 (Carville, 2005; Dealey, 2005)
  99. 99. WOUND DRESSING REVIEW7. Hydrofiber dressings AquacelPrimary dressing:• Heavily exudating or infected wounds. 99 (Carville, 2005; Dealey, 2005)
  100. 100. Application:• Clean wound base.• Line the wound base with product.• Cover with a secondary dressing.• Can be left insitu up to 7 days, dependant on exudate level.Contraindications/ Possible Side effects:• Heavily infected wounds require Hydrofiber impregnated with Silver.• Do not use in people allergic to hydrocolloids. 100 (Carville, 2005; Dealey, 2005)
  101. 101. WOUND DRESSING REVIEW8. Non-crystalline Silver dressings Acticoat® Aquacel Ag® Actisorb plus® (charcoal)Primary dressing:• Infected wounds (150 pathogens including MRSA and VRE), burns, donor and recipient sites. 101 (Carville, 2005; Dealey, 2005)
  102. 102. Application:• Clean wound base.• Moisten product with sterile water, daily if not enough exudate.• Cut to wound size and shape, apply blue side down.• Cover with a secondary dressing.• Can be left insitu up to 7 days, dependant on exudate level.Contraindications/ Possible Side effects:• Do not use on people going for a Magnetic Resonance Imaging.• Do not use in people allergic to silver. 102 (Carville, 2005; Dealey, 2005)
  103. 103. WOUND DRESSING REVIEW9. Zinc dressings Steripaste® Viscopaste® Flexidress® Gelocast®Primary dressing:• Slough wounds, epithelializing wounds and to protect limbs at risk of skin tears or degloving. 103 (Carville, 2005; Dealey, 2005)
  104. 104. Application:• Cut length as required, usually 3-4 times the size of the wound .• Fold to make a patch and place over wound.• Requires a secondary dressing.• Can be left insitu up to 7 days.Contraindications/Possible Side effects:• Allergy to zinc 104 (Carville, 2005; Dealey, 2005)
  105. 105. WOUND MANAGEMENT PRODUCTS10. Other dressings Cadexomer Iodine Vacuum assisted closure (VAC) 105 (Carville, 2005; Dealey, 2005)
  106. 106. REFERENCESSchultz, G.S., Sibbald, R.G., Falanga, V., Ayello, E.A., Dowsett, C., Harding, K., Romanelli, M., Stacey, M.C., Teot, L., Vanscheidt, W. (2003) Wound bed preparation: a systematic approach to wound management. Wound Repair and Regeneration, 11(2), S1-S28.Watret, L. (2005). Teaching wound management: a collaborative model for future education. Retrieved 6 September 2009, from World Wound Wide: http://www.worldwidewounds.com/2005/november/Watret/T eaching-Wound-Mgt-Collaborative-Model.html 106
  107. 107. REFERENCESFalanga, V. (2000). Classification for wound bed preparation and stimulation of chronic wounds. Wound Repair and Regeneration, 8(5), 347-352.Falanga, V. (2004). Wound bed preparation: science applied to practice, in European Wound Management Association (EWMA) Position Document, Wound Bed Preparation in Practice, London: MEP Ltd.Lansdown, A.B.G. (2004). A review of the use of silver in wound care: facts and fallacies. British Journal of Nursing, 13(6), S6-S19.Lineaweaver, W., Howard, R., Soucy, D., McMorris, S., 107 Freeman, J., Crain, C., Robertson, J., & Rumley, T. (1985). Topical antimicrobial toxicity. Archives of Surgery, 120, 267-270.
  108. 108. REFERENECEMyers,A.B, (2008).Wound management. Principles and practice.(2nd ed.)Pearson Education Australia PTY.( pp.71-155)Bennett, L.L., Rosenblum, R.S., Perlov, C., Davidson, J.M., Barton, R.M., & Nannet, L.B. (2001). An in vivo comparison of topical agents in wound repair. Plastic and reconstructure surgery, 108(3), 674-685.Carville, K, (2005). Wound Care Manual (5th ed.). Osborne Park, Australia: Silver Chain.D’Arcy, P.F. (1972). Drugs on the skin: a clinical and pharmaceutical problem. Pharmaceutical Journal, 209, 491-492.Dealey, C. (2005). The Care of Wounds: A Guide for Nurse (3rd ed.). Oxford, UK: Blackwell Publishing. 108Fernandez, R., Griffiths, R., Ussia, C. (2002). Water for wound cleansing. Cochrane Database Systematic Review, 4.

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