A few years back, Mary Madison’s husband developed a pressure injury caused by sitting for long periods behind the wheel of a city bus.
Her many years as a long-term care director of nursing and most recently as clinical consultant for Briggs Healthcare taught her one thing in this instance: Those types of wounds should never be treated lightly. It didn’t help that her husband was an insulin-dependent diabetic, which presented additional, complex healing challenges as well.
When the wound stalled after three or four healing attempts, Madison “self-referred” her husband to a local wound clinic. Lucky for her, the attending physician on duty just happened to also be a certified wound care specialist, who quickly identified a special ointment targeted specifically for the wound and her husband’s condition.
It wasn’t long after that the wound healing accelerated and, to Madison’s delight and answered prayers, completely healed. The wound has never returned, but her husband did resume his six-hour daily weekday route.
Often, it takes personal experience to drive home the importance of having product-savvy wound care specialists who can quickly apply the most appropriate dressing.
“The most popular attributes in wound dressings continue to be consistent with the qualities of an ‘ideal dressing’ and encompass foam wound dressings, gentle silicone adhesive products, and those that address wound bed characteristics, such as bioburden or MMP activity, in addition to exudate management,” says Holly Korzendorfer, PT, Ph.D., CWS, FACCWS, chief innovation officer for DermaRite Industries.
While dressings support wound healing, a holistic approach brings to bear clinical expertise and assessment, as well as close, ongoing monitoring.
“Optimal skin health management starts with a focus on prevention methodologies including skin care, nutrition and support surfaces,” says Jacob Katz, director of marketing for Medline. “When skin breakdown happens, clinicians must be ready to tackle those challenges with a comprehensive range of advanced wound care solutions that optimally address the particular clinical context, patient and wound type.”
The physical aspect of wound care, meanwhile, involves many moving parts.
“A good basic wound care formulary should provide the treatment nurse with a variety of tools, including wound cleanser, periwound skin prep, and dressings to support wound healing throughout the continuum, from dry to heavily draining wounds and those with bioburden or infection,” says Elaine McGowan, BSN, RN, CWCN, vice president of clinical affairs for DermaRite.
Some of the most popular types of wound dressings now on the market include:
• Prevention dressings, which are intended for use on intact skin with high risk for pressure or friction wounds. Types of products can include multilayer foam, film and hydrocolloid dressings;
• Non-odorous wound dressings such as foam with silicone contact layers and saline gels;
• Gelling fiber, foam dressings, as well as alginate, gauze and wound fillers, for heavily draining non-odorous wound dressings;
• Antiseptics with silver, medical grade honey, iodine, methylene or polyhexamethylene biguanides, as well as charcoal-based dressings, for odorous or purulent wounds;
• Collagenase applied in the bed of slough and eschar wounds, covered by a secondary dressing;
• Collagen dressings applied to the wound bed as well as bioengineered skin substitutes, for so-called “stalled” wounds that have clean beds but no forward apparent progress.
As with most medical products, buyers choose one type of wound dressing over another for a myriad of reasons. Some involve clinical preference or loyalty. All involve some kind of assessment that links the dressing to the specific wound attributes.
Once convinced of any dressing’s efficacy, many users prefer dressings that are easy to apply.
“Facilities are looking for painless dressings with easy application,” says Eula Reynolds, RN, MSN, CWS, director of clinical education for DermaRite. “Dressings with easy application save valuable nursing time, and dressings designed to reduce pain make it easier for residents to remain compliant with treatment plans.”
Therein lies a problem for some caregivers, many of whom wastefully change extended wear dressings too soon, whether they be honey, silver or foam, which can lead to adverse consequences.
“Changing extended wear dressings too frequently also increases the risk of skin stripping and pain upon removal,” says Steven Antokal, RN, BSN, CWCN, CCCN, DAPWCA, director of clinical education for DermaRite. “Unfortunately, when this happens, it is attributed to the product rather than user misunderstanding.”
Dressing choices are another common — and costly — option in wound care, according to Joyce Black, Ph.D., RN, FAAN, a professor at the University of Nebraska Medical Center College of Nursing.
One is using occlusive dressings like films and hydrocolloids on necrotic wounds, which can encourage anaerobic bacteria growth. Another is applying dressings instead of topical treatments to sacral wounds because shear forces can easily pull them off or cause the dressing to wrinkle. Also, using wet-to-dry dressings on granulating wounds often leads to bleeding when they are removed.
As McGowan notes, “The vast majority of dressings support moist wound healing. The challenge for the treatment nurse is to understand which dressing is best suited to the specific need of that wound at that time. It can be very confusing to sort through appealing marketing claims for simplicity or universal use.”
Still, “wound dressings are one aspect of wound care,” Black says. “While the wound is the most visible aspect of the injury, it is the patient’s body that heals the wound.”
Stephanie Yates, MSN, RN, ANP-BC, CWOCN, a nurse practitioner/clinical nurse specialist at Duke University Hospital-Duke Cancer Center in North Carolina, agrees.
“It is important to understand that topical therapy will always be just one component of the care required to heal wounds,” says Yates. “In long-term care especially, recognizing that we care for the ‘whole’ patient and not just the ‘hole’ in the patient is extremely important. Utilizing the entire team by providing them the knowledge and basic skillset to provide optimal bedside wound care will have the best impact on wound healing and overall patient outcomes.”
Working in tandem
Whomever the task falls upon, the key is properly assessing the resident, any active wounds and most important, anticipating wounds before they happen. As Briggs’ Madison, RN, RAC-CT, CDP, has learned, nursing facilities invest in wound care specialists because “they’ve seen a wide variety of wounds and have the experience to work with the resident’s physician to prescribe the proper dressing and care.”
Among the important factors to consider in any exercise is “choosing the right dressing for the wound based on an accurate assessment, using correct application and removal technique and managing wear time correctly,” McGowan explains.
“It is important for wound treatment nurses to have an understanding of the wound healing process and how the particular dressing they are considering or using supports that process. They also need to know that, as a wound improves, the type of dressing needed to support healing to closure is quite likely to change.”
Wounds typically undergo several different types of dressings during the healing process, as Madison observes.
“It is not uncommon at all to change dressings and treatments to get to the goal line of healing the wound,” she adds.
As Katz notes, “clinicians often consider more advanced treatment methodologies like collagen dressings or skin substitutes when a wound remains stalled after issues like necrotic tissue, bacterial burden and wound drainage are addressed.”