Lecture 6

Wound Treatment Options

 Being able to differentiate among the various
treatment options, when and how to apply them, in
what combinations, and when to change them has
indeed become both an art and a science.
 Providing quality care for wound patients starts with
an analysis of the patient’s individualized wound
assessment and continues with developing a plan of
care, selecting the proper product, and re-evaluating
the plan of care as appropriate.
 Wound dressings can present a challenging decision
for clinicians
Treatment Decisions

 Optimal wound interventions should be

dependent on the basic principles of wound
care, attentive wound assessment, and
expected outcomes.
 A complete wound assessment should be the
driving element in all treatment decisions.
 Wound assessment should be based on the
principles of wound care.
 Principles of Care: The MEASURES Acronym
 Treatment goals may aim to achieve a clean
wound, heal the wound, maintain a clean
wound bed, or place the patient in another
setting to continue care.
 The goal of care then becomes using the right
product on the right wound at the right time.
For example, a granular, non draining moist
or wet wound needs to maintain a moisture
balance that is conducive to healing.
 The primary dressing choice would be a product
that maintains a moist environment but doesn’t
cause maceration of the wound bed.
 In another example, the goal of dressing selection
for a necrotic draining wound is to loosen or
soften the eschar for surgical debridement or to
assist in autolytic debridement of the wound
absorb the excess exudate, and prevent trauma to
surrounding tissue.
 Secondary dressings are those that cover a
primary dressing or secure a dressing in
place.
 Clinicians should know which dressings are
safe to be put into the wound itself and which
are used as securement products.
 Several dressings on the market act as both
primary and secondary dressings.
 Dressings should be matched carefully to the
wound, the patient, and the setting.
 For example, a deep wound with a large
amount of drainage will require a highly
absorbent dressing such as foam.
 As the depth and amount of drainage
decrease, a dressing such as a hydrogel,
hydrocolloid, or film might be used.
Moist Wound Therapy and Dressing
Options
 The essential function of a wound dressing is to
provide the right environment to enhance and
promote wound healing.
 Research over the past 50 years has led to the
generally accepted phenomenon that moist wound
dressings create an optimal environment for
wounds to heal faster and with less scar formation.
 The following synopsis reviews the major dressing
categories and provides helpful practice points on
what, when, and how to use these dressings.
Transparent Film Dressings

 Transparent film dressings are thin

polyurethane membranes. They are coated with
an adhesive that allows them to adhere to the
wound margins without sticking to the actual
wound.
 Transparent films have no absorptive capacity
but do transmit moisture vapor and are
semipermeable to gases.
 This covering allows epithelial cells to migrate
over the surface of the wound.
 Fluid may accumulate under these dressings.
This fluid is sometimes mistaken for pus, a
sign of infection
 When excess fluid accumulates or leaks out
from the sides of the dressing, the dressing
needs to be changed.
 Transparent film dressings provide a valuable
protective barrier against outside
contaminants, fluid, and bacteria.
 Transparent films also add a layer of
protection to the wound bed to minimize
further damaging trauma.
 They provide protection from friction and aid
in autolytic debridement and pain control.
 Most films can be left on for up to 7 days.
 These dressings are indicated for wounds
with absent or low levels of exudate.
 Transparent films can be used on a variety of
wound types, such as stage I and II pressure
ulcers, superficial wounds, minor burns, or
lacerations; over sutures, catheter sites, and
superficial dermal ulcers; and for protection
of the skin against friction.
 Transparent dressings can be used on central
lines, peripherally inserted central catheter
lines, and infected wounds.
Hydrocolloid Dressings

 Hydrocolloid dressings were introduced in the

1980s and were the mainstay for wound
management for many years.
 Hydrocolloids are impermeable to gases and
water vapors and are composed of opaque
mixtures of adhesive, absorbent polymers,
pectin gelling agents etc. (Fig. 9-4).
 Hydrophilic particles within the dressing react
with the wound fluid to form a soft gel over the
wound bed.
 Hydrocolloid dressings may have a noticeable
odor during dressing changes. This is normal in
the absence of clinical signs of infection.
 Hydrocolloid dressings are sold in sheet, paste,
and powder forms and are available in many
sizes.
 Adhesive properties and ability to absorb exudate
vary by product. Most of these dressings are
adhesive so care must be taken when using on
fragile skin.
 Correct application requires the dressing to be
bigger than the actual wound size.
 The dressing should be changed as
recommended from 3 to 7 days and often
depends on the amount of exudate.
 Hydrocolloids are indicated for minimally to
moderately heavy exudating wounds,
lacerations, pressure ulcers, granular wounds, or
necrotic wounds as well as under compression
wraps.
 Hydrocolloids also provide a moist
environment that is conducive to autolytic
debridement.
 Excessive maceration can occur if the
dressing isn’t changed appropriately.
 Hydrocolloids are often used as a preventive
dressing on high-risk areas (sacrum, heels)
and around surgical wounds to protect the
skin from frequent tape removal.
Hydrogel Dressings

 Hydrogel dressings have provided clinicians

with a viable means to hydrate or, stated
differently, donate moisture to dry wound
beds.
 This moist environment facilitates autolysis
and removal of devitalized tissue.(Fig. 9-5).
 The main application for hydrogels is
hydrating dry wound beds and softening and
loosening slough and necrotic wound debris.
 Hydrogels have a limited absorptive capacity
due to their high water concentration.
 Some hydrogels have other ingredients, such
as collagen, or starch, to enhance their
absorptive capacity and will absorb low to
moderate amounts of exudate.
 They can be used for many types of wounds,
including pressure ulcers, partial and full-
thickness wounds, and vascular ulcers.
 One of the benefits of a hydrogel is that it can
be used with topical medications or
antibacterial agents.
 Hydrogels are packaged as sheets, tube gels,
sprays, and impregnated gauze pads or strips
for packing tunneling and undermined areas
within the wound bed.
 Some require a secondary dressing to secure
the hydrogel; new versions have adhesive
borders.
Foam Dressings

 Foam dressings are highly absorbent and are

usually made from a polyurethane base with
a heat- and pressure-modified wound contact
layer (Fig. 9-7).
 Foam dressings are permeable to both gases
and water vapor, and their hydrophilic
properties allow for absorption of exudate
into the layers of the foam.
 Foam dressings are indicated for wounds with
moderate to heavy exudate, prophylactic
protection over bony prominences or friction
areas, partial and full-thickness wounds, necrotic
wound beds, skin tears, under compression
wraps, surgical wounds, in combination with
other primary dressings.
 They can also be used on infected wounds and
can be left on up to 7 days, depending on product
and exudates.
 Foams shouldn’t be used on dry eschar
wound beds because they could cause further
desiccation of the wound site.
 Foams may be used in combination with
topical treatments and/or enzymatic
debriders.
 Foams are available in many sizes and
shapes, including cavity dressings.
 Caution with fragile skin may be warranted.
Collagen Dressings

 Collagen is a major protein of the body and is

necessary for wound healing and repair.
 Collagen dressings either are 100% collagen or
may be combined with alginates or other
products.
 They are a highly absorptive, hydrophilic, moist
wound dressing (Fig. 9-9).
 Seaman suggests that collagen powders,
particles, and pads are useful in treating highly
exudative wounds.
 If the wound has low to moderate exudate, sheets
should be used. If the wound is dry, gels should be
used.
 Collagen dressings can be used on granulating or
necrotic wounds and on partial- or full-thickness
wounds.
 They may be used with other topical agents. A
collagen dressing should be changed every 3 to 7
days.
 Collagen dressings require a secondary dressing for
securement.
Antimicrobial Dressings
 Antimicrobial dressings are different than topical
antibiotic therapy.
 They provide the benefit of an antimicrobial effect against
bacteria and a moist environment for healing. (Fig. 9-10).
 Antimicrobial dressings do not replace the need for
systemic antibiotic therapy; rather, they serve as an
adjunct in treating wound infections.
 Antimicrobial dressings are available in a variety of forms:
transparent dressings, gauze, foams, and absorptive fillers
etc.
 Some of these dressings can remain in place for 7 days.
Mechanical

 A large number of devices and therapies can be

considered in the group of mechanical modalities.
Included in this category are negative pressure
wound therapy (NPWT), compression therapy,
and energy-based therapy (electrical stimulation,
light, and ultrasonic).
 Mechanical therapies impact wound healing via
several mechanisms including angiogenesis,
cellular stimulation, bioburden reduction, and
enhanced tissue perfusion.
 Negative Pressure Wound Therapy
 NPWT is in its third decade of use in the United
States and has become an accepted therapy for
many chronic and, in some cases, acute wounds.
 It is commonly used to assist with wound closure.
In general, NPWT is indicated for full-thickness
wounds that require contraction and granulation
tissue formation.
 Reduction of wound volume is one of the most
widely recognized outcomes from using NPWT.
 NPWT applies subatmospheric pressure, or
suction, to the wound bed by way of a device
that is attached to a wound contact layer
(interface dressing) through a plastic tube
(Fig. 9-11).
 Most clinicians have migrated to the use of
foam interfaces based on adverse outcomes
that have been reported with gauze.
Compression Therapy

Venous Compression Therapy

 Compression therapy is the foundation for successful
management in patients with edematous wounds
caused by venous insufficiency and/or lymphedema.
 Compression therapy wraps are used to manage fluid
accumulation and promote sufficient return of venous
blood back to the central system and lymph back into
the bloodstream.
 The substances transported by the lymphatic system
are called lymphatic loads and consist of protein,
water, and fat from the digestive system.
 It is worth noting that the edema associated
with venous insufficiency is different in
consistency from the edema or fluid
accumulation that is seen in lymphedema.
 Protein-rich lymphedema fluid appears to be
more “viscous” or thicker than the edema
associated with venous insufficiency and
requires different treatment interventions,
including higher compression forces when using
wraps or garments.
Compression Dressings
 Short-stretch or rigid compression systems are
particularly suited to managing the fluid
accumulation of lymphedema and are also
indicated for patients with a combination of
venous insufficiency and lymphedema in the
same leg.
 An Unna boot is a “short-stretch” system that
includes a moist layer impregnated with several
substances, including zinc oxide, calamine.
 Long-stretch bandages are so called due to
their large amount of extensibility and elastic
recoil back to near-original configuration.
 While short-stretch bandages require the
patient to be ambulatory or able to engage
the calf muscles effectively (ideally by
walking), long-stretch bandages have been
shown to be suitable for individuals who are
not active or who are nonambulatory.
 Clinicians need to be trained and skilled to
proficiently and safely apply these
compression wraps, keeping in mind that
they should be applied according to the
manufacturer’s detailed directions(Fig. 9-15).
Compression Devices
 Some compression systems do not fall into
the wrap or bandage category.
 These include garments that are usually
short-stretch systems consisting of material
that does not give way during ambulation;
these systems often include Velcro straps to
help secure and conform the garment to the
extremity contours (Fig. 9-16).
Electrical Stimulation
 Electrical stimulation has been used for more than
three decades to accelerate the rate of chronic
wound healing.
 Healthcare professionals who have used ES
consider it to be one of the most cost effective,
therapeutically efficacious tissue repair and wound
healing accelerators in our wound care tool kit.
 Unfortunately, ES is not widely used due to the
lack of knowledge, education, and training in the
application of this energy.
 ES uses an electrical current to transfer energy to the
tissue. This energy produces a number of cellular
processes and physiological responses that are
important to wound healing, including:
 stimulation of fibroblasts to enhance collagen and
DNA synthesis
 increase in the number of receptor sites for growth
factors
 alteration in the direction of fibroblast migration,
activation of cells in the wound site, improved tissue
perfusion, and decreased edema.
Ultrasonic Energy

 Therapeutic ultrasound delivers energy through

mechanical vibrations in the form of sound waves
at frequencies above detection by the human ear
(>20 kHz). Ultrasound affects tissue through
thermal and non thermal mechanisms, which are
determined by the physical properties, which are
associated with ultrasound:
 (1) frequency or the number of oscillations a
molecule undergoes in 1 second and
 (2) intensity or level of power.
High-Frequency Ultrasound:
 High-frequency ultrasound is used 1 to 3 MHz range to
promote soft tissue injury healing and occasionally
reported to facilitate wound healing.
Low-Frequency Ultrasound:
 Recently, low-frequency ultrasound (LFU) available for
wound care and is the most common type of US device
used in wound care today.
 Delivery of LFU to wounds has been shown to effectively
deride necrotic tissue, eradicate some strains of bacteria
from the wound, and facilitate the wound healing process.
Scar Management

 Patients, clinicians, and researchers are all

concerned about scar appearance. Progress has
been made in our understanding of the
mechanisms involved in producing an
exaggerated scar.
 The scientific principles for scar management and
minimization—support, controlled inflammation,
adequate hydration, and remodeling/maturation
of collagen form the basis of product selection for
scar control strategies.
 Widgerow and colleagues have described a
patented process of applying a cream/gel
that contains antiscar active agents (Centella
asiatica, dimethicone, Bulbine frutescens) to
the surface of microporous tape.
 This process has been used successfully for
scar management. Within 2 minutes, the
active agents in the gel are absorbed through
the tape and onto the scar tissue.
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