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Wound Series Part 2: Introduction To Chronic Wound Treatment (FL INITIAL Autonomous Practice - Differential Diagnosis)

2 Contact Hours
This course is only applicable for Florida nurse practitioners who need to meet the autonomous practice initial licensure requirement.
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP)
This course will be updated or discontinued on or before Saturday, March 25, 2023
Outcomes

≥ 92% of participants will know how to manage typical chronic wounds.

Objectives

After completing this course, the participants will:

  1. Examine the expected healing pathways in acute versus chronic wounds.
  2. Illustrate the expected needs of acute, uncomplicated wounds.
  3. Illustrate the expected needs of common chronic wounds.
  4. Identify important considerations for cleansing wounds.
  5. List basic wound dressing supplies, which may be useful in caring for wounds.
  6. List essential wound care supplies relevant to any healthcare setting.
  7. Select 5 essential items that should be assessed, addressed, and included in wound care documentation.
  8. Outline considerations for pain management of pain in chronic wounds.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Linda J. Cowan (PHD, ARNP, FNP-BC, CWS)

Introduction

This course is an overview of wound care basics for most typical chronic wounds. This course is not meant to be a comprehensive or all-inclusive course that details advanced wound therapies for the wound care specialist. Rather, it helps the clinician/nurse (in any setting) become more familiar with the basic principles of good wound healing. This module aims to provide an introductory guide to wound dressings, thereby answering the age-old question, "what should I put on the wound?" Also, this module includes a basic overview of pain management for wounds - an under-addressed clinical problem.

The Problem of Wounds

Worldwide, millions of chronic wounds require treatment each year, resulting in a global dilemma with increased morbidity and healthcare costs. It has been estimated that more people throughout the world have chronic, complex, or non-healing wounds than the total US population with cardiovascular disease (approximately 15 million), asthma (18 million), or diabetes (29.6 million).1 Chronic, complex or non-healing wounds represent a major health problem and a growing economic concern. To improve wound healing outcomes and decrease the number of chronic or non-healing wounds worldwide, evidence-based wound prevention and treatment strategies are necessary.2

Expected Pathways to Healing: Acute Wounds vs. Chronic Wounds

Wounds occur due to a disruption in the skin's integrity due to injury (such as surgery or trauma) or disease. Acute wounds are those that follow an orderly, expected pathway to healing. The anticipated timeline for the expected pathway to healing is dependent upon intrinsic factors (such as age, body build, and genetic factors), extrinsic factors (such as mechanical stress, temperature, smoking, radiation, debris, chemicals/medications, and infection), and the size of the wound or extent/depth of the tissue disruption. In other words, normal, acute wound healing may not occur the same number of days or weeks for all individuals. Acute wound healing for most full-thickness injuries of human tissue follows an orderly (though sometimes overlapping) 4 step process immediately after wounding: activation of the clotting cascade (hemostasis), inflammation, proliferation, and scar tissue maturation/remodeling.2-4

Partial-thickness versus full-thickness wounds. When an alteration in skin integrity occurs, such as when a teenager falls from a skateboard and scrapes his/her knee, it results in a wound. Suppose the wound is superficial and extends only through the epidermis and perhaps involves the uppermost part of the dermis (but does not extend through the dermis or involve subcutaneous tissue or underlying structures). In that case, it is considered a partial-thickness wound.3 We anticipate this type of wound will heal by regenerating skin cells and re-epithelialization (superficial skin cells will migrate over the injury and "close the wound"). This wound may not scar permanently. If the wound extends through the epidermis and the dermis and includes subcutaneous tissue or underlying structures, it is considered a full-thickness wound. We expect this type of wound to heal by the more complex four-step process listed above, ultimately resulting in scar tissue formation. The wound's location determines the depth of tissue loss required to establish if a wound is partially or fully-thick.3-5 Some parts of the body (over the anterior shin, the knuckles of the hands, bridge of the nose, eyelids, etc.) have very thin skin and do not have a significant amount of subcutaneous fat/tissue. A shallow wound over these areas would be a full-thickness wound though they may only extend 2mm deep (or less). Alternatively, wounds over the buttocks or fleshy parts of the body may be of a similar depth yet remain partial-thickness wounds because they do not extend through the dermis into subcutaneous tissue. Areas of the body, such as the ears and bridge of the nose, have cartilage directly covered by the dermis and epidermis. Any wound that involves cartilage is a full-thickness wound, even if it appears very superficial.3,6

Wound healing intentions. Wounds are said to be healing by primary intention if a linear wound (such as a surgical incision) is re-approximated (edges pulled together) and sutured, stapled, glued, or taped together (without gaps) as an initial treatment approach. These wounds will typically form a "healing ridge" by post-operative (post-closure) day 5 in healthy individuals.5 This healing ridge is evidence of collagen deposition "knitting" the two separate wounded edges together, which will eventually result in a healed surgical site. In such a case, the skin at the wounded site should have the same tensile strength as surrounding tissue after the healing process is completed. This point is important to remember as we move on to discuss wounds that heal by secondary intention.

Full-thickness wounds are described as healing by secondary intention if they are left open to heal or "fill in" with new granulation tissue and finally close by re-epithelialization. Scar tissue in full-thickness wounds that heal by secondary intention (or scar tissue formation) will continue to mature 12-18 months after complete closure of the wound opening. The tensile strength of the resulting "scar tissue" in the area of a wound healed by secondary intention will never reach more than 80% of the surrounding tissue's tensile strength. Therefore, this will always be a "weak spot" in skin integrity, prone to breakdown before the surrounding tissue. Therefore, a full-thickness pressure ulcer in a location likely exposed to repeated pressure such as the ischia or coccyx, which healed by secondary intention instead of flap closure, will be at greater risk of recurrence. This is one reason that surgeons prefer to create surgical skin flaps to close certain wounds such as clean, uncomplicated, full-thickness pressure ulcers in relatively healthy individuals (with the best chance of surgical healing), instead of leaving these wounds open to heal by secondary intention.4-5

On the other hand, full-thickness wounds that are initially sutured closed, re-opened (or left open at the start) for a while, and finally sutured, stapled, glued, or taped closed again, are said to be closed by tertiary closure. These wounds heal by a combination of scar tissue formation and surgical wound healing. Therefore, their suture lines may or may not reach the surrounding tissue's tensile strength, depending on the amount of scar tissue formation.5

The Process of Full-Thickness Wound Healing

As discussed above, full-thickness wounds healing by secondary intention heal by scar tissue formation. When wounded, the human body sets into motion a cascade of processes resulting in new collagen production to fill the open defect of a full-thickness wound in the skin/tissue. If the skateboarder is young and healthy (e.g., with adequate tissue perfusion, oxygenation, nutrition, and without serious comorbid conditions), his/her knee will bleed for a few seconds, clotting factors, and fibrin will start clotting the blood. Chemical signals (cytokines) will be initiated, which will result in localized edema, redness at the area, slight warmth, and pain. The localized pain, edema, warmth, and redness will typically resolve in 3-7 days (inflammatory phase of wound healing). If the wound bed is not kept moist, the wound will dry out, and a scab will form. Next, the body will produce enzymes (matrix metalloproteinases or MMPs) under the scab to lift it, especially at the edges. The wound bed under the scab will be moist to promote cellular communication, proliferation, and movement.2-5 The skateboarder will likely pick the scab off of the wound, especially if it feels tight or "itchy." However, the scab will form again, smaller this time, as the wound contracts. If all goes as expected, the wound will completely close (re-epithelialize) in a few weeks. As described, this is an acute wound.

Interestingly, George Winter demonstrated in 1962 that open wounds (not sutured surgical wounds), which are kept continuously moist, actually heal almost 50% faster than those allowed to dry out and scab over.6 The skateboarder's scenario demonstrates uncomplicated acute wound healing. The typical needs of acute wounds versus chronic wounds are described below.

The typical needs of the uncomplicated ACUTE wound in a healthy individual include:

  1. Moisture balance: Keeping the wound bed moist will allow optimal cellular communication, fibroblast proliferation, keratinocyte differentiation, and migration. Preventing too much moisture will prevent maceration and avoid excess enzyme levels (such as MMPs) in the wound fluid.7
  2. Protection: Keeping the wound covered with an appropriate dressing will protect from external contamination (bacteria, parasites, foreign bodies, etc.) as well as friction and repeated trauma. It will also provide thermal protection, and of course, prevent the wound bed from drying out if a moisture retentive dressing is used.

In contrast to acute wounds, any wound that does not follow the expected orderly pathway to healing is chronic. Chronic wounds most often get "stuck" in the inflammatory phase of healing, resulting in delayed wound healing, and often, persistent edema, redness, and pain.2-5

Inflammation in chronic wounds typically starts as it does in acute wounds: wounding, bleeding, clotting cascade, release of cytokines, edema, warmth, redness, pain. However, unlike acute wounds, in a chronic, complex, or recalcitrant wound, the expected pathway to healing stops here and never progresses out of a chronic inflammatory state. The presence of biofilm, or overwhelming infection; malnutrition; immune suppression; certain medications, and various other factors can contribute to a wound remaining in a chronic inflammatory state. Chronic wounds get 'stuck' in the inflammatory phase of wound healing.2,5,7

The typical needs of the CHRONIC wound are similar to the acute wound with one exception:

  1. Moisture balance: Keeping the wound bed moist will allow optimal cellular communication, fibroblast proliferation, keratinocyte differentiation, and migration. Preventing too much moisture will prevent maceration and avoid excess enzyme levels (such as MMPs) in the wound fluid.2,7
  2. Protection: Keeping the wound covered with an appropriate dressing will protect from external contamination (bacteria, parasites, foreign bodies, etc.) as well as friction and repeated trauma. It will also provide thermal protection, and of course, prevent the wound bed from drying out if a moisture retentive dressing is used.4,5,7
  3. Address the chronic wound environment to revert it back to an acute environment to get the wound "back" on a healing track.2,4,5

Remember, this course only addresses the basic needs of wounds and provides a general overview of wound dressings and topical wound treatments. More advanced chronic wound treatments and adjunctive therapies will be discussed in a future course.

Basic Wound Care

This section seeks to provide specific basic information to help you approach the wound from a nursing or caregiver perspective, which focuses on the basic cleansing and dressing of wounds.

Ideally, care of a wound should begin with a "game plan." There is no strict 'recipe' that will fit all wounds, but the following are general measures and evidence-based recommendations that should be considered with all wound care.2,4,5 Typically, the process of wound dressing changes will look something like this:

  • Verify current orders. If it appears inappropriate or non-evidence-based wound dressings/topical therapy has been ordered, you should feel free to question this and make more appropriate evidence-based recommendations.5
  • WASH YOUR HANDS
  • Gather supplies
Common wound care supplies: gloves (sterile or non-sterile/clean, according to the type of wound and/or your facility’s policy), 4”x4” gauze, saline or non-cytotoxic wound cleanser,20 disposable measuring tape, skin prep wipes, sterile/disinfected scissors, primary dressing, secondary or cover dressing (if needed), tape or securing device, biological waste disposal bag, and drape(s).
  • Set up your workspace: there should be a clean drape for all supplies to sit on, appropriate disposal containers handy, extra gloves, etc.
  • Explain the procedure to the patient before you begin, ask if they have any questions or concerns
  • Make the patient comfortable – they will likely remain in the same position for 15-30 minutes, so the patient should not be standing or holding themselves in an uncomfortable or unnatural position for wound care – also, consider pre-medicating the patient for pain (30 min before wound care for oral analgesics)
  • Make sure that the person performing the wound care is also comfortable (example: raising the bed if necessary, so they are not 'bent over' to do the wound care)
  • WASH YOUR HANDS
  • Don your gloves and remove the old dressing (discarding the old dressing and your gloves in a biohazard or appropriate container), noting the characteristics of the wound, wound exudates (drainage), and specific needs of the wound bed (see 'TIME' anagram below)8
  • WASH YOUR HANDS again (alcohol-based hand cleanser is ok for non-soiled hands in most cases unless C. Deficile is suspected in the patient)10
  • Don new gloves
  • Cleanse the wound with a non-toxic wound cleanser
  • Measure and photograph the wound if necessary
  • Apply a new dressing and secure the dressing appropriately (be mindful of the best way to secure the dressing to avoid trauma to the surrounding skin – perhaps consider using a skin barrier wipe to the skin surrounding the wound where any adhesives will be applied)
  • Discard gloves and used supplies inappropriate medical waste container
  • WASH HANDS after wound care
  • Educate the patient and family (and other caregivers if applicable) about the steps for wound care, frequency, next follow up appointment if applicable), what to expect during wound healing, and what to report to healthcare provider(s)
  • Document the wound care, planned follow up, and what education was provided

Let us break the process down into a few individual considerations (remember this is a "basics" course, so please forgive the simplicity of a seasoned wound care practitioner). Gathering supplies, selecting the appropriate materials, setting up your workspace, and making the patient and caregiver comfortable are self-explanatory.

Hand Washing. Do not take hand washing for granted! You have heard it said that the most important infection control practice is hand washing. This is true. Proper handwashing prevents infection: Wash with soap under running water for at least 15 seconds—no short cuts. Wearing gloves when you perform wound care is necessary in most cases unless it is a close family member or the patient is doing wound care for themselves. However, wearing gloves is no substitute for handwashing!10

Specific Wound Needs. Wound care has advanced tremendously with modern technology. This is good news for patients but complicates things for healthcare providers. Forty years ago, there was only a small list of wound care products to choose from, and today there are thousands. However, clinicians need not fret about approaching wound care in modern healthcare. Clinicians need only to remember a few basic principles similar to the ABC's of CPR. Think of this as the "TIME" for wound care. The wound bed preparation concept describes a systematic approach to addressing the wound bed's specific needs in full-thickness open wounds.8 Evidence-based literature describes several anagrams, such as T-I-M-E or T-I-M-E-S, to help clinicians perform evidence-based wound care.2,8

  • T is for Tissue - the amount of non-viable or necrotic tissue in the wound bed should be noted and attended to (typically by debridement or removal of the necrotic tissue).
  • I is for Infection - infection should be identified and determined if it may require systemic treatment (critical infection) versus non-critical chronic bacterial colonization that may require only local management (by debridement and topical therapies).
  • M is for Moisture – moisture in the wound bed should be managed. A balance of moisture is important for wound healing. Topical wound care (especially dressings) should prevent the wound bed from drying out while eliminating excessive moisture in the wound bed. When there is excessive moisture in the wound and exceeds the dressing's capabilities, it often causes moisture damage to the skin surrounding the open wound (maceration). Dressing selection is most important for addressing this specific need of the wound bed.
  • E is for Edge of the wound - attention should be given to the wound edges. Rounded, "rolled" wound edges prevent epidermal cell migration, which may impair wound closure. Tracking or tunneling in the wound bed and undermining (a 'lip' or ledge under the wound edge) may also impair wound healing. Undermining is often caused by shearing forces upon the wound area, frequently seen in pressure ulcers around the sacral area. The patient is repeatedly sliding down in the bed.

An article by Carville17 suggested also addressing the tissue and skin surrounding the wound opening, adding an "S" to the above anagram. S - The surrounding skin and tissue should be examined for the presence of or worsening of erythema (redness), edema (swelling), warmth, and skin lesions (blistering, rash, irritation, callus, or maceration, etc.).18 Other publications have described algorithms for wound management2 or mnemonics (similar to the T-I-M-E-S approach) to guide clinicians in deciding if local treatment is adequate or if systemic treatment may be advised (NERDS and STONES)7:

Using the NERDS mnemonic, if 3 or more are present, treat topically:
  • Nonhealing wounds
  • Exudative wounds
  • Red and bleeding wound surface granulation tissue
  • Debris (yellow or black necrotic tissue) on the wound surface
  • Smell or unpleasant odor from the wound
Using the STONES mnemonic, if 3 or more are present, treat systemically:
  • Size is bigger
  • Temperature of 3o F or more versus mirror image
  • Os (probe to or exposed bone)
  • New or satellite areas of breakdown
  • Exudate is increased
From: Sibbald RG, Elliott JA, Ayello EA, Somayaji R. Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015©. Adv Skin Wound Care. 2015;28(10):466-478. doi:10.1097/01.ASW.0000470851.27030.98

Wound Cleansing. Many experts agree it is necessary to cleanse wounds at each dressing change to remove wound exudates, cellular waste, debris, bacteria, etc.3,5,9 However, caution is warranted regarding antimicrobial wound cleansers. Several studies report on the cytotoxicity of various common wound cleansers.23 Cytotoxicity relates to the substance being toxic to human tissue cells. Cytotoxic wound cleansers will kill germs and kill healthy cells such as fibroblasts (white cells that manufacture collagen/new tissue) or epidermal keratinocytes (important skin cells).3,5,7 Also, many of these cleansers are antimitotic (prevent cellular mitosis and regeneration), which is how some chemotherapy agents function to prevent cancer cell growth. While that may be a desirable trait for cancer treatment, it may not be as desirable for a wound cleanser!

In most cases, wound experts recommend using water or saline to cleanse the wound. 2,3,5,9 Some articles suggest tap water may be appropriate to cleanse a chronic wound. However, a Cochrane systematic review of research exploring this tap water question concluded that the decision to use tap water to cleanse wounds should consider the quality of water, nature of wounds, and the patient's general condition, including the presence of comorbid conditions. They also point out that water must be potable for tap water to be considered for wound cleansing. Caution may be warranted for several reasons when considering tap water. Most of the systematic review studies were small and did not have adequate sample sizes to determine significant differences between groups. It is not known if the water used for wound cleansing vs. normal saline was tested for bacterial, cysts, fungi, or presence of any other contaminants. If obtained from a well, tap water may contain contaminants such as bacteria or other contaminants undetectable to the human eye. Alternatively, "city water" is typically chlorinated at around three parts per million or 0.3mg/L and also typically contains fluoride (0.5mg/L to 1.0mg/L) - it is unknown what effect this may have on cellular activity in the wound bed, and this was not reported on by the studies included in the Cochrane systematic review. Therefore, the author recommends using primarily saline or a proven non-cytotoxic wound cleanser.

An exception to using cytotoxic wound cleansers is when the benefits outweigh the risks. For instance, in the case of localized bacterial invasion in which the host is unable to overcome the bioburden of the infecting organism(s) with its immune defenses (such as pseudomona aeruginosa infection resulting in further wound deterioration), the fibroblasts and epidermal keratinocytes are not likely to survive this hostile wound environment anyway. Therefore, it may justify using a short-term application of cytotoxic wound cleanser, such as diluting Dakin's solution (sodium hypochlorite) just long enough to eradicate the infecting organisms.9 Yes, this is likely to impair cellular function temporarily, but the infecting organisms would do far worse if you did not address/control them. Once the wound is "cleaned up" (perhaps a few weeks), you should return to non-cytotoxic moist wound healing principles for wound care.

A Word about Dakin’s Solutions

Ohio State University Medical Center (OSUMC) Department of Inpatient Nursing published a nice patient education pamphlet, “How to Make Dakin’s Solution” (available HERE)

 

This pamphlet describes diluting 3 ounces of common (unscented) household bleach (5.25% sodium hypochlorite solution) with 32 ounces of clean, boiled water (buffered with ½ teaspoon baking soda/sodium bicarbonate) to make a full strength Dakin’s solution (0.5% sodium Hypochlorite solution).

To make ½ strength Dakin’s solution (0.25% sodium hypochlorite), use only 3 tablespoons (48ml) bleach mixed with the same amount of water (32 ounces) and baking soda (1/2 tsp). OSUMC reports tightly sealed jars of these solutions may be stored at room temperature up to one month (in a dark jar), but once opened, any unused solution should be discarded within 48 hours.

Many clinicians are badly informed concerning Dakin’s solution, especially: when to use and not to use it, solution storage, documentation, and cytotoxic versus non-cytotoxic strengths. Here are some things every clinician should know about Dakin’s:

  1. As described above, full strength Dakin’s solution is a 0.5% sodium chlorite (hypochlorous acid) solution. Most are buffered with sodium bicarbonate to bring the PH up to one more easily tolerated by human tissues.
  2. At Full Strength, half strength, quarter strength (0.125% sodium hypochlorite), and even one-eighth strength (0.0625% sodium hypochlorite), Dakin’s solution is cytotoxic to fibroblasts and keratinocytes. Full strength Dakin’s solution would need to be diluted 50 times (one-fiftieth dilution) in order to reach a 0.01% sodium hypochlorite solution (non-cytotoxic).
  3. Clinicians should ask:
    1. What strength was ordered?
    2. Is this strength appropriate?
    3. Is it ordered short-term or long-term? (Short term use may be appropriate to address a high localized bioburden because the benefits outweigh the risks).

Documentation of the use of any sodium hypochlorite solution should always be done by recording the exact strength that was used. Many times all strengths are just recorded as “Dakin’s solution” but this is in effect the same as documenting that insulin was given without recording the exact strength. Dakin’s solution is a 0.5% sodium hypochlorite solution and is often diluted because of its high cytotoxic properties. RECORD the correct strength!!!

A nice chart called “Know the Code” describes the different dilutions of sodium hypochlorite solution is available HERE

"Cleansing" the wound should not only address washing or rinsing a wound but also includes debridement or addressing the removal of non-viable or devitalized (necrotic) tissue from the wound bed.9 Types of cleansing or debridement approaches should be based on a holistic approach to wound management, including the specific condition(s) of the wound (and patient), the established goals of treatment, and patient preferences (if possible).2

Removing Necrotic or Non-viable Tissue from the Wound Bed

Necrotic tissue is a breeding ground for bacteria. It impairs wound healing (e.g., impairs optimal cellular communication and proliferation and acts as a physiological barrier to new tissue deposition and wound contraction).4,5 Removing this unhealthy tissue (debridement) may be achieved by a variety of means: Sharp debridement, either selective or non-selective (with a scalpel, scissors, curette); enzymatic (collagenase ointment or similar); autolytic (promoting the body's enzymatic activities); mechanical (rough friction or wet-to-dry), irrigation (including surgical water jet), and biosurgical or larval debridement (maggots).4,9,10,11,12,13

In almost all cases, necrotic tissue should be removed when safely possible. This removal includes slough (white, yellow, grey "chicken fat" appearing tissue), fibrin (adherent, white-yellow, or grey fibrous non-viable tissue), and eschar (typically thick, brown to black, "leathery" dead tissue). There are a few exceptions to this rule. One important exception is in the case of intact, hard, black eschar on the foot's heel. There is no way to determine the depth of tissue damage underneath this eschar, so removing it may expose the bone and predispose the patient to infection and osteomyelitis. "Intact" is the keyword here. If this eschar is dry, NOT soft, or boggy or fluctuant, and does not have any lifting at any of the wound edges or drainage, it may be beneficial to leave this eschar alone. Of course, pressure should be offloaded from the area, and the eschar should be kept clean and dry.2,14 Cover the eschar with dry gauze for protection and "paint" it daily with a small amount of 10% Povidone Iodine solution (commonly known as Betadine solution, providing 1% available Iodine) and letting it air dry thoroughly before applying dry gauze for protection and padding.2 With this tissue in place, it may act as a protective "body bandage" – keeping bacteria and contaminants out of the wound. Under this eschar, the wound healing process may continue if other wound healing impediments are addressed (offloading pressure, adequate nutrition & blood flow, adequate immune function, and tissue perfusion). If the wound under the eschar follows a healing trajectory, the eschar may lift itself after several weeks and display newly epithelialized skin underneath. In some cases, it may lift prematurely at an edge or start feeling boggy or fluctuant underneath the eschar and may start draining. In this case, it may be best to remove the eschar.2,14

Debridement

Typical methods of debridement include sharp debridement, mechanical, autolytic, enzymatic, and larval debridement.2,14 Sharp debridement is usually performed with a scalpel, curette, or scissors. This debridement may occur in a surgical suite by a surgeon or at the bedside by a physician, PA, ARNP, or certified wound specialist if allowed by state board scope of practice limitations. Enzymatic debridement is typically achieved by applying ointment (collagenase) to the wound bed. Mechanical debridement may be accomplished by wet-to-dry dressings, by rubbing/friction while cleansing the wound, or by pulsed water jets & hydrotherapy (pulsed lavage, whirlpool). Autolytic debridement occurs by promoting natural enzymes in wound fluid to degrade non-viable tissues – usually by placing an occlusive or semi-occlusive dressing over the non-viable tissue. Autolytic debridement may be accomplished by osmotic wound products such as medical-grade honey or gauze saturated with hypertonic sodium chloride. These products "draw" fluid from wound bed tissues into the wound product and loosen necrotic tissue.2,14 Larval debridement is performed by allowing sterile maggots to remove non-viable tissue.2,13

"Natural" Debridement Therapy

Maggots are the unsung heroes of wound healing. Maggot(s) or larval debridement therapy (MDT or LDT) has been utilized for medical purposes for hundreds or thousands of years. Mayan Native Americans and other ancient cultures have documented reports of maggots being used in certain medical treatments, especially for wound care. Larvae of certain fly species, such as Lucilia sericata (green bottle fly), remove only dead tissue while promoting healthy tissue in the wound bed, helping wounds heal faster.12-14

Dr. John Forney Zacharias (1837-1901), a Confederate American Civil War surgeon, is recognized as the first healthcare provider in the US who intentionally applied maggots for wound care/debridement purposes. He noted that "maggots could clean a wound better in one day" than any other agent they had at their disposal. He also accredited maggots with saving many soldier's lives. In WWI, an orthopedic surgeon named Dr. William S. Baer recognized maggots' efficacy to "clean up" compound fractures and large open flesh wounds when he discovered them in several untended war wounds from the battlefield. He credited the blowfly larvae with preventing sepsis in these battlefield cases. He was very impressed with maggots' usefulness as a medical treatment, and after his battlefield experiences, he determined to conduct research using blowfly larvae at Johns Hopkins. In 1929 he started using maggots he found in the neighborhood or those he grew on a windowsill. Two patients contracted tetanus from contaminated maggots (one died), so he developed sterile maggot growing procedures. He used maggot therapy in 21 patients with chronic osteomyelitis, which did not respond to other treatments. He demonstrated rapid wound debridement of necrotic tissue, a return of the wound bed to an alkaline ph environment, the reduction of bacteria, reduced odor levels, and complete healing of the osteomyelitis infections within six weeks.14

Regrettably, with the development of antibiotics in the 1940's and various skin and wound antiseptics, the use of LDT declined. It became a standard of care to use antibiotics in and on the body and antiseptics on the skin and the wound. Maggot therapy was essentially abandoned in favor of more modern or "easier" methods. Arguably, one of the biggest reasons LDT may have lost favor in clinician's eyes was not ineffectiveness (for they remain a most effective form of debridement) but rather was the "yuck factor" - patients, their caregivers, and clinicians found it distasteful to apply small squirming worms that could crawl out of a wound.12,14

Fortunately, with the advent of antibiotic-resistant organisms and increasing drug sensitivities, there was a renewed interest in the "natural" aspect of Maggot therapy in the 1980s. The Food and Drug Administration (FDA) cleared medicinal maggots (Phaenicia or Lucilia sericata) for debriding non-healing necrotic skin and soft tissue wounds, including diabetic foot ulcers, pressure ulcers, non-healing surgical or traumatic wounds, and venous stasis ulcers. In the US, larval therapy with maggots is classified as a medical device. However, in Europe, Canada, and Japan, maggots are classified as medicinal drugs. Maggots used in the US for larval debridement therapy are all processed under controlled laboratory conditions and are sterile (both free of disease and unable to reproduce). Larval debridement of non-viable tissue within chronic wounds results partly from the proteolytic digestive enzymes liquefying the necrotic tissue. The larvae then suck up (along with bacteria and biofilm) and remove from the wound bed. As such, they are the most efficient way to debride a wound without the typical pain or bleeding associated with other forms of debridement, such as sharp debridement. Research suggests they effectively eliminate drug-resistant organisms such as MRSA (methicillin-resistant staphylococcus aureus), and they do not excrete any bacteria into the wound.12

Infection

In many cases, wound inflammation is often mistaken for wound infection since the signs of inflammation are warmth, edema, pain, and localized redness.15 Patients with these symptoms are often placed on antimicrobial treatment regimens without the benefit of microbiological studies to guide them (no quantitative tissue cultures from the wound). This may be one contributing factor in the development of drug-resistant organisms. There has been much written about wound infection, and other authors can address this better than this brief wound care review.2,4,5,12,13,15

Nevertheless, it is one of the most requested topics of basic wound care courses (to know when to treat and when not to treat "infection"). Therefore, we will quickly summarize some important facts and helpful tips regarding wound infection:

There is a difference between chronic bacterial colonization, critical colonization, and critical infection in a wound. Chronic bacterial colonization does occur in most chronic wounds. If the bioburden (high levels and certain types of bacteria) in the wound is not high enough to impair wound healing and does not invade surrounding tissue, the wound may close when other comorbid conditions are addressed (such as nutrition), even if the bacteria are not removed or eliminated by the clinician. These cases of chronic colonization do not typically require antimicrobial intervention. In most of these cases, there may be persistent wound exudates. Still, typically these wounds do NOT exhibit worsening pain, worsening edema, or spreading erythema (redness) beyond 1cm from wound edges. Alternatively, any open wound which is not improving AND has worsening symptoms of pain, worsening edema, or spreading warmth or erythema, should be evaluated for critical colonization (bacterial load is starting to penetrate surrounding tissue or impair wound healing). Critical colonization or infection is characterized by a high bioburden, which requires intervention.2

Critical colonization or infection may be determined by quantitative tissue culture (gold standard) typically obtained by a collecting small piece of tissue from the wound bed (usually a 3mm punch biopsy, a thorough curette scraping, a needle biopsy, or a small 2-4mm size tissue wedge removed by scalpel and pick-ups). Also, wound fluid may be aspirated and placed in a culture medium tube for wound culture. Any organism identified in greater than 105 or 100,000 (10x10x10x10x10) colony-forming units (CFUs) per gram of tissue or milliliter of wound fluid within the wound could be considered a critical infection requiring intervention. Certain organisms are highly virulent (such as beta-hemolytic streptococcus) and will require intervention even if found in small amounts within the wound bed. Suppose your facility does not perform quantitative culture analysis but reports bacterial growth in a semi-quantitative (1+, 2+, 3+, or 4+) scale. In that case, this may be equated to quantitative measures by considering 3+ may be close to 105 CFU, but 4+ is more than 105 CFU and considered a critical infection requiring intervention.3 Some experts have pointed out that host immunity + virulence of organism + environmental factors + bacterial load are factors to consider when evaluating critical colonization and infection versus chronic colonization, which would not require intervention. Infection represents an imbalance in these factors, which results in impaired wound healing or invasion of bacterial organisms into the surrounding tissue. Any wound which fails to progress for two weeks or more should be evaluated for high bioburden, keeping in mind that immune-compromised individuals may not display any classic signs or symptoms of infection (warmth, redness, pain, or edema).3,15

Most nurses only collect wound surface swab cultures and do not typically collect tissue samples from the wound bed. However, there is much variation among swab culture techniques, and this may alter results significantly. Swab cultures of the wound bed surface immediately after removing a dressing may contain dressing contaminants and mostly loose free-floating bacteria. They may not represent what is actually in the wound bed. Also, the presence of necrotic tissue in the wound bed may influence culture results. Wounds with non-viable tissue in the wound bed should be debrided before swab cultures whenever possible. How the swab culture is collected is extremely important to an accurate diagnosis. Is the swab just lightly rubbed along the surface of the one with one stroke in one direction? Is it collected with a back and forth motion across all surface areas of the wound with moderate downward pressure? Is it rinsed with sterile saline first? These questions should be resolved with standard evidence-based wound culture collection protocols, on which all clinicians can agree.3 The author recommends using a curette scraping of the wound bed if available and a wound certified nurse or healthcare provider may do this within their scope of practice. Otherwise, a modified Levine technique may be utilized if swab cultures are the only option for culturing a wound.

Levine technique for obtaining swab culture (when a quantitative tissue sample is not an option): Rinse the wound bed once with sterile saline (non-bacteriostatic and preservative- free). Moisten the sterile culture swab with sterile non-bacteriostatic and preservative-free saline and rotate the swab completely over a 1cm2 area in the wound bed where it is free of necrotic tissue. Press down slightly to illicit fresh wound fluid. Take your time to allow adequate time for fluid collection. Place in appropriate culture media transport tube and take care that the sample does not sit at room temperature longer than the lab recommends. Note: A wound culture left on the desk overnight will likely need to be repeated. Check your lab’s policy on this!

The presence of biofilm (a protected colony of micro-organisms within the wound) is increasingly becoming associated with non-healing wounds. Wounds that have a biofilm often display impaired healing. Biofilms are not detectable to the naked eye and are often overlooked by traditional swab culture laboratory techniques. They are resistant to topical as well as systemic antimicrobial treatments. Frequent debridement may be one way to reduce the presence of biofilm in wounds (maggot debridement, sharp debridement, ultrasonic debridement, etc.).3,12,15

Wound Assessment and Monitoring

As a general rule of thumb, the wound care provider ordering the wound care should re-evaluate the wound for progress at least two weeks after the initial wound orders are placed. If the wound is stable, the topical wound treatment is performing as anticipated. The wound is progressing as expected. The wound treatment may be continued, and the follow-up could be extended to once every 2 to 4 weeks. Studies indicate that wound healing (size reduction) in 4 weeks may predict the likelihood of healing by 12 weeks. If the wound has not improved within 2 to 3 weeks or if there has been a significant change in the patient's condition, the wound should be reassessed.9 The clinician should decide if a change of wound treatment is in order or if other factors need to be addressed, which may impair wound healing (nutrition, medications, glycemic control, infection, etc.).3,9 After addressing these factors, have the patient return to the clinic in another week or two to re-evaluate progress with the current treatment. If no progress is noted or the wound worsens, a change in treatment may be warranted.3,9

Wound Documentation

Many algorithms and forms now exist to assess, document and monitor wounds. Documentation consistency between healthcare providers is essential for effective communication. See "Top 20 strategies for effective skin and wound documentation" (p37) in Clinical Guide to Skin and Wound Care (7th Edition). Consider using a standardized skin and wound assessment template in your documentation or electronic health record (EHR). The Bates-Jensen Wound Assessment Tool (BWAT) and the Pressure Ulcer Scale for Healing (PUSH) are just a few examples.17 Essentials of wound documentation (especially at initial evaluation) include (but is not limited to) 8,16,17:

  • Chief Complaint (including pain level)
  • History of Present Illness and Comorbid Conditions
  • Type of Wound (including suspected etiology)
  • Location of Wound
  • Duration
  • Types of Wound Treatments Already Tried
  • Patient / Caregiver Knowledge Level
  • Medical, Family, and Social History
  • Review of Systems
  • Physical Assessment
  • Risk Assessment(especially for pressure injury risk, if applicable)
  • Skin and Wound Assessment (including key components of T-I-M-E-S or D-I-M-E
  • Wound measurements (at least Length cm X Width cm x Depth cm), including the extent of any peri-wound erythema or rashes
  • Exudate amount and color
  • Exudate or wound odor
  • Wound bed description (% of viable versus non-viable tissue in the wound bed, tissue color, etc.)
  • Localized or generalized edema noted
  • Procedures Performed
  • Supplies and Tests Ordered
  • Patient/Caregiver Education Provided (and response)
  • Care Plan
  • Discharge/Follow-up Plan

Measuring the wound is an essential component of wound monitoring and documentation. Wounds may be measured using various techniques, but the two most common techniques are the clock method and the longest axis method. The measurement method used should be performed consistently by all care providers. Only one method should be used for all wound measurement documentation for the entire facility to minimize confusion and inconsistency in the patient's charts. The clock method consists of imagining the top of the patient's head to be at the 12 o'clock position of a clock and the feet' soles to be at the 6 o'clock position of an imaginary clock. All wounds are measured, with the length being the wound's measure and the 6 to 12 o'clock axis and the width being the measure of the wound opening along with the 3 to 9 o'clock axis.17 This works well to get the same measures no matter what position the patient is lying or sitting in. The longest axis method consists of taking the wound opening measurements along the wound's longest axis as the length and the width measurement as the measurement of the wound opening along the perpendicular axis. Wound depth is measured the same way for both of these methods. Using the blunt end of the cotton-tipped applicator, hold the stick lightly resting upon the deepest portion of the wound and using a gloved hand, grasp the stick at the wound edge, and measure the wound's straight depth at the deepest portion of the wound and record this as straight depth. Tunnels or tracking in the wound or undermining (lip under the wound edge's inner aspect) should be measured at most shallow and deepest points. It should also be noted if tunneling or tracking connects two wounds or connects with any joint space or underlying structures.17

Photographing the wound (if desired) as an additional component of wound monitoring includes establishing a routine frequency of photographic documentation, a consistent camera and distance from the wound for all photographs, and a measuring ruler in the frame next to the wound for size reference. You must consider who is taking photos. If another person is taking the pictures, make sure they follow infection control practices and do not touch the patient with the camera or anything in the patient's room, especially if they will be taking the camera back to a central work area or other patient's room. If the same clinician performs the dressing change, care should be taken to follow strict infection control protocols concerning handling the camera and where it is stored during wound care. For example, it should not be laid on the patient's bed or bedside table without a clean barrier under it. It should not be handled after touching the patient, the wound dressing, or wound care supplies without first washing your hands. Hands should be washed again after handling the camera. The camera should not be close to the wound during dressing changes if at all possible. During dressing changes, bacteria may be aerosolized and could contaminate the camera. The camera should not be taken from one patient's room to another for other photos without first using some kind of disinfecting wipe or changing camera covers if disposable covers are used. 

Suppose photographs are to be used in the electronic health record. In that case, the author recommends that a photo of the patient's ID bracelet be taken, followed by a photo of the wound, then the ID bracelet again, so that this sequence of photos may be uploaded into the appropriate electronic health record, and minimize the chance of the picture being uploaded to the wrong patient's chart. In most cases, identifiers such as patient name, initials, date, etc., should not be included in any photo used for educational purposes. However, follow your facility's protocols for taking and uploading wound photographs.

Moisture Control

One of the main functions of a wound dressing or wound therapy is moisture management. Specifically, to maintain a moist wound bed while also eliminating excessive wound drainage.7 Since George Winter's seminal work in 1962,6 demonstrating open wounds treated with dressings that maintained a moist environment healed almost 50% faster than wounds allowed to dry out, no published studies have been able to refute the effectiveness of moist wound healing. Current scientific investigations not only support what has been known about moist wound healing but serve to explain further the role of a moist wound bed in relation to the local cellular activity associated with wound healing (cytokine signaling, fibroblast cell proliferation, collagen and matrix synthesis, epithelial cell migration, etc.).3,5,7,9,13

Common Wound Dressings Overview

Why are we still using wet-to-dry? There are hundreds of commercially available wound care products in the United States. Numerous dressings or topical wound care applications have reported successful wound healing results in clinical trials. Yet, wet-to-dry dressings are still among the most frequently ordered wound care modalities in nearly all healthcare settings.18 Wet-to-dry dressings are no longer evidenced-based practice for wound care.13,18 As the name implies, a wet-to-dry dressing ultimately results in a dry wound bed (even if for limited amounts of time). Research demonstrates these dressings disrupt granulating tissue, impair epithelial cell migration, leave behind foreign bodies in the wound bed, increase the risk of infection, aerosolize bacteria, and cause severe pain upon removal.18 Nevertheless, wet-to-dry dressings have been a standard, traditional, or 'default' dressing for decades.13,18 Modern wet-to-dry dressings are accomplished by moistening sterile cotton gauze with a solution (usually 0.9% normal saline) and placing it in the wound, allowing it to dry, then removing it dry from the wound bed (along with tissue that adheres to it), thus performing mechanical debridement. There are several reasons why this form of debridement may be detrimental to the wound bed and unnecessary with so many other forms of wound debridement available today. Cost, compliance, pain, increased risk of infection, and re-injury to healthy granulating tissue are several of these reasons.13,18

The author believes that most healthcare providers have continued with wet-to-dry dressings more out of misunderstood tradition than evidence-based wound care practices. Furthermore, the use of wet-to-dry dressings as a wound care modality may be outdated and used with inappropriate frequency in today's health care arena.18

When, Where, What, Why, and How?

If not wet-to-dry, then what? How do you select a moist wound dressing? There are so many from which to choose. What dressing has the most evidence supporting it? How often should you change the dressing? Unfortunately, several systematic reviews have failed to produce strong evidence in favor of one specific dressing type for all wounds. Most clinicians who are not familiar with modern wound products just want to know, "if not wet-to-dry, then what one product can safely be used in its place?" The answer to this question should be, "it depends."

Wound experts now realize the "one size fits all" approach is not ideal for wound care or dressing product selection. Multiple EBP wound treatment algorithms exist to assist the clinician in selecting wound treatment approaches. Krasner, Sibbald & Woo developed a Conceptual Framework for Wound Dressing Product Selection©.26 This model reminds health care providers that wound care should be delivered using a "Holistic, Interprofessional, and Patient-Centered Approach©." This approach should also agree with the principles of evidence-based practice (EBP). The principles of EBP affirm that health care should be delivered based on the strongest and most current research evidence + the clinician's experience & expertise + the patient's (and family's) preferences and values.19

Before you can determine anything about the wound, you must assess the wound. However, the wound is only one small part of a person. In assessing the wound, do not forget to assess and talk to the person attached to the wound.20 Assess the person (physically as well as psychosocially). What are the preferences, personal needs, likes, dislikes of the patient (and their caregiver)? What are their feelings about the wound/wound care? For a caregiver who gets sick and faints at the sight of blood, asking them to empty bloody drainage from a drainage tube may not be a good choice. As you assess the wound itself, identify the wound and comorbid conditions' etiology, which may affect wound healing. In Krasner, Sibbald & Woo's model, they suggest approaching wound care with one of 3 options or "goals" in mind.26

  1. Is the purpose of wound care curative or to heal the wound?
  2. Is the goal of wound care temporary "maintenance" or to prevent further deterioration until the patient can tolerate more aggressive treatment? This scenario may be applicable if a patient has a gangrenous toe or non-healing/necrotic arterial foot ulcer. Still, the patient is also in the ICU following a massive stroke and cannot tolerate any surgery until he/she is hemodynamically stable. In other words, the patient's condition needs to stabilize before aggressive approaches to wound healing can be safely deployed.
  3. Is the goal of wound care palliative? Knowing the wound is not likely to heal (as at the end of life with multiple organ failure). Different products and approaches may be employed for wound care if the purpose of wound care is not to heal or close the wound but to provide pain relief, moisture management, or odor control and prevent or reduce the risk of spreading infection. This may frequently occur with malignant lesions in hospice patients, and these patients may present challenging situations. Still, rewarding outcomes may be possible to ease a person's suffering or improve quality at the end of life.

Basic Dressing Types

The most effective and economical substitute for saline moistened gauze (wet-to-dry) dressings is gel moistened gauze dressings. However, there are now many evidence-supported wound dressings to address various types of wounds' specific needs. This section is a basic introduction to some common dressings that have moderately strong evidence supporting their use. Please see Table 1 for a list of common wound dressings and suggestions for frequency of dressing changes. Resources for the information in this section of the course were obtained from >10 main sources.3,8,9,13,21,22 Also, the Agency for Healthcare Research & Quality (AHRQ) has evidence synthesis summaries and technical assessments published or currently in progress (such as a review of skin substitutes for chronic wounds)21, which may be pertinent to wound care.  With all current evidence guiding practice, it is recommended to continually re-evaluate the strength of the evidence as new evidence is generated.22 

The Ideal Dressing. The ideal dressing should promote the best environment in the wound bed to promote wound healing. In other words, it should maintain a moist wound bed, be thermally insulating, protective to the wound, free of particles that could remain in the wound and become foreign bodies in the wound, be vapor permeable, hypoallergenic, non-toxic, comfortable, and cost-effective.3,7,8,9,13 Also, if at all possible, the wound dressing should also be aesthetically acceptable to the patient/caregiver and promote the patient continuing as many daily living activities as possible (within the limits of his comorbid conditions). The average health care provider or medical clinic should have at least a basic familiarity with the following products and should probably have at least one of each type of dressing on hand/in stock:

Gauze

Gauze (and "nonstick" Telfa). Gauze comes in a plethora of forms, sizes, shapes, and layered products. The most common gauze products are sterile or aseptic (packaged individually, in packages of 2 or in bulk packages of 50 or 200 cotton gauze, woven, 8 or 12 layered, 4" x 4" or 2" x 2" sizes. Telfa is gauze, which is coated with a plastic film to help render it "non-adhesive." Gauze also comes in larger bulk dressings such as ABD pads (originally known as Army Battlefield Dressings, but now are commonly referred to as "abdominal dressings"). Today, these dressings are commonly made with bulky absorbent layers of cotton batting and woven gauze in larger sizes such as 5" x 9" or 8" x 10." Gauze dressings are also manufactured in woven gauze of one rolled length (roll gauze) in a variety of widths (such as 2" of 4" or 6" widths). Care should be taken when using certain types of roll gauze or woven gauze as a primary dressing in a wound bed. Some gauze products may leave behind small pieces of organic cotton material, becoming foreign bodies in the wound, and perhaps facilitating bacteria's growth or promoting hypergranulating tissue. Gauze may be used as both primary and secondary dressings and may come already impregnated with other substances such as calamine, petrolatum, wound gels, silver, etc. Also, combination products may have layers of gauze combined with layers of other wound products such as charcoal, alginates, adhesive backings, or borders.

Wound Gels

Whereas wet to dry dressings are moistened with saline and allowed to dry out (and therefore, not recommended for routine wound care), wound gels are a good alternative that effectively maintains a moist wound bed. The clinician may moisten the gauze with a wound gel or use a pre-packaged gel impregnated gauze. Typically, this only needs to be changed once a day instead of 2-3 times per day. Wound gel dressing changes would be less painful than wet-to-dry. Wound gels come in amorphous gels (in tubes) or sheets of flexible semisolid gel. Wound gels are commonly made of organic polymers that maintain moisture in the wound bed and swell with water or wound drainage. Also, wound gel may contain silicone, water, glycerin, polyethylene oxide, alginate, or collagen. These wound gels' common brand names include (this is not meant to be all-inclusive): SAF-gel®, Vigilon®, Elastogel®, Curasol®, Solugel®, Intrasite® Gel, Purulon® Gel, DuoDERM® gel, NStimulen® collagen gel, Carrasyn®, Curagel®, Nu-Gel®Restore®, XCell®, etc. Some gel sheets, such as "Vigilon®," come with polyethylene film covers on each side that should be removed before placing gel sheets on the wound (this will allow more vapor permeability). Gel products may absorb up to 5 or more times their body weight in wound drainage yet will not dry out or dissolve. Typically the gel product is placed in the wound bed and covered with a secondary dressing to secure in place (such as gauze or foam).39,23 These products are normally changed daily, though gel sheets on certain wounds such as superficial wounds and skin tears may be left on for one week if the skin tear is clean (non-infected) with a well-approximated flap and is not heavily exudating. Wound gel sheets that come with adhesive borders may typically be changed three times per week. Wound gels are appropriate for full-thickness, shallow or deep wounds with scant to small amounts of drainage or varying amounts of drainage where the wound bed may dry out at times. Silicone gel sheets may also help prevent or treat wound scarring (keloid/hypertrophic tissue) for up to one year after wound closure.3

Care should be taken to manage moisture so that excessive moisture cannot seep out over the surrounding wound edges, causing maceration. Skin Barrier wipes or creams may help protect periwound skin from adhesives (barrier wipes) or excessive moisture (barrier creams such as zinc oxide or dimethicone). These are applied at each dressing change.

Impregnated Gauze

Another simple dressing to use is impregnated gauze. Pre-packaged impregnated gauze products are typically impregnated with petrolatum, hydrogel, Bismuth Tribromophenate®, hypertonic sodium chloride, zinc, or crystalline iodine compound (iodoform), to name a few. These dressings' common brand names include (this is not meant to be all-inclusive): Vaseline® Gauze, Adaptic®, Xeroform®, Curasalt®, Mesalt®, etc. The most basic and inexpensive petrolatum impregnated gauze may average $40 or less per box of 50. These dressings are conforming and may be a good choice when filling tunnels or tracking as long as one piece and not multiple pieces are packed loosely into the tunnel. These dressings provide a non-drying and moisture-retaining wound interface. They conform to the wound bed, and petrolatum impregnated products may help protect periwound skin if shallow abrasions may be placed on the wound overlapping the edges. Normally these dressings are changed daily and covered with a secondary dressing such as gauze pads or roll gauze, foam, bandage, or wraps.

Hydrocolloids

Hydrocolloid dressings are typically opaque, self-adherent "patch" type dressings made of sodium carboxymethylcellulose, pectin, and gelatin mixed with polymers and adhesives. They also have a semipermeable film or foam sheet covering, which makes them generally waterproof. However, waterproof does not mean it can be submerged, such as in a bathtub or pool. These dressings are flexible wafers of differing sizes, thicknesses, and shapes (some may be cut to the desired size and shape). They can conform to many areas of the body. These dressings' common brand names include (this is not meant to be all-inclusive): Restore®, DuoDERM®, DuoDERM® CGF, Tegasorb®, Comfeel®, Granuflex®, and 3M Tegaderm® hydrocolloid thin.3,9,13 When exposed to exudate (wound drainage), the polysaccharides & other polymers absorb water and swell but remain contained in the adhesive matrix. Some have marks to indicate when the wound drainage exceeds the dressing's limit and is time to change. Most, if cut to size, should be cut larger than wound. These dressings are typically changed every 2-5 days, and it is best to use a skin barrier wipe applied to the periwound skin before applying the hydrocolloid.

Alginates and Fiber Gelling Dressings

Alginates are super absorbent fibers typically composed of calcium alginate manufactured from brown seaweed that becomes gel-like when exposed to sodium-rich wound exudates. It resembles angle hair and is manufactured from brown seaweed. They may absorb up to 20 times their weight in wound exudates.3,9,13 This makes them a good choice for highly exudating wounds. However, they are not recommended for dry or only slightly moist wound beds, as they will not remain a gel without the presence of moisture from the wound bed. Thus, they may dehydrate the wound bed or allow the wound bed to dry out. Alginates may be available as sheets or pads and ropes and are known for some hemostatic properties, making them a good choice for a wound bed that may ooze a small amount of blood after sharp debridement. Also, some alginates may have silver incorporated into the fibers as an antimicrobial agent. Alginates typically require a secondary cover dressing such as gauze or ABD pad and are changed daily or as necessary to manage wound exudates.

Hydrofiber

Hydrofiber dressings are non-wicking, absorptive primary dressings made of sodium carboxymethyl-cellulose fibers that absorb wound drainage and turn into a gel sheet.3, 9,13 They may also keep the wound bed moist if the wound is sometimes dry (you would moisten them with saline or water). Hydrofibers act somewhat like alginate but will not promote hemostasis like alginates. Some hydrofiber dressings include 1.2% silver as an antimicrobial component (usually delineated by the silver element symbol "AG" in the hydrofiber name). They are appropriate for full-thickness wounds with minimal to moderate amounts of drainage. They are typically changed once every 1 to 3 days and require a secondary cover dressing.

Foams

Foam dressings are typically both absorptive and protective.3,9,13 They may be selected to provide conforming padding and may be used in combination with other products (such as alginates or hydrofibers) if needed. Foams may be used as packing material in large wounds to fill dead space. Not all foam dressings are appropriate for infected wounds. Check manufacturer guidelines if an infection is an issue. Some foam dressings are impregnated with silver or other antimicrobial material (such as Methylene Blue and Gentian Violet or polyhexamethylene biguanide/PHMB) or coated with a silicone interface.

Silver Products

Silver ions may be incorporated in wound gels, woven fabric dressings, foam, rope, alginates, or hydrofiber dressings. Most silver fabric dressings are not very absorbent. They are used primarily to deliver silver ions to the wound bed for the silver's antimicrobial effects. However, silver alginates, hydrofibers, foams, or composite dressings are absorbent. Silver ions are activated by wound exudates or water; some silver products (Acticoat three days or seven days) should not be moistened with sodium chloride (saline). Most ionic silver products should not be mixed with hydrogen peroxide or sodium hypochlorite (Dakin's or DiDaksol) solutions because the ions will inactivate each other. Ionic silver products should not be combined with iodine products for the same reason. Silver dressings may need secondary dressings to hold them in place or provide extra absorption and may be changed daily up to every seven days, depending on the product.

Iodine Products

In general, a 10% povidone-iodine solution provides about 1% of available iodine and is commonly used as an antimicrobial. It should not be used in typical chronic wound care due to its cytotoxic properties (but may be used short-term if infection warrants it or "paints" stable dry, intact eschar).3,9 However, a cadexomer iodine is available, which is antimicrobial while remaining non-cytotoxic to the wound bed. Cadexomer iodine is available in a wound gel (thick paste) or a flexible pad, which is typically applied to the wound bed with a secondary dressing on top and left in the wound bed for three days, or until the color changes from an orange-brown to a grey-brown. They are used for antimicrobial effects on infected rooms and are effective against most bacteria, including pseudomonas, staphylococcus aureus and streptococcus, and fungus. Some literature suggests that caution be exercised when using a slow-release iodine product in patients with thyroid disease due to iodine's potential systemic uptake.

Compression and Layered Dressings3, 24

Compression dressings or bandage wraps are primarily used for lower extremity venous insufficiency. Compression garments are also appropriate for extremities affected by lymphedema (such as mixed etiology lower extremity edema, and after cancer surgeries such as mastectomies with axillary lymph node removal) or burns. Short-stretch compression is typically used for lymphedema (these are NOT ace bandages). Long-stretch compression (multilayer wraps and ace-type bandage) is also the typical treatment for venous leg wounds. It is important to verify arterial perfusion to the affected limb before applying compression. Compression may be applied in 2 to 4 layers. A therapeutic layer such as zinc oxide or calamine impregnated strips applied first, an absorbent layer next, possibly a bandage layer or Coban layer on top. These dressings may be applied every few days to weekly, depending upon the amount of wound exudates. Once edema is under control and wounds healed, the patient should wear life-long compression stockings (apply daily first thing in the morning before ambulating and remove at night just before retiring to bed).

Composite dressings.9 Composite dressings are combination dressings of various sizes made up of two or more separate materials to address the unique needs of certain wounds. These dressings tend to be layered with a contact layer (may be non-adhesive), an absorbent layer, and possibly an antimicrobial layer or odor-absorbing layer (such as charcoal). They also may have an adhesive border to secure them to the wound site.

Advanced Therapies and the Future of Wound Care

Tissue-engineered skin substitutes, matrix dressings, electrical stimulation, collagen products, platelet-rich dressings, and negative pressure wound therapy are some of the advanced wound therapies which are becoming more commonly used. As technology advances, additional novel therapies are being developed, including bioactive dressings,13 surfactant gels,28 nanomaterials,29 and dressings which not only treat the wound but also monitor the wound and provide real-time information to clinicians on a phone app.30 Staying up to date with advancing technologies in the treatment of wounds is a challenge for nurses and other healthcare providers, but attending wound conferences and online CEU courses is a great place to start.

Pain Management for Chronic Wounds

The Joint Commission (TJC) lists pain management as a quality indicator for acute care settings.25 Basic pain management includes an accurate assessment and documentation of wound pain. While pain management may be addressed most in burn wound settings, it is increasingly addressed in other chronic wounds (and rightly so!). The gold standard for an accurate assessment of the patient's pain is the patient's self-reported pain level. Whether a pain scale of 0 (no pain) to 10 (excruciating pain) is used, or smiling faces/grimacing faces, the pain level should be documented exactly as the patient reports it. The onset, location of the pain and the quality of pain (stabbing, shooting, throbbing, sharp, dull, constant or intermittent, intensity) along with what factors relieve the pain or make the pain worse (walking, standing, elevating the leg, etc.) should be ascertained and documented. The effects the pain has on the patient and any pain management history and current pain regimen should also be determined. Also, determine the patient's pain management goals.27

Worsening wound pain is one hallmark of a deteriorating wound and may be more indicative of infection than other observable signs such as edema, warmth, and erythema surrounding chronic wounds.3,15 Woo and Sibbald developed a Chronic Wound Associated Pain (WAP) model to address the patient, the cause, and the wound. This algorithm may help determine an evidence-based approach to wound pain management. Persistent chronic pain is highly individualized and requires highly specialized medical care. If wound-related pain is not well managed, patients should be referred to specialists who can address their wound pain.25,27 Persistent or chronic pain itself may impair wound healing by causing vasoconstriction and decreasing perfusion, so every attempt should be made to address chronic wound pain.3

Pain with dressing changes may be managed by topical anesthetic products such as 2% or 4% topical Lidocaine Jelly, or EMLA cream, or systemic medications such as NSAIDs or opioids. Topical anesthetics (Lidocaine, Prilocaine, etc.) should be applied with enough time before dressing change or debridement for the medication to take effect (approximately 10 min). Similarly, systemic pain medication should also be administered with enough time for pain relief (at least 30 minutes) . Addressing the pain when an infection is suspected would include addressing the infection. Certain wound products may assist with pain management in specific types of wounds. Matrix applications using small intestine submucosa (SIS) technology (typically porcine) have successfully relieved some wound pain, particularly over donor sites from split-thickness skin grafts. Glycerin or silicone-based gel sheets and hydrogel sheets (cross-linked polyethylene oxide and water) such as Vigilon may be cool and soothing to partial thickness wounds such as second-degree burns, and silicone helps reduce scarring after wound closure.9 Be on the alert for new, different (especially worsening), or the persistent pain associated with chronic wounds. Persistent pain in a neuropathic extremity with a chronic wound, as well as may be associated with osteomyelitis.5,8,9,15

Table 1

Wound Product (Basics) Table
Type of product (typical costs)Some Examples (not all-inclusive) *Brands/NamesTypes of woundsAction
Petrolatum or Hydrogel Impregnated gauze ($)Vaseline Gauze, Adaptic, Xeroform; Skintegrity, Elta, Restore, DermaGauze, Curafil, Curad Petrolatum GauzeShallow and dry wounds; abrasions, skin tears, etc.Provides non-drying and moisture-retaining wound interface, conforms to the wound bed, petrolatum impregnated products may help protect periwound skin if shallow abrasions. They are typically changed daily, though they may be left in place over well-approximated, non-infected skin tears up to 1 week.
Wound Gels/Hydrogels ($-$$)SAF-Gel, Vigilon, Elastogel, Curasol, Solugel, Intrasite Gel, Purulon Gel, DuoDERM gel, Stimulen collagen gel, Carrasyn, Curagel, Nu-Gel, Restore, XCell, (Hypergel is a hypertonic saline gel)Dry to minimally draining wounds; partial and full-thickness depth, 2nd-degree burns, exposed tendonsOrganic polymers maintain moisture in the wound bed and swell with water/drainage (some can absorb up to >5x their weight in exudate). These gels typically will not dry out or dissolve. It may be changed daily, though some gel sheets such as skin tears may be left on for one week if a well-approximated flap. Some gel sheets (particularly glycerin or silicone) may also be used over scars to reduce hyperkeratosis (keloid formation).
Hydrocolloids ($-$$)Restore, DuoDERM, DuoDERM CGF, Tegasorb, Comfeel, Granuflex, 3M Tegaderm hydrocolloid thinPartial and full-thickness wounds; minimal to moderate drainageTypically a flexible wafer of differing sizes, thicknesses, and shapes (some may be cut to desired size and shape); forms an Impermeable barrier (most are waterproof); self-adhesive; may contain gelatin, pectin, and carboxy-methylcellulose together with other polymers and adhesives. When exposed to exudate (wound drainage), the polysaccharides & other polymers absorb water and swell but remain contained in the adhesive matrix. It may be changed every 3-5 days.
Transparent films ($-$$)Op-Site, 3M Tegaderm, PolySkin, Suresite, Blisterfilm, Argomed and Argomed plus TPU films, Mefilm, Uniflex, AcuDermPartial-thickness or shallow wounds with minimal to small drainageMost are polyurethane films; provide moisture retention and may provide skin protection. May also assist with autolytic debridement. Most are oxygen or vapor permeable (not 100% occlusive). Sometimes used to "waterproof" a wound
Hydrofiber ($$-$$$)Aquacel, Aquacel AGMostly shallow; partial to full-thickness; minimal to moderate drainageNon-wicking, absorptive dressing made of sodium carboxymethyl-cellulose fibers absorbs wound drainage and turns into a gel sheet. They may also keep the wound bed moist if the wound is sometimes dry (moisten with saline or water). Act somewhat like alginate but will not promote hemostasis like alginates. Typically changed 1-3 days.
Non-adherent polyurethane foam or Silicone interfaced foam; ($$)Optifoam, Mepilex, Mepilex Border, Mepilex Transfer, Allevyn, PolyMem, Lyofoam, HydrasorbShallow wounds to those with some depth; partial to full-thickness; minimal to heavy drainageAbsorptive & protective - provides conforming padding and may be used in combination with other products (such as alginates or hydrofibers) if needed; Some have self-adhesive borders. Foams that have a silicone contact layer may be useful in reducing hypertrophic (keloid) scarring. Some have multiple layers (such as polyurethane foam+ polyacrylate fibers + waterproof film in Mepilex). Typically changed 1-3 days.
Calcium Alginate ($$)CalciCare, AlgiSite M, Maxsorb, Algicell, SeaSorb, Restore Calcium AlgiModerate to heavily draining wounds with no necrotic tissueHighly absorptive fiber (rope or pad) product made from brown seaweed. May absorb up to 20 times their weight. Turns to gel when moistened with wound drainage. Change daily. May promote hemostasis.
Foams ($$)Optifoam, Mepilex, HydrasorbDeeper, full-thickness; moderate to heavy drainageAbsorptive and protective - provides conforming padding and may be used in combination with other products (such as alginates or hydrofibers) if needed; Foams may be used as packing material in large wounds to fill dead space.
Impregnated Foams ($$$)Hydrofera BlueFor exudating wounds; Can be used in pressure ulcers, venous ulcers, arterial ulcers, donor sites, abrasions, lacerations, superficial burns, etc.Absorptive and bacteriostatic wound dressing made of Polyvinyl alcohol sponge, methylene blue, and Gentian violet. May help prevent infection or manage bioburden in the wound. It also binds endotoxins, which may aid in patient comfort (may be useful in pyoderma cases). Contraindicated for 3rd-degree burns. May also use with enzymatic debriders. First dressing change at 24 hours. After that, it may be changed every 72 hours – however, do not allow the wound bed to dry out.
Silicone ($$)Mepitel, Elastogel, ectDry to exudating wounds or delicate wound beds (exposed tendons, etc.); or over newly closed wounds with a high risk of scarringSome are fenestrated (have holes in them, such as Mepitel) and may be applied directly to wound bed under negative pressure wound therapy or other dressing as a nonstick primary dressing. Some are thicker and used over shallow wounds or newly closed wounds to prevent hypertrophic (keloid) scarring. It may be changed every 2-7 days.
Roll Gauze ($) Deeper, full-thickness; moderate to heavy drainageAbsorptive and may be used to fill dead space; may also be used in combination with other products (such as alginates or hydrofibers) if needed; Kerlix not recommended due to loose fibers
Antimicrobial silver-impregnated woven fabricActicoat Burn (3day), 7day, flex, surgical site dressingsNot for very dry woundsNot very absorbent - used primarily to deliver silver ions to wound bed for antimicrobial effects. Silver ions are activated by wound exudates or water; some silver products should not be moistened with sodium chloride (saline) or sodium hypochlorite (Dakin's or DiDaksol) solutions because the ions will inactivate each other. Silver products should not be combined with iodine products.
Other silver productsSilver wound gels; Silver gel sheets (Silvasorb), silver alginate; silver hydrofiber, silver foam, etc.Application varies by type of base productUse silver gels as you would other wound gels, use silver alginates as you would other alginates, silver foams as you would other foam dressings, except silver products should typically be used as primary dressings and not secondary dressings (so the wound bed receives the benefits of the silver antimicrobial).
CompressionProfore, Profore lite, Unna Boots (with zinc oxide or calamine impregnated contact layer) or multilayer (2-4 layer) wraps, ace wrapsFor lower extremity venous woundsLong-stretch compression (multilayer wraps and ace bandage) is the typical treatment of choice for venous insufficiency and venous leg wounds. Verify arterial perfusion to the affected limb first!
Silver Nitrate sticksSameFor minor active bleeding or hypergranulating tissue in the wound bed or at wound edgesApplied directly to rolled wound edges, hypergranulating tissue in wound bed; chemically cauterizes acute bleeding (must be used by a healthcare provider who can perform chemical cauterization within their scope of practice).
Collagenase ointmentSantylWounds with necrotic tissue in the wound bedOnly FDA approved active enzymatic ointment to help remove necrotic tissue from the wound bed
Antifungal skin products2% miconazole nitrate in powder, spray, cream, lotion, or ointment. Aloe Vesta Antifungal; Monistat 1, Neosporin AF, Baza Antifungal; Carrington Antifungal; Fungoid; Lotrimin AF, etc.Skin with a fungal rashGenerally for fungal rash affecting the skin around the wound. Typically apply a small amount, gently rubbing it into the skin so it is no longer visible. The powder may be applied with a light dusting, then gently rub onto affected skin (and may blot with skin barrier liquid to seal in, if excessive moisture is present or under ostomy appliance).

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References

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