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

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.

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

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

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

• 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:

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.

"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

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

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.

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

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

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.

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

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

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.

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:

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.

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.

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

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