Challenges in long term care settings
Access to community tissue viability teams and district nursing for residential care in this current climate may be limited. The nurses and senior carers managing residents wounds, can be a daunting task when faced with a box full of dressings.
Understanding when there are changes to the wound bed and topical treatment options is part of ongoing wound care. Where there may be reduced temporary community support, having a better understanding of wound bed changes and tissue management may be beneficial for the in-house senior nurse or carer and residents.
The same can be said for managing trauma injuries such as skin tears, which can cause bleeding and stress to the residents and the care provider.
A really good guide on managing skin tears can be found here.
I am often asked by care providers for basic management training for their teams. There is a plethora of dressings available in the market place today which can be confusing and costly if inappropriately used (Newton 2003).
Where there is no tissue viability input needed at the wounds stage for the resident, or they do not meet the referral criteria to tissue viability team, nurses in homes are the key wound managers.
I will therefore be going through the types of dressings most commonly used in long term care and what their purposes are in tissue management.
Brief history of dressings
There are many dressings around and I’m sure, we as TVNs, have our favourites. I have heard many an old wives tale over the years of ‘home remedies’ which I better not list incase someone gives it a try.
Modern medicine is just that, ‘modern’, and there are records of very interesting wound treatments historically such as: Cow dung (I have been advised by some military nurses I met that this is still used in poorer areas to form a splint for suspected fractures as sets well), spiders webs, herbs, maggots (still used) and leeches were among the many dressings used for healing wounds. It was even a belief that wounds should produce pus to heal; if pus was not found in the wound, the doctor would introduce it by taking it from another patient’s wound. It was known as ‘laudable pus’. Some of the early milestones in moving wound management research forward are:
- Galen of Pergamum 130AD-120AD. The most important was the acknowledgment of the importance of maintaining wound-site moisture to ensure successful closure of the wound was recognised by Galen of Pergamum. This was largely ignored until 1962 when Winter researched moist wound healing and confirmed that wounds require moisture to heal.
- Ambroise Paré (1509-1590) was an innovative French surgeon who served as royal surgeon for a number of French kings, including Henri II. Having been apprenticed to a barber, Paré joined the army in 1536, and spent much of the next 30 years as a military surgeon. He improved or invented many techniques, especially in the treatment of war wounds.
- Ignaz Philipp Semmelweis (1818-1865) a Hungarian obstetrician who discovered how hand washing and cleanliness in general in medical procedures prevents maternal deaths.
- Florence Nightingale (1820-1910) laid the rules down for infection prevention for nursing which was so significant in preventing infections in general, but wound management still relied on a mishmash of old wives tales and doctor’s experiences and was still not recognised science in it’s own right.
- Robert Wood Johnson (1893-1968) was the co-founder of Johnson & Johnson, began in the 1870s producing gauze and wound dressings treated with iodine.
These innovations in wound-site dressings marked the first major steps forward in the field since the advances of the Egyptians and Greeks centuries earlier.
Wound assessment
It is important to remember that dressings do not heal wounds rather they provide an optimum environment for wound bed tissue management. With any new wound, a thorough wound assessment is required.
The basic wound assessment charts and including comprehensive wound assessment there are many tools and guides available.
Any wound that has become static or non-healing it may be considered a chronic wound and require more comprehensive assessment.
There are many reasons why a wound may not heal with both intrinsic and extrinsic factors.
Intrinsic reasons may include underlying pathophysiological status such as anaemia, diabetes, vascular disease, poor nutritional status, family history, previous injuries in the area.
Extrinsic factors may include environmental factors, poor wound bed management.
With both the extrinsic and intrinsic factors affecting each other you cannot treat one of the above in isolation without assessing and reviewing the others.
Remembering the mantra of treat the whole patient not the hole in the patient.
Check your wound management or tissue viability policy and review your wound assessment charts. For more junior nurses this can be done as part of a mentorship in house to lead the way to become a wound care champion. For examples of wound assessment charts both basic and comprehensive search your local policy or look online.
‘Treat the whole patient not the hole in the patient.’
We will be now looking at wound bed management aspect including dressings and dressing selections.
Wound bed preparation/management
Dressings may assist with the wound bed management aspect, so you can see this is just a small part (be it a very important part) in the wound healing process.
Wound healing continuum
Time
The time acronym is commonly used when assessing a wound bed. This stands for:
Tissue, inflammation, moisture, edges. See below table:
(Ousey et al 2016)
With this in mind the below will list the most common types of wound care products (dressings) to manage these tissue types. All the below information is from my ‘go to guide’ in practice, the wound care handbook. I would always have this with me. Also The British National Formulary (BNF). The wound care handbook can also be accessed online here and includes list of dressing names, sizes and cost. Anybody who subscribes to the Journal of Wound Care would get the hardcopy free each year.
Dressing types and uses:
I have listed the most common dressings below along with their key indication for use = (I) and Precautions/contra-indications = (P ).
For full list of indications and precautions please see here a guide link for any dressing you are prescribing or requesting.
Alginates
Alginates are particularly suited for highly draining wounds and bleeding wounds due to their high absorbency and haemostatic properties. (Sood et al 2014).
I: Alginates can hold up to 20 times their own fluid in weight. Indicated for moderate to large exuding wounds.
P: Not suitable for dry necrotic wounds. At dressing change all alginate fibres must be removed from wound bed to prevent inflammation.
Example: Kaltostat
Antimicrobials
(Refer to last week’s article on the use of antimicrobials.)
I: Reducing the bacterial bio-burden of the wound bed when becoming critically colonised.
At present topical applications of Silver, Iodine, PHMB, and honey remain the most popular.
P: Use of any antimicrobial requires carful consideration, and with overuse may lead to increased resistance over time. Review at each dressing change for any improvements in wound bed colonisation. Iodine can be contra-indicated in patients on thyroxine and should be used with secondary advice from a specialist.
Example: Aquacel AG
Hydrocolloids & hydrogels
I: Suitable for clean, granulating wounds or sloughy/necrotic wounds. They are indicated for low to moderate exuding wounds as they have limited absorption. Some dressings are composed of alginate and hydrocolloid to increase absorbancy such as Biatain Alginate
P: Should not be used on infected wounds. Watch out for periwound maceration if hydrating the wound bed is the goal.
Example: Duoderm, Intrasite Gel
Absorbants (secondary dressing)
Absorbent dressings are the mainstay of ‘simple’ wound care, but are becoming more sophisticated. They may come as Foams or Superabsorbants:
- Foams
Easy to apply many have inbuilt silicon border enabling a less traumatic removal. Foams often satisfy many of the conditions of the ideal wound dressing.
I: Suitable for low to moderate levels of exudate. Able to conform to body contours Can be used as secondary dressing for example over a hydrogel.
P: Not a highly absorbent dressing, with out for periwound maceration. May cause erythematous reaction on sensitive skin.
Example: Mepilex Border
Superabsorbants
I: Designed for highly exuding wounds, these often contain fluid-retaining superabasorbant particles with water repellent and air permeable layers protect against contamination
P: May become heavier on the lower limb when left in situ, ensure this will not affect the patients ability to mobilise safely.
Example: Zetuvit Plus
Odour-absorbent
Wound Malodour can be a distressing concern for patients and cares. Malodour is a result of bacterial metabolism and the production of noxious agents such as volatile fatty aides (VFAs).
I: These dressings often have activated charcoal as there main compostion. They have the ability to absorb toxins and control malodour making them ideal for fungating and other wounds.
P: Charcoal dressings are not indicated for dry wounds.
Example: CarboFlex
Films
These are semipermeable dressings. They prevent ingress of microbes and foreign matter but allow the wound to ‘breathe’.
You will find these more commonly used in acute sectors or upon discard post operatively.
I: For use on shallow wounds such as donor sites, minor burns, grazes and post-operative wounds.
P:Not designed for moderate to heavy exuding wounds.
Example: Tegaderm Film
Bandages and stockinettes
These are highly conformable with a two way stretch. Often made from Cotton and polyamide. Also stockinette’s are often preferred over bandages by patients who feel more comfortable. Many report it feels like they are wearing tights and stops the bandages slipping down in bed.
I: Fixation of wound and/or ointment dressings.
P: Not to be used as compression. Must hold primary or secondary dressing in place but NOT compress the limb. May be contra-indicated in Arterial disease.
Example: K-Lite, crepe bandage, CliniFast Stockinette.
Compression bandages
Available as bandages, hosiery or wraps
I: To assist venous return to the heart, avoiding/reducing venous hypertension.
P: NOTE: No Px of compression for your resident should be administered where no previous specialist or vascular input is offered. Resident will need vascular assessment from qualified nurse who has undertaken formal leg ulcer management course and doppler ultrasound course with competencies complete.
Wound contact layers
These are often simple dressings but with a major role to play in wound management.
These products tend to include using soft silicone, or combinations of hydrocolloid and petroleum jelly. While others may use combination of polyester net and petroleum jelly.
I: Often used fro superficial and trauma injuries such as a burns and skin tears, preventing and secondary absorbent sticking to traumatised wound bed. Where patients find wound dressings extremely painful at the wound bed, these may offer a less traumatic dressing removal.
P: Carful not to leave on too long where the dressing may dry out. Granulation tissue may begin to grow through the mesh thus causing trauma on removal.
Examples: Mepitel, Jelonet
Steroid tape
NOTE: Must be prescribed by GP, TVN, ANP, dermatologist after assessment.
I: Over granulation of wound. Adjunctive therapy for chronic, localised dermatosis that may respond to topical corticosteroids
P: Chicken pox, vaccinia, roseca, fungal infections, dermatitis, hypersensitivity to tape.
Example: Haelan Tape, (sometimes Trimovate Steriod Cream Px for stubborn over granulation with the aim to suppress the inflammation response) (BNF 2020)
Skin protectants
‘Repeated exposure to urine and/or faeces can lead to changes in skin pH from the normal acidic pH of 4 to 6 to an alkaline pH (>7). Using alkaline soaps can also increase the skin’s pH. Once the skin pH is raised into the alkaline range, the skin lipids are altered, leaving the skin vulnerable to damage’ (McNichol 2018).
I: Barrier creams, film sprays and wipes protect the skin from excoriation by wound exudate, urine and faecal matter.
P: Traditional Barrier creams such as zinc based ointments such as sudocream should not be used if using continence products as has been shown to block the wicking layer of the pad, thus causing skin irritation.
Example: Prosheild, Caviilon, LBF.
- Further specialist wound dressings such as topical negative pressure (TNP), larval therapy (maggots), paste bandages, compression only to be prescribed on advice from specialist.
I hope this has been a helpful basic guide on wound bed management and dressings.
In this time we are having to work differently, do consider using any available online Telehealth platforms available to your area. Ask your TVN or GP if they are happy to remotely communicate to discuss patients.
Where you do this, do not forget to document your communication and any plans made and disseminate to all involved and store in patients records.
Review your wound management policy and request the local formulary from either your CCG or TVN.
Going forward I would love to see Nursing and Residential care have access to a basic in-house formulary, following training and devised competencies to increase both the practitioners confidence in treating wounds and the patent outcomes.
There are so many resources to access for updates and self care guides with my new favourite ‘Wound Care TV’. Click here for short and informative videos from leading TVNs.
Good luck out there in practice and don’t forget to join the Pressure Ulcer prevention Champion Group on facebook for further support, resources and tips. Also let me know what other subjects you would like me to cover.
References:
Hees, C (2005) Clinical Guide-Wound Care 5th Edition. Lippincott William & Wilkins.
Sood, A. Granick, M. Tomaselli (2014) Wound Dressings and Comparative Effectiveness Data. Journal of advanced wound care. accessed online 28th April 2020 available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4121107/
McNichol, L. Ayello, Elizabeth A. Phearman, Laura, A. Patricia A. Culver, A. (2018) Incontinence-Associated Dermatitis: State of the Science and Knowledge Translation. Advances in Skin & Wound Care: November 2018 – Volume 31 – Issue 11 – p 502-513. accessed online 29th April. available at https://journals.lww.com/aswcjournal/Fulltext/2018/11000/Incontinence_Associated_Dermatitis__State_of_the.4.aspx
Newton, H. (2013) An introduction to wound healing and dressings
British Journal of Healthcare Management.. accessed online 28th April 2020. Available at: https://www.magonlinelibrary.com/doi/full/10.12968/bjhc.2013.19.6.270?utm_source=TrendMD&utm_medium=cpc&utm_campaign=British_Journal_of_Healthcare_Management_TrendMD_0
Ousey, K. Rogers, A, Rippon, M (2016) Hydro-responsive wound dressings simplify T.I.M.E. wound management framework. British Journal of Community Nursing, Vol 21, No 12, Community Wound Care. accessed online 28th April 2020. available at: https://pdfs.semanticscholar.org/313b/571f69ce7f7506ead6e0e30e0199cb4d4002.pdf?_ga=2.138170608.1518212371.1588078325-1378984362.1588078325
https://www.woundcarehandbook.com/
https://www.woundcaretv.com/#dressing_selection
https://www.woundsinternational.com/resources/details/managing-skin-tears-in-practice
