Keys To Effective Wound Dressing Selection

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Insights On Ordering Dressings And Collaborating With Ancillary Services

Determining the needs of the served population and establishing a cost-effective and efficient product inventory is important. Chronic wounds may take months to heal so one may consider referral to wound care specialty practices. Carrying a large variety of dressings in the office setting may be unrealistic. A small stock of basic dressings is usually adequate. There are multiple medical supply companies that deliver ordered supplies to the home and bill insurance directly. While there is no one-size-fits-all answer, most wound care lines consist of both baseline and advanced products. Remember that many product indications overlap and that several products may support the same goal.

Achieving a positive outcome often requires collaboration with community, family and ancillary services such as physical therapy or home care. When home care is in place, the agencies may have a wound care consultant available to assist with development of an optimal dressing plan. Be aware that home care agencies and rehab facilities may operate out of one specific product formulary so it is best to order wound care products by category (i.e. hydrocolloid, calcium alginate, etc.) rather than by product name. If the patient or family is expected to change the bandage at home, one should ensure the patient or family’s ability to understand instructions for dressing changes, including attention to infection control. Many areas have private home wound care consulting companies as additional resources.

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Author(s): 
Nancy Slone Rivera, MS, ANP-C, CWON, CFCN, and Stephanie C. Wu, DPM, MSc

   While sharp debridement of a wound is often the first choice in wound debridement, clinicians may not fully accomplish this in the office setting and patients will need continued treatment at home.19,20 In cases of established eschars, the use of cross hatching and wound gel/impregnated gauze can initiate autolytic debridement.21 To avoid peri-ulcer skin irritation, regular dressing changes with cleaning/irrigation and maintenance debridement of liquefied tissue are necessary. Hydrogel sheets are useful for autolytic debridement of thinner non-viable tissue and to maintain moisture in an adequately hydrated but minimally draining wound. Dressing changes every three to seven days are usually adequate. Hydrogels may also maintain tendon integrity.22

   Hydrogel dressings are considered primary dressings as one applies them directly onto the wound. Most insurance plans will approve a secondary or cover dressing for the wound in combination with hydrogel dressings. Gauze pads or foams are acceptable choices as secondary dressings.

   There are few contraindications to the use of hydrogel dressings. They are not suitable for highly draining wounds and one should not use them on dry, stable eschar in a limb with poor arterial circulation until obtaining vascular consultation. Softening the eschar can allow for bacterial introduction and lead to gangrene.23

Maximizing The Efficacy Of Hydrocolloid Dressings

Hydrocolloid dressings generally consist of a semi-permeable film coated with an absorbent mass of sodium carboxymethylcellulose, pectin or gelatin. Upon contact with wound fluid, these occlusive dressings slowly gel and maintain a moist wound environment. Furthermore, they do not allow oxygen, water or bacteria into the wound. Accordingly, researchers believe these dressings facilitate angiogenesis, granulation and a slow autolytic debridement.24

   One can use hydrocolloids on both full and partial thickness wounds. However, they are not suitable for highly draining or infected wounds as they have limited absorptive qualities and can promote maceration of the periulcer skin. The dressings can stay in place for three to seven days and are commonly used in settings such as home care and facilities where sharp debridement is not readily available. Their multiday wear time can decrease costs associated with care.25 Additionally, hydrocolloid dressings can help decrease pain at the wound site.26

   Two common complaints associated with these dressings are the odor and murky drainage noted at time of dressing removal. Liquefied necrotic tissue is generally tan or brownish in color with an odor, and is often mistaken for purulent drainage. One should evaluate the wound for infection after cleansing, not immediately upon removal of the dressing.

   Sharp debridement can be painful for venous leg ulcers. Hydrocolloids are an acceptable initial dressing choice for use under compression, especially when the wound has dry, fibrous slough. The dressing will soften the dry fibrous slough to facilitate sharp or mechanical debridement after one to two dressing changes. One can also use hydrocolloid dressings in conjunction with offloading for gentle debridement of posterior heel decubitus ulcers. However, plantar ulcers may be a relative contraindication for hydrocolloid dressings as they can cause maceration of tissue due to dependent drainage.

   Hydrocolloids come in several forms with the most common form being a sheet with or without an adhesive border. One can use a hydrocolloid as a primary dressing, as a secondary dressing over an alginate when the drainage is moderate, or even over a hydrogel to further facilitate autolysis. Hydrocolloids are not cost effective for wounds that require more than three dressing changes a week. Similar to hydrogels, hydrocolloids are not appropriate for arterial wounds with dry stable eschar until there has been a team consultation.23,27

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