II. Pearls: General Dressing Guidelines

  1. Reassess wound at a minimum of weekly intervals
    1. Change management if no improvement in 3-6 weeks
  2. Sheet dressings should extend 1-2 cm beyond margin
  3. Gently irrigate wounds with each dressing change
    1. See Wound Cleansing
  4. Write date and time of dressing change on dressing
  5. Treating Candidiasis at wound edges
    1. Apply zinc oxide with Nystatin mixture (1:1)
  6. Decreasing wound maceration
    1. Apply stomal adhesive wafer around wound
    2. Apply vaseline around wound edges
    3. Apply zinc oxide around wound edges
    4. Foam Dressings may be preferred over transparent films, hydrogels on fragile skin
  7. Dry surrounding skin
    1. Keeps the peri-ulcer skin dry, but ulcer bed moist
  8. Exudate control
    1. Dressing controls exudate without dessicating ulcer
  9. Optimize caregiver time
    1. May avoid Saline Gauze Dressing (time intensive)
    2. Consider Hydrocolloid Wound Dressing
  10. Prevent abcess formation
    1. Loosely fill all cavities with dressing material
    2. Do not overpack
  11. Consider applied Growth factors at Night
    1. Animal studies suggest benefit

III. Preparations: Dressings based on exudate amounts

  1. Dry to minimal exudates
    1. Transparent Film or Polyurethane Dressing (e.g. Tegaderm)
    2. Hydrogel Dressing
    3. Saline Gauze Dressing
  2. Mild to moderate exudates
    1. Hydrocolloid Dressing (e.g. Comfeel)
    2. Foam Dressing
  3. Moderate to heavy exudates
    1. Alginate Dressing (Sorbsan)
    2. Consider stomal or collection bags
    3. Consider Hypertonic Saline Gauze (Mesalt)
      1. May cause tissue destruction

IV. Preparations: Dressings based on wound tissue color

  1. Red (granulation) or pink tissue (epithelialization)
    1. Keep wound clean and slightly moist
    2. Cover with Transparent Film Dressing (e.g Tegaderm)
    3. Consider topical antimicrobial (e.g. Bacitracin)
  2. Yellow wound (soft, yellow, creamy slough)
    1. Debride non-viable tissue and absorb excess exudate
    2. Alginate Dressing (e.g. Sorbsan) changed bid to tid
      1. Rinse wound with saline between dressings
    3. Hydrocolloid Dressing changed every 7 days
  3. Black wound (hard, dehydrated, necrotic eschar)
    1. Wound Debridement
    2. Hydrogel Dressing or Transparent Film Dressing
    3. Follow management of yellow wound above

V. Preparations: Dressings for infected wounds

  1. Avoid Transparent Film Dressing (e.g. Tegaderm)
  2. Preferred Strategy
    1. Topical antibiotic
    2. Saline Gauze Dressing (Wet-to-Dry Dressing)
    3. Avoid prolonged use longer than 5 days
  3. Dressing Options
    1. Amorphous Hydrogel Dressing (e.g. Duoderm Gel, Intrasite)
    2. Foam Dressings (e.g. Allevyn, Lyofoam)
    3. Alignate Dressing (e.g. Kaltostat, Sorbsan)
      1. Especially if excessive exudate present

VI. Preparations: Dressings for wound cavities

  1. Alginate Dressing Packing Fiber (for excessive exudates)
  2. Saline Gauze Dressing
  3. Hydrogel Dressing (mild to moderate exudate)
  4. Hydrocolloid Dressing pastes (mild to moderate exudates)
  5. Foam Dressing fillers (any exudate)
  6. Expanding dressings (only fill cavity by 50%)
    1. Dermasorb Spiral Wound Dressing
    2. Cutinova cavity
  7. Iodine Impregnated Gauze (Iodoform Gauze)
    1. May cause tissue destruction

VII. Preparations: Dressings for wound protection

VIII. Protocol: Pressure Sores (Decubitus Ulcer) Non-infected wounds

  1. Grade I Pressure Ulcer (protect skin)
    1. Transparent Film Dressing or Polyurethane Dressing (dry wounds)
  2. Grade II (promote moist Wound Healing)
    1. Transparent Film Dressing or Polyurethane Dressing (dry wounds)
    2. Hydrogel Dressing (mild exudate)
    3. Hydrocolloid Dressing (mild to moderate exudate)
    4. Foam Dressing (any exudate amount)
  3. Grade III or IV Pressure Ulcer
    1. Saline Gauze Dressing (Wet-to-Moist Dressing)
    2. Hydrogel Dressing (mild exudate)
    3. Hydrocolloid Dressing (mild to moderate exudate)
    4. Foam Dressing (any exudate amount)

IX. Protocol: Pressure Sores (Decubitus Ulcer) Infected wounds

  1. Wound care
    1. Continue until infection resolves
    2. Cleanse the wound daily
    3. Apply topical antibiotic covered by appropriate dressing (see below)
  2. Dressings
    1. Saline Gauze Dressing (Wet-to-Dry Dressing)
    2. Hydrogel Dressing (mild exudate)
    3. Alginate Dressing (moderate to heavy exudate)
  3. Refractory wounds not improving after 2-4 weeks or with signs of Cellulitis or Sepsis
    1. Tissue culture
    2. Consider Osteomyelitis
    3. Start systemic antibiotics
    4. Continue wound care as above

X. Protocol: Pressure Sores (Decubitus Ulcer) Necrotic Stage III to IV Wounds

  1. Wound Debridement
    1. Sharp Debridement is required in advancing Cellulitis or Sepsis
    2. Autolytic Debridement may be used in nonurgent wounds (see dressings below)
  2. Apply a dressing that assists Autolytic Debridement
    1. Hydrogel Dressing (Mild to moderate exudate, may be used in infected wounds)
    2. Hydrocolloid Dressing (Moderate Exudate - avoid in infected wounds)
    3. Alginate Dressing (Moderate to Heavy Exudate, may be used in infected wounds)

XI. Protocol: Pressure Sores (Decubitus Ulcer) - Example protocols

  1. Sequential protocol for non-infected wounds
    1. Clean ulcer with saline during dressing change
    2. Calcium Alginate Dressing for first 4 weeks
      1. Change dressing when saturated or every 2 days
    3. Hydrocolloid Dressing for next 4 weeks
      1. Change dressing every 3 days or more
    4. Efficacy
      1. Results in faster healing than hydrocolloid alone
    5. References
      1. Belmin (2002) J Am Geriatr Soc 50:269-74
  2. Sample Mayo Protocol
    1. Solutions
      1. Saline
      2. Dakin's Solution (1/2 strength)
        1. Has antibacterial activity
        2. Can prepare with 0.5 tsp bleach in 1 gallon water
      3. Acetic acid 0.25%
        1. For pseudomonas infection (green discharge)
        2. Can prepare with 1/4 cup vinegar in 1 quart water
    2. Dressings
      1. Weaping, moist lesion: Wet-to-Dry Dressing
        1. Dakin's Solution soaked gauze for most lesions
        2. Acetic acid for pseudomonas infected lesions
      2. Dark, leathery eschar: Sulfamylon penetrates eschar
      3. Other dressings
        1. Xeroform/vaseline
        2. Silver nanotech (e.g. Aquacel Ag)
          1. Effective, and use is common in Europe
        3. Avoid Duoderm for Pressure Sores
    3. Other measures
      1. Vacuum Assisted Closures (VAC)
        1. Highly effective in Pressure Sore healing
    4. References
      1. RP Clay (Fall 2005) Mayo Geriatric Reviews

XII. References

  1. Habif (1996) Clinical Derm, Mosby, p. 810-13
  2. Krasner (1995) Prevention Management Pressure Ulcers
  3. Lewis (1996) Med-Surg Nursing, Mosby, p. 199-200
  4. Lueckenotte (1996) Gerontologic Nurs., Mosby, p. 800-7
  5. PUGP (1994) Pressure Ulcer Treatment, AHCPR 95-0653
  6. Way (1991) Current Surgical, Lange, p.95-108
  7. Bello (2000) JAMA 283(6): 716-8
  8. Bluestein (2008) Am Fam Physician 78(10): 1186-94
  9. Degreef (1998) Dermatol Clin 16(2): 365-75
  10. Findlay (1996) Am Fam Physician 54(5): 1519-28
  11. Knapp (1999) Pediatr Clin North Am 46(6):1201-13
  12. PUGP (1995) Am Fam Physician 51(5):1207-22

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