PRODUCTS FOR THE “WOUNDED”

1. PRODUCTS FOR THE “WOUNDED” SHAWNEEN SCHMITT, RN MSN MS CWOCN CFCN WOCN ADVISOR FOR THE WISCONSIN PRESSURE UCLER COALITION AUGUST 19, 2010

2. OBJECTIVES • State the three primary classifications of wound care products in maintaining the wound bed • Identify three criteria in choosing a wound care product • Explain at least four wound care products that should be in a basic wound care formula • Describe three products that can be used for treatment of a pressure ulcer • Identify at least two resources for wound care product information

3. Wound Care Product ClassificationBased on Wound Base Color • Red (Granulation) • Maintain wound moisture and protect tissue • Pink (Healing Epithelial) • Protect new tissue • Yellow (Devitalize Slough or Non-viable Fibrin) • Remove/Debride • Purple (Ecchymotic/DTI) • Protect intact skin • Black (Eschar or Necrotic Tissue) • Remove/Debride

4. Wound Care Product ClassificationBased on Wound Moisture Level • Dry • Re-hydrate • Reduce pain • Wet • Remove excess fluid/exudate • Prevent hypertrophic tissue formation • Reduce bacterial load/odor • Balanced • Maintain a moist wound environment • Maintain to prevent tissue dryness or maceration

5. Wound Care Product ClassificationBased on Wound Depth • Partial Thickness • Shallow Abrasions/Denuded Skin/Excoriations • Skin Tears • Stage 2 pressure ulcers (Including blisters) • Protect tissue from further damage • Maintain moisture balance • Approximate skin edges if appropriate

6. Wound Care Product ClassificationBased on Wound Depth • Full Thickness • Deep cavity/Dead space • Undermining • Tunneling/tracking • Stage 3 & 4 • Exposed bone, tendon • Biofilm present • Fill in wound spaces (cavity/tunnel/undermining) • Maintain moisture level • Remove non-viable tissue/debride and/or biofilm • Protect exposed bone, tendon • Control odor

7. Wound Care Product Selection • There are over 3,000 different products to choose from • No one product is the panacea for wound care • Many products may need to be used in combination to aid in wound healing and should be based on assessments, principles of wound healing and wound care • Many products are now designed for pain management • Wound dressings should be changed as the wound healing process progresses or deteriorates • Many products are designed to reduce the number of dressing changes thereby reducing the disruption of the wound bed environment

8. Principles of “MEASURES” • M = minimize trauma to wound bed • E = eliminate dead space (tunnels, tracts, undermining) • A = assess and manage the amount of exudate • S = support the body’s tissue defense mechanism • U = use non-toxic wound cleansers • R = remove infections, debris, and necrotic tissue • E = environment of wound is maintained including thermoregulation and moisture • S = surrounding tissue is protected from injury and bacteria Barnanoski, S. (1999, January) Wound Dressings: Challenging Decisions, Home Healthcare Nurse

9. Characteristics of an Ideal Dressing • Maintain moisture balance • Facilitate autolytic debridement • Be comfortable for the patient and eliminate pain • Eliminate dead space • Be absorbent • Provide thermal regulation • Act as a bacterial barrier • Be cost effective • Ease of dressing application and removal and maintenance • Ease of understanding for caregiver to use • Available in numerous shapes and size or can be cut into an appropriate shape Seaman, S. (2002, January) Dressing Selection in Chronic Wound Management, Journal of the American Podiatric Medical Association

10. Basic Wound Care Formulary • Absorptive dressing • Alginates (Calcium)/Hydrofibers • Contact layers • Foams • Gauze • Hydrocolloids • Hydrogels • Skin Barriers • Tape • Transparent film • Wound Cleansers

11. Absorptive Dressings • Description: Multilayer dressings that consist of fiber layers such as cellulose, cotton or rayon that can manage moderate to heavy drainage usually for full thickness wounds • Advantage: • Can be used as a primary or secondary dressing and are easy to apply and remove • Help with autolytic debridement • Disadvantage: May adhere to base causing pain • Examples: Abdominal (ABD) pad, Exu-Dry

12. Alginates (Calcium)/Hydrofiber • Description: Alginates are primarily from brown seaweed and is manufactured into soft nonwoven fibers twisted into ropes or pads or a composite of a cellulose-like polysaccharide that is highly absorptive that forms a gel with wound fluid that conforms to shape of the wound. Can absorb up to 20-30% of fluid weight • Advantages: • Used to fill wound cavity/dead space • Used for autolytic debridement • Maintains moist wound environment • Helps with pain management and some odor control • Disadvantages: • May be expensive if dressing is changed frequently • Not to be used on dry or low exudate wounds that could dehydrate • Requires a secondary dressing • Examples : Algisite M, Aquacel, Carboflex Odor, Melgisorb, 3 M-Tegen

13. Contact Layer • Description: Single mesh layer of non to low tissue adherence dressing that is impregnated with a substance such as petroleum, zinc, bismuth, silver or aqueous saline in which exudate can pass through • Advantages: • Protects the wound base from injury and reduce pain • May include some antimicrobial properties • May be left in place when changing the secondary dressing • Disadvantages: • Needs a secondary dressing • May disrupt wound healing if it dries out • Not to be used with heavy exudating wounds can cause maceration • Not to be used on non-viable tissue • Examples: Adaptic, Cuticerin, Xeroform, Petroleum gauze, Mepitel

14. Foams • Description: Hydrophilic polyurethane or gel film-coated dressing that is highly absorptive that come in a variety of thickness with or without an adhesive/silicone border that fill a wound cavity and is designed for non-traumatic removal. Designed for maintaining moist wound environment and thermal regulation. • Advantages: • Non-adherent reducing pain for friable tissue/fragile skin • Easy to apply and remove • Can leave in place up to seven days • Good for partial thickness wounds • Disadvantages: • May need a secondary dressing, tape or gauze wrap • Not for dry/eschar wounds • May cause maceration • Examples: Mepilex, Allevyn, Polymem, Tielle, Lyofoam, 3M Foam

15. Gauze • Description: Manufactured in many forms made usually of an open woven or unwoven bleached cotton fibers with different degrees of fineness in different sizes and widths (rolls) that can be impregnated with other substances used for draining wounds, to fill cavities/dead spaces and for a primary or secondary dressing. Often used for non-selective mechanical debridement. • Advantages: • Inexpensive and readily available • Can be used on infective wounds • Has a wicking action • Disadvantages: • May disrupt wound healing • Fibers may shed and adhere to wound tissue • Frequent dressing changes required • May cause may if left to dry in wound • Not effective in maintaining a moist wound environment • Research has shown that more bacteria is released in the air when removed

16. Hydrocolloids • Description: An occlusive dressing comprised of hydrophilic colloid particles such as gelatin and pectin combined with sometimes an alginate or foam that can absorb 3-5 times its weight of wound fluid forming a gel over the wound based that is manufactured in various shapes thickness and sizes as well as a paste for cavity wounds. Can be used as a primary of secondary dressing. • Advantages: • Impermeable to bacteria and other contaminants • Used for autolytic debridement • Molds/conforms to wound • Disadvantages: • Not to be used on heavily exudating or infected wounds, tunnels, tracts • Prevents gas exchange between the wound and environment • May curl at edges and injury fragile skin • Does not fill in dead space • Examples: Duoderm, Comfeel, 3M Acrylic, Replicare, Triad Hydrophilic Filler

17. Hydrogels • Description: Are primarily comprised of 80 – 95% water stabilized with glycerin or other polymers to provide a moist healing wound environment that can promote granulation, epithelialization and/or autolytic debridement of slough/eschar. They come in sheets and tubes. • Advantages: • Soothes painful wounds • Can be impregnated with gauze to fill dead space • Used to re-hydrate wound tissue • Disadvantages: • May increase peri-wound maceration • Needs a secondary dressing but not foam or hydrocolloids • Daily dressing changes may be needed to prevent drying of tissue • Examples: Solusite, Normigel, Instrasite, Flexigel, Vigilion, Curosol, Elta

18. Skin Barriers/Protectants/Sealants • Descriptions: Barriers come in a variety of formulations such as a non-alcohol polymer (plastic) spray/wipe or a dimethicone/silicone cream, petrolatum transparent ointment and zinc oxide based non-transparent cream/paste for the purpose of protecting peri-wound skin edges and some open partial thickness areas. • Advantages: • Protect against moisture, friction, and adhesives • Versatile • Readily available and inexpensive • Reduces pain • Disadvantages: • May be messy, rub off • May prevent primary or secondary dressing or tape from sticking to skin • Examples: Vaseline, 3M No Sting, Desitin, Remedy, Critic Aid, ProShield

19. Tape • Description: Tape is one way of securing a cover dressing to the skin to keep dressing in place over wound. Tape are made with a variety of materials (paper, plastic, cloth, foam) and come in different widths, shapes, adhesives and hypoallergenic and antimicrobial properties. • Advantages: • Can be inexpensive • Can be used to approximate wound edges • Disadvantages: • Can cause skin stripping/blistering • Can cause allergic reactions • May not adhere to skin • Requires a skin protectant barrier before application • Can contribute to wound infection Examples: Medipore, Hypafix, Transpore, Micropore, Dermapore, Steristrips

20. Transparent Films • Description: A polyurethane or co-polymer with a porous adhesive layer that allows oxygen to pass through the semipermeable membrane between wound and environment. It act as a moisture vapor barrier by being impermeable to water, leaking of wound fluids and entry of bacteria as long as it remains intact to the skin. Used as a primary or secondary dressing. • Advantages: • Aids in autolytic debridement • Can visualize wound base for inspection • Prevents or reduces friction/shear • Waterproof for bathing • Disadvantages: • Not to be used on heavy exudating wounds • May cause skin shear on fragile skin and dislodge on high-friction areas • May need a skin protectant for some adhesives • May be difficult to apply or handle • Examples: Tegaderm, Mefilm, Opsite, Comfeel

21. Wound Cleansers • Description: A solution that provides the essential step in wound management by cleaning the wound surface of debris such as non-viable tissue and reduce bacteria contaminants or remove biofilm and other foreign material. To do this, the cleaning agent should not be cytotoxic to the wound tissue (specifically the white blood cells and fibroblasts) in combination with a delivery device that will provide sufficient mechanical force to remove surface debris without injuring the tissue. • Examples: • Isotonic (normal 0.9%) saline) in a spray bottle or with gauze • Water (sterile or non-sterile without any contaminants, No well water) • Commercial cleanser that are pH-balanced – for dead space • Contain surfactants the help with the release of surface debris especially good to remove fecal contaminants • Can be highly cytotoxic when dilutions are concentrated such as 1:10 to 1:1000 • Safe to use is Dermal Cleanser, Hollister Skin Cleanser • WARNING: Betadine, Dakins (bleach), Hydrogen Peroxide, Granulex, Phisohex are very cytotoxic and should never be put in a wound

22. Pressure Ulcer Wound Management Products • The use of moist wound therapy and the management of exudate is critical in wound healing of this type of wound • Depends on the stage of the wound (partial vs. full thickness) on what is selected • If there is any necrotic tissue it needs to be removed autolytically. Remember moist saline (w-d) with gauze is a form of mechanical debridement and should not be done on good red health tissue. • So what would you choose for a: • Stage 2 with a blister • Stage 3 with yellow dry fibrin

23. RESOURCES • http://www.worldwidewounds.com/2007/may/Fletcher/Fletcher-Dressings-Cutting-Guide.html • http://www.worldwidewounds.com/ • http://www.medicaledu.com/prodindx.htm • http://www.woundcareresources.net/ProductsList.pdf • http://www.dressings.org/ • http://www.woundsource.com/ • http://www.woundcareprotocols.com/links.htm • Go to the website of the company product for information • Clinical Guide: Skin and Wound Care, 6th Edition, (2008) Cathy Thomas Hess • Wound Care Essentials: Practice Principles (2004) Sharon Barnoski and Elizabeth Ayello

24. Next Session – October 21, 2010 – 1-2PM • On Advance Wound Care Modalities • Antimicrobial dressings (Silver, Iodine, Honey) • Antifungal products • Specialty dressings (Hyluronic Acid, Interdry, Silicone) • Collagen (Prisma, Promogram, hyCure, Fibracol) • Chemical Debrider (Santyl) • Engineered Tissue (Apligraf, Dermgraft) • Extracellular Matrix (Oasis) • Growth Factors (Regranex) • Negative Wound Pressure Therapy (NWPT) • Normothermic Therapy • E-Stim • Compression Therapy

25. Thank You for Your Attention and Be Sure to Call in for the Next WPUC Session Q & A ??? sschmitt@communitymemorial.com