Archive for the ‘Moist Wound Dressing’ Category

Maceration and Hydrogels? Just Say Whoa

Thursday, July 21st, 2016

How do you use hydrogel dressings to keep wounds moist without causing maceration? Very carefully.  

 

Maceration and Hydrogels? Just Say Whoa

 

If you’ve ever taken a long bath or spent an afternoon in a swimming pool, you’re familiar with what happens to your hands and feet: they become soft, white, and wrinkled up like prunes. This is a classic case of maceration, which occurs when skin tissue is exposed to excessive moisture over a period of time.

As clinicians, we regularly treat patients with wounds (which need to be kept moist) that are surrounded by tissue that needs to be kept dry. So knowing how to properly treat the wound without causing maceration makes all the difference in the healing process.
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Moisture Associated Skin Damage: Know Your Type

Friday, March 4th, 2016

Know how to correctly identify these four common types of Moisture Associated Skin Damage (MASD) for best wound care practices.

MASD Categories

 

It might sound reasonable to assume that Moisture Associated Skin Damage (MASD) is the result of, well … moisture. The fact is that it takes more than just moisture to cause MASD, which is the inflammation and erosion of the skin that’s caused by prolonged exposure to various sources of moisture, including, urine, stool, perspiration, wound exudate, mucous, or saliva.  Skin does not break down in water alone.  However, when moisture on the skin is combined with friction, chemical irritants or bacterial/microbial factors, that’s when the real damage occurs.

For effective wound care, clinicians must be able to properly assess MASD from the onset – even if at first the diagnosis isn’t obvious. It all begins with good clue gathering, and knowing the characteristics of each of the four common types.

Identifying MASD

Because moisture on the skin increases skin permeability (which alters pH and cools the tissue), it compromises the barrier function of the skin’s protective acid mantle. This, in turn, makes the skin more susceptible to friction and shearing forces.

Correct MASD identification is critical for treatment, and should begin as soon as initial signs appear. The first step is to conduct a complete skin assessment. Don’t ever assume that you know what’s going on at first glance. Follow the general rule of thumb for any wound expert, and keep looking! Take your time, be methodical, and note the location, texture, moisture level, maceration, denuding and changes in skin color.

Know your type

Incontinence-Associated Dermatitis (IAD)

One of the most common forms of MASD is incontinence-associated dermatitis (IAD), which is the inflammation of the skin from extended exposure to urine or stool.  You may also know it as perineal dermatitis, irritant dermatitis or diaper rash (in children). The highest-risk patients are those that have both fecal and urinary incontinence.

As mentioned earlier, moisture requires an additional irritant in order to produce MASD. Urine contains ammonia, which increases the skin’s pH and destroys the protective acid mantle.  Adding to the problem, frequent skin cleansing in response to urinary or fecal incontinence can increase the risk of breakdown. Even incontinent briefs can contribute to IAD by causing perspiration in the affected area. Although the briefs pull the actual fluids away, the microclimate remains moist and warm.

So how do you know if it’s IAD? Here are typical characteristics:

  • Found over fatty tissue of the buttocks, perineum, inner thigh and groin (though they can occur over bony prominences).
  • Distributed in a consolidated or patchy formation.
  • Covers diffuse areas, shaped like a mirror image in the skin fold or linear area in the anal cleft.
  • Is superficial or partial thickness in depth. Note: if there’s tissue destruction into the subcutaneous tissue or deeper, it must be staged as a pressure ulcer (for more information, see the WCEI blog “Will the Real Pressure Ulcer Please Stand Up?”)
  • Presents with non-uniform redness in the wound bed, maceration in the surrounding skin and peri-anal redness. No necrosis.
  • Has diffuse and irregular wound margins.

Intertriginous Dermatitis (ITD)

Intertriginous dermatitis, also called intertrigo, is an inflammatory condition of opposing skin surfaces caused by moisture.  You’ll find it in skin folds, such as under the breasts, in the axillary (armpit) area, or inguinal (groin) region. It’s particularly common in obese patients.

Moisture can become trapped in the skin fold, where there is a lack of air circulation.  The excess moisture causes the dead cells in the uppermost layer of the skin (the stratum corneum) to become saturated and then puff up. The result is rough textures (which means they won’t glide very well), and the result is skin-on-skin friction.

Characteristics of ITD:

  • Found in the skin folds.
  • Distributed in a linear, mirror image on each side of the fold
  • Always partial thickness.
  • Presents as mild erythema (redness) that can quickly progress to erosion, oozing, maceration or crusting.
  • Surrounding skin is often macerated and prone to bacterial and fungal infections such as candidiasis.
  • Can be painful, itchy and may produce odor.

It’s important to realize that a patient can suffer from both IAD and ITD at the same time, coexisting side-by-side.

Periwound Moisture-Associated Dermatitis

Periwound moisture-associated dermatitis occurs when the skin adjacent to a chronic wound becomes exposed to exudate or toxins from bacteria in the wound bed, causing inflammation and erosion. This is a result of too much exudate that hasn’t been properly managed. Left untreated, the periwound will eventually break down and the wound will enlarge.

Infected wounds are especially prone to periwound moisture-associated dermatitis because they produce more exudate.  The condition is more common in the elderly and immunocompromised, but our clinical practices can contribute as well. This can be due to a number of risk factors, including improper dressing selection, infrequent dressing changes, and aggressive tape removal.

Peristomal Moisture-Associated Dermatitis

The final common type of MASD is peristomal moisture-associated dermatitis.  This form of inflammation and skin erosion occurs only in ostomy patients.  It begins at the stoma/skin junction, and can extend outward as much as 4 inches in any direction.  As many as 50% of patients with a stoma experience this condition, which can be extremely detrimental to their quality of life.

Peristomal moisture-assisted dermatitis can happen around any stoma, including tracheostomies, gastrostomies, urostomies, and colostomies.  However, ileostomy patients – those with stomas at the small intestine – have the highest risk since the effluent (output from the stoma) is watery and caustic.  When the pouching system leaks due to improper sizing, an uneven peristomal plane or incorrect wear time, the effluent causes skin irritation and potential breakdown.

Pay close attention to the area around the stoma, keeping a close eye out for potential problems, including well-defined erythema, edema, and loss of the epidermis. You may also see papules, vesicles, itching, crusting and oozing. As with other forms of MASD, it’s important to address the problem early.

Do you know your MASD types?

What types of MASD have you encountered the most in your facility, and have you ever had trouble identifying them? Do you have any tips for MASD identification, and has early identification made a difference in patient outcome? Please tell us about your experiences by leaving your comments below.

Wound Care Education Institute® provides online and onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and OMS national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®). For more information see wcei.net.

Warm Wound Healing? It’s All About Foam Dressings

Thursday, February 4th, 2016

Keeping a wound warm is an important part of wound care treatment, and foam dressing does the trick because it effectively maintains optimum temperatures and promotes healing. 

Foam for Warm Wound Healing

 

For wound care clinicians – and anyone else who ever treats wounds – it’s important to know that moist wounds heal faster. However, moisture on any surface (including wounds) will begin evaporating when exposed to air, and at a quicker rate as the surface cools. So the challenge of healing wounds effectively is to keep a wound moist and warm. Fortunately, foam dressings maintain optimum healing conditions, and help our patients heal faster.

Why warm is better

As wound tissues lose moisture, a cooling effect occurs in the wound. Because cells and enzymes function optimally at normal body temperature, a drop of just 2 °C is sufficient enough to negatively affect the biological healing process.

In fact, when a wound dressing is changed, it can take a wound base temperature up to four hours before it returns to normal. This is an important factor to consider when anticipating healing times, as well as when prepping your patient for a dressing change. Additionally, when tissue cooling occurs, it can lead to a higher risk of infection due to vasoconstriction, and hemoglobin’s increased need for oxygen. This, in turn, decreases the amount of oxygen available for neutrophils, which fight infection.

So how does this all tie in to dressings? By using the right type of dressings – and applying them properly – you can create an optimum environment for wound healing. The dressing that keeps the wound bed the warmest is foam.

Foam Dressing

Semipermeable polyurethane foam dressing is nonadherent and nonlinting. It has a hydrophobic or waterproof outer layer, and provides a moist wound environment. Other characteristics of foam dressing include:

  • It is permeable to water vapor, but blocks the entry of bacteria and contaminants
  • It can be purchased in various thicknesses, with or without adhesive border
  • It is available in pads, sheets, and cavity dressings

Consider using foam as primary or secondary dressing for partial- and full-thickness wounds, with minimal to heavy drainage. In addition, foam dressing:

  • Works well for granulating and epithelializing wounds
  • Provides insulation to keep wounds warm
  • As secondary dressing for wounds with packing
  • Can be used to absorb drainage around tubes
  • Helpful for hypergranulation tissue along with compression

The advantages to using foam dressing on wounds are that it:

  • Provides moist wound healing
  • Doesn’t adhere to the wound
  • Provides cushioning
  • Is easy to apply and remove
  • Can be used with infected wounds
  • Provides a bacterial barrier
  • Is effective with hypergranulation
  • Can be used under compression
  • Can be cut to accommodate tubes

The disadvantages to using foam dressing on wounds include:

  • It could be expensive if exudate requires daily dressing changes
  • Wound beds may desiccate if there is no exudate from the wound
  • A secondary dressing might be required
  • If it becomes saturated, it can lead to maceration of the periwound
  • It is contraindicated for use with third-degree burns, dry eschar, and sinus tracts

What do you think?

Knowing that moist and warm wounds heal faster obviously makes using the right dressings (and applying them properly) crucial to effective wound care. Do you regularly use foam dressings, and have you noticed a difference in healing time? And have you learned any special application techniques that help keep wounds at an optimum body temperature? We’d love to hear about your experiences – please leave your comments below.

Wound Care Education Institute® provides online and onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and OMS national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®). For more information see wcei.net.

Wet-to-Dry Dressings: Here We Go Again

Thursday, October 15th, 2015

 

Wet-to-Dry dressingsIn the modern world of wound care, we’ve seen drastic improvements in treatment options over the years. So it’s always a surprise when we hear that there are still orders being submitted these days for outdated practices. In this case, we’re talking about those dreaded wet-to-dry dressings.

Why is this still happening – even though the disadvantages to this approach are well-documented? Could it simply be due to a lack of education? Or maybe it’s due to the unavailability of other wound care products that have been shown to yield much better (and safer) outcomes. Whatever the reason, we’re here to double-down on this: no more wet-to-dry dressings.

What is Wet-to-Dry?

Wet-to-dry is a form of mechanical debridement, and is substandard for wound care.  Here’s how it works:

  • A moist saline gauze is placed onto the wound bed.
  • The dressing is allowed to dry and adhere to the tissue in the wound bed.
  • Once the gauze is dry, the clinician forcefully removes the gauze.
  • Any dead tissue that has adhered to the dry gauze will then be removed from wound bed.
  • These steps are to be repeated every 4 to 6 hours.

 A Reality Check

Although this is technically the way wet-to-dry dressings are applied, most often clinicians will modify it by moistening the gauze prior to removal. This is so that it won’t stick to the wound bed and cause bleeding and trauma, or remove healthy tissue along with it.  The problem is that, while well-intentioned, the moistening of the gauze before removal, which spares the patient pain, defeats the original purpose (mechanical debridement). In addition, the prescribing clinician’s orders are not being followed.

To further complicate matters, some professionals with prescriptive authority write for this dressing but do not understand it is for debridement.  For example, a Physician’s Assistant once explained that he thought this type of dressing meant that the wound bed would be kept moist and covered with a dry secondary dressing.  So in many cases, we have wet-to-dry orders being written by someone who doesn’t understand what they’re ordering, and we have clinicians implementing these orders incorrectly.

The 2014 International Pressure Ulcer Guidelines clearly state that wet-to-dry dressings can be painful and may remove healthy tissue.  It also states that they are being used less frequently. In fact, research shows that this procedure is associated with slower healing rates and are costly in professional time due to the need for frequent wound dressing changes.

We Have Solutions

So, what is the answer to this ongoing problem for wound care practitioners?  It’s all about education, and everyone can help by:

  1. Sharing information. Proper educational resources and information regarding this issue need to be shared with not only nursing staff, but also with those who write the orders.
  2. Making a plan. Talk to your medical director and plan a short educational program to present alternatives for those with prescriptive authority.
  3. Asking for change. Ask for a facility policy change from your medical director that states wet-to-dry dressing orders are no longer acceptable.
  4. Talking about it. Keep the discussion going and enlist help from all levels of the organization.
  5. Learning from others. There are plenty of success stories out there from facilities that have planned for and implemented change involving key stake holders. Know that changes can be made, and don’t get discouraged if it doesn’t happen quickly. Remember, your patients are counting on you.

What do you think?

Do you work in a facility that has eliminated wet-to-dry dressings?  How did this change in policy take place, and do you have tips for others who are dealing with this problem? We would love to hear about your experiences having to do with this topic. Please leave your comments below.

 

The Battle of Wound Healing: Dry vs. Moist

Thursday, October 8th, 2015

The truth about moist wound healing, related cost savings, and the risks of keeping wounds dry.

Do Wounds BreatheWhen you were a kid, you probably had your share of cuts, scrapes and other childhood wounds that required a good old-fashioned bandage. And somewhere along the way you were most likely told to “… take the bandage off to let it breathe.” This advice, which essentially is what we now call dry wound healing, surely came from a parent, well-intentioned friend, or perhaps even a health professional.

Today, we know better. Thanks to lots of research and a better understanding of wound treatments, we know that in most cases, moist wound healing is the better way to go.

History of Moist Wound Healing

In the early ‘60s, while parents, caregivers and clinicians were commonly telling patients to just “let it breathe,” British-born pioneer Dr. George Winter decided to conduct a little research on the subject. His findings demonstrated that moist wounds healed faster, which flew in the face of conventional wisdom at the time – that dry and scabbed wounds promoted healing.

Winter’s research ultimately changed minds, and led to what is now considered a principle practice: moist wound healing. In fact, his work revealed that wounds heal twice as fast when placed in a moist environment.

Moist Wound Healing Today

While it’s been a long time since Winter’s research served to shift wound care practices away from the dry and scabby kind, there are still a number of uneducated clinicians who continue this outdated approach, ignoring the increased risk of bacterial infection. Some even believe that dry wound care is better because it’s cheaper – saving money on bandages and other supplies.

Not only is this approach short-sighted, it’s incredibly negligent. Responsible clinicians know that when it comes to wounds:

  • Optimum healing occurs when the wound temperature is near normal body temperature.
  • Even a 2°C drop in temperature can delay wound healing for up to four hours.
  • Oxygen is needed for every phase of wound healing.
  • Cooling the wound by leaving it uncovered will cause vasoconstriction and decrease the oxygen available for white blood cells to fight off infection.
  • Uncovered wounds lead to higher risks of infection and prolonged healing rates.

What About the Cost?

Sometimes old-school clinicians argue that dry wound healing is cheaper, and worth the risks involved. This theory doesn’t hold water considering that one single infection will negate any cost savings there might have been, plus this puts patients at risk for sepsis or a number of other preventable complications.

The dressings required to keep a wound covered, warm and moist are actually not expensive, and are considered the standard of care today.  To ignore or reject this approach is foolish, and places practitioners at legal risk should it result in a bad outcome.

But What About Acute Wounds?

There are exceptions to moist wound healing, and this includes the treatment of acute wounds.  According to the Centers for Disease Control and Preventions (CDC), once an incision line is closed and there is no drainage or chance of infection, an acute wound may be left open to air.  When the incision line is re-approximated, epithelialization can be complete within just 72 hours.

The timeframe when acute wounds need to be kept covered is much less than in healing full-thickness chronic wounds, which tend to be open longer and require the production of granulation tissue in order to fill in the deficit, and then epithelial tissue to replace the missing skin on top.

Advocate for Proper Wound Healing

So now that you know the truth about moist wound healing versus the outdated dry wound method, what can you do? Next time you witness a clinician leaving a chronic wound open to air:

  • Take the time to educate them on the principles of modern wound healing.
  • Provide them with copies of any written Standard of Care for wound healing that contains this preferred approach.
  • Encourage them to continue their wound care education – our patients rely on us to know how to help them heal as quickly and safely as possible.
Next time you see a clinician leaving a chronic wound open to air, educate them on modern wound healing.Click To Tweet

Tell Us Your Stories

Have you encountered fellow clinicians who defend dry wound healing when moist healing should be used? Have you had to discuss this issue with colleagues or attempt to educate resistant wound care providers? How did you handle the situation? Please tell us about your experiences by leaving your comments below.

 

The Winter of 1962

Monday, November 3rd, 2014

Why do we do what we do today in wound care? Modern wound management all started back in the 1960’s when Dr. George Winter found that wounds that were kept moist healed twice as fast. By keeping the wound environment moist it mimicked the natural environment of the cells in the body and we had decreased cell death, increased angiogenesis or new blood vessel formation, enhanced autolytic debridement, increased re-epithelialization and the patient had decreased pain. In short better wound healing was occurring with moist healing principles.  Moist_Dry_Wound_Healing

More studies continued and focused on water vapor loss, which lead to heat loss of the wound. The loss of moisture from any surface is accompanied by cooling of that surface, and when the wound loses tissue moisture there is cooling off the wound. Epidermal cells will only migrate over viable tissues; a dry crust or scab impedes the resurfacing process. Our wounds need to be maintained at or near normal body temperature to heal. A drop in temperature in the wound bed of 2°C is sufficient to alter healing and slow or stop healing, and it can take up to 4 hours for that wound to get back to normal healing temperature! As our wound cools off other negative things occur too, vasoconstriction occurs and the wound bed doesn’t get the needed blood and oxygen for our white blood cells to function effectively. This results in the white blood cells not being able to fight off bacteria, and the wound ends up at risk or with an actual infection.

In summary, for wound care, the 1960’s were really the start of something great! Faster healing times and better out comes for my patient! We now practice moist wound healing principles, we know the wound needs to be kept warm and moist, and needs to have a constant supply of oxygen to fight off infection.

Today we accomplish this with dressings that support moist wound healing. We use dressings that have the technology to be left in place for long periods of time and keep the wound bed warm. Long gone are the days of TID dressing changes, remember it takes the wound bed 4 hours to return to normal healing temperature! When it comes to modern day wound care, the 60’s is where we still are at!