A healthy wound environment is essential for healing. The type of wound care treatment chosen can have either a positive or a negative effect on this process. Starting with the basics and adding on treatments as needed can make a big difference.

Treatment choices are based on the etiology of the wound, wound environment, and the patient’s underlying medical conditions. We’ll begin with the basics of wound care and then look at additional treatments and adjunct therapies.

A friendly foundation

Cleansing: Cleansing the wound assists in removing exudate, debris, bioburden, and loosely adherent slough from the wound bed. Normal saline is a common choice for cleansing and generally accepted as safe for all wound types. Wound cleanser sprays are a common surfactant-based alternative to saline, which may be a good choice when using dressings or topical medications with silver. Dressings and treatments with higher doses of silver may have reduced effectiveness with use of normal saline because chloride in normal saline can reduce the release of the silver ions in the dressing or treatment.

A hypochlorite solution may be useful for highly bio burdened or locally infected wounds. It is bactericidal and useful against E.  coli, Streptoccocus, Staphlococcus, and Pseudomonas and has been shown to be effective against highly resistant organisms such as MRSA and VRE. Likewise, an acetic acid solution has been shown to be effective against Pseudomonas.

Debridement: According to the National Library of Medicine, debridement is used as an important part of preparing the wound for healing by removing dead tissue, films, and bioburden. There are many types of debridement including sharp, mechanical, enzymatic, autolytic, and biologic. The choice of one type of debridement over another is usually made with the specific wound, underlying conditions, and patient tolerance level in mind.

Sharp debridement is common in the OR and in treatment facilities. It is useful for a more selective tissue removal. Mechanical debridement (such as wet to dry dressings) is less selective and can remove granulating tissue along with the necrotic tissue. With sharp and mechanical debridement, pain control is essential.

Enzymatic and autolytic debridement are less painful but require more time to remove necrotic tissue. These are good choices for patients with difficulty controlling pain or a lower pain tolerance. Biologic debridement is the least common form of necrotic tissue removal and includes sterile maggots that are placed on the wound bed and secured with a dressing. These maggots only remove the devitalized tissue leaving the newly granulating tissue unharmed.

Dressing selection: Choosing the type of dressing can seem overwhelming, as there are so many available today. Primary dressings are placed against the wound bed. Some of the most common types of primary dressings are antimicrobials, collagens, foams, gels, hydrocolloids, and gauze. A secondary dressing is placed over the primary dressing and used for absorbing excess fluid, securing the primary dressing, and periwound skin protection. Common secondary dressing choices are gauze, ABD pads, and super absorbers.

Building on the foundation

Now that you’ve established a clean wound bed and applied a new dressing, there may be some additional treatments needed — especially if your patient has an underlying medical condition such as diabetes or peripheral vascular disease.

Compression: The use of compression is common for leg wounds caused by underlying venous insufficiency. Two layer and four-layer wraps are common, and Unna boots, tubular bandages, and home compression stockings may also be used. Unna boots should be used on patients who are ambulatory, as the calf pump used during walking is important to the effectiveness of the wrap.

Tubular dressings are a lower compression choice and can be used as you await results of vascular studies, for heart failure patients with ejection fractions less than 30-35%, and for patients who do not tolerate the more traditional two-layer wrap or Unna boot. Home compression stockings are an important part of a lifelong maintenance plan for the venous patient once their ulcers have healed.

Total contact casts: These are used for foot ulcers where the goal is for complete offloading to allow the wound to heal. Total contact casts are considered the “gold standard” in diabetic foot ulcer treatment. These casts are normally changed one to two times weekly. The contraindications for contact casts include acute infection, a highly exudative wound that requires dressing change more than twice weekly, peripheral arterial disease, and high fall risk patients.

Negative pressure wound therapy: Vacuum-assisted closure is a type of wound treatment used to assist a wound in granulation and contraction of the wound edges. This is done by applying either a foam or gauze dressing to the wound bed and covering it with a semi-occlusive dressing. The dressing is connected to a mechanical device that creates negative pressure. The negative pressure extracts exudate, increases perfusion to the wound bed, and decreases congestion in the tissues.

Negative pressure is appropriate for a wide array of wound types but should not be used on malignant wounds, untreated osteomyelitis, wounds with large amounts of necrotic tissue, fistula to organs, or near exposed organs/arteries/anastomotic sites.

Treating infection: Oral and topical antibiotics may be used to treat local infections. A critically colonized or infected wound will stall the healing process. Identifying and treating the organism can have the wound on its way to healing again in no time.

Adjunct wound care treatments

Hyperbaric oxygen therapy: This is a common adjunct treatment to standard wound care. It uses pressurized, 100% oxygen to create new blood vessels that deliver vital nutrients to the wound.

Skin substitutes: These may be used in outpatient settings and can be natural or synthetic. They assist in wound closure by donating important material to the wound bed such as extracellular matrix.

Finding what your patient needs and what works best for their wound may take time and patience but, fortunately, there are myriad options available today. Fitting those pieces together and healing the wound is truly something that you and your patient will want to celebrate together.

Take our engaging, evidence-based Wound Care Certification Courses for nurses, registered dietitians, physical therapists, and more professionals. Choose the format that suits you and get access to tools to help you ace your exam.

Tara Call Triplett, RN, WCC, CHFN

Tara Call Triplett has over 20 years of experience as a registered nurse and is the founder of Call to Health Communications. She is nationally certified in both wound care and heart failure. Triplett currently leads an amazing team of clinicians at an award winning outpatient wound care clinic. She has a passion for teaching and mentoring the next generation of wound care clinicians.

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