Wound dressings

Attention

Do not use hydrogen peroxide
Do not swab wound with cotton wool
Do not let wounds dry out. Heal faster and better when kept moist — exception is dry gangrene
Use normal saline to clean wounds
Only use antiseptic solution if needed to wash dirty or infected wounds — chlorhexidine preferred
Syringe irrigate with normal saline or povidone iodine
Throw away

Chlorhexidine aqueous solution (water-based) 24 hours after opening
Chlorhexidine alcohol solution 7 days after opening

Remember:

If it is wet you need to control the exudate (ooze)
If it is dry you need to hydrate the wound only (except dry gangrene on toes)
Consider the whole person, the whole story
If in doubt — wound specialist consult

What you do

Before dressing wound —

Consider other problems that could affect healing
Assess the wound
Have a management plan

Irrigate wound gently with normal saline
Use gauze to remove slough
When trimming wounds — remove smallest amount of skin/tissue possible
Do not trim wound if no foot and/or leg pulses — not enough blood for healing, a small cut while trimming may cause the wound to get worse
Select appropriate dressing — see Table 7.1 and How to manage and dress different types of wounds
Consider whether dressing

Protects wound from secondary infection
Provides a warm, moist wound healing environment
Can be removed without damaging wound
Removes drainage and debris
Is free from particles and toxic products

Cover dressing with crepe bandage to hide and protect wound if needed
Encourage person to shower every day, except where dressings can't be wet
Provide appropriate information so person/carer can help with wound care

Table 7.1 Wound dressings

Type of wound	Dressing	What dressing does
Dry necrotic Sloughy or clean	Hydrogel (eg Solosite, Intrasite)	Rehydrates wounds Removes dry slough Removes necrotic tissue
Wet sloughy or clean	Calcium alginate (eg Sorbsan, Kaltostat)	Absorbs exudate Removes wet slough
Wet or dry Shallow wounds — primary dressing	Foam (eg Allevyn, Biatain)	Absorbs exudate Protects low exudate wounds
Wet to very wet	Exudate manager (eg Zetuvit, Mesorb)	Absorbs exudate Provides protection
Dry to lightly moist	Film island dressing (eg Opsite post op, Asguard clear island)	Protects wounds Maintains moist environment
Dry to lightly moist Shallow wounds only	Hydrocolloid (eg Comfeel, Duoderm) Do not use on top of other dressings	Rehydrates wounds Removes dry slough and necrotic tissue
Wet and sloughy	Hypertonic saline (eg Mesalt, Curasalt) Do not use on painful wounds Dot not sit on good skin — cut to size	Cleans and removes wet slough
Inflamed wet or dry Infected wet or dry	Silver coated dressing (eg Acticoat, Acticoat Flex) Do not use if thick slough or necrotic tissue	Reduces infection and inflammation
Offensive smelling Infected sloughy Infected wet or dry	Cadexomer iodine (eg Iodosorb ointment, Iodosorb paste) Wet — use ointment Dry — use powder Do not use on children under 12 years or pregnant women Do not use when allergy to iodine	Cleans wound Reduces infection
Colonised wet or dry (sloughy/necrotic — but not actively infected)	Enzye alginogel (eg Flaminal hydro, Flaminal forte) Wet — use Flaminal Forte Dry — use Flaminal Hydro Do not use on very wet wounds	Reduces bacterial load of wound Cleans wound that may become infected without treatment

How to manage and dress different types of wounds

Do weekly tracing to make sure wound is healing (getting smaller)
If wound continues to improve — continue with same plan/dressing
If wound deteriorates or becomes bigger — reassess using TIME
If wound continues to deteriorate — wound specialist or medical consult

Epithelising wounds — wounds that are healing over

Protect and encourage healing
Use a foam (eg Allevyn, Biatain) or film island dressing (eg Opsite, Asguard)

Granulating wounds — wounds with a red wound base — Figure 7.21

Figure 7.21

Do not debride
High exudate — use calcium alginate (eg Algisite)

Cover with foam (eg Allevyn, Biatain)
OR exudate manager (eg Zetuvit, Mesorb)

Low exudate — use hydrogel (eg Solosite, Intrasite) to promote moist environment

Cover with secondary dressing that will keep in moisture (eg adhesive foam, hydrocolloid or film island dressing) — see Wound dressings table

Hypergranulation/overgranulation in wounds — wound tissue grows higher than skin level — Figure 7.22

Figure 7.22

Remove overgranulation by debridement

Check if person is on anticoagulant therapy (eg warfarin, enoxaparin, rivaroxaban)

OR use caustic stick/silver nitrate stick to remove overgranulation

Apply paraffin to good skin for protection from nitrate stick
Then apply silver nitrate stick to overgranulation

OR use pressure pad

Cover wound with thick gauze pad
Strap firmly in place with strips of non-woven dressing (eg Fixomul)
Cut strips in downward direction to the box to get non-stretch weave
Apply strips by pulling firmly in different directions

Necrotic wounds — wounds with dry dead tissue — Figure 7.23

Figure 7.23

Check aetiology (cause and circumstances) of wound first (eg diabetes)
Debride — but only if adequate pulses are present

Surgical debridement may be necessary — with sharp instrument

Score thick necrotic tissue if necessary

Use scalpel to cut lines through top layer of thick eschar (dead tissue) to allow gel to absorb into dry hard tissue

Needs hydration — use a hydrogel dressing (eg Solosite, Intrasite)

If no signs of bacterial infection use film island dressing (eg Opsite, Asguard) or hydrocolloid (eg Comfeel, Duoderm) to speed up rehydration

Do not hydrate dry gangrene (black fingers or toes)

Paint with povidone-iodine (Betadine) and leave to dry — wound specialist/medical consult

Sloughy wounds — wounds with wet or dry sloughy tissue — Figure 7.24

Figure 7.24

Need dressings that assist with autolytic (natural) debridement

Low exudate — use hydrogel (eg Solosite, Intrasite)
Moderate to high exudate — use hypertonic saline gauze (eg Mesalt, Curasalt). Do not use on painful wounds
High exudate — use calcium alginate (eg Algisite)

May need sharp debridement which will speed up healing by stimulating the inflammatory response

Infected wounds — Figure 7.25

*Do not use cadexomer iodine if under 12 years, pregnant or breastfeeding

Figure 7.25

Need topical antimicrobial dressings — silver coated dressing (eg Acticoat) or cadexomer iodine* (eg Iodosorb)

Bite wounds/dirty, traumatic wounds — use silver coated dressing
Sloughy infected wounds — use cadexomer iodine*. Do not use silver coated dressing on thick slough

Do not use hydrocolloid (eg Comfeel, Duoderm) as a dressing cover
High exudate

Silver coated dressing (eg Acticoat) with calcium alginate (eg Algisite) over the top
OR for small wounds — cadexomer iodine* powder (eg Iodosorb)
Cover with foam (eg Allevyn, Biatain) or exudate manager (eg Zetuvit, Mesorb) for absorbency

Low exudate

Sheet of silver coated dressing (eg Acticoat sheet) — moisten twice a day, or wet daily while showering
Cover with non-woven dressing (eg Fixomul)
OR for small wounds — cadexomer iodine* ointment (eg Iodosorb) and cover with adhesive foam (eg Allevyn, Biatain) or film island dressing (eg Opsite, Asguard)

Remember:

Silver coated dressing (eg Acticoat)

Broad-spectrum topical antimicrobial — works within 30 minutes
Has anti-inflammatory properties
Cannot debride thick slough or necrotic tissue

Cadexomer iodine (eg Iodosorb)

Do not use if under 12 years, pregnant, breastfeeding
Stimulates wounds that are not healing (static) or chronic
Reduces colonisation / bioburden of wounds
Cleans sloughy infected wounds

Colonised wounds that are not actively infected

Use an enzymatic gel (eg Flaminal)

Moderate exudate (eg Flaminal Forte)

Cover with adhesive foam (eg Allevyn, Biatain) or exudate manager

Low exudate (eg Flaminal Hydro)

Cover with adhesive foam (eg Allevyn, Biatain) or film island dressing (eg Opsite, Asguard)

Wounds with high bioburden — a lot of dead or necrotic (non-viable) tissue, offensive odour but not actively infected

Wash first with a wound anti-infective (eg Prontosan), rinse thoroughly with normal saline, then apply enzymatic gel (eg Flaminal)
OR wash with povidone-iodine for 2 minutes, rinse thoroughly with normal saline, then apply enzymatic gel (eg Flaminal) or cadexomer iodine (eg Iodosorb)
Povidone-iodine wash effective in reducing wound colonisation especially MRSA

Hydrocolloid dressing

(eg Comfeel, Duoderm)

For wounds with no or low exudate
Very good for friction burn/gravel rash. Change daily, it will lift out gravel you have not been able to remove

What you do

Leave on for 3–7 days — change daily to remove gravel
Change if there is leakage
Can use tape to hold onto skin if needed

Non-woven adhesive

(eg Fixomull, Hypafix, Mefix)

Use to hold dressings on or to protect healed burns from rubbing or friction (eg under bra straps)

Attention

Do not use if skin is fragile or broken

What you need

Non-woven dressing

Also need for removal

Do not use Zoff adhesive remover
Use non irritating silicone based adhesive remover (eg Niltac, Remove)
If not available use oil — olive, vegetable, baby oil. Do not use peanut oil — potential allergic reaction
Plastic cling wrap
Bandage
Sink, bath/shower

What you do

Cut amount needed from roll, take off backing paper, put straight on healed burn/wound sticky side down

Do not overlap dressing by more than 2cm
Do not stretch dressing

To cover joint — bend limb, put along line of long bones
Explain to person/carer how to care for dressing

For first day — keep dry
If it gets wet — gently pat dry
After first day — wash gently with ordinary soap and water twice a day, pat dry. Do not soak in water

Leave on for 5–7 days

To remove

Silicone based adhesive remover (eg Niltac , Remove or Brava) OR

Soak dressing all over in oil
Wrap in cling wrap and cover with bandage

Leave for 4 hours or more — can be left overnight
Wash gently in shower/bath, remove dressing

Silver coated dressing

(eg Acticoat)

Use for partial thickness burns at risk of infection, full thickness burns smaller than a 20 cent piece. See — Management of minor burns
For animal or human bite or dirty injury to reduce risk of infection
Coated with slow-release nanocrystalline silver. Keeps wound moist, kills bacteria, stops infection

Attention

Do not use if person allergic to silver
Water activates silver
Do not use saline or salt water, will stop silver working (deactivate)
Keep dressing moist not soaking

What you need

Sterile water or clean tap water
Silver coated dressing (eg Acticoat)
Scissors
Non-woven adhesive

What you do

Set up sterile dressing area
Cut piece of dressing a little bigger than wound
Wet dressing with sterile or clean tap water then gently squeeze out
Wait a few minutes to lessen stinging, then lay dressing on wound (blue side down for Acticoat)
Cover with non-woven adhesive
Tell person to wet dressing twice a day to activate silver. Do not use saline or salt water
Check every day but do not open dressing. Wash any exudate (ooze ) off dressing with clean or sterile water
Leave for 3 days

To remove

Wash in shower or with normal saline to loosen dressing
OR use commercial silicone based adhesive remover (eg Niltac)
Do not put oil on non-woven adhesive — not needed as only small amount in contact with healthy skin
Brown or silver colouring on unburnt skin is not harmful and will wash off