SWRWC Toolkit: Wound Cleansing and Dressing Selection Enabler

SWRWC Toolkit: Wound Cleansing and Dressing Selection Enabler Resources available at www.woundcare.thehealthline.ca Topic PowerPoint Voice-Over Segments Other On-line Resources Links to OTN Webcasts Function of Dressings SWRWCF: Function of Wound Dressings (55 min) SWRWCF: Matching Dressings to Wound Characteristics including High Exudate Management (32 min) H.PRODUCT SELECTION AIDES H.2 CAWC PRODUCT PICKER H.2.1 Purpose and Instructions for Use of CAWC Product Picker Tool/ purchase information for poster H.2.2 CAWC Product Picker Tool print as 8.5 x 14 H.4 Industry how-to files of all of the dressings in the HealthPro contract, 8.5 x 14 The absorbent capacity of a dressing is defined as: the volume of fluid contained in the dressing at the time at which strike-through occurs. Strike-through is defined as: the point at which absorbed fluid reaches the outer surface or edge of a dressing (Thomas and Fram 2001 http://www.worldwidewounds.com/2001/december/thomas/absorbency-wound-dressings.html). In addition to absorbing exudate, many dressings also allow the exudate to evaporate through the outer dressing over a period of time. This is called the moisture vapour transmission rate (MVTR). The South West CCAC has attempted to identify how much exudate various dressings can handle, indicated by [1+] etc. The descriptions of the exudate amounts indicated with * are from the Bates-Jensen Wound Assessment Tool (BWAT) (Toolkit Section B.6): o Small [1+] *Wound tissues wet; moisture evenly distributed in wound; drainage involves 25% of dressing, o Moderate [2+] *Wound tissues saturated; drainage may or may not be evenly distributed in wound; drainage involves 25-75% of dressing o Large [3+] Wound tissues saturated with drainage involving 75-100% of the dressing o Copious [4+]*Wound tissues bathed in fluid; drainage freely expressed. Copious exudate often requires more frequent dressing changes if the dressing is unable to contain the exudate for extended periods of time. See Section E.1.3 Daily Visits as Exceptional Situation for Healable and Maintenance/Palliative Wounds. The following table is intended to be used as a practice enabler to match dressings to the wound characteristics. SWRWC Toolkit: H.5 Wound Cleansing and Dressing Selection Enabler_June 13_2012 1

1. Open Surgical Incision (incision may still be sutured or stapled but there are small dehiscence s or incision line is exudating). Please see tunnels and undermining for open surgical wounds (Section 9). Goal: Absorb exudate, protect from external contaminants, prevent infection and allow healing. 2. Clean Epithelializing Wound Goal: Provide environment conducive to wound healing without trauma Choice of Choose a dressing that can be left insitu as long as possible to avoid disruption of the migrating epithelium. DO NOT flush or irrigate as you may force surface bacteria deeper into the incision. Pour solution or cleanse with sterile gauze and saline. Always cleanse from incision line out to avoid introducing bacteria from skin. Choose a non-adherent dressing with a secondary absorbent dressing, or a combination dressing that provides non-adherent, absorptive and resistance to bacteria. o Hydrofiber [2+] o Hydrocolloid thin [1+] o Surgical strip dressing [1+] DO NOT irrigate with pressure higher than 7 PSI - pour room or body temperature solution over the wound bed; cleanse the periwound skin. Do not use antimicrobial solutions. If the wound depth is <1-2 mm with minimal exudate consider: o Transparent Film Membranes [1+] (some exudate will evaporate-can be used over alginate dressings) o Hydrogel only if very dry (use under other dressings) o Absorbent Clear Acrylic Dressing [2+] q 7-14 days or more (Retains moisture and growth factors, decreased need for frequent dressing changes) o Thin hydrocolloid [1+] q 5-7 days (Retains moisture and growth factors) o Non-adherent foam border dressing [2+] SWRWC Toolkit: H.5 Wound Cleansing and Dressing Selection Enabler_June 13_2012 2

3. Clean Granulating Wound decreasing in size 20-30% in 3-4 weeks* Goal: Provide environment conducive to wound healing without trauma 4. Clean Granulating Wound NOT decreasing in size 20-30% in 3-4 weeks* *Granulating wounds not decreasing in size may have a localized infection or chronic inflammation Goal: Treat chronic inflammation to reduce MMPs and promote healing, resolve biofilm or local infection preventing healing Do NOT use occlusive dressings if infection is suspected DO NOT irrigate with pressure higher than 7 PSI - pour room or body temperature solution over the wound bed; cleanse the periwound skin. Do not use antimicrobial solutions. o Hydrofibres and alginates [1+ to 2+] - form a gel-like mass on the wound surface (require secondary dressing) o NPWT [2+ to 4+] (can be primary or secondary) o Foams border dressings [2+ to 3+] (can be primary or secondary) (Not appropriate for daily dressing changes) o Hydrocolloids [1+ to 2+] (can be primary or secondary) Irrigate with 7-15 PSI using at least 150 ccs of solution or a smaller amount of a commercial spray wound cleanser with surfactants at room or body temp. Cleanse and protect the periwound skin. Antimicrobial dressings with pro-inflammatory actions to kick-start acute inflammation: o Cadexomer iodine ung. [1+] o Povidone iodine [0], o Manuka Honey [all <1+ to 2+] (all require secondary dressing) Chronic inflammation: o Calcium Alginates [2+](contribute to the initial inflammatory response required to start healing), o Protease Inhibitor dressings [<1+](remove or reduce chronic inflammatory cells from wound surface and provide growth factors) o Foams border dressings [2+ to 3+] (Not appropriate for daily dressing changes) o Hydrocolloid dressings [1+ to 2+] but not if on a plantar foot surface SWRWC Toolkit: H.5 Wound Cleansing and Dressing Selection Enabler_June 13_2012 3

5. Necrotic healable wound (debridement is appropriate) Goal: debridement of necrotic tissue, prevent infection, and support healing. 6. Necrotic nonhealable wound where debridement is NOT appropriate Goal: stabilize and dry necrotic tissue to allow gradual autoamputation or epithlialization under the eschar, without extension or infection. Irrigate with 7-15 PSI using at least 150 ccs of solution or a smaller amount of a commercial spray wound cleanser at room or body temperature. Cleanse and protect the periwound skin. Foul odour indicates aneorobes (see# 6) If slough: o Hydrocolloid [1+ to 2+] (Promotes autolytic debridement and granulation- does not require a secondary dressing, but hydrofiber [2+] can be used under it) o Hydrogels [1=] (Add moisture to support autolytic debridement with correct secondary dressing) o Hypertonic Gauze [1+](Supports autolytic debridement- there may be an increase in the amount of drainage and the size of the wound during initial treatment) o NPWT (Supports autolytic debridement but wounds should be reasonably debrided prior to starting (check organizational policy & procedure for % of necrotic tissue allowed) If eschar: Have ET or WCS nurse cross-hatch hard eschar before applying hypertonic gel [0] and cover with woven gauze dressing (not non-woven gauze or absorbent pads) o Composite dressings [2+] with water-proof or occlusive outer layer (Support autolytic debridement) o Foams [2+]with transparent film or waterproof outer layer (Support autolytic debridement) If there is exudate, cleanse the periwound skin. Pat dry. The intent is to allow the necrotic tissue to dessicate and remain stable; a topical application of povidone-iodine solution (not detergent scrub) or Chlorhexidine is appropriate. Warning- Application of moisture retentive dressings in the context of ischemia and or dry gangrene can result in a serious life- or limb-threatening infection. If a non-stick surface is not required, simply saturate a gauze with either povidone-iodine or chlorhexidine and place it to cover the necrotic tissue and the wound edges. As the necrotic tissue dries and dessicates over time, there will be less absorption of the antiseptic solution. If a non-stick dressing is needed, povidone-iodine non-adherent dresssing can be used. Or, leave open to air after painting with antiseptic, or cover with a loose non-woven gauze that will not be occlusive or adhere to the necrotic tissue. Use inexpensive gauze, or if exudate is large, choose an Ultra-absorbent dressing [3+ to 4+] SWRWC Toolkit: H.5 Wound Cleansing and Dressing Selection Enabler_June 13_2012 4

7. Malignant Goal: Decrease odour and bleeding, maintain dignity 8. Wound with debris or contamination/ Superficial & Partial thickness burns Goal: Effective cleansing and debridement of debris or contamination/ healing of superficial & partial thickness burns with minimal discomfort and prevent infection. Choose a dressing that manages exudate and protects periwound skin Foul odour indicates presence of aneorobes- use antimicrobial solution, &/or topical Metronidazole vaginal cream or gel. Painful or friable tumor tissue may not tolerate irrigation with 7-15 PSI or handheld shower. Warm the solution to body temperature to decrease discomfort, may have to use pour or compress method of cleansing until pain is controlled. o Topical Metronidazole vaginal cream or gel for anerobic odour o Non-Adherent (soft silicone wound contact layer, Petrolatum, non-adherent mesh, Mylar perforated polyester film) [0] to reduce pain and avoid trauma causing bleeding (will require secondary dressing) o Charcoal dressings [1+ to 2+] to adsorb odour (some can be used as the primary dressing while others are layered on top of primary dressing all require a cover dressing) o Calcium alginate [2+] for friable, bleeding wounds o Foams border dressings [2+ to 3+] (Not appropriate for daily dressing changes) Irrigate with 7-15 PSI using at least 150 ccs of solution or a smaller amount of a commercial spray wound cleanser at room or body temperature. Cleanse and protect the periwound skin. May cleanse small burns with lukewarm tap water and mild soap Wounds with Debris: o Hydrocolloid [1+ to 2+] (Promotes autolytic debridement and granulation- does not require a secondary dressing) o Hydrofibers [2+](promote autolytic debridement and bacteria adhere and are trapped by fibers] o Hydrogels [1=] (Add moisture to support autolytic debridement with correct secondary dressing) o Hypertonic Gauze [1+](Supports autolytic debridement- there may be an increase in the amount of drainage and the size of the wound during initial treatment) Superficial & Partial Thickness Burns: Choose a primary antimicrobial dressing if desired for prophylaxis, cover with moisture retentive secondary unless using HydrofiberAg superficial/partial thickness burn protocol (www.woundcare.thehealthline.ca SWRWCF Toolkit Section F.8.4) o Foams dressings [2+ to 3+] (Not appropriate for daily dressing changes) SWRWC Toolkit: H.5 Wound Cleansing and Dressing Selection Enabler_June 13_2012 5

9. Tunneling or Undermined Wound Goal: Gradual contraction of tunnel or undermining and growth of healthy granulation tissue from base until dead space is gone and epithelialization can occur. Irrigate using a 5Fr catheter or soft-cath with a 30-35 cc. syringe and 150 to 500 cc. solution at room or body temperature. Irrigate until returns are clear. Gently palpate over undermined or tunneled areas to express any irrigation solution that is retained. Do not force irrigation when resistance is detected. Consult physician if sharp debridement needed. General Principles:Both have the potential for infection and abscess formation. Wound packing must be firm enough to prevent premature bridging of granulation tissue in the base, causing pockets and future abscesses, yet: o allow the wound to contract and heal from the base and o serve as a conduit or wick to allow the exudate to drain. Avoid packing tightly at the opening, as this can plug the exit leading to increased pressure within the cavity as the exudate volume increases, causing painful extension of the cavity (Birchall& Taylor 2003). Fill dead space with filler dressings such as : o Hypertonic Gauze [1+](Helps to reduce edema and exudate) o Hydrofibres and Calcium alginates [2+](Form a gel-like mass on the wound surface in combination with exudate but must retain integrity so that they can be removed in one piece - Lee et al. 2009 recommend that you not use hydrofibers in tunnels where you cannot see the bottom) NPWT [4+] does not require a secondary dressing If biolfilm or localized infection is suspected or present: o AMD ribbon packing [<1+] or kerlix [1+] o Gauze ribbon packing [<1+] buttered with Cadeomer iodine o Hypertonic Gauze [1+](Helps to reduce edema and exudate) o Hydrofiber/aginate Ag [2+](Form a gel-like mass on the wound surface in combination with exudate but must retain integrity so that they can be removed in one piece - Lee et al. 2009 recommend that you not use hydrofibers in tunnels where you cannot see the bottom) o Nanocrystalline AG [1+] o Foam dressings [2+ to 3+] (Not appropriate for daily dressing changes) SWRWC Toolkit: H.5 Wound Cleansing and Dressing Selection Enabler_June 13_2012 6

10. Localized & Spreading Infection Goal: Resolve infections and prevent recurrence. (this information also appears in the SWRWCF Toolkit Section E.3 Wound Infection Treatment) Two-week challenge: May use a 10 14 day cleansing regime with an antimicrobial solution (prolonged use of antiseptics is NOT recommended but may be appropriate for maintenance wounds). Irrigate with 7-15 PSI using at least 150 ccs of solution or a smaller amount of a commercial spray wound cleanser at room or body temperature. **NB- do not use Chlorhexidine near the ear due to the danger of hearing loss if the product enters the ear canal**** Cleanse and protect the periwound skin. May need to increase dressing frequency until S&S of infection decrease. Localized infection: use topical antimicrobial dressings: o Povidone Iodine mesh [0] dressings not for highly exudative wounds) o AMD antimicrobial - packing strips [<1+], kerlix roll [ 1+] o Hydrofiber Ag [2+](may need to be pre-moistened) o Nancystalline Ag [1+] o Ag Hydrofiber-Alginate [2+] o Cadexomer iodine ung. [1+] care to be taken on bone or tendon which may be at risk of dehydration with lower exudate levels viii ) o AMD antimicrobial transfer foam [1+](may require a non-adherent contact layer) Spreading infection: will need systemic antibiotics in addition to thorough wound cleansing and antimicrobial dressings as above Prevent strike-through of secondary dressings (where exudate soaks through or leaks from sides, creating a pathway for bacteria) Do not use occlusive dressings in presence of or suspected anerobic infections. o Foam dressings [2+ to 3+] (Not appropriate for daily dressing changes). Use with caution on plantar foot dressings where increased exudate may cause maceration and extension of wound. SWRWC Toolkit: H.5 Wound Cleansing and Dressing Selection Enabler_June 13_2012 7

11. Maintenance Wd. Goal: To prevent infection /extension, and assess readiness to adapt lifestyle choices to allow healing. 12. Painful Wounds Goal: Assess and manage pain WITH dressing change, pain AFTER dressing change and pain BETWEEN dressing changes. See SWRWCF Toolkit Section B.5.1-5 for resources Drsg: Cleansing will be dependent on characteristics of wound bed. Low-toxicity antiseptic cleansers are generally used ongoing. Advanced wound products that promote moist wound healing are more expensive than gauze or cotton-based products, but usually require less frequent dressing changes. Choose dressings as per characteristics of wound..eg. if tunnels or undermining, refer to that section. o Abdominal pads [2+] Painful tissue may not tolerate irrigation with 7-15 PSI or hand-held shower. Warm the solution to body temperature to decrease discomfort, may have to use pour or compress method of cleansing until pain is controlled. Protect painful wounds from trauma at dressing removal: o Clear Acrylic dressing [2+] o Foam with silicone contact layer [2+] o Hydrocolloid [1-2+] May need to add absorbent layer (hydrofiber or alginate) does not require secondary dressing o Non-Adherent (soft silicone wound contact layer, Petrolatum, non-adherent mesh, Mylar perforated polyester film) [0] Pain Control o IBU foam [2+] Releases ibuprofen in the presence of exudate for shallow wounds not extending into the subcutaneous tissue Topical Analgesia: o Morphine can be prescribed mixed with Intrasite gel to use topically for extremely painful palliative wounds (e.g.malignant wounds), evidently without risk of systemic absorption. A treatment guideline can be found at http://www.elht.nhs.uk/pdf/10.pdf o Topical lidocaine preparations can also be used in painful wounds at dressing change, or injected into the tubing going to the dressing of topical negative pressure wound therapy prior to the dressing change. Systemic absorption is high when applied to wound surfaces, and should only ever be used under physician or nurse practitioner orders o Foam dressings [2+ to 3+] (Not appropriate for daily dressing changes) o Hydrocolloiod [1-2+] or Ultra-absorbent dressings [3+ to 4+] SWRWC Toolkit: H.5 Wound Cleansing and Dressing Selection Enabler_June 13_2012 8