Proper Wound Assessment and Dressing Selection
By Marcy A. Turkos, DPT, CWS
With the aging population on the rise as well as the increasing rates of both obesity and diabetes, the number of challenging wounds presenting in the long term care environment continues to rise, according to the Centers for Disease Control and Prevention. As a result, practitioners are being held to higher standards in providing optimal wound care, even for the most challenging patients.
Long gone are the days of wet-to-dry dressings being part of a standard wound care protocol,1 and contemporary practitioners must look toward more modern evidence-based wound care products that promote moist wound healing and work toward achieving the goals of wound bed preparation while continuing to consider cost-effectiveness. Choosing a topical wound care dressing from the plethora of products available can be daunting. How can you sort through theory, research, and product claims to choose the best product for any given situation?
Optimizing Wound Assessment
Wound assessment presents the opportunity to determine the most appropriate dressing plan of care. Assessment must include not only examining how the wound is currently presenting but also considering the patient’s status and realistic goals for treatment. By utilizing goal-oriented strategies after assessment, healthcare practitioners can set the most appropriate goals, including, but not limited to, promoting closure or preventing worsening of the wound, medically managing the underlying disease states, educating the patient or caregivers, managing pain and psychological needs, and managing nutritional needs.
Once all of these factors are taken into account, practitioners can work to accurately diagnose, assess, and manage the wound. The first step requires understanding the wound’s underlying etiology and aims to provide the standard of care for that etiology. For example, venous leg ulcers are a sign of underlying venous insufficiency and without appropriate compression dressings in place, the wounds may never progress toward healing. Unna’s boots and multilayer compression bandages are examples of simple and cost-effective ways to manage venous leg ulcers.2
Additionally, pressure ulcers most often need to be off-loaded with both positioning and the use of appropriate support surfaces.3 Arterial wounds need to be closely monitored, with severity dictating whether to consult a vascular specialist.4 The gold standard for healing diabetic foot ulcers is the total contact case, with an 88% healing rate in six weeks. There are newer versions of easy-to-apply total contact casting that have removed the barriers to providing this therapy.5
After determining the wound etiology and implementing the standard of care for the particular type of wound, a decision must be made as to what type of dressing to place on the wound bed. Dressing selection must meet clinical goals but also take into account nonclinical issues. Clinical goals may include managing bioburden, obliterating dead space, absorbing and containing drainage, promoting a moist wound bed, providing thermal insulation, and protecting from trauma and bacterial invasion. Nonclinical considerations include product availability and costs, nursing time, a patient’s psychosocial issues, and educational needs required for use.
The next step in dressing selection focuses on incorporating the theory of wound bed preparation. The paradigm shift more than 10 years ago changed the concept of the dry wound bed to moist wound healing and optimally to wound bed preparation, meaning that it’s desirable to prepare the wound bed to allow granulation and epithelialization to occur.
The TIME algorithm6 assists in remembering the important steps that can help to guide dressing choices. The T represents the need for tissue management and optimal debridement. Nonviable tissue must be removed from the wound bed for the wound to improve. There are many methods to facilitate debridement, including autolysis, sharp/surgical debridement, enzymatic debridement, maggot debridement, and mechanical debridement.
Sharp debridement is not indicated for every wound or patient, and maggot therapy is, at times, not socially accepted. Mechanical debridement may be painful and is nonselective, potentially harming healthy tissue. Enzymatic debridement involves placing an enzyme onto the wound bed to assist with digestion of the nonviable collagen. Autolytic debridement is painless and can be accomplished with certain wound dressings. MEDIHONEY active Leptospermum honey dressings have grown in popularity over the past five years for their ability to facilitate autolytic debridement and to help jump-start slow-healing wounds.7 Hydrocolloid dressings also have been shown to provide an environment optimal for autolytic debridement.8
The I represents the need for infection control and bioburden management. With the increasing rates of drug-resistant bacteria, it is no longer considered standard of care to utilize topical antibiotics for wound infection prevention. It has been documented that when infection prevention is the goal, it is safer to utilize modern dressings, such as barrier dressings containing cationic biocides, to disrupt bacteria without fostering resistance. Bioguard dressings have not been shown to foster resistant bacteria even after successive rounds of testing.9
When infection is present, along with treating systemically as indicated, the topical dressing choices also can help to manage the excessive amounts of bacteria. Most frequently, silver dressings or cadexemer iodine dressings are chosen. However, there is a recent (and increasing) concern about the overutilization of silver dressings, resulting from the theory that bacteria already are showing resistance to certain silvers and also have been shown to be cytotoxic to fibroblasts.10 A recent international consensus paper recommends the limited use of silver dressings for wounds showing signs or symptoms of infection and limiting a treatment period to a two-week time frame.11
Maintaining the proper moisture balance within the wound bed accounts for the letter M. Ensuring adequate moisture for the fibroblasts to reproduce and the keratinocytes to migrate across the wound bed is of utmost importance. However, if a wound is too moist and the wound dressing is not actively holding the cytotoxic wound exudate away from the healthy wound tissue, it could slow wound healing.
Some dressings may absorb fluid, but the amount of compression exerted on the dressing must be considered. Even if a dressing can absorb significant amounts of wound fluid, if the dressing then is placed under pressure (eg, under the foot of an ambulatory patient or under the pressure point of a pressure ulcer patient), it may be releasing the wound fluid again, exposing the wound tissue to the harmful wound fluid. Wound exudate contains an imbalanced amount of cytokines that can degrade the extracellular matrix and also may selectively inhibit the healthy proliferating cells.
Last, the E represents the epithelial edge advancement for which the optimal moisture balance is necessary. If a wound bed is too dry, the keratinocytes will not be able to migrate across the wound bed to produce the new skin. If the wound bed is too moist, the edges can be damaged by maceration, which has been shown to slow wound healing. The use of modern wound dressings such as foams, alginates, and hydrogel-colloidal sheets may optimize the moist wound-healing environment. With highly exudating wounds, the use of superabsorbent polymer dressings such as XTRASORB can help to prevent maceration.12
After addressing the necessary standards of care based on wound etiology, deciding on the goals, and taking into consideration TIME management, it is necessary to narrow the choices for the primary and secondary dressings to be chosen to achieve the aforementioned goals. Primary dressings indicated for dry to moderately draining wounds include hydrogels, hydrocolloids, Leptospermum honey, and hydrogel colloidal sheets. If the wound is draining moderately to heavy amounts of exudates, you may want to consider alginates or foams. If the wound has signs or symptoms of infection, there are numerous antimicrobial dressings available for a variety of wounds types.
When choosing a secondary dressing or a way in which to adhere the dressing to the patient, it’s essential to consider periwound skin integrity. Avoiding adhesive or the use of a silicone-based adhesive may be beneficial for patients with fragile skin. For extremity wounds, conforming bandages or wraps can be considered to avoid adhesives entirely.
Chronic wounds are problematic for our healthcare system, and nonhealing wounds cost the United States billions of dollars annually. Understanding the importance of proper wound assessment, setting appropriate goals, and maintaining the proper moisture balance can help to improve healing even within challenging patient populations.
Also, understanding the importance of tissue management, infection control, moisture management, and epithelial edge advancement and then using those goals as a pathway to assist in choosing both a primary and secondary dressing can help to not only heal wounds more effectively but also may help a facility to be more cost effective. There is a wide variety of evidence-based modern wound care products that can help in the complicated process of healing chronic wounds.
— Marcy A. Turkos, DPT, CWS, is the clinical field manager for Derma Sciences in Princeton, New Jersey, and a certified wound specialist, as designated by the American Board of Wound Management.