SWRWC Toolkit: Wound Cleansing and Dressing Selection Enabler
Topic
Function of Dressings
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Resources available at www.woundcare.thehealthline.ca
PowerPoint Voice-Over Segments
Other On-line Resources
Links to OTN Webcasts
SWRWCF: Function of Wound Dressings (55 H.PRODUCT SELECTION AIDES
min)
H.2 CAWC PRODUCT PICKER
SWRWCF: Matching Dressings to Wound
H.2.1 Purpose and Instructions for Use of CAWC
Characteristics including High Exudate
Product Picker Tool/ purchase information for
Management (32 min)
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
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Wound Assessment
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
Type of
Intervention
Cleansing:
Primary
Dressing:
Secondary
Dressing:
Treatment Choices
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+]
Cleansing:
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.
Choice of
If the wound depth is <1-2 mm with minimal exudate consider:
Dressing:
o Transparent Film Membranes [1+] (some exudate will evaporate-can be used over alginate
Choose a
dressings)
dressing that
o Hydrogel only if very dry (use under other dressings)
can be left insitu o Absorbent Clear Acrylic Dressing [2+] q 7-14 days or more (Retains moisture and growth factors,
as long as
decreased need for frequent dressing changes)
possible to
o Thin hydrocolloid [1+] q 5-7 days (Retains moisture and growth factors)
avoid disruption o Non-adherent foam border dressing [2+]
of the migrating
epithelium.
SWRWC Toolkit: H.5 Wound Cleansing and Dressing Selection Enabler_June 13_2012
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Wound Assessment
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
Type of
Intervention
Cleansing:
Primary
Dressing:
Secondary
(Cover)
Dressing:
Cleansing:
Primary
Dressing:
Secondary
(Cover)
Dressing:
Do NOT use
occlusive
dressings if
infection is
suspected
Treatment Choices
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+]
o Composite dressings [2+ to 3+] (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)
o Ultra-absorbent dressings [3+ to 4+]
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 Composite dressings [2+ to 3+]
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
o Ultra-absorbent dressings [3+ to 4+]
SWRWC Toolkit: H.5 Wound Cleansing and Dressing Selection Enabler_June 13_2012
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Wound Assessment
Type of
Intervention
Cleansing:
5. Necrotic healable
wound
(debridement is
appropriate)
Primary
Goal: debridement
Dressing:
of necrotic tissue,
prevent infection,
and support healing.
Secondary
(Cover)
Dressing:
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.
Cleansing:
Primary
Dressing:
Treatment Choices
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
Secondary
(Cover)
Dressing:
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
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Wound Assessment
7. Malignant
Goal: Decrease
odour and bleeding,
maintain dignity
Type of
Intervention
Cleansing:
Primary
Dressing:
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.
Secondary
(Cover)
Dressing:
Cleansing:
Primary
Dressing:
Choose a
dressing that
manages
exudate and
protects periwound skin
Secondary
(Cover)
Dressing:
Treatment Choices
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 Composite dressings [2+ to 3+]
o Foams border dressings [2+ to 3+] (Not appropriate for daily dressing changes)
o Ultra-absorbent dressings [3+ to 4+]
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 Composite dressings [2+ to 3+]
o Foams dressings [2+ to 3+] (Not appropriate for daily dressing changes)
o Ultra-absorbent dressings [3+ to 4+]
SWRWC Toolkit: H.5 Wound Cleansing and Dressing Selection Enabler_June 13_2012
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Wound Assessment
Type of
Intervention
Cleansing:
9. Tunneling or
Undermined
Wound
Goal: Gradual
contraction of
Primary
tunnel or
Dressing:
undermining and
growth of healthy
granulation tissue
from base until dead
space is gone and
epithelialization can
occur.
Secondary
(Cover)
Dressing:
Treatment Choices
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 Composite dressings [2+ to 3+]
o Foam dressings [2+ to 3+] (Not appropriate for daily dressing changes)
o Ultra-absorbent dressings [3+ to 4+]
SWRWC Toolkit: H.5 Wound Cleansing and Dressing Selection Enabler_June 13_2012
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Wound Assessment
10. Localized &
Spreading Infection
Goal: Resolve infections
and prevent recurrence.
(this information also
appears in the
SWRWCF Toolkit
Section E.3 Wound
Infection Treatment)
Type of
Intervention
Cleansing:
Primary
Dressing:
Secondary
(Cover)
Dressing:
Treatment Choices
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 levelsviii)
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 Composite dressings [2+ to 3+]
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.
o Ultra-absorbent dressings [3+ to 4+]
SWRWC Toolkit: H.5 Wound Cleansing and Dressing Selection Enabler_June 13_2012
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Wound Assessment
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
Type of
Intervention
Cleansing:
Primary
Dressing:
Secondary
(Cover) Drsg:
Cleansing:
Primary
Dressing:
Secondary
(Cover)
Dressing:
Treatment Choices
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+]
o Ultra-absorbent dressings [3+ to 4+]
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 Dressing:
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 Composite dressings [2+ to 3+]
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
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