WOUND DRESSINGS

A dressing at its very basic is a covering applied over an open wound to form a barrier between the wound and the external environment. There are multiple forms of dressings available to the wound clinician, and they all serve the following important functions:

• To protect the wound from infection and trauma
• To promote a moist wound environment that is conducive to healing
• To absorb excess drainage from the wound bed
• To protect the intact skin surfaces surrounding the wound

Choosing the Correct Dressing

A wound dressing is only one component of wound healing, but it is an important one. Deciding on the most appropriate dressing for a particular wound is a team effort. The guiding principle is to maintain an environment conducive to moist wound healing. In simple terms, “a dry cell is a dead cell” and will hinder rather than aid the progression of the wound healing. During the process of wound healing, the type of wound dressing used may have to be changed more than once to address the changing characteristics of the wound (Baranoski & Ayello, 2020).

Some recommendations for clinicians to keep in mind when deciding on a wound dressing include:

• Moist does not mean “soupy.” If the wound has too much drainage, then an absorptive dressing will be required.
• If the wound is dry, then moisture must be added.
• If there is undermining or tunneling, packing is required.
• Periwound areas must be protected from damage.

Other issues to consider when choosing a wound dressing are the frequency of dressing changes, the availability of supplies, and the time and personnel required to perform the dressing change. All of these are factors in a realistic and well-laid-out plan of care for the patient.

FREQUENCY OF DRESSING CHANGES

When looking at the frequency of dressing changes, one of the first questions to consider is how often the wound must be assessed. The answer to this question is highly individualized. Patients with a systemic condition and an infectious wound or a wound at increased risk for infection require close monitoring. The decision may be made to perform daily or twice-daily dressing changes. Most, if not all, of these patients will be in a facility. For patients at home, home healthcare nursing and family support are required.

With chronic wounds that are progressing and infection free, once-a-week dressing changes are normally recommended. Many of these patients will be living at home, and some may be in nursing homes or assisted-living facilities. The patient, family members, or facility staff will require instructions on daily monitoring of the dressing and for signs and symptoms to be reported immediately to the clinician.

AVAILABILITY OF SUPPLIES

Availability of supplies is usually not a problem in an acute-care facility or nursing home. However, for patients in assisted-living facilities and those living at home, the question of who will provide the wound care supplies and how they will be paid for must be taken into account. The case manager or social worker on the wound care team will address the major concerns surrounding the procurement of supplies, but all team members must be aware of the insurance and financial restraints that may limit the options.

TIME AND PERSONNEL REQUIRED

Time and personnel are considerations regardless of the care setting. For example, a highly complex, open abdominal wound on an obese patient with diabetes who is in the intensive care unit and requires conscious sedation for sterile dressing changes will require the presence of the anesthesiologist, one to two clinicians skilled in wound care, and other staff members to help with positioning the patient, opening supplies, and maintaining a workable environment. From start to finish, the time commitment for this procedure could take up to three hours. A dressing choice to consider in this situation may be negative-pressure wound therapy—which would require dressing changes only every 48 to 72 hours depending on the wound status—rather than the larger commitment it would take in time and staff to apply daily dressings (see “Negative-Pressure Wound Therapy” later in this course).

Time must be considered not only for the clinician but for the patient and/or caregiver. Patients who visit an outpatient wound clinic may have to take time off from work, and their caregiver may have to take time off to bring them to the clinic. In many instances, patients and family will state that they can only come once a week, and the wound care team must take this into account when developing the treatment plan.

Dressing Types

There are thousands of wound care products on the market, and choosing among them can be a daunting task. However, every facility, clinic, and home health agency involved in wound care will carry a wound care formulary. Who decides what products are made available? Ideally, this is a joint decision between all interested parties, such as administration, purchasing department, and wound care clinicians.

There are frequent changes in the many different companies’ dressings, names, and types, and so it is important to gather up-to-date information on dressing options before selecting a particular dressing. Some major dressing companies include Hollister, Convatec, Medline, 3M, Healthpoint, Johnson & Johnson, and De Royal. (This is not a complete listing and is not intended as a recommendation of one brand over another.)

Several major types of dressings are discussed below.

ALGINATES

Usually referred to as calcium alginates, these dressings are made from lightweight seaweed. Alginate dressings can absorb up to 20 times their weight in wound exudate, and they are an ideal choice for moderately to highly draining wounds. They are available in flat dressings of various sizes and also as a rope dressing (Baranoski & Ayello, 2020).

Forms

There are two forms of alginate dressings. One will turn into a gel after it comes in contact with the wound drainage, and the other retains its original shape while it absorbs drainage. The choice of alginate used is usually based on clinician preference.

Advantages

Some dressing brands now offer the option of a silver alginate, which provides the antimicrobial action of silver to the wound bed. Alginate dressings can assist in hemostasis, making them a first-line option for bleeding wounds. Since the dressing remains soft and moist, it does not stick to the wound tissue and does not cause pain to the patient upon removal.

Frequency of Dressing Changes

Alginate dressings can normally remain in the wound for up to 72 hours. However, the frequency of dressing change is determined by the amount of drainage and the frequency of wound assessment indicated in the patient’s wound care plan.

Clinical Guidelines for Use

For deep wounds, a single layer of alginate dressing is applied directly to the wound bed and then covered with layers of fluffed gauze to fill the cavity of the wound. Using layers of alginate dressings to completely fill the wound will not increase the rate of healing and is not cost effective. Alginate rope should not be placed in narrow tunnels, as there is a possibility that small pieces of the dressing could be left behind. Once the alginate dressing is removed from the wound, the wound bed must be cleaned thoroughly to completely remove the dressing residual (Bryant & Nix, 2016; WOCN, 2022).

HYDROCOLLOIDS

Hydrocolloid dressings help to prevent secondary infections. They are made from a gelatinous substance and have a self-adhesive surface. They provide for limited absorption of wound drainage and are suitable for shallow, dry wounds.

Forms

These are wafer-like, flexible, water-impermeable dressings that conform well to different wound locations. They are available in dressing, paste, and powder forms.

Advantages

Hydrocolloids are simple to apply, and because of their conformity, range of sizes, and varied shapes, they can easily be applied to wounds on most parts of the body. Due to their occlusive nature, they promote a moist wound environment, maintain wound temperature, and protect the wound from contamination (e.g., a coccyx wound in an incontinent patient).

Frequency of Dressing Change

The recommended frequency of dressing change is twice weekly. If the wound must be assessed more frequently, a different dressing should be considered.

Clinical Guidelines for Use

Hydrocolloids can be used to protect fragile skin and are often cut into strips to be applied as a “picture frame” along the periwound area to protect it from trauma and drainage and as a surface for attaching a secondary adhesive dressing. They are not an appropriate dressing for infected wounds.

To properly apply a hydrocolloid dressing, the clinician ensures it is larger than the wound size. Optimal dressing adherence is achieved when the dressing extends a minimum of 2.5 cm onto the skin surfaces around the wound.

Hydrocolloids produce an odor that is noticeable when the dressing is removed, and the gelatinous material of the inner layer can be mistaken for purulent drainage. The clinician must educate the patient, family, and other staff about this and instruct them to adequately flush and clean the wound after removing the dressing and then assess for signs of infection (Baranoski & Ayello, 2020).

HYDROGELS

These are hydrating dressings (i.e., they donate water to the wound bed) and are suitable for shallow wounds with scant drainage. They can also be used along with other agents such as topical medications and antibacterial substances.

Forms

They are available as solid gel dressings, impregnated gauze dressings, and amorphous hydrogels composed of gelatin, polysaccharides, and polymers. The liquid gel is applied directly to the wound bed and covered with moistened, fluffed gauze.

Advantages

These are a cost-effective and easy-to-apply dressing. The hydrogel sheet dressing produces a cooling effect on the wound, which can help with pain management. These dressings can also be safely used during radiation therapy. They are a recommended dressing for use on donor sites, superficial surgical wounds, and chronic wounds (in which they can be used to promote autolytic debridement).

Frequency of Dressing Change

There is flexibility in how often hydrogel dressings can be changed, depending on the characteristics of the wound. Such dressings can be replaced once or twice daily or left in place for up to three days.

Clinical Guidelines for Use

The clinician must avoid overpacking the wound and instruct caregivers likewise, since this may cause pressure on the wound bed, damage newly forming tissue, and impede wound healing.

Hydrogel sheet dressings may also cause maceration of the periwound area, and the dressing must be cut to fit within the wound area without overlapping onto intact skin. Applying a liquid barrier film to the periwound area provides an extra layer of protection.

When using the liquid gel form of the dressing, the clinician applies at least 1/8-inch thickness along the surface of the complete wound bed and covers this with the fluffed moistened gauze.

If the dressing has dried out, it must be moistened prior to removal in order to prevent pain and discomfort and to avoid damaging healthy wound tissue. The use of this dressing should then be reassessed as to frequency and cover dressings used to prevent it from drying out (Bryant & Nix, 2016; Baranoski & Ayello, 2020).

HYDROFIBER

The main component in hydrofiber dressings is carboxymethylcellulose, which is responsible for its absorptive ability. These dressings are sometimes confused with alginates because of their ability to absorb wound drainage (WOCN, 2022).

Forms

They are available in sheet and ribbon dressings and in plain and antimicrobial forms.

Advantages

These dressings have been shown to reduce bacterial burden in wounds due to their ability to absorb exudate-containing bacteria.

Frequency of Dressing Change

The frequency of dressing changes depends on the amount of wound drainage. Heavily draining wounds may require daily dressing changes, while in wounds with moderate amounts of drainage, the dressing can be left in place for 2–3 days.

Clinical Guidelines for Use

Hydrofiber dressings cannot be used in dry wounds. They also require a secondary dressing to hold them in place. If the dressing becomes overpowered by wound drainage, there will be leakage onto the periwound area (WOCN, 2022).

FOAM

Foam dressings are capable of absorbing large amounts of wound drainage while maintaining a moist wound environment. Most foam dressings are made from polyurethane with a matrix of small open cells that absorb drainage from the wound bed (Bryant & Nix 2016; WOCN, 2022).

Forms

Foam dressings come in many shapes and sizes, including special shapes that can be used on elbows, heels, and the sacrum. They are available in a plain form and also impregnated with antimicrobial agents (Baranoski & Ayello, 2020). Foam dressings can be either adhesive or nonadhesive. They come in various thicknesses, ranging from 7 mm to less than 1 mm.

Advantages

Foam dressings are highly versatile and have been shown to decrease wound pain, especially when being removed from the wound bed. They can be used successfully under compression therapy with venous ulcers and as a secondary dressing to supplement absorption in heavily draining wounds. Although they do not relieve pressure, foam dressings can be used to protect against shear injuries.

A traditional foam dressing will usually require a secondary dressing to hold it in place. However, newer thin foam dressings usually have an adhesive wound surface layer and outer layer of transparent film that provides a waterproof surface. Many foam dressings also come with an adhesive border (Bryant & Nix, 2016; Baranoski & Ayello, 2020).

Frequency of Dressing Change

Depending on the type of wound and the amount of drainage present, foam dressings can be left in place for variable lengths of time, ranging from one day up to one week.

Clinical Guidelines for Use

Due to their versatility, foam dressings are widely used in wound care. However, they should not be used on dry wounds or wounds with very little drainage. Manufacturers frequently indicate the absorption capacity of foam dressings, and the clinician must follow these guidelines when choosing foam dressings for a particular wound. Foam dressings can be cut and shaped to align with body contours. Care must be taken to apply the correct side of the dressing to the wound bed; this is often indicated on the dressing itself with the instructions “this side up.”

COMPOSITE

Composite dressings combine more than one physical property in a single dressing and can serve multiple functions (Bryant & Nix, 2016; Baranoski & Ayello, 2020). They provide adhesion, absorption of wound drainage, and a protective barrier against bacterial infection.

Forms

Composite dressings are multilayer dressings, and they conform to anatomical curvature. They come in several different shapes and sizes.

Advantages

Composite dressings are easy to apply and remove. The adhesive border around the edge of the dressing secures it to the periwound area, removing the need for a secondary dressing. Composite dressings can be used in conjunction with other topical wound therapies, such as topical medications applied to the wound bed. Composite dressings can enable autolytic or mechanical debridement of the wound (Baranoski & Ayello, 2020).

Frequency of Dressing Change

According to the condition of the wound, dressing changes can vary from daily to three times a week.

Clinical Guidelines for Use

Since composite dressings come in several different sizes, the correct size must be chosen for the wound. These dressings cannot be cut, since this will compromise the structure of the dressing. The correct size will allow the dressing to extend for one inch onto the intact periwound area.

CONTACT LAYER

Contact layers are thin, nonadherent layers that are placed directly onto the wound bed. They have an open-weave or perforated structure that allows drainage to pass through the layer to be absorbed by the dressing placed over it.

Forms

Contact layers come in various sizes and types. Many are gauze-based dressings permeated with petrolatum or oil; some are perforated, silicone-impregnated sheets; others are perforated cloth-like sheets.

Advantages

Contact layers protect the wound surface from trauma and help maintain a moist wound environment. They conform well to the wound surface. They are easy to apply and remove from the wound bed, and they assist in pain-free dressing changes. Contact layers can also be used in conjunction with topical medications applied to the wound (Baranoski & Ayello, 2020).

Frequency of Dressing Change

Contact layers can be left in place for a week. They do not usually need to be removed with each dressing change.

Clinical Guidelines for Use

Contact layers are often used on surface wounds of the extremities, but they can also be used to line the base of deeper wounds to prevent filler dressings from sticking to the wound bed. Contact layers are not recommended for dry wounds, for areas of tunneling or undermining, or for wounds where the drainage has a thick consistency (WOCN, 2022; Bryant & Nix, 2016).

ANTIMICROBIAL DRESSINGS

Antimicrobial dressings cover a wide selection of wound care products, including:

• Cadexomer iodine dressings
• Silver dressings
• Honey dressings
• Hydrofera Blue dressings

These products are effective against a broad spectrum of microorganisms that cause wound infection and biofilm formation (Bryant & Nix, 2016; Baranoski & Ayello, 2020).

Forms

Antimicrobial dressings come in several different forms, including sheet dressings, pads, rope, powder, creams, and ointments (Baranoski & Ayello, 2020).

Advantages

These dressings provide absorption of wound drainage and maintain a moist wound bed. They provide the wound with a constant delivery of antimicrobial agents that eradicate bacteria from the wound. Rope forms of these dressings can be used to wick drainage from areas of tunneling. Honey dressings help to reduce wound odor. Antimicrobial dressings can be used in conjunction with compression for venous ulcers of the lower extremities. They can be easily removed from the wound and decrease discomfort during dressing changes.

Frequency of Dressing Change

The frequency of dressing change depends on the properties of each type of dressing and the amount of wound drainage. Silver dressings are usually changed every 72 hours; honey dressings can be left in place for up to seven days.

Clinical Guidelines for Use

Guidelines are specific to the type of antimicrobial dressing being used:

• Cadexomer iodine dressings release a constant amount of iodine to the wound and can be left undisturbed in the wound bed for 72 hours. They are contraindicated in patients who are allergic to iodine, shellfish, or dyes (Shah et al., 2018).
• Manuka honey dressings can remain in the wound for up to seven days. However, dressing changes may need to be done more frequently if there is a high volume of wound drainage.
• Hydrofera Blue dressings are a combination of methylene blue crystal and gentian violet, both with a long history of use in healthcare. They are active against several organisms, including methicillin-resistant S. aureus (MRSA) (Wound Source, 2021; WOCN, 2022). They can be used in conjunction with collagenase, used under compression therapy, and left in a wound for up to seven days.
• Silver has been used for centuries in healthcare, and in recent times it has been found to be a potent agent in wound care. Silver dressings come in foam, alginate, contact layer, powder, and rope forms. They function in one of two ways: the dressing donates silver to the wound bed or the silver remains in the dressing material, which absorbs the wound drainage and destroys the bacteria contained in it (Baranoski & Ayello, 2020). Silver dressings can be left in place for up to seven days and used under compression therapy.

COLLAGEN

Collagen dressings help to stabilize the chemical balance in the wound by decreasing the level of proteases (which destroy the newly forming collagen fibers in the wound bed). Collagen dressings are derived from either type 1 bovine collagen, avian collagen, or type 3 porcine collagen (Bryant & Nix, 2016).

Forms

Collagen comes in flat dressings, gels, pads, particles, and freezer-dried sheets (Bryant & Nix, 2016; Baranoski & Ayello, 2020).

Advantages

Collagen dressings are easy to apply and can be used for either partial- or full-thickness wounds. They are absorbent dressings, while at the same time they maintain a moist wound environment. Collagen dressings are comfortable, can be used with topical wound agents, and are easy to apply.

Frequency of Dressing Changes

The frequency of dressing changes will depend on the state of the wound—how far along it is in the healing process and the amount of wound drainage. Since these are relatively expensive dressings that usually do not require daily changes, they are typically left in place for 3–7 days.

Clinical Guidelines for Use

Collagen dressings can be used on a wide range of wounds, including donor sites, surgical wounds, wounds with tunneling and undermining, and chronic wounds. They are not recommended for dry wounds, wounds with necrotic tissue present, or for patients who are sensitive to bovine or pork products (some patients may also have a religious or ethical objection to the use of such animal products). Collagen products require a secondary dressing, and some may need to be rehydrated before being removed from the wound (Baranoski & Ayello, 2020).

TRANSPARENT ADHESIVE DRESSINGS

These are thin, plastic dressings with an adhesive surface that sticks to the wound margins without adhering to the wound itself. They are most frequently used as a cover dressing, for example, with an alginate dressing (Bryant & Nix, 2016). They can also be used to cover IV sites and as a primary dressing for both shallow and dry wounds (Baranoski & Ayello, 2020).

Forms

Transparent dressings come in a range of shapes and sizes that adapt easily to different anatomical sites.

Advantages

Although they are not able to absorb wound drainage, transparent dressings facilitate moist vapor transfer and atmospheric gas exchange. At the same time, they provide a waterproof covering for the wound and protect against external bacterial infection; for this reason they are a good choice for wounds at high risk of stool and urine contamination. They are also a good choice when autolytic wound debridement is required. Since they are unable to absorb drainage, they retain moisture on the wound surface (often referred to as a “greenhouse effect”); this aids in the process of autolytic debridement (Bryant & Nix, 2016; Baranoski & Ayello, 2020).

Frequency of Dressing Changes

Transparent dressings are usually changed every three days, although they can be left in place for up to seven days (Bryant & Nix, 2016; WOCN, 2022).

Clinical Guidelines for Use

Transparent dressings are not recommended for wounds that require frequent monitoring, such as infected wounds. These dressings cannot be used as a primary dressing for wounds that have tunneling or undermining. Transparent dressings should provide a one-inch overlap onto the periwound area, and if necessary, a liquid skin barrier is applied onto the periwound area to provide protection from skin stripping when the dressing is removed (Bryant & Nix, 2016; WOCN, 2022).

SUMMARY OF DRESSING TYPES

Name (Type)	Use(s)	Advantages
Alginates (absorbent, made from light seaweed)	In moderately to heavily draining wounds	Can stay in the wound for up to 72 hours Flat and rope dressings available Silver impregnated available
Hydrocolloids (occlusive)	For autolytic debridement; to protect periwound area from trauma and drainage	Simple to apply Wide range of sizes and shapes Conformity to wounds on most parts of the body
Hydrogels (hydrating; donate water to the wound bed)	In shallow wounds with scant drainage	Cost effective Easy to apply; help with pain management Can be used on donor sites Promote autolytic debridement
Hydrofiber (absorbent; made from carboxymethylcellulose)	In moderately to heavily draining wounds	Will not adhere to wound bed Available in plain and antimicrobial forms
Foam (absorbent, can be adhesive or nonadhesive)	In moderately to heavily draining wounds; under compression; to protect against shear injuries	Highly versatile; reduce wound pain Available with adhesive borders
Composite (combination)	To provide adhesion, absorption of wound drainage, and protective barrier against bacterial infection	Easy to apply and remove Can serve multiple functions Can be used in conjunction with other topical wound therapies such as topical medications applied to the wound bed
Contact layer (nonadherent layers placed directly onto wound bed)	To allow drainage to pass through to absorptive dressing above	Protect the wound from trauma Help maintain a moist wound environment
Antimicrobial (cadexomer iodine, silver, honey, Hydrofera Blue)	Against a broad spectrum of microorganisms that cause wound infection and biofilm formation	Versatile, can be used with compression therapy Help reduce wound odor Easily removed; decrease discomfort during dressing changes
Collagen (derived from type 1 bovine, avian, or type 3 porcine collagens)	To stabilize the chemical balance in the wound by decreasing the level of proteases, which destroy the newly forming collagen fibers in the wound bed	Easy to apply Help maintain a moist wound environment Can be used with topical wound agents

Changing Dressings

In general, changing a dressing daily allows for assessing the condition of the wound and progress of the healing process. However, the frequency of dressing changes depends on the status of the wound and the amount of wound drainage.

Since wounds require being at body temperature for healing to occur, it is important to be aware that any time spent in changing a dressing, or even cleansing the wound, will cool down the wound, which can then take several hours to come back up to body temperature after being re-covered. This may slow the healing process. Therefore, it is important to be organized and prepared prior to beginning the procedure and to choose a dressing that will minimize the need for frequent changes.

WHEN TO CHANGE

The first thing to determine is the time when the dressing change will be done. Planning ahead and adopting a patient-centered approach is important. Most patients have many other activities going on during a hospital stay, and the same is true in nursing homes and assisted-living facilities. For example, in a hospital setting, it is not a good idea to show up for a dressing change just as a patient returns from physical therapy and is already tired and ready for a nap. It is also important for home health nurses to collaborate with patients and families when scheduling visits.

PAIN MANAGEMENT

Once a dressing change time has been decided on, the next issue is pain management. Will the dressing change be painful? Does the patient have pain medication ordered? Clinicians usually request that the physician order a dose of pain medication specifically for dressing changes. The medication must be given so that there is adequate time for it to take effect prior to beginning the procedure, usually 30–60 minutes before the dressing change. Consider topical pain medications such as Lidocaine for point-of-use pain management. If the wound dressing has dried out, soak it completely and remove gently to lessen pain (Baranoski & Ayello, 2020).

DRESSING CHANGE PROCEDURE

Following is an example of the steps a clinician will follow when changing a dressing. Always follow facility protocol. When the patient has more than one wound, each wound is regarded as a separate treatment.

1. Identify the patient according to facility protocol.
2. Explain how the dressing change will be performed and position the patient to expose the wound area.
3. Ensure that all supplies are available on a clean, dry working surface, conveniently positioned near the patient. If a sterile dressing is being applied, then a sterile work area must be created. However, most wound care dressings are done using “clean technique” (see below).
4. Wash hands, then gently remove the old dressing and dispose of it according to facility protocol.
5. Don new gloves and perform a wound assessment (as described earlier in this course).
6. Clean the wound and apply a new dressing per instructions in the wound care plan.
7. Pack narrow tunnels loosely with ribbon gauze or other sterile rope dressing as ordered. The end of the gauze is placed in the wound to ensure that the packing is removed with the next dressing change. The goal of packing is to remove drainage and to allow the tunnel to collapse from the distal end to the wound bed. The dressing material used in the wound bed can be placed in areas of undermining if the depth is such that removal of the dressing material can be adequately done.
8. Cover the wound with a secondary dressing, e.g., a border foam dressing.
9. Assist the patient into a comfortable position.
10. Discard all used supplies per facility protocol.

Immobilizing Wounds Near Joints

Wounds occurring over a joint or in close proximity to one may need to be immobilized, since repeatedly moving a wound by contracting nearby muscles will slow wound healing and increase the size of the eventual scar.

Plastic or aluminum splints can sometimes be added to the outer bandages of a wound. Otherwise, a separate splint may be placed along the joint. At times, a plaster cast may be needed. Also available are joint immobilizers, which can be soft (like a sling) or rigid (like a knee brace).

Physical therapists have extensive knowledge of anatomy and correct positioning, and as part of the wound team, they can provide interventions that will reduce swelling in the affected area and provide correct immobilization to aid in tissue regeneration without impairing joint function. The goal is to optimize correct positioning of the joint, avoid joint contractures, and maintain neurovascular functioning while promoting wound healing. A splint should be correctly sized, applied, and carefully monitored to support appropriate joint positioning and avoid loss of joint mobility. For example:

• Knees are supported in a position of 10 degrees flexion.
• Ankles are dorsiflexed and supported in a position of 90 degrees.
• The shoulder is maintained parallel to the chest.
• The elbow is supported at 90 degrees flexion.
• The wrist is sustained in a neutral position.
• Fingers are flexed.
  (DeYulis & Hinson, 2022)