by Connie Yuska, RN, MS,CORLN, and Kim Kehoe, BSN,RN, CWOCN, DAPWCA

ound care costs the U.S. healthcare system morethan $20 billion each year, including more than$4 billion spent on wound management products.

While prevention, early detection and rapid, effective interventionare the hallmarks of an effective wound care program, woundhealing is a complex process that can be compromised bya number of factors. Successful treatment and managementof wounds is a creative and dynamic process requiring thecomprehensive teamwork of healthcare professionals workingtogether to assess both the patient and the wound.

Since thorough and regular examination remains the mosteffective way to detect patient wounds, healthcare workersneed to be proficient in recognizing the signs and symptomsof basic and atypical types of wounds. If staff members areunable to identify specific atypical wounds, they should atleast identify what is abnormal so the wound care specialist

Assessrngboth the patientand the wound

can be alerted and treatment plans altered if necessary. Allclinical staff members should be knowledgeable regardingpressure ulcers (including staging), arterial ulcers, venousinsufficiency ulcers, diabetic neuropathic ulcers, and burns aswell as ulcers related to shear, friction, and moisture.

It's also important that wound examination be done on aconsistent basis. For example, immobilized patients needto be turned regularly and examined completely to avoidmissing a forming pressure ulcer. Stage I pressure ulcers maybe difficult to identify because they are not readily visible andthey present with greater variability, which means that withouta proper assessment, a pressure ulcer might not be noticeduntil it is a Stage 2, The good news is that systematic effortsat education, heightened awareness and specific interventionsby interdisciplinary healthcare teams have demonstrated thata high incidence ofpressure ulcers can be reduced.

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Even with proper care, however, some wounds will fail toheal in an appropriate fashion and may become chronic. With somuch at stake, it important that you and your staff take appro-priate steps to encourage wound healing. There are fiveprinciples to consider when planning wound care:1. Is the wound healing?

If the answer is yes, then proceed with best practice princi-ples including providing an optimal moist woundenvironment. However, if the answer is that the wound isnot healing, consider other factors that affect woundhealing. Address issues of moisture, nutrition, mobility.pressure, friction and shear.

2. Is the wound wet or dry?If the wound is wet or there is drainage, it must becontained. Applying an absorbent product or one thataddresses the drainage should be a focus. If the wound bedis dry, a product that donates moisture to the wound bedmay be necessary. Research has demonstrated that woundsheal better, faster, and with less scarring and pain in a moistenvironment.

3. What is the condition of the periwound skin?If the skin around the wound is compromised, denudedor "raw," the secondary or anchoring dressing choice willbe affected. Consider products that are non-adherent andwill not stick to fragile periwound skin. If the periwoundskin is not compromised an adhesive dressing may beconsidered.

4. Is the tissue necrotic or viable?If the wound bed is viable or living, measures should betaken to maintain the living tissue, such as maintaining amoist environment. If the wound bed is covered withnecrotic tissue, slough or eschar, debridement is in order.Be sure to assess whether debridement is consistent withthe overall goals for the patient.

5. Dead Space: Does the wound have depth?If the wound has depth or dead space, loosely filling thewound cavity is necessary to allow closure by secondaryintention, or "from the bottom up." If the wound is superfi-cial or "flat," usually a cover dressing is acceptable.

The choices for treatment are based on a complete assess-ment of the patient, expected healing time and the amountof exudates in the wound bed. The following is adapted fromThe Wound Care Handbooft, comprehensive guide available aspart of Medline Industries Inc.'s Wound Care Compass programthat details the basics of wound care and how various treatmentsare applied by practitioners in the field.

Transparent FilmTransparent films can be used as a primary or a

secondary dressing. As a primary dressing they are idealfor a dry to minimally draining wound. They are availablewith and without antimicrobial properties.

Hydrocolloid DressingA hydrocolloid is designed for use as a primarr

dressing, coming in direct contact with the wound bed.It is used for moist to moderately draining wounds. Otherdressing choices should be considered if the dressingchange frequency is greater than three times per week asthe hydrocolloids are completely adhesive.

Hydrocolloid,designed as

primarydressing.

Hydrogel (Amorphous, Sheetsand lmpregnated Gauze)

A hydrogel gel is a primary dressing that is designedto provide a moist wound healing environment. In theamorphous form it can be used to fill a defect, either aloneor in an impregnated gauze application. The sheet can beused for flat to shallow wounds that need to be kepthydrated while provided gentle or non-adhesive properties.Hydrogel dressings help with autolytic debridement andoffer antimicrobial properlies. They are available with andwithout antimicrobial properties.

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Transparentfilm, used

as primary orsecondarydressing.

Six Tips for Creating a Consistent

1 .

Effective Wound Gare Program

Hire skilled and experienced wound carespecialists to provide expert care to patientswith chronic or acute conditions. Wounds thatdon't heal properly can lead to additionalserious health problems, so it's particularlyimportant to have the right team of profes-sionals involved in resident care with the rightset of treatment products and practices.

Understand the full scope of the patient'sneeds. Mobility, age, nutrition, continence,disease and other factors all have a part toplay in how wounds heal, so its important thatfacilities have the right mix of skilled staff inplace to treat the complexity of a patient'sneeds and utilize high-quality products to helppromote wound healing.

Keep abreast of quality of care requirementsfrom local, state and federal agencies.

Emphasize continuing education for staff, resi-dents and their families. The range of treatmentoptions for wounds continues to evolve, andaccordingly, so must the type of care provided.

Be willing to use a wide range of treatmentoptions. Similar wounds tend to respond tosimilar treatment options but not always. That'sbecause each patient-and their nutrition,overall health and goals differ. That's why it isimportant to continually assess the treatmentoption and intervene if the wound does notrespond. In addition to products used totreat the wound itself, there are also seating,positioning and support surfaces that can helppromote healing and redistribute pressure.

Take advantage of specialized training andinservices on products and treatment optionsprovided by advanced wound care suppliers.For example, Medline developed a Wound CarePrevention & Treatment Compass program forit's customers that is based on research andconsultation with over 20 leadine medical and

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Hydrogeldressing,

provides moistwound healing

environment.

AlginateAlginate is derived from seaweed and designed to absorb

exudates in a wound. It subsequently becomes a gel andfacilitates autolytic debridement while creating a moist woundhealing environment. Depending on the wet strength of theproduct, the alginate can either gently fill a wound or beplaced into undermining and tunneling. It can easily beirrigated out of the wound bed at each dressing change. Thisproduct also comes in an antimicrobial form.

Alginate, derivedfrom seaweed,

designed toabsorb exudates

in wound.

FoamThese dressings are designed for use of a moderate to

heavily exudating wound. Foam dressings typically wick thefluid up into the dressing. When used to manage large amountsof fluid, they can help with autolytic debridement while main-taining a moist wound healing environment. These dressingscan also provide antimicrobial properties. They can be used

Foam dressing,designed for

moderateto heavily

exudating wound.

Which ever dressingyou choose, it should beselected based on a thoroughassessment of the patientand the wound.

for wound care as well as around percutaneous sites that mayhave increased leaking, or secretions such as a tracheotomy,feeding tube, and a gastrostomy or jejunostomy tube. Theyare available with and without antimicrobial properties.

Antimicrobial DressingsThese dressings come in many sizes and shapes. Their

use of design depends on their fluid-handling capabilities.They are available as powders, f i lms, foams, alginates,sheets, gels and dressings to fill or cover a wound bed. Aftercareful assessment of the patient and their wound it may bedetermined that an antimicrobial dressing is approprrate notonly to manage the bacteria in a wound, but as a prophy_lactic dressing as well. The broad spectrum of antimicrobialproperties make these dressing a good choice for chronicwounds, complex situations, patients with known drugresistance and those at risk for further complications. Thesedressings maintain a moist healing environment, helpwith autolytic debridement and reduce the surface bacteriain the wound bed.

Antimicrobialdressings

reduce surfacebacteria in

wound bed.

Secondary DressingsSecondary dressings are designed to cover the primary

dressing. They should be chosen based on similar wear_timesas the primary dressing. There are many additional character_istics to consider when choosing a dressing. These includetransparency, absorption, bacterial barrier and waterproofproperties. Other features may include the ability to securethe dressing without the use of adhesives.

Secondarydressing,designedto coverprimary dressing.

Which ever dressing you choose, it should be selectedbased on a thorough assessment of the patient and the wound.It is expected that as the wound is progressing through thephases of wound closure towards healing, less absorptiveproducts will be needed and increased wear time should not beexpected. If the wound is not progressing as expected in a sevento 14 day time frame, reassess the patient and the wound todetermine if there have been changes and whether or not thewound has the ability to close. *

Connie Yuska, RN, MS, CORLN isvice president of Clinical Services forMedline Industries Inc. and hosts a seriesof free educational webinars on pressureulcer prevention for both acute and long-tetm care professionals ( www.medline.com/pressureulcerprevention/webinar). A grad-uate of the J&J/Wharton Nurse ExecutiveProgram, she is a member of the Board of

the lllinois Organization of Nurse Leaders and a member ofthe American Organization of Nurse Executives. Most recently,she served as the Chief Nursing Officer of a large communityhospital in Chicago and as a consultant for Joint CommissionResources in the Qualiry and Patient Safety Solutions division.

Kim Kehoe, BSN, R1/, CWOCN,DAPWCA is a Clinical Education Specialistfor Medline Industries' Advanced SkinandWound Care Division. She is a certffiedWound, Ostomy and Continence Nursethrough the WOCN Certification Boardand a member of the WOCN Society,the Association for the Advancementof Wound Care and a Diplomat of the

American Professional Wound Care Association. Kim hasmore than 26 years of Nursing experience that includesPerioperative and Critical Care Nursing, with the past 17 yearsdedicated to ET/WOC l{ursing bonsulting in acute, home andlong term care settings.

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