Long-Term Care Survey Alert

Published on Fri Aug 17, 2007 PDF

Follow these 4 rules of thumb for healing wounds effectively.

Your facility's wound outcomes will only be as good as its wound care strategies. So make sure you're not using outdated or inappropriate modalities that can impede healing or worsen a wound.

Rule No. 1: Pause before you use gauze. Dorothy Doughty, RN, MN, COWN, FAAN, sees a number of problems with using wet-to-dry gauze dressings to mechanically debride a wound.

"For one, the drainage passes through the gauze, producing a hypothermic effect," which has a negative effect on the "wound repair process," says Doughty, director of the Wound Ostomy Continence Nursing Education Center at Emory University in Atlanta. "The cells don't work as well when they are hypothermic.

"There's also the potential to remove healthy tissue when you remove the gauze," adds Doughty. "If people use gauze that has loose fragments, then they can leave foreign bodies in the wound," she adds. And "there's a tendency to overpack a wound, which produces an unwanted pressure-dressing effect."

Sue Gardner, RN, PhD, CCWN, notes that using wet-to-dry saline dressings for mechanical debridement is perhaps not the "best choice" compared to occlusive dressings that promote autolytic debridement or enzymatic preparations or conservative sharp debridement.

Salient point: And when using saline dressings to provide moist healing for a clean wound bed, "you can't let the dressing dry out," cautions Gardner, a nursing professor at the University of Iowa. To prevent that from occurring, you usually need to put a secondary dressing over the wet gauze, she adds.

Avoid contaminated gauze, advises Kathleen Thimsen, RN, ET, MSN, president of RARE Consulting Group Inc. in Belleville, IL. For example, beware using "cheap" gauze imported from Pacific Rim countries and gauze in non-sterile "loaves," she says. "Don't use the gauze if you find debris in the gauze package," Thimsen cautions.

Rule No. 2: Revisit policies for using antiseptics. The Agency for Healthcare Policy and Research (now the Agency for Healthcare Research & Quality) pressure treatment guidelines in 1994 cited evidence that antiseptics can damage healing cells in cell cultures, and recommended not using antiseptics in pressure ulcers, notes Janet Cuddigan, PhD, RN, CWCN, CCCN, a nursing professor at the University of Nebraska. As a result, "clinicians swung to not using them ... but the pendulum is swinging back because studies show that some antiseptics may have less toxicity." Yet "other people still maintain that antiseptics damage healing cells," Cuddigan notes.

"But if you have a wound that's so grossly infected that it has virtually no chance of healing and the patient is on the cusp of getting septic, you need to clean up that wound rapidly," says Cuddigan.

"Some people have the clinical opinion that it's OK to use antiseptics like Dakin's solution in conjunction with debridement in that situation as a temporary strategy to reduce bacterial burden" until you can get culture results and start appropriate antibiotic therapy.

Doughty notes that what you can say across the board about antiseptics is that you shouldn't use them once you've eliminated necrotic tissue and controlled bacterial counts.

Rule No. 3: Use the right treatments at the right time. "Most of the time, topical wound therapy needs to change as the wound progresses," says Doughty.

Examples: If you have a necrotic wound, use a topical agent that debrides, such as an enzymatic agent, advises Doughty. Once a wound is debrided, you may find that it has depth and is "probably exudative," she adds. In that case, you need a filler dressing that can absorb exudate, says Doughty.

"As the wound fills in and the exudate volume diminishes, you need a cover dressing that protects and provides some hydration."

Rule No. 4: Avoid stirring up quality-of-care concerns with whirlpool debridement. Wound contamination is a concern with whirlpool, says Thimsen.

Also, whirlpools are easiest to use for debriding extremity wounds like leg ulcers, notes Doughty. But that approach may be contraindicated for patients with venous ulcers for two reasons. For one, the patient with a venous ulcer shouldn't have her legs in a dependent position, she says. And the warmth of the whirlpool causes vasodilation and more leg edema in a patient with a venous ulcer, Doughty adds.

Also, patients with arterial wounds have poor perfusion and "can't handle the heat of the whirlpool," so you have to be careful to avoid burns, she notes.

An alternative: Pulsed lavage for debridement rather than the whirlpool. The pulsed lavage is usually done by physical therapists but can be performed by nursing, Doughty says.