Introduction

Being a wound care professional is often a lot like being a detective. You have to decide what caused the wound, what is contributing to its not healing and how you are going to get it to heal. I have decided to start a series of “cases” that are commonly overlooked or seen in the chronic wound care setting. The cases will focus on real-life scenarios—moisture-associated skin damage versus pressure injury, red leg syndrome versus venous stasis ulcer, how to identify pyoderma, and the importance of a moist wound healing environment. This series will also provide practical strategies for overcoming healing obstacles for slow, non-healing, and challenging wounds.

Where do we start? The first thing you need to do is go back to the critical thinking lessons we learned in elementary school: the what, why, when, where, and how. First the what. This is looking at the pathophysiology of the wound, what is causing it. Next the why. Focus on why this wound is not healing. Are you missing something? Then the when. When did this wound start? Did the patient have an accident that caused it? Next the where. Look at where on the body the wound is located. Are there any other wounds anywhere? Finally, the how. Focus on how the wound got to this point and what has been tried in the past. For this first entry I want to look at the basics. We need a good foundation before we can focus on actual cases.

Dressing Selection

We know as wound care professionals that NO single dressing or product will be utilized from the beginning to the completion of healing. As the wound condition changes, so will the type(s) of dressing(s) required to address issues and to promote the progression of healing. Often we base our dressing selection on:

• The measurements of the wound.
• The wound location
• The surrounding skin condition
• The tissue type in the wound bed
• The amount of exudate or dryness of the wound
• The presence of infection or biofilm
• Whether there are any tunneling or sinus tracts
• Whether there is a skin sensitivity or the patient’s age

Other considerations that we need to remember include:

• Whether the dressing is considered a primary or secondary dressing
• The desired frequency of dressing changes
• The caregiver’s or patient’s ability to change the dressing

When we look for the perfect primary dressing, the dressing that is going to come into contact with the wound bed, we look for compatibility with the current wound status. This dressing may be hydrating or absorptive and will promote a moist healing environment, provide breathability with an ideal moisture vapor transfer rate, promote autolysis, provide insulation, be impermeable to microorganisms, and be atraumatic to the periwound skin.

When we look for the perfect secondary dressing, the cover dressing, we look for many of the same properties as in an ideal primary dressing. We also consider how the dressing performs as a cover, meaning there is minimized movement, as well as minimized skin stripping on the removal of the dressing. We also need to remember when prescribing dressings what the insurance coverage is for these dressings. Are they covered to be changed daily, or every other day? We can’t talk about dressings without mentioning wet-to-dry gauze dressings. This is the most common wound dressing used in health care facilities of all types.¹ The dressing consists of dry gauze moistened with a fluid and placed into or over the wound. This type of dressing is NOT always appropriate.

Considerations include that the open weave can allow the wound to dry out, it allows for loss of tissue temperature, it may damage healthy tissue and result in pain, it requires frequent dressing changes, and it can result in the release of bacteria into the air.¹

Moist Wound Healing Environment and Wound Exudate

The next basic step of good wound care is to maintain a moist wound healing environment. Insufficient moisture in exposed wound tissues causes desiccation and cellular death and prevents epithelial migration.² Excessive moisture resulting from exudate inhibits cell proliferation and breaks down matrix components. Moisture balance in the wound bed is maintained by the appropriate choice of dressings.

How do wounds loose moisture? Wounds loose moisture by two methods, exudate production (liquid) and evaporation (vapor). A controlled water vapor transmission rate promotes wound healing through wound re-epithelization and contraction enhancement.³ Wound dressings should be able to absorb liquid, as well as prevent moisture vapor loss from exposed wound tissues. The ideal moisture vapor transmission rate (MVTR) is a rate of 2028.3 ± 237.8 g/m² × 24 hours. This ideal rate provides an optimal moist environment locally to promote wound healing and to improve proliferation and function of epidermal cells and fibroblasts.⁴

When we talk about wound exudate, we need to look at the good versus the bad. First, what is exudate? Exudate is a fluid that is leaked out of blood vessels, a natural healing mechanism in acute wounds, and it can be difficult to manage. Exudate can be good and bad. Exudate is good because it provides a moist wound environment, enables the diffusion of immune mediators and growth factors, acts as a medium for the migration of tissue-repairing cells, supplies essential nutrients for cell metabolism, and promotes the separation of dead or damage tissue through a process of autolysis.⁵ The exudate becomes bad when it is in the wrong amount (too much or too little), when it is in the wrong place (commonly in skin folds), and when it has the wrong composition (infectious process).

What’s Next

Now that we have covered the basics of wound care and dressing selection let’s get to the cases…………..

References

1. Dale B, Wright D. Say goodbye to wet-to-dry wound care dressings: changing the culture of wound care management within your agency. Home Healthc Nurse. 2011;29(7):429-440.

2. Weigand C, Tittelbach J, Hipler U, Elsner P. Clinical efficacy of dressings for treatment of heavily exudating chronic wounds. Chronic Wound Care Manag Res. 2015; 2:101-111

3. Cutting, KF. Wound exudate: composition and functions. Br J Community Nurs. 2003;8(9 Suppl):4-9.

4. Xu R, Xia H, He W, et al. Controlled water vapor transmission rate promotes wound-healing via wound re-epithelialization and contraction enhancement. Sci Rep. 2016;6:24596. https://doi.org/10.1038/srep24596. Accessed December 4, 2020.

5. Bjarnsholt, T, Schultz G, Kerketerp-Moller K; et al. The role of biofilms in delayed wound healing. In: Wound Union of Wound Healing Societies (WUWHS), Florence Congress, and Position Document. Management of Biofilm. London, United Kingdom: Wounds International; 2016.

About the Author

Emily Greenstein, APRN, CNP, CWON, FACCWS is a Certified Nurse Practitioner at Sanford Health in Fargo, ND. She received her BSN from Jamestown College and her MSN from Maryville University. She is certified as an Adult-Gerontology Nurse Practitioner through the American Academy of Nurse Practitioners. She has been certified in wound and ostomy care through the WOCNCB for the past 8 years. At Sanford she oversees the outpatient wound care program, serves as chair for the SVAT committee and is involved in many different research projects. She is an active member of the AAWC and currently serves as co-chair for the Research Task Force and Membership Committee. She is also a working member of the AAWC International Consolidated Diabetic Ulcer Guidelines Task Force. She has been involved with other wound organizations and currently serves as the Professional Practice Chair for the North Central Region Wound, Ostomy, and Continence Society. Emily has served as an expert reviewer for the WOCN Society and the Journal for WOCN. Her main career focus is on the advancement of wound care through evidence-based research.