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By Root 1854 0

already present in living cells and is therefore compatible with human tissue (Lawrence 1997). Used at body temperature, it is the safest and best cleaning solution for non-contaminated wounds (Fletcher 1997, Miller and Dyson 1996). Although sodium chloride has no antiseptic properties, it dilutes bacteria and is non-toxic to tissue (Thomas 2009). Tap water is also advocated for cleaning chronic wounds (Riyat and Quinton 1997). A study demonstrated that, in comparison with sterile 0.9% sodium chloride, lower rates of infection were found in the group where tap water was used (Angeras et al. 1992).

Principles of dressing a wound

With the exception of wounds where the main aim is to ameliorate symptoms such as malignant wounds, an ideal wound dressing must be capable of fulfilling the following functions.

Removes excess exudate and toxic components.

Maintains a high humidity at the wound–dressing interface.

Allows gaseous exchange.

Provides thermal insulation.

Is impermeable to bacteria.

Is free from particulate or toxic components.

Allows change without trauma.

Is acceptable to the patient.

Is highly absorbent (for heavily exuding wounds).

Is cost-effective.

Provides mechanical protection.

Is conformable and mouldable.

Is able to be sterilized.

(Field and Kerstein 1994, Hampton 1999, Morgan 2000)

In addition, the dressing should minimize pain, odour and bleeding and be comfortable when in place.

A moist wound environment has been shown to affect a wound in the following ways. It:

increases rate of epithelial migration

reduces the lag phase between epithelial cell proliferation and differentiation

encourages synthesis of collagen and ground substance

promotes formation of capillary loops

decreases length of inflammatory phase

reduces pain and trauma due to dressing adherence

promotes breakdown of necrotic tissue

speeds wound contraction.

(Flanagan 1999, Garrett 1997, Miller and Dyson 1996, Williams and Young 1998)

Preprocedural considerations

Equipment

Dressings are named and categorized to make choices more clear (see Table 15.3 for details of groups of dressings). The dressing that is applied directly over the wound bed is the primary dressing. Dry dressings (such as gauze) do not provide most of the criteria for an ideal dressing and should not be used as a primary contact layer as they are likely to adhere and disturb healing (Dealey 2005). This depends on the definition of ‘dry’ dressing as some dressings appear dry but ‘gel’ on contact with the wound, which maintains a moist environment, and are non-adhesive, thus becoming ‘wet’ (examples include Aquacel, alginates and hydrocolloids). The wound itself has the ability to produce moisture.

Wet dressings, such as hydrogels, can make a wound too wet and be responsible for maceration if used inappropriately (Hampton and Collins 2004).

Occlusive dressings achieve many of the criteria for an ideal dressing. They affect the wound and healing in several ways. They have the ability to maintain hydration and prevent the formation of an eschar. As they are designed for moderate exudates, chronic wounds (or fungating wounds) and pressure sores are often dressed with occlusive dressings that are bordered with adhesive. They have a combined primary and secondary layer (examples include Mepilex, Lyofoam, Allevyn and Granuflex). If patients have sensitive skin (or are undergoing radiotherapy) and adhesive borders are traumatic, dressings should be held in place with netting (Netelast) or bandages. A simple secondary dressing is a gauze layer or dressing pad and tape or bandage to secure (see Table 15.3).

Care should be taken with wounds that are difficult shapes to treat. These include long, narrow cavities which require a dressing that can be comfortably inserted into the space but removed easily without leaving any fibres behind and without trauma (Bale 1991).

Dressings should be changed when leakage occurs or the dressing no longer absorbs exudates, around every 2–7 days or as instructed (Hess 2005).

Assessment and recording tools

The wound should