Dressing question

[Anna Flaxis, BSN, RN]

I posted this in the Wound Care forum, but I'm not getting any replies, so I thought I'd post it here.

Recently I worked with a nurse who placed a wet to dry dressing over a closed, non-draining skin abscess. She stated that the abscess was an open wound, due to the presence of three small tracts about the size of large pores where it had previously drained about a week prior. I did not observe any drainage, yet she stated that the wound was currently draining, but it had dried out due to the lack of a proper moist dressing. Her rationale was that the saline moistened gauze would draw out pus.

She moistened two gauze 4x4s with sterile saline solution, folded them in half, placed them on the reddened, non-indurated dome, and covered it with Tegaderm.

I was more than a little puzzled at this approach. First, I disagreed with the assessment that this was an open, draining wound, and second, I didn't think a wet to dry dressing was indicated. Third, her dressing wasn't really a "wet to dry" as I understand it. If she really was intending to place a wet to dry, her technique was incorrect.

As I understand it, an appropriate dressing for a skin abscess would be a nonstick absorbent pad secured with some roller gauze or a medipore square, with warm compresses applied 3-4 times daily.

I am willing to admit that there is a lot I don't know, and that maybe I'm wrong. She does have 20 years' experience, and seemed very confident in her assessment and judgment.

Also, she had advised the patient to shave around the abscess so that the Tegaderm would stick better. I was concerned that shaving so close to the abscess might create microabrasions that could lead to further infection/cellulitis. She said that since the patient was already on abx, that it would be okay. My contention is that since not every bacteria is susceptible to every abx, the patient would still be at risk.

Any insight?

[sauconyrunner]

I'm not in wound care so I can not hazard a guess as to the correct dressing...though I would go with what the order says to dress it with.

But you are entirely correct about the shaving and the antibiotics. We are told not to shave people for major surgery which is a far cleaner environment. Like you said, not every anti is going to kill every germ. I'm frankly a bit horrified at her statement.

[Burn-Unit-RN]

I can give a little insight into this. A wet to dry 4x4 covered with a tegaderm would not be the proper way to dress that. The tegaderm does not allow the absess to dry out at all (because ultimately that's why you would I&D it). Honestly, if it looks the way you describe it, the outer skin should be washed with hibiclens and kept open to air to allow it to dry out. If it were more open than you described, a non stick dressing (such as adaptic or even a simple telfa pad) with a thin layer of bacitracin covered with DSD and secured with medipore or paper tape would be indicated. The fact that it appears reddened is slightly concerning, so on your next shift be sure to make note of whether the redness has spread. I am sure this nurse is very experienced, just not with wound care, so next time go with your gut or even consult the MD or wound care RN at your institution.

[Anna Flaxis, BSN, RN]

I suggested washing with Hibiclens and covering with a Telfa, but she didn't take my suggestion.

No doctor order for any specific kind of dressing, just a verbal to "keep it covered", hence my thinking that just a nonstick pad secured somehow would suffice.

I really respect this nurse's experience, which was why I had to question my assumptions.

[mama_d, BSN, RN]

Gotta love those vague doctor orders, don't cha? We have one who's famous for saying "I don't do wound care..do whatever you want." I'm always tempted to put that as an official order, but we all know who that would come back on.

I'd probably use telfa or a Mepilex border as well. It's been a LONG time since I've seen gauze and tegaderm used as a dressing. Especially in a population with fragile skin, tegaderm can be a nightmare.

[mappers]

I thought wet to dry was used to debride, and that it was old-fashioned and not the best choice to use these days??

[minnymi]

I posted this in the Wound Care forum, but I'm not getting any replies, so I thought I'd post it here.

Recently I worked with a nurse who placed a wet to dry dressing over a closed, non-draining skin abscess. She stated that the abscess was an open wound, due to the presence of three small tracts about the size of large pores where it had previously drained about a week prior. I did not observe any drainage, yet she stated that the wound was currently draining, but it had dried out due to the lack of a proper moist dressing. Her rationale was that the saline moistened gauze would draw out pus.

i know next to nothing about wound care, but it makes sense to me if there were large pores draining previously and the pores are still there, but not draining... then it definitely could have dried out. plus, if there was redness around the wound...it makes me think even moreso that there was puss in there that needed to come out. now, if she's going about it the right way...i have no idea.

[Do-over, ASN, RN]

Certainly not an expert, but I've only ever packed open wounds with wet-to-moist type dressings.

From what you describe, I probably would have used telfa under a gauze square...

[leslie :-D]

if the abscess hasn't drained, then it absolutely has to...no way around it.

if it doesn't drain, it'll only continue to grow in size and eventually burst.

i agree that warm compresses are the way to promote drainage.

if that doesn't work, the dr. needs to incise it so it can drain...

which should be the goal from all healthcare team members.

if you cannot get the dr to commit to a particular type of dsg tx, then maybe discussing the cn/nm may be necessary.

good luck.

leslie

[Anna Flaxis, BSN, RN]

Leslie,

It had already come to a head and drained a week prior, and was a fraction of its original size. It was not indurated at this time. The doctor had examined it the day before and chose not to drain it further, had prescribed another course of abx, and instructed the patient to "keep it covered".

[Anna Flaxis, BSN, RN]

Thank you for the replies, everyone. I've been doing more research, and have come to the conclusion that, while the other nurse's dressing style was not clinically indicated, most likely it was not harmful to the patient. It did not cause maceration to the skin, thank goodness. I have also been reminded again, to trust more in my own clinical judgment, and not let my confidence be undermined just because another nurse has a gagillion years of experience. Of course, I will always be a collaborator; that's just a core aspect of my practice. But if one person is telling me one thing and my gut is telling me another, maybe a third opinion is in order.

[leslie :-D]

i agree with your conclusion, stargazer...

knowing that it had already drained, i agree that the other nurse's way probably didn't do any harm.

i like your attitude though.

keep it going.:)

leslie