Wet-to-dry dressing question

  1. 0
    Hi all,

    I had a pt the other day whose dressing orders bugged me and I want to see if anyone has some insight. I was desperate to get the wound care team to consult on him, but most of when I had him was over the Christmas holidays and it seems they were on vacation. Anyhow, the guy was a repeated pressure ulcer pt who came in with a necrotic (presumed) stage IV covering his entire buttocks areas. They debrided it in OR and ordered wtd dressings tid w/ dakens. The wound though post-OR was very odd, it had a few pockets of tissue or small tunnels but was otherwise a smooth, shiny pink surface with some small areas of yellow. It looked like a stage II ulcer except that so much of the area had been eaten away, assumedly from past hx, that it was totally hard.

    I received him from a nurse yesterday and upon removing the wtd dressing, there were little bleeding spots all over the wound bed and as I say, the tissue looked almost uniformly pink. Given that, isn't wtd dressing far to harsh? I was under the impression it was used for debridement (and even that was in question r/t to efficacy, risk profile, etc). I really think that some sort of foam or allevyn or something to keep the wound moist would have been ideal, but I do not think at my facility that's a decision we can make w/o MD orders. In any case, the pt was a plastic surgery pt, shouldn't they have a better idea than most about appropriate wound dressings? I did not feel comfortable applying wtd over thin pink tissue like that, anyone have more experience in this domain and care to shed some light?
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  3. 17 Comments so far...

  4. 2
    it does sound like the dsg order needs to be updated, to reflect the pink, viable tissue now present.

    until the order is changed, i'd keep it a strictly wet dsg.
    soak w/ns, before removing.

    leslie
  5. 1
    Could you have called the surgeon, given him an update on what the wound looked like and asked if he wanted to change the type of dressing until the wound care team could see the pt (assuming the MD wanted a wound consult)? I would have called and documented appropriately if there were no new orders, CYA.
    prettyinblu likes this.
  6. 0
    In this case it was night shift so the primary team wasn't around and night floats rarely-never make shifts on things of that nature, nor do they, in most cases, have the expertise to do so. It's one thing I really hate about nights. I guess my question is really:

    a) was the wtd dressing appropriate?
    b) if not, what can I do as an RN between getting updated orders?

    Thanks for the replies thus far! I sort of like the idea of doing moist dressing, though I guess I don't fully understand how that practically differs from wtd (is it just remoistening prior to removal?)
  7. 1
    Quote from CharmedJ7

    a) was the wtd dressing appropriate?
    b) if not, what can I do as an RN between getting updated orders?

    Thanks for the replies thus far! I sort of like the idea of doing moist dressing, though I guess I don't fully understand how that practically differs from wtd (is it just remoistening prior to removal?)
    wtd is appropriate IF there is dead tissue/eschar that needs removing.

    and yes, rewetting prior to removal, to ensure it is painless.

    leslie
    prettyinblu likes this.
  8. 0
    Doesn't re-wetting it prior to removal kind of totally defeat the purpose of a wet to dry dressing?
  9. 1
    Quote from JustinAllen
    Doesn't re-wetting it prior to removal kind of totally defeat the purpose of a wet to dry dressing?
    Precisely, it does, which is potentially what you want if the wtd dressing order was inappropriate in the first place. But I think I'd only do it as a temporary stay until I could talk to the primary team about getting a more appropriate order so to avoid getting written up for insubordination. But I still don't entirely understand why MDs write orders for wtd dressings for essentially indefinite periods, I mean, once the necrotic/eschar is out, what's the continued benefit of doing it? How can a wound fully heal if you keep ripping off the granulating tissue?
    leslie :-D likes this.
  10. 4
    Quote from JustinAllen
    Doesn't re-wetting it prior to removal kind of totally defeat the purpose of a wet to dry dressing?
    why would one use wtd, when there isn't any dead tissue present?
    there's nothing that needs debriding...
    so if the order is still wtd, then the kindest thing you can do, is wet the darned dsg before removing.

    leslie
    fromtheseaRN, michelle126, tyvin, and 1 other like this.
  11. 0
    Quote from CharmedJ7
    In this case it was night shift so the primary team wasn't around and night floats rarely-never make shifts on things of that nature, nor do they, in most cases, have the expertise to do so. It's one thing I really hate about nights. I guess my question is really:

    a) was the wtd dressing appropriate?
    b) if not, what can I do as an RN between getting updated orders?

    Thanks for the replies thus far! I sort of like the idea of doing moist dressing, though I guess I don't fully understand how that practically differs from wtd (is it just remoistening prior to removal?)
    Sorry I asumed you worked days, I think the suggestion of a moist dressing until the order can be changed is the best thing. Leave a big note on the front of the chart so the doc will see it when he rounds in the a.m.
    I had a plastics doc who would come in and do this huge dressing change on his pt Q am at 0645 when I need to give report at 0700 and I would get stuck in the patient room until 0715 without fail.
  12. 0
    Ive been doing wound care for 2 years in LTC and Ive used WTD on pink viable tissue before. Ive learned that it promotes granulation and circulation (so a little bleeding while removing is not necessarily a bad thing)


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