Wet-to-dry dressing question

[CharmedJ7]

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?

[ComfieShoes]

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

No!! The idea is to debride the wound by pulling off necrotic tissue that has adhered to the dressing. If you rewet the dressing the adhering tissue softens and may not pull away from the wound bed.

If the dressing change is painful, give analgesics thirty minutes before doing the procedure. It does help to blunt the pain of the procedure and can almost completely kill post-procedure pain.

[leslie :-D]

No!! The idea is to debride the wound by pulling off necrotic tissue that has adhered to the dressing. If you rewet the dressing the adhering tissue softens and may not pull away from the wound bed.

i am only referring to wetting a dsg prior to removal, on a pink NON-necrotic wound bed.

the current wtd dsg is now inappropriate, and was suggesting what to do until orders are updated.

leslie

[wound warrier]

As a wound specialist, wet to dry dressings should be a thing of the past. WTD was used to debride, and in the true sense of the dressing, should be left on until dry and then pulled of (while dry) to debride. The problem with this is that it will also pull off the good granulation tissue!! Also, wounds need a moist environment and correct temp for healing, and each time a dsg is changed it takes the wound 4 hrs. to get back to the correct temp. Therefore, doing a WTD dsg 3-4 times a day really cuts down on the healing time!! Unfortunately, nurses (myself included) would have an easier time milking ducks than to get a plastics MD or surgeon to change his ways. In the case mentioned at the start of this thread, I maybe would have used an alginate, or an alginate with silver in it (to cut down the bacteria) and then a foam such as allevyn. This type of dsg can stay on for a number of days, I prefer to change every 3 days.

[KellyRPNinOntario]

Im a new grad...one quick question. I read that Dakins solution also kills healthy cells??? So I was assuming this practice is also outdated?? Also, we can't change a stage IV ulcer to anything less....eg it cant go backwards to a stage III. It would be documented as healing but NEVER backward which could explain why it was still documented as a stage IV??

[CoffeeRTC, BSN, RN]

Im a new grad...one quick question. I read that Dakins solution also kills healthy cells??? So I was assuming this practice is also outdated?? Also, we can't change a stage IV ulcer to anything less....eg it cant go backwards to a stage III. It would be documented as healing but NEVER backward which could explain why it was still documented as a stage IV??

Yes, Dakins kills heathy tissue or prevents it from healing. As the OP mentioned, the wound had some yellow slough or might have been necrotic at one time. Dakins and a wet to dry would be appropriate for this type of wound. Her question dealt with the fact that is wasn't appropriate any more and what she should do in the time it took to get a new order. *If this was LTC, it might take a day or so to reach the surgeon esp at the holidays in a non emergent situation as this*

Dakins is normally written with a time period and then the wound is reevaluated and the order changed. I havent used it in quite a few years, but man..every so often we get a real stinky infected wound this would be good for.

[OgopogoLPN, LPN, RN]

I never see WTD dressing orders and learned in school (2.5 years ago) that they are pretty much obsolete and old school. There are so many amazing wound care products and methods out there (VACs etc) that require far less nursing time and unnecessary trauma to the wound bed.