wet to dry dilemma

  1. Ok guys, I am a new nurse. Have only had my license for about four months now- but have always had a passion for woundcare- dating back to my STNA days of assisting with drsg. changes or peeking under them. I was taught that wet to dry drsg.s were old school- and no longer viewed as benefical as they removed healthy new granulation tissue upon removal-when done properly-thus impedeing the healing. Here's my dilemma- if this type of dressing is so prehistoric, and potentially harmful to a resident (staff has a history of incorrect procedures ie; using Ns to "loosen" the gauze, and cutting the gauze to "fit nicely")- am I obligated, as the treatment nurse to do something here? I mean- I know that we're expected to have current knowledge of acceptable practices- and to not do those viewed as harmful (ie;the H2O2 or iodine wound cleansers). I really am out of my realm here- but, I truely do not feel comfortable with this. The wound in question is on a 98 yr. old women with a recent amputation of a toe for full-thicken venous stasis ulcer-not closed, with wet to dry drsgs. I tried to get clarification from the Dr. today- with no reply, so this is the only order I have for care. What is my liability here as the treatment nurse? There is alot more to this particular case- one in which I feel very uncomfortable with on several fronts- but that's another thread for another day. I really feel that we're leaving this woman open to some nasty infection that could cause alot of problems- not to mention poor healing. Maybe I just really need a hug.....but this situation is greatly disturbing to me. I could really use some input from the pros here.
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  2. 23 Comments

  3. by   renerian
    I have seen NS W-D do wonderful things. It depends on the person, the wound and their healing abilities I think. If you were doing it for awhile without results I would look at other options.

    renerian
  4. by   BadBird
    Does your hospital have a skin/wound assessment person you could consult. I still do a lot of wet to dry dressings with good results.
  5. by   bossynurse
    We use normal saline W-D dsgs all of the time w/ great results.
  6. by   adrienurse
    Ouch! I do not use wet to dry. It's an excellent way of removing new granulation tissue. Traumatic and painful.
  7. by   sunnygirl272
    remember..there is a diff between wet to dry and wet to moist....
    wet to dry-purpose is to debride, should not be moistened prior to removal.
    wet to moist- purpose is to maintain moist wound be and promote granulation, should be moistened prior to removal and should be either chaneg more freq or changed to hydrogel if it consistantly dries out.

    know many docs that don't know there is a diff...they write "wet to dry" for everything, not knowing that there is a diff...
  8. by   Serani
    I am a wound care nurse for a community/home health nursing service. We do not use any wet to dry wound dressings (we have a policy which states this!) due to the continual disturbance of new granulation tissue, the inability to keep the wound moist and thus delay epithelialisation and the need to change the dressing more often resulting in wound temperature loss again resulting in delayed healing (each time a wound is exposed it take approx 4 hours to regain the temp required for active healing).
    If a wound requires rapid debridement as this may I would consider the use of Iodosorb or Iodoflex (providing the client has no allergy to iodine or a previous thyriod issue, I presume she is not pregnant at 98) short term which assists with wound bed preparation - that is preparing the wound bed for optimum healing - ie. reducing slough, reducing colonisation (bugs on wounds but not at infection stage) and also has the added benefit of reducing odour if this is a concern.

    I believe as an RN we have the responsibility to ensure we are kept up to date with 'best practice' and evidence based research and 'wet to dry dressings' are not recommended with the advent of more appropriate and effective dressing products. I always encourage our RN's to question orders and to request rationale. In my experience I have written to doctors and made suggestions for wound management with rationale for each step of the wound plan and have had positive responses - I think many doctors have NO idea of wound management.

    If we receive a medical order which is not considered 'best practice' we will not carry this out. ( I do live in Australia - maybe it is different here to the US) We educate all our clients as to modern wound care practice.

    MOST IMPORTANT WOUND CARE TIP:

    Always seek to identify and control the underlying cause of the wound.
  9. by   renerian
    Once again I state I have seen wet to dry and wet to moist heal very very fast. I have seen dressing that are meant to stay in longer lead to infection and maceration....after all if the doc wants it, he or she is the one who choses. I have had lots of docs order them and not budge even when things were not going well with the dressings.

    Lots of things to consider,

    Good thoughts everyone! Good thread!

    renerian
  10. by   jenac
    Thanks you all for your input. I have some experience with wet to dry drsg.- but never have I seen them ordered so routinely.

    Serani- this is exactly what I was asking about. The "new" school of thought is that these types of drsg. are not benefical (as you've stated), but as everyone else has said- they are obviously still used-widely. As a woundcare nurse-I'm questioning my liability in using these drsg. when they are being taught as no longer benefical. I realize that I am obligated to clarify it, I've attempted that with no response. If this wound doesn't heal appropriately, or if the resident should become septic due to an infection originating in the wound, am I than held liable due to my care? Am I making sense? Look at it this way- if state walks in, sees this drsg as inappropriate or not benefical, or if the care of this wound isn't the most optimal care available- am I as the treatment nurse than liable? That is the core of my question I guess. Can anyone tell me? Renerian?
  11. by   CWOCN
    Are you certain this was a venous wound and not an arterial wound? We usually don't see venous wounds down past the ankles. If her arterial circulation is compromised, I'd be very careful with the w-d thing. I would choose an antimicrobial barrier ointment to be applied and keep the bed moist. If you are debriding a wound with necrotic (yellow or black) tissue, w-d can work, though it is very non-selective (takes off the good and the bad), and can be dangerous if there is a vessel close by. Look at the goals for a 90 plus year old woman. There is a chance that if her circulation is crummy, she may NEVER heal. That may be, but your job is to keep her out of infection...hope this helps.
    Michelle, RN CWOCN
  12. by   RNonsense
    All you can do here is try to relay your information to the physician. Are you a certified ET/Wound Care RN? If not, perhaps request a referral to one if needed ( We need referrals here)

    They say you can't put a new head on an old body..I don't know if this Dr. is approachable or not to new ideas but it's worth a shot.

    Just also, FYI...I work Vascular-thoracic surgery and we still do a fair amount of wet-to-dry with great success.
  13. by   deegal.lpn
    I would'nt use wet to dry. not with all the new products available for wound care. its known to damage granulation tissue which is very delicate. I see surgeons order this tx all the time. This women I assume had an amputation R/T diabetes or poor circulation, therefor she is very prone to infections. If it is a fresh surgical wound or clean wound stage 3 or 4 absent of eschar or slough the wound bed only needs to be kept moist, (solosite or other wound moisture gels) being careful to only get gel in wound and not on surrounding tissue also assessed often for infection. If eschar or slough is present you can use a chemical debriment agent first (santyl oint) if an infection is suspected polysporine powder can be mixed with santyl. There is lots of information on wound care and lots of different products to try.
  14. by   Rand
    Reevaluate the wound in 2 to 4 weeks. No improvement might lead to change in treatment.

    Regards,
    Rand

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