ATTN WOC Nurses - Wound Care Questions from New Home Health Nurse

wooh, BSN, RN · Jan 19, 2012

I'll try to answer some of the ones I'm familiar with. Hopefully a WOC nurse will see this soon. (Some of the questions I remember being answered in a class that I took, but it's been too long.)

1. A duoderm is this rubbery type of thing that will stick to the skin. They're traditionally put on pressure sores. I personally HATE them and they've fallen out of favor. But some old school folks swear by them. My problem with them is they're often used on the butt, which means they get stool stuck on them and if you try to remove a duoderm before its time (IIRC it's a week, but it's been a long time since I've used one, so probably wrong on that.) Anyway, try to remove it early, it will pull off skin with it. There are better dressings now. But old habits die hard.

2. Tegaderm is a clear plastic dressing that sticks on one side. Most often used over an IV site. There are probably better things for wounds. I personally like them if I'm at work with a cut finger. I put on a bandaid, then cover around it with 1 or 2 tegaderms. Keeps all the water out. That's a major downside, as it will also keep ALL of the moisture in as well.

4. Wet to dry. If you do a true wet to DRY, it's going to indiscriminately yank up all the tissue that's stuck to it. Not just the yuck your trying to get rid of, but new healing tissue as well. And it hurts like hades. I've noticed physicians often order this if they want to keep the woundbed moist. In which case it's actually a wet to moist dressing. Which can sometimes work. It's old school and with the new dressings and treatments, I'm sure there's more modern things. But it's cost effective and easy to do. If keeping the wound bed moist is the purpose, don't just rip it off if it's dry. Dampen it with some saline so you don't rip up the wound bed. And when putting in a new one, don't saturate the gauze until it's dripping, you want damp. Soaking wet leads to what's called "prune skin." Like sitting in your bath too long. :)

6. Mepilex is AWESOME. It's a silicone that does a good job of keeping wounds the right amount of moist. I'm a fan of the mepilex transfer around Gtube sites. I'm not familiar with the heel dressings though.

The other stuff I'm not sure at all about. Hopefully a WOC nurse will be around soon to answer your questions and correct my answers as needed. :)

Home Health Columnist / Guide · Jan 20, 2012

Ask if your agency has a wound care formulary that lists wound products your agency typically uses.

Ours also lists types of wounds that you would use product on. Additionally, ask if you can spend a day with your wound care expert: WOCN or CETN nurse to get 1 on 1 training.

See Wound Care Words Of Wisdom --lists wound types and best products to use along with amounts Medicare will allow.

wooh, BSN, RN · Jan 20, 2012

Great post you linked to! Thanks! I'm going to have to check back later to read it all when my brain isn't fried.

MommaNurse26, LPN · Jan 20, 2012

ok, been researching my little heart out and decided to add to my own posting answering some questions bc i am sure there are going to be future nurses with the same questions...

foam dressings - absorptive, provide moist envioroment, promote autolytic debridement, protect, can be used with topicals. good for flat or cavity wounds, where a non-adherent surface is important.

hydrocolloids (duoderm/tegasorb/hydrocol) - turn to gel as they absorb moisture, provide a moist enviroment, promote autolytic debridement and are impermeable to oxygen, water and water vapour. good for min. to mod. exudate, including necrotic and sloughy wounds. can be used as a secondary drsg. should not damage new granulation. not good for infected wounds. the drsg can produce a foul odor that is confused with infection.

unna boots - is a compression dressing used to treat edema, ulcers and sores. they are made of zinc oxide (to ease skin irritation and keep area moist while promoting healing) and cotton (some boots also contain calamine and glycerin.) this boot is best for an active patient who can move on their own, bc the muscle contraction upon movement helps with healing and promotes venous circulation. {wrap approx 2 inches from tip of toe, upwards stop below the knee. make sure the boot is not to tight as it can constrict - if you have never applied the boot ask to see one done first - never wrap from knee to toe. secondary wrap with kerlix roll- refer to other posts for more specific details on wrapping faq). there can be issues regarding chf - so make sure its not contraindicated in your patient.

hydrogels - gel that protect the wound from dessicating. hydrogel is contraindicated in wounds with mod to heavy exudate bc iit can cause maceration. basically, hydrogels keep the wound moist

alginates - primary dressings for wounds that have moderate to heavy exudate (cut to size of wound) placed in wound beds to absorb exudate keep wound moist. once the alginate gets wet it forms a gel to cover the wound. it can absorb 20x its weight in exudate. it facilitates autolytic debridement and needs a secondary dressing. (do not get wet - should be used dry) not to be used in dry wounds.

tegaderm / bioocclusive- is a moisture/vapor permeable film drsg that is waterproof. prevent dessication. maintain moist enviroment. they are clear films. can be used as a secondary to wounds to elbows, heels, knees, wrists. should be used for light to med exudate.

santyl ointment - continuously removes necrotic tussue from wound allowing granulation and epitheliazation to occur. good for chronic pressure ulcers, dm ulcers, venous ulcers, severe burn areas... do not use with iodine or silver as they inactivate the collagenase. apply to wound to avoid erythema to surrounding tissue. d/c when necrotic tissue is gone and granulation tissue present.

this is all i have so far... please add anything you experienced nurses may know.

LDRNMOMMY, BSN, RN · Jan 22, 2012

Not a WOC, but I have been working in a wound care clinic for almost a year. You have been given great advice so far. Does your agency carry Alevyn heel dressings? Smith & Nephew - Allevyn* Heel I LOVE them for heels and I also place them over TMA stump dressings for protection.

We use Santyl frequently as well. Our MD almost 99% of the time will have us mix it with Gentamycin ointment. It absolutely can be used alone. I would not mix it with anything else unless the order says to, but that is JMO. Make sure you are applying it nickel thick to the wound bed, which is about the thickness of the center of a regular Oreo cookie.

paddler · Jan 25, 2012

I would like to add, regarding the secondary ointment with Santyl is because Santyl, while debriding slough and eschar will also debride healthy periwound tissue and can cause maceration. So, often it is necessary (depending on the depth of the wound bed and type of dressing used) to protect the periwound skin and larger areas of granulation or epithelialization in the wound bed with a benign barrier ointment of some kind.

PsychNurseWannaBe, BSN, RN · Feb 1, 2012

I would like to add, regarding the secondary ointment with Santyl is because Santyl, while debriding slough and eschar will also debride healthy periwound tissue and can cause maceration. So, often it is necessary (depending on the depth of the wound bed and type of dressing used) to protect the periwound skin and larger areas of granulation or epithelialization in the wound bed with a benign barrier ointment of some kind.

Santyl does not debride healthy tissue. It can macerate healthy tissue but Santyl ezymatically debrides collegen. Also, for the most part, you should skin prep the periwound which will protect it from maceration.

PsychNurseWannaBe, BSN, RN · Feb 1, 2012

Additionally:

Foam dressing are the warmest dressing. Helps with a nice warm moist environment.

Hydrocolloids: Should never be put on diabetic feet. And for someone who made a butt comment. There is duoderm spots which help vs sticking a big 4 x 4 on the butt and getting it soiled. Hydrocolloids do help with shearing forces. But yes, once they are on... they are on, I always wait until day 2 AT THE EARLIEST to take off ( and that is only if I have too). Normally go 3 to 5 days, but I stay with 3 because I want a nurse to be checking the wound. Duoderm CGF are nice for exudate. It locks it in. The reason why you never use it on an infected wound is it occlusive and anaerobic bacteria can start. You should treat an infected wound with ATB. Treat the infection and then the wound.

Tegaderm: I would not use for moderate wound drainage, possibly min drainage if it is a Tegaderm + Pad. But a clear tegaderm does not have absorptive properties.

Santyl is normally applied every day. Orders for BID is a big waste of money as it takes 24 hours for it to really work. I have stopped using Santyl alot and switched to Medihoney which in my opinion works far better and is cheaper, plus it can stay on for several days. It will pull more fluid to the wound which is fine, just make sure you have a secondary dressing that will be able to accumulate drainage. Then you don't have to worry about silver ions.

For the most part... all my wounds get skin prepped (non alcohol type). Including wound vacs.

Psych, RN, BSN, WCC

CoffeeRTC, BSN, RN · Feb 4, 2012

We use santyl on occasion and I'd love to get them to do it once a day (a lof of our orders say bid..they really just need to be using a better secondary dressing)

Years ago..it used to be polysporin powder and santyl mixed...again..we quit using it years ago.

A lot of nurses don't know how to use the santly correctly and end up wasting alot of it.

I always cleans with nss, skin prep the periwound area or apply a layer of A&D or vasaline to protect the periwound, apply the santle cover.