Steps of a wet to dry dressing

[oxyjen]

Hi, I need to write a plan of care for a wet to dry dressing, lots of steps and I'm not sure when the sterile gloves go on. Could you help?

Here is the scenerio I've come up with:

position patient pad bed, emesis basin handy for later irrigation

open and arrange supplies

nonsterile gloves

remove old dressing

measure wound with cotton applicator tip

irrigate wound with NS and Toomey stringe

apply sterile gloves

pack wound with 4x4's

dry skin which is wet with irrigant

apply ABD pad and tape

Please rearrange these if they aren't in the right order. Add your rational so I'll understand better. Thank You!

[woundnurse7]

Well believe this, it is a quote from a law suit in regard to fraudulent billing 'Hogue E, 2003': "Physicians orders to apply betadine on a routine basis to a patients pressure ulcer may provide an excellent example of this type fraud. the application of betadine to patients pressure ulcer is clearly outside standards of care for the treatment of pressure ulcers. Thus, if agency staff members render care ordered by the physician and submit a claim for payment for this care. the claim is false even though every thing on the claim form is true because the services provided were not reasonable, necessary, and appropriate." Like wise, the NPUAP Clinical Practice Guidelines dictate (pg. 84) to avoid gauze dressings, and these are the standards that you will be held accountable to in a court of law. Believe that!!!

[lalaxton]

I'm just wondering if your going to tell a doctor "NO NO NO NO" when he writes an order for a wet to dry dressing change? My suggestion is do not believe everything you read or see, lol

If a doctor writes an order to give a medication that you know is clearly going to harm your patient, are you going to give it? You are responsible for your own practice, regardless of what a physician orders. Contrary to popular belief, physicians can learn from nurses. Let's help those who are still using these outdated practices to learn better wound care technique. There is a wealth of information out there about not using wet to dry dressings. Simply Google the term.

[Hoosiernurse, ADN, RN]

Yes it is still being taught and this is 2007. I am really interested in learning more. Please email with more info if possible. Thanks

It's now 2010, and I worked for two months at our hospital's wound care clinic. I was instructed to do a w/d dressing for a patient, and this clinic is being run by a prominent independent wound care company who sends their physicians and nurses to special training to be certified to work in the clinic. Is it possible that it still has use in certain kinds of wounds? It wasn't something we did often at the clinic.

HoosierNurse

[Hoosiernurse, ADN, RN]

Non of those were wet to dry! wet to dry is not done 3 times a day. The reason for wet to dry is to debride a wound. If it's done 3 times a day, there isn't enough time to allow the gauze to dry. That being said, this is cruel! Think of it, it's meant to debride. The dressing is left in place until it drys out, then the nurse comes along and pulls this dry dressing out, supposedly debriding as it comes out, causing bleeding and further tissue damage! Would ANYONE want this done to them?????

If the dressings are too wet, then there is maceration! This treatment is archaic!(sp) sorry for such a miserable response, but that type of dressing makes my knees weak!!!!

I understand your concern, and I think in some cases it would cause damage, depending on the wound. However, I was just thinking about the couple of months I spent at our hospital's wound care clinic, learning the ropes. I don't think any w/d dressing I've ever seen come off compares to the staggering amount of carnage after they do an actual debridement of a wound. Virtually every wound that came in, unless it was almost totally healed, got chopped with with that currette. When I came in after to clean things up and replace dressings, there was blood and tissue everywhere. WOW! When I'm taking off a w/d, if it sticks too much I wet it with saline. With wounds, they tell me at the clinic, the benefit is to get down to the beefy, red, tissue for better healing.

I'll have to read up on w/d and see what the latest research is, but I know that physicians and wound care nurses are still using them at our hospital, and they have to be recently trained. I guess there isn't a consensus on this treatment, yet.

HoosierNurse

[tyvin, BSN, RN]

Well, I had to join this site as I'm reading this thread and no one is coming up with alternative treatments for wounds to replace the now controversial wet to dry.

I have discovered a wound treatment that I literally swear by and all the docs I know are prescribing it. It's called NWPT (negative wound pressure therapy). Look it up folks; it's been around for quite awhile. There are several different ways to dress and change this dressing which is a sponge (2 types of sponge look in the order for which type or both how; usually it's the polyurethane that's used).

There are some good videos on YouTube showing a couple of different ways to change this NWPT.

The only drag with this is the machines that induce the negative pressure are made mainly by one company and they will not sell them but only can be rented so it can get spendy. But since there is so much juried reviews and studies done on NWPT that in most cases the health insurance will cover it. It only becomes a problem when you want to do this at home. I just had an insurance company deny it for a client's home health wound saying that wet to dry would be just as effective. Ahhhhhhhhhhhhh! Who are those nurses that work at the insurance companies.........and what's up with monopoly on these machines.

Anyway; good luck to all and if you're a student look into this and suggest it next time a difficult wound turns up and no one knows what to do.

[Bklyn_RN]

Just today a PA wrote an order for a wet to dry dressing. I refused to pick up the order. The wound care nures was telling me a hospital can be sited by JACHO for doing wet to dries.

[proudharbor]

here is the procedure of performing a wet-to-dry dressing fyi: hope it will help.

1, check md's order. obtain necessary supplies, e.g. barrier gloves, appropriate tape, necessary sterile dressings (2x2s, abd), sterile ns, sterile applicators, sterile gloves, measuring device, and so forth.

2. introduce self. hand hygiene and identify patient with 2 identifiers--full name and date of birth. provide privacy and explain procedure to patient.

3. assess patient's need for pain medication 30 minutes prior to dressing change. assess patient's knowledge of procedure and if appropriate to participate. assess if patient at risk for impaired wound healing.

4. clean off overbed table to use as clean field. assess need and wear appropriate personal protective equipment. hand hygiene. position and drape patient.

5. apply clean barrier gloves. remove tape and dressing, taking care not to dislodge drains or tubes. properly dispose of dressing.

6. inspect wound and observe drainage on dressing.

7. assess and measure wound--depth, width, length, tunneling, drainage, surrounding skin, wound bed, using sterile applicator and measuring device.

8. remove and dispose of gloves properly. hand hygiene.

9. open sterile supplies using surgical asepsis

10. pour cleansing solution (normal saline) over gauze. apply sterile gloves.

11. wring out excess ns and fluff dressing before loosely packing woven-mesh gauze directly onto wound bed. gauze is not to touch surrounding skin.

12. use sterile applicator to ensure dead spaces are loosely packed with gauze.

13. apply secondary dressing over wet gauze. secure dressing with tape.

14. date, time and initial dressing change on tape.

15. dispose of all supplies. remove and dispose of gloves properly.

16. hand hygiene. reposition patient for comfort.

17. ask patient if discomfort noted during procedure.

18. document with focus note.

19. report findings & unexpected outcomes such as unusual bleeding, delayed wound healing or signs of dehiscence or evisceration to your nurse and md.

[margo533]

OMG, is this still going on??? I've been retired since 2008, and the wet to dry was being contested even when I went back to school and became a CWOCN in 1995! NO, NO, NO, NO--- NO WET TO DRY DRESSINGS!! This has been emperically validated time after time, go into the WOCN Journals for definitive statements on this issue. (Nowhappywoundnurse, you made my day!) ;->

[wound warrier]

I agree with margo533, wet to dry dressings are not the thing to do - but try and tell the MD's, vascular docs and plastics docs about it. Difficult to believe that in this day and age the wet to dry dressings are still being used.

[CharmedJ7]

This is such a frustrating issue for me at work. Wtd dressing bid and tid is just about all I see (I work on a surgical floor) and often it just seems downright cruel/irresponsible to follow that order. We have a wonderful wound care nurse who will step in on occasion and change the dressing to something different, but realistically she can't step in for every case and getting the MDs to change the order is extremely difficult, especially since I do not fully understand the other products on the market.

Does anyone work @ a hospital where wtd dressings used to be routine but are not any longer, and if so, how did this change come about?

[margo533]

For a clean surgical wound, you want the wound bed to remain moist (not wet); if it dries out, it's not going to heal. Wet-to-dry drsgs mean just that--moist gauze that's allowed to dry out so that when it's removed, it takes the non-viable tissue with it; THIS IS NEVER, EVER DONE WITH A FRESH SURGICAL WOUND. NEVER! The surgeons obviously don't want the wound to dry out, so the best post op dressing order for a non-infected, uncomplicated surgical wound would be "continuous moist saline dressings- change daily".

The simple addition of a wound gel applied to the wound bed, topped with moist gauze will provide a "continuous moist dressing" and keep the wound bed moist between daily drsg changes--which is the objective. (BID and TID dressings are completely unnecessary, indeed they are detrimental, since wound bed temperature influences rate of healing; dressing removal lowers temps for hours after dressing is changed.)

The literature going back 15 years is loaded with studies validating the above. Your wound care nurse should be familiar with the literature and I'm surprised if she isn't working with nursing administration to bring physicians and nursing staff up to date and current with evidence-based practices. In addition, these BID and TID drsg changes take nursing time away from other duties, and contribute to nurse work overload, higher labor costs, and staffing problems.

Administrators definitely are interested in containing costs, so I suggest you print this out and show it to your nurse Manager or Director. :)

(My credentials: CWOCN 1995-2010; I retired in 2008 and my certification expired as of Jan 1, 2011)

[carleah]

From my experience wet to dry dressings are still widely used at the prison where I've workedin recent years. The CNA's do well with these dressings although they are more labor intensive and take longer to heal. Old habits die hard.