wet to dry dilemma

[jenac]

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.

[Rand]

Reevaluate the wound in 2 to 4 weeks. No improvement might lead to change in treatment.

Regards,

Rand

[susanmcb]

Dear Wound Care Experts,

This is an interesting thread. I am not a wound care nurse, but happened upon your forum by searching on Xenaderm--my mother was recently perscibed and wondered what it was.

Anyway, she has also had wet to dry dressings used and I attended a nursing meeting a few weeks back that discussed evidenced based practice using wet to dry dressings as example of evidenced based practice that is not always followed. What is interesting to me is that the group was indicating wet to dry was the appropriate treatment, yet I see in this forum discussion considerable debate, including definition issues, i.e. wet to "dry" or wet to "moist". Can someone clarify what the scientific evidence really is on this topic?

One last note: we (as healthcare professionals) are to follow evidenced based practice--yet standardized definitions, practice protocols and communication seems a huge issue.

Thanks to all for the interesting posts--especially the "new nurse", what a great nurse you are! Questioning and seeking the best answers for your patient and profession.

Susan

[CWOCN]

Dear Wound Care Experts,

This is an interesting thread. I am not a wound care nurse, but happened upon your forum by searching on Xenaderm--my mother was recently perscibed and wondered what it was.

Anyway, she has also had wet to dry dressings used and I attended a nursing meeting a few weeks back that discussed evidenced based practice using wet to dry dressings as example of evidenced based practice that is not always followed. What is interesting to me is that the group was indicating wet to dry was the appropriate treatment, yet I see in this forum discussion considerable debate, including definition issues, i.e. wet to "dry" or wet to "moist". Can someone clarify what the scientific evidence really is on this topic?

One last note: we (as healthcare professionals) are to follow evidenced based practice--yet standardized definitions, practice protocols and communication seems a huge issue.

Thanks to all for the interesting posts--especially the "new nurse", what a great nurse you are! Questioning and seeking the best answers for your patient and profession.

Susan

I'd check page 52 of the AHCPR (now AHRQ) guidelines for the treatment of pressure ulcers. The evidence-based research is in there. This really isn't new information, though. Dr. Winter did his research in the early 60's to show that W-D isn't the best for wound healing. Medicare recognizes that it delays healing, and if we have a pateint who comes in for hyperbarics, or even a VAC, we have to make sure that the wound care they had the last thirty days was "appropriate", and w-d isn't considered the best clinical standard. There is also a good article on the difference of opinion between practitioners who order wet to dry, and the nurses who do the care---they don't agree on what the definition of a w-d is!!! Please remember also that in any nursing book, the ONLY indication a wet to dry is listed as used for is one that requires debridement. If you have a clean granular wound, that is not an appropriate choice. Think of getting a book on wound care that indicates what each dressing is for and how to use it. It is like a drug book for dressings. Remember that the clinician who performs the wound care is responsible for the wound care done...with or without a doctor's order.

[renerian, BSN, RN]

Again if taken off correctly and not yanked off dry..sometimes NS W to D does work..

Coin toss.......sometimes doesn't

I think the key is realizing not one, two or three treatments work on everyone. I personnaly could not afford a 100 dollar vac dressing and many of my patients cannot either.

I have done indigent care in homes that have no utilities or inside bathroom/dirt floors and had to make due dressing with things I cannot even post here due to lack of money/insurance/you name it. KNow what..they all healed without the marvels of expensive dressings.

Just some thoughts from the peanut gallery

renerian

[alintanurse]

I have to agree with renerian,many of the orders for wound care I've dealt with were for w-d and they healed without problems. I always reevaluate the wound each visit and if it doesn't seem to be responding---then its time to try something else. My patients were predominently poor and living conditions many times terrible. Cost of supplies is always a factor(like it or not).

[Sapphy, BSN, RN]

OK so I have a dehisced abdonimal incision... well I don't have it, a pt does. I just became a member of the wound care team last thursday (YAY!!!) so i am still learning. The wound dehisced on Sunday, we called the surgeon who did not see the guy till Wednesday when he preceded to open him all the way up and debride him and leave him open. The order was for a wet to dry dressing daily. When we changed the dressing for the first time, the wound measured 11cm length, 3 cm width, and 2.4 cm depth. Taking the old dressing off caused a lot of bleeding in the guy for the first day. Our WCC changed the dressing change to BID and that seemed to alleviate the problem. We took a picture of it thursday and today when I did wound care rounds, I took a new one. You would not even believe the difference. I have been using kling with NS covering that with 4X4's and an ABD. New measurements are 10.3 cm length, 3 cm width, and 1.9 cm depth.... in 3 days time! I am not so sure how this is a bad thing given those results....

Is there a better way for us to be treating this wound?

[CWOCN]

Sometimes wounds do okay and heal in spite of what we do to them. Using the principles of wound management, removing or controlling the cause of the wound or it's failure to heal is key. If an infection has causes the wound to dehisce, then I suspect the person may be doing okay because of antibiotic therapy. Why could you not put a wound VAC on this wound? That would be standard and would probably speed up the discharge from the hospital. Who will be doing BID dressings at home? Is this practical for this patient? A longer acting absorbent dressing that will wick off drainage, provide a moist environment, and protect the wound is what you want to see in a dressing. The AHCPR (AHRQ) guidelines state on page 53 that wet to dry is not a continuously moist dressing, and that is what a wound really needs to heal. Perhaps a wound gel if the bed is clean will let the wet to dry gauze last a bit longer. Every 4-6 hours for a wet to dry dressing is really ideal if you must do a wet to dry. Let's not forget the original intent of the wet to dry...Debridement. If the wound is clean and granular, then wet to dry is really not the best clinical practice.

[wocnnurse]

Wound appearance changes everyday, that is why in your daily assessment, you recommend a treatment according to the kind of wound you have. NS wet to dry in my experience is very good in slow debridement of deep sloughy areas. When I see some granulation going, I then switch to a wound gel. And when you say "wet", it's not sloppy wet but the sponge is wringged out of extra NS so that it has the chance to absort the dead byproducts of wound healing.

Goodluck!

[Tom85]

wet to dry - USE TENDERWET by medline. great wet to dry soultion. instead of the gauze soaked in saline there are already presoaked in ringers solution.

[leslie :-D]

Ouch! I do not use wet to dry. It's an excellent way of removing new granulation tissue. Traumatic and painful.

when i remove a dry dsg, i moisten the wound bed w/ns just so it doesn't remove viable/granulated tissue.

[Dianne Powell CWCN]

Wet to dry dressings are NOT in best practice! Period. There are pleant of less painful more effective treatment out there and have been for years.

[esperanzita]

I'm also a treatment nurse stuck in the uncomfortable position of getting outdated treatment orders from doctors and outdated advice from supervisors. I guess that sounds negative (I just got off work). I mean, everyone is well-meaning, but I worry about my liability a lot.

One way I protected myself when the state came was via documentation. When I call the doctor and get no new order, I write in the nurses notes: "[description of wound]. MD notified with no new orders at this time." Or, when I call the doctor and they don't call back, I write it in the nurses notes that they haven't responded yet.

CYA!

Oh, and enjoy wound care