Health Articles

Made of natural polysaccharides found in brown seaweed, the dressing (eg, Sorbsan, Kaltostat) is a high-quality textile fiber pad capable of absorbing 20 times its weight in exudate. On contact with exudate, the dressing forms a soft gas-permeable gel, thereby maintaining a moist environment for wound healing.
Guidelines for use: (1) After the wound is irrigated with normal saline, the dry dressing is applied. (2) As the alginate turns into a gel in the wound, it may produce an unpleasant odor of seaweed, which can be controlled by placing a charcoal pad over the outer gauze dressing. (3) If wounds have heavy exudate, the dressing may need to be changed once or twice daily. As the wound heals, the dressing may be left on longer, up to several days.

These polymers (eg, Vigilon, Gel-Syte) absorb wound exudate to form water-soluble gelatinous substances. Semitransparent and nonad-hesive, these dressings provide a moist environment for wound healing.
Guidelines for use: (1) The dressing may be refrigerated to promote patient comfort. (2) After the wound has been gently cleaned with normal saline, the dressing (which should extend IV2 in. beyond the wound edges) is applied directly over the wound. (3) The dressing occasionally causes maceration of the surrounding skin. (4) If intact, the dressing may be left on for 1 to 3 days.

These dressings (eg, Debrisan, Bard Absorption Dressing, Hydra-Gran) consist of hydrophilic beads, grains, or flakes that absorb excess wound exudate and necrotic debris, which may inhibit tissue regeneration. The dressings also keep the wound moist enough to encourage healing and deodorize the wound.
Guidelines for use: (1) The products, reconstituted according to the manufacturer’s instructions, are gently packed into the wound and covered with a dry outer dressing. (2) The absorption dressings usually must be changed once or twice a day.

These proteolytic and fibrinolytic agents (eg, Travase, Elase, Santyl) act against devitalized tissue. They are most useful on superficial wound layers. Because these agents must be in contact with the substrate of the wound, they are ineffective on dense, dry eschar. They should be used as an adjunct to mechanical or surgical debridement.
Guidelines for use: (1) All hardened or dry eschar should be removed or crosshatched so the enzyme can come in contact with the wound substrate. (2) Because some preparations, such as Elase powder, become inactive in 24 h, they must be reconstituted for each use. (3) An-tibacterials and antiseptics (eg, povidone-iodine, hexachlorophene, silver nitrate, hydrogen peroxide, and benzalkonium chloride) may inhibit the action of Travase.

These opaque, gas-impermeable occlusive dressings (eg, DuoDERM, Comfeel Ulcer Care Dressing, Restore) consist of inert hydrophobic polymers containing fluid-absorbent hydrocolloid particles. When these particles come in contact with wound exudate, they swell, forming a moist gel that promotes cell migration, cleaning, debridement, and granulation. These dressings work on the principle that optimal wound healing occurs in a closed, moist environment. The lack of atmospheric oxygen is not thought to prevent healing in superficial wounds.
Guidelines for use: (1) The wound and surrounding skin should be cleaned before applying the dressing. The surrounding skin must be dry so the dressing will adhere. (2) The dressing should cover the wound and extend at least IV2 in. beyond its edges. (3) The dressing is not recommended if signs of infection (elevated temperature, purulent malodorous exudate, inflamed borders) are present. (4) The dressing may initially enlarge the wound because of its debriding action. (5) The dressing may be left on for up to 7 days unless exudate leakage occurs.

Polyurethane dressings (eg, Biocclusiye, Tegaderm, Op-Site) are permeable to gases and vapors but not to fluids; thus, oxygen can reach the healing tissues, but contaminating fluids can not. These dressings work on the principle that healing occurs more quickly in a moist environment. Usually left in place for 5 to 7 days, the dressing maintains the wound exudate against the wound surface, promoting epithelial cell migration across the wound.
The exudate that collects under the dressing varies in color and consistency from thin, clear, and serous to thick, cloudy, and brown. This variation is normal, and the exudate should not be drained. If exudate leaks to the surrounding skin, the dressing may need to be changed or a different product used. If wound infection is suspected, the dressing should be changed daily. As the amount of exudate decreases, the exudate becomes darker and begins to dry. When healing is completed, the dressing may be removed or may be used to protect the new skin from shearing, friction, and maceration.
Guidelines for use: (1) The wound and surrounding skin must be cleaned, and the surrounding skin must be dry so the dressing will adhere. (2) The dressing should cover at least a 1-in. margin around the wound. (3) The dressing should not be stretched tightly over the wound; such stretching exerts shearing forces against the tissues. (4) Dressings may be cut or overlapped without reducing effectiveness. (5) If excessive exudate threatens to loosen the dressing, the exudate may be aspirated through the dressing, using a small-bore needle. The dressing may reseal itself or may need to be patched with another piece of dressing.

These barriers (eg, United Skin Prep, Bard Protective Barrier Film) contain plasticizing agents and alcohol; they provide a protective waterproof coating over affected areas, reducing maceration and shearing. Liquid barriers may be applied using a spray, wipe, or roll-on method. Generally, they do not irritate the skin and are not affected by urine, perspiration, or digestive acids. Although insoluble in water, they can be dissolved by a soap solution. NOTE: Tincture of benzoin should not be used on reddened areas. Because of its high alcohol content, it becomes sticky when dry, and fragile skin may be inadvertently pulled.
Guidelines for use: (1) The skin must be gently cleaned and then rinsed and dried. (2) The liquid barrier should be applied and allowed to dry for one minute. (3) The patient may feel a momentary sting when the barrier is applied to excoriated skin.

The dressings and topical agents most commonly used to treat pressure sores include liquid barriers, film dressings, hydrocolloid dressings, debriding enzymes, absorption dressings, hydrogels, and calcium alginate dressings.

NOTE: Heat lamps are not recommended for treating a pressure sore at any stage. Besides posing a risk of injury, these lamps dehydrate wounds, inhibiting the healing process.
Stage 1
Cleaning the wound with normal saline solution only is safe and effective. Selection of the dressing may be dictated by location of the wound; either a liquid barrier, a film dressing, or a hydrocolloid dressing may be used. All decrease friction, shearing, and maceration.
Stage 2
The wound should be cleaned with normal saline solution. The dressing choices include film, hydrocolloid, and hydrogel dressings. Moist normal saline dressings may be used, although they require more frequent changes and tend to be less comfortable. Dry sterile dressings are not recommended because they dry out the wound and delay healing.
Stage 3
The intense focus on local care may mean that risk factors are overlooked. However, risk factors must be assessed and modified. For healing to occur, the wound must be free of infection and necrotic tissue. If signs of infection are present (elevated temperature, malodorous exudate, inflamed tissue surrounding the wound), culture and sensitivity studies should be performed. Until the results are known, wound and skin precautions should be taken.
If necrotic tissue is present, mechanical, surgical, or chemical debridement may be performed to attain a clean wound base. For mechanical debridement, irrigation with normal saline is used to clean the wound of purulent drainage or necrotic debris. Antiseptic agents (eg, 1% povidone-iodine, 3% hydrogen peroxide, 0.5% sodium hypochlorite, and 0.25% acetic acid) are not recommended as irrigating agents because they have been found to adversely affect wound healing unless carefully diluted to specific noncytotoxic concentrations. The wound may be irrigated with a catheter-tipped syringe, using aseptic technique. Alternatively, a high-pressure dental irrigation device provides a pulsating stream that both aids debridement and stimulates circulation. A wet-to-dry dressing, consisting of plain loosely woven gauze without cotton filling, moistened with normal saline is then gently packed to conform to the wound without extending onto the intact skin, since this may cause tissue irritation or maceration. The packing material should be appropriate to the wound size and depth, and care must be taken not to pack the wound too tightly, since this inhibits the absorptive capability of the dressing and applies pressure on the area. Loose necrotic tissue and wound drainage are absorbed into the dressing and removed with each dressing change (usually q 8 h). Other packing materials include the absorption and calcium alginate dressings described below.
An appropriately sized outer dressing should be applied over the packed wound to prevent contamination from the environment. This dry, sterile dressing should be secured with hypoallergenic tape or other devices, such as Montgomery straps or stockinette. The intact surrounding skin should be protected.
For local control of infected wounds (as evidenced by a bacterial count > 105/gm of tissue), 1% silver sulfadiazine can be used to reduce bacterial counts and establish a clean wound. A sterile glove should be worn during application, and the agent should be worked into the crevices of the wound. Then the wound should be covered with a fine mesh gauze.
Mechanical debridement is minimally effective on eschar. Surgical debridement is the quickest way to remove necrotic tissue and the only effective way to remove eschar. However, surgical debridement may increase the risk of hemorrhage, infection, wound enlargement, and pain. Chemical debridement (using enzymatic agents) is most effective when used in combination with mechanical or surgical debridement.
After debridement, a moist environment should be maintained to facilitate granulation and wound healing. Either a moist normal saline dressing (changed every 6 to 8 h) or an absorption or calcium alginate dressing may be used.
Care of a stage 3 pressure sore is costly and labor-intensive. Although many such wounds heal slowly by secondary intention, surgical closure is often needed to shorten hospitalization and rehabilitation.
Stage 4
Care of a stage 4 pressure sore is similar to that of a stage 3 pressure sore. Variations may be indicated in the presence of sinus tracts or exposed bone. Irrigation should be performed as described for stage 3. If sinus tracts are present, an appropriately sized red rubber catheter attached to an irrigating syringe may be used to direct the flow of irrigant. All exudate and necrotic debris must be removed from narrow pathways.
The wound, including crevices and sinuses, should be packed loosely. If used, gauze should be kept in one piece for easy removal and to ensure that no dressing material will be left in the wound. Rolled gauze is available in various widths; if more than one roll is needed, the rolls should be tied together. Exposed bone should be covered with a wet, normal saline dressing, which should be changed q 4 h to avoid drying and maintain viability of the bone tissue. An outer dressing should be applied as with a stage 3 wound.
Surgical debridement to thoroughly excise infected or necrotic tissue usually is followed by a musculocutaneous flap procedure. Postoperative care includes monitoring the patient for infection and keeping pressure off the flap site.

Specific treatment of a pressure sore is based on its stage. With all stages, identifying and reducing risk factors and performing appropriate interventions are essential. Specific types of dressings and topical agents are described under DRESSINGS AND TOPICAL AGENTS, below.