If you are like millions of people with a wound, you may be wondering how to change a wound dressing and what is the best way to care for your wound? How do you change the wound care dressing you have been using or start using a new prescribed dressing? Maybe you are asking how do I apply this new dressing or what makes a foam special versus calcium alginate? The Specialists at Vohra Wound Physicians created this overview to provide you with some basic wound care principals and an overview of wound care dressings, how to apply them and some general wound management tips so you can better understand your wound care.
What is Wound Care?A wound is any break or disruption of healthy skin. There are many types of wounds, and doctors usually refer to those that recently happened as “acute wounds” and those that have been present for several weeks or longer as “chronic wounds.” The medical care of wounds is what we call wound care or wound management. This includes things like cleaning the wound, applying medications, putting a bandage or dressing on the injury, and other actions needed to have the skin heal. When we speak about wound care, there are a few terms that we use to describe things.
SkinThe skin, something we all learn about when we are kids, is the layer covering our body that protects us and keeps germs out. The skin is made up of different layers, and underneath the skin are our muscles and bones. If a wound occurs in the skin, it may not be very deep and may just be a superficial wound. It may only involve the top layers of the skin, or it may be much deeper and extend through the deepest layers into the fat, muscle, or bone beneath the surface. The first are superficial wounds like when you fall and scrape your knee as a kid while the second is like a cut that goes so deep the fat is seen, and you must go to the doctor and have stitches to close the wound.
Wound Care Certification
Wound bedWhen caring for a wound or break in the skin, it is essential to look at the wound thoroughly. The area between the edges of intact, healthy skin is the surface of the wound. Like the crater on the moon, there is an edge, and there is a bottom. The surface of the crater is like the surface of the wound. This surface we refer to as the wound bed.
How to measure your wound
When we describe how severe the wound is, we measure from the edges of the wound (up/down and left/right). Measure from the point on the edge closest to your head to the edge closest to your feet). Then measure from the edge on one side to the edge on the other side (this is the length and the width of the wound). To measure how deep the wound is, measure from the base of the wound up to the surface. Like a crater, the depth is the measurement from the deepest point in the cavity up to the surface. You can use a clean piece of paper held next to the wound and a pen to mark on the paper how big the wound is. Then use a ruler or tape measure to determine the sizes you marked on the paper. If you don’t have a ruler, you can use an object from around your house to get a reasonable estimate of the size.
For example, a dollar bill is about 6 inches long and two and a half inches tall. At the same time, a quarter is approximately 1 inch wide, and a dime is about one half of an inch wide; a Q-tip is almost exactly 3 inches long. A piece of paper is eight and a half inches wide by 11 inches long: fold it once to make it narrow, and now you have something that is about 4 inches wide by 11 inches long. Measuring a wound is essential to see how the wound is healing and changing in size over time. Getting the measurement exact is not as important as it is to measure it the same way each time and keep a record of the size each time you measure the wound. Usually, once a week is as often as you need to measure a wound. Before measuring your wound, it is ideal that you clean the wound by wiping the surface of the wound.
To clean the wound, use wound cleansers or saline. It is easy to make your own saline (a form of salt water) at home. It is essential to use water that has been sterilized (sterile water) by boiling the water for 20-30 minutes. You can buy distilled water that has already been boiled and filtered. An easy way to make saline is to mix one cup (8 ounces) of distilled water with ½ a teaspoon of table salt. Find a complete set of directions here on how to make saline.
Types of WoundsEarlier, I mentioned that a wound might have recently occurred or developed, or it may have been present for several weeks or months. New wounds, wound doctors refer to as “acute”, and those that have been present for a longer time they refer to as “chronic.” There are many types of wounds, and any acute wound can become a chronic wound with enough time. Some common types of wounds are pressure wounds or bedsores, wounds on the leg caused by vein problems or artery and blood circulation problems. There are wounds on the foot that can occur with diabetes. Skin cancers or problems with the immune system can also result in wounds. There are many names doctors use for these types of wounds. The most common are “pressure ulcers,” “venous ulcers,” “arterial ulcers,” and “diabetic ulcers” or “diabetic foot ulcers.”
Acute WoundsAn acute wound is one that has recently developed. Acute wounds can be the result of an injury such as a scrape, fall, or a cut, or they may be a surgical wound or burn wound. These types of wounds can quickly heal if they are cleaned, protected, and bandaged correctly. They can also become worse and develop into infected wounds, or they can fail to heal and linger for weeks, months, or even years and are then “chronic” wounds.
Chronic woundsChronic wounds are those that have failed to heal after several weeks and have not responded to cleaning and bandaging efforts. These can be long-standing bedsores, leg ulcers, or other problems that just will not go away.
Types of Chronic Wounds
Pressure injuries also called pressure ulcers or bed sores are wounds of your skin caused by prolonged pressure on the skin. These usually develop in people confined to bed or a wheelchair and occur over the bony parts of your body, like the tailbone, hips, or heels. Pressure wounds are caused by sitting or lying in one position for too long. Pressure reduces blood supply to the skin and the tissue under the skin. If you don’t change position frequently, the blood supply will decrease, and a sore develops. A pressure injury can appear as a tender red area, a purple bruised area, or a black area that can appear like a scab.
Pressure wounds can rapidly become worse and can become an open draining sore. They can be very deep down to the bone and can be life-threatening if not treated properly, and an infection develops. The best way to treat a pressure wound is with prevention. Avoid spending long periods in a chair or bed. Keep your skin healthy and dry. Mild soap and water should be used to clean the skin. Apply lotion to skin after bathing. To prevent pressure injury, foam pads, pillows, and special mattresses can be used to reduce prolonged pressure on the skin. It is also essential to move frequently and to sit and lay in a variety of positions for short periods of time.
Venous ulcers are open sores caused by problems with blood flow (circulation) in your leg veins often associated with a history of varicose veins. Venous wounds typically occur because of damage to the valves inside the leg veins. These valves control the pressure in the veins. When the pressure inside your veins does not drop when you are walking, the condition is called sustained venous hypertension. This prolonged hypertension can lead to wounds on the lower leg. Venous ulcers are typically red, irritated skin rashes that develop into open sores. They can be identified by closely observing the appearance of your legs.
Other symptoms include itchy dry skin on the legs, hardened skin around the ulcer, red-purple or brown color on the skin, cracked or dry skin that may open up. The treatment of venous ulcers involves specialized wound care that can include wrapping the leg or applying special bandages or stockings to compress the leg to reduce swelling. These are sometimes called compression wraps or compression stockings.
Arterial wounds or ulcers are a slow healing area of broken skin on the lower leg, foot, or toes and are usually dry wounds. They are found with cool skin and weakened pulses in the affected extremity. The skin appearance may change and look shiny or dry. There can also be a loss of hair on the leg impacted. Arterial wounds or ulcers can be small and are often painful. These ulcers develop when the arteries or vessels that carry blood from the heart to your body’s tissue become narrowed or blocked. When this occurs, it affects the delivery of nutrients and oxygen to the skin of your foot or leg.
Lack of blood supply and nutrients can cause the failure of the skin to heal after an injury. It is common to have pain in the leg or legs with walking, and this pain is better with sitting and resting. This pain is commonly like a cramp in the leg. In people, arterial problems (also referred to as peripheral arterial disease or PAD) pain will often be worse at night and is relieved by dangling the foot down off the side of the bed. You are at greater risk if you smoke, are diabetic, or have a history of heart disease. All of these factors can cause narrowing of arteries which can reduce blood flow.
Diabetic foot ulcers or diabetic foot wounds are wounds that occur on the foot in people with diabetes. They occur in about 15% of people with diabetes. Commonly located on the bottom of the foot, they can develop in anyone with diabetes. People who have diabetes that requires insulin are at a higher risk of developing wounds, as are people with diabetes-related kidney, eye, and heart disease. Diabetic foot ulcers form due to a combination of factors such as lack of feeling in the foot, poor circulation, foot deformities, irritation of the skin, and trauma. It is common with diabetes to lose some or all of the ability to feel pain in the foot.
Many times, a wound is discovered when drainage (exudate) or a stain on the socks is noticed. Redness and swelling may also be associated with a diabetic wound, and these are signs of infected wounds. Diabetic foot ulcers or wounds most commonly occur on the bottom of the foot. They can cause infections and even lead to amputation of the foot or leg. If you have a wound, you may notice your blood sugar levels are higher despite taking your medications and eating as you would normally. This rise in blood sugar levels may be a sign of infection. Proper treatment of a diabetic foot wound is essential to prevent the wound from getting worse. Good care of your feet and nails, proper fitting shoes, and daily inspection of your feet for any injury, cracks, or openings are essential in preventing a small problem from becoming a serious one.
Infection, Necrosis, and Debridement
Wounds can develop infections from bacteria or other germs, and this can complicate and delay the healing of the wound. Wounds do not need antibiotics to heal. There is no best antibiotic for wound healing. Most wounds are not infected and do not need antibiotics. The overuse of antibiotics in the form of ointments or taken as pills can result in drug-resistant bacteria to develop and can make things worse. If your doctor has determined you have a wound infection or an infection around your wound (periwound skin), she will prescribe antibiotics for you to take. In that situation, your doctor will be treating a specific problem and often wound pain is the first sign of infection.
Antibiotic ointment is not needed on most wounds, and you should never apply hand gel or use hand sanitizer to clean your wound. Many things can cause a wound not to heal correctly. One of the main reasons for a wound not to heal is that there are dead cells or tissue in the wound, and this material is called necrosis. Necrosis occurs when healthy parts of the skin or the tissues under the skin die. Removing this dead material allows the body to replace this area with new cells.
The removal of dead or necrotic tissue is a procedure your wound doctor may perform with a sharp knife or other surgical instruments to help the wound heal. Your doctor may prescribe a medication to clear away the dead material. One method of debridement is to allow the body to remove the dead tissue itself through something called autolytic debridement. This type of debridement works best with certain types of dressings and for certain wounds. Often after a wound has been cleaned and debrided, a temporary dressing will be applied just until a more advanced dressing is applied. This temporary dressing is usually a piece of gauze dressing or a gauze pad, sometimes called a dry dressing. Dry dressings are named dry because they are simply a dry piece of bandage material without any medication or ointment that gets placed over the wound.
Apply wound care dressingWhat are the main types of wound care dressings that you can use? There are three categories: those that make a wound drier, those that make a wound wetter, and those that protect a wound. In addition to these three, there are a few more special dressings. We think of dressings or bandages as those that help absorb moisture or help a wound that is very wet to dry out and those that add moisture or help make a dry wound wetter.
Steps to applying or changing a bandageWhen applying a new wound care bandage or dressing, it is essential to follow a few simple steps. Because a wound is an opening to the outside it is not sterile and we apply dressings using a clean dressing technique.
- Assemble all of your wound care supplies that you will need to change the dressing.
- Clean gloves (sterile gloves are not needed)
- A clean surface to place everything on (such as a clean piece of aluminum foil or clean paper
- The new bandage to be applied
- Saline or wound cleanser to clean the wound
- Several pieces of gauze to use in cleaning or wiping the wound
- Trash bag
Step twoWash your hands with soap and warm water for 20-30 seconds. After washing and drying your hands, put on clean gloves to remove the old dressing and perform the dressing removal step. Observe if there is fluid or drainage and note the drainage or wound fluid that is on the gauze. Wounds with a lot of fluid draining from them are exuding wounds. Now clean the wound by wiping with some gauze pads and saline or wound cleanser. Wipe the wound in small circles this from the middle of the wound outward and finally the skin around the wound edge. You may need several pieces of gauze. Dispose of the dirty bandage, gauze used to clean the wound, and dirty gloves in the trash.
Step threeMeasure the wound and record the length and width and the depth of the wound. Measuring should occur anytime the wound looks different and at least once per week. Write the measurements down so you can give them to your doctor or nurse.
Rewash your hands with soap and water for 20-30 seconds and dry them. Put on a new pair of clean gloves (you do not need sterile gloves). Now you will apply the new wound treatment and dressing. Your doctor may prescribe a medication to apply, such as an ointment, a gel, a liquid, or a spray. The medication should be applied as directed and, if needed, to spread it across the wound, clean cotton-tipped applicator like a Q-tip should be used. After any medication has been applied, you will place the primary dressing (this is the one that is placed in contact with the wound bed first).
The primary dressing will then be covered by a secondary dressing (if one is recommended by your doctor). The dressing may have a part that sticks to the skin to hold it in place, or you may need to use tape to secure the secondary dressing. If no secondary dressing is used, you may need to secure the primary dressing with bandage tape. There are several types of dressings, each used for different reasons, and we will describe them below with some tips for correctly applying them to the wound.
What type of wound care dressing is right for your wound?There are a variety of bandages and dressings that can be used to treat a wound. Each dressing has its special characteristics and properties. Not every dressing is suitable for all wounds. Bandages are different, and the fundamental division is those that help a wound stay moist to create a moist wound environment, absorb drainage or wound exudate, and provide a structure that helps the wound heal more quickly.
Gauze or Cloth
Gauze is what probably comes to mind when you think of a bandage. It is what you see in the movies wrapped around the wounded warrior’s head, for example. Gauze comes in many shapes and sizes. Most of the time, gauze is either going to be used from a roll or a small folded piece. Gauze is cotton or other fibers woven together to make a type of cloth. In the past, these bandages were often strips or pieces of old cloth that had been cut up and then washed and sterilized. In the modern era, they are made for dressing a wound and come neatly packaged in plastic or paper wrapping.
Gauze is often referred to as a “dry” dressing or a “dry protective” dressing. It may be the only dressing, or it may be the second or “secondary” dressing placed over another dressing. The gauze is secured or stuck in place with bandage tape. A piece of gauze is also handy to wipe or clean the wound after wetting it with saline. There are some made with special materials or coated with medication depending on what the wound needs. Some specialized gauzes are nonstick gauze, and some can even prevent bacteria from growing.
There are many types of foam dressings, and they are usually made from polyurethane (similar to the stuff used to make cushions and mattresses). Foam is soft and acts like a very thin sponge. Because a foam acts like a sponge, it can absorb fluid easily and can provide some cushion to protect the wound and normal skin. Foam does not stick and is very flexible and can be cut to the size of the wound. A foam dressing is usually used to treat a wound that has fluid draining from it.
Foams are excellent because they help keep the wound from becoming too dry (wounds heal best when there is some moisture present). Foams come in all kinds of shapes, sizes, with adhesives, special coatings, and in multiple layers. Sometimes they are the only dressing used on the wound, and other times they are the first or primary dressing. Another dressing is placed over the foam (the secondary dressing). When applying a foam dressing, we usually use a size that will cover the wound plus about an inch of normal skin around the wound. Foams can be left on the wound for 2-3 days and do not need to be changed every day unless they become saturated and can no longer absorb any fluid.
Alginate is a particular type of dressing that is made from the fibers of seaweed and contains calcium and sodium. These dressings are usually referred to as “calcium alginate.” They appear as white wisps, almost like a cotton ball but have properties that are much more sophisticated then cotton fibers. The alginate fibers can be formed into sheets or ropes and are used in wounds that have lots of fluid draining from them.
As a primary dressing, alginates create a protect gel and serve as both a barrier and an absorber of liquid. Alginate will absorb 20-30 times its weight in fluid and is generally changed every 1 to 3 days. If the fibers stick to normal skin, moistening them with saline or wound cleanser allows them to be removed easily. Some alginate dressings are combined with other materials to create specialized types of dressings. Specialized alginate is “silver alginate,” where silver has been added. Silver can help kill or prevent bacteria from growing in the wound.
A hydrogel is a special dressing that is used to create a moist wound and help the wound heal. Hydro-for water as these dressings typically contains 70-90% water. The material that makes up the hydrogel is synthetic pharmaceutical material or polymer. The polymer is such that it is not absorbed or broken down, but it can hold water and then slowly release this moisture into the wound. Hydrogels come in various forms and can be applied to the wound by squeezing out of a tube or bottle. They may be used as a sheet of jelly-like material or a gauze coated with a hydrogel.
These are special dressings composed of two layers—one on the outside and the other layer in contact with the wound. The inner layer is made of special materials that form a gel and can absorb some liquids. The outer layer is impermeable and prevents bacteria from getting into the wound and allows the wound to heal in a moist environment. They are some of the most used wound care dressings and are painless when removed or changed. They can help the body to remove dead necrotic tissue through a process called autolytic debridement.
When the wound bed looks beefy red (granulation tissue) this is a sign it is healing. Hydrocolloids when first applied, these dressing appear and feel like a thick sticky piece of flexible tape (they come in various sizes, shapes, and thickness). After they are on the skin, they soften and become very flexible. When removed, they are usually a bit wet and gooey or gel-like on the inside. These dressings can remain in place for up to 7 days. They can be used as the only dressing, or they can be used as the “secondary” dressing.
Transparent FilmsFilms are a transparent dressing like a piece of clear plastic. They have adhesive on part or all of the surface of one side. As highly flexible dressings, these can be used on a variety of wounds. They allow oxygen to pass through them. They also help the wound to self-debride (autolytic debridement). They allow you to see the wound at any time without having to remove and change the dressing.
CollagenDressings that are made of collagen are specialized bandages that help the body heal the wound by assisting in the natural rebuilding process. Collagen is scaffolding or building blocks of protein, needed to heal a wound. Because collagen helps certain wounds to heal by assisting the body in the healing process, these dressings can heal certain wounds faster. Collagen comes in many forms but typically is available in sheets and powder form.
Adhesive tape usually comes in the form of a role. The tape itself or the “backing” is some material like paper, or “silk,” or even plastic that is coated on one side with a sticky adhesive. The backing or non-sticky side and the adhesive come in a variety of widths, thickness, and stickiness. All tape will stick to the skin, and when the tape is removed, this can cause damage to normal skin. Everyone’s skin is different, and some people have skin that is sensitive to some tapes and adhesives.
The adhesive or the material that makes the tape stick is different for each, and some stick more firmly than others. Some resist water and do not fall off if they get wet. Adhesive remover can be used to get the sticky part off the skin. These are supplied as a spray or as little pads. If you do not have a medical adhesive remover, you can use a little mineral oil or even vegetable oil to remove adhesive painlessly.
Dressing Change Instructions
Now you have the perfect dressing, and you know how to change the bandage. The question remains of how often the dressing should be removed and replaced with a new one. When should you change the dressing on a wound? Do you change the dressing daily, more often or less often, maybe it should be changed every two or three days? Changing your dressing is a simple process and follows the same few steps every time:
- Wash your hands
- Put on Clean gloves
- Remove the old dressing and dispose of it
- Clean the wound
- Wash your hands
- Put on clean gloves (sterile gloves are not needed)
- Apply the new dressing and secure it in place
How often a dressing is changed will depend on the wound, and the type of dressing you are using. Your doctor will tell you how often it should be changed if the dressing falls off, becomes too wet, or gets soiled from the outside of the dressing. These are all times you will also need to apply a new bandage. Your doctor may determine that an ointment is best for your wound.
Some ointments are used to protect normal skin, others help kill bacteria, and some may even help the wound heal faster. One ointment commonly prescribed is silver sulfadiazine and this has antimicrobial properties. There is no one best ointment for wound healing. Every wound is different, a specialized wound doctor or your Vohra Wound Physician should be consulted to manage your wound and prescribe the right type of treatment for you.