Choosing a dressing: A matter of art and scienceByLiza G. Ovington, PhD, CWS
President, Ovington & Associates
The choices you have for wound management products can be staggering. Just considering the eight semi-occlusive dressing categories of films — foams, hydrogels, hydrocolloids, contact layers, alginates, collagens, and composites — there are almost 200 brand options. Within the category of hydrocolloids alone there are more than three dozen brands from which to choose.
So how do you know what dressing to choose for a particular wound? How do you choose a general category, much less a specific brand?
A number of authors have proposed criteria for selecting a particular type of dressing for a particular wound.1-4 Almost all agree that dressing selection is not a simple "cookbook" process but involves knowledge and consideration of these factors:
• general principles of the wound healing process;
• the features and capabilities of different dressing materials;
• the features and status of the wound in question.
The critical principles of optimizing the wound healing process to keep in mind when choosing a topical dressing include minimizing trauma to the wound bed, removal of necrotic tissue, avoidance of toxic solutions or materials, elimination of dead space, prevention of excess exudate, and maintenance of a moist, clean wound bed.3 (These principles are translated into dressing features or performance parameters in the tables on p. 49.)
Principles of the wound healing processMost of the performance parameters listed in Table One are common to all types of semi-occlusive dressings; however, certain types of dressings perform better in some areas than others. In general, the various types of semiocclusive wound dressings can all maintain a moist wound environment if used appropriately. Areas in which they may vary include their ability to absorb exudate (or, conversely, their ability to donate moisture to an already dry wound), their conformability or ability to adhere to anatomical contours (joints, areas of flexion) or fill a cavity, and whether they are self-adhesive or require a secondary dressing for attachment.
A thorough wound assessment is without exception the most critical part of dressing selection. The wound will "tell" you what it needs if you do the assessment correctly. In other words, the features of the wound will guide you to a particular dressing category. Wound assessment should include at a minimum: location, dimensions, exudate amount, wound bed tissue type, and conditions of wound margins. Table Three demonstrates how the assessment information leads you to a dressing performance parameter.
Wound assessment should be an ongoing part of dressing selection because a single wound will have different needs throughout its healing course, and this may necessitate using different types of dressing materials in its management. For example, more absorbency may be needed in the initial inflammatory phase of healing than during the granulating and epithelializing phases. A necrotic, sloughy wound may require moisture to aid in debridement and then need only a moisture-retaining dressing once it has started to granulate.
Besides the specific information provided by assessment of the wound, anticipated dressing frequency can also impact your choice of dressing type. In general, the longer you want to leave the dressing in place, the greater absorbent capacity (if the wound is exuding) or greater adherent capability you should seek.
Finally, it is possible that the patient or the patient’s environment may affect your choice of dressing materials. Krasner writes of patient criteria and setting criteria as components of dressing selection.4 A mobile, active patient may present different demands on the wound dressing from a bed- or chairbound patient. The patient’s need to shower or bathe without disturbing the wound dressing could influence selection toward an adherent waterproof secondary dressing as opposed to a tubular retention bandage, for example.
Selecting proper dressingHere are some examples: For a shallow wound with light drainage on a finger, an extra-thin foam may meet absorbency and conformability needs. A deep, heavily draining wound on the sacrum may require the higher absorbency of an alginate or foam, but the depth may favor the use of an alginate in the rope form, which is more easily packed into a cavity. A secondary dressing must then be selected to secure the alginate to the patient. A film or thin hydrocolloid dressing may meet the adherent demands of the sacral location, or an adhesive foam product may hold the alginate in place as well as increase the absorbent capacity.
A wound on the heel may require the superior adherent capability of a regular or extra-thin hydrocolloid — but what if that same wound is exuding heavily? You may consider applying an alginate and securing it with the hydrocolloid.
A dry escharic wound may require the moisture-donating ability of an amorphous hydrogel to soften the eschar and promote autolytic debridement. A secondary dressing to keep the gel in place in or on the wound could be a film or other adherent low-absorbency product.
Concerning wound margins, if you remove a dressing and find the margins macerated, this is an indication that the dressing type you just removed was not absorbent enough for the wound.
In general, you will be guided to a category or type of dressing by your assessment of the wound. In terms of then selecting a specific brand of dressing in that category, your choice should be guided by your experience with different brands or perhaps by availability (see box, above).
References1. Alvarez A, Rozint J, Wiseman D. Moist environment for healing: Matching the dressing to the wound.Wounds1989; premier:35-49.
2. Willey T. Use a decision tree to choose wound dressings. AJN 1992; 43-46.
3. Baranoski S. Wound assessment and dressing selection. Ostomy/Wound Management 1995; 7A (suppl):7S-14S.
4. Krasner D. "Dressing decisions for the twenty-first century: On the cusp of a paradigm shift." In: Krasner D, Kane D. Chronic Wound Care. 2nd ed. Wayne, PA: Health Management Publications; 1997, pp. 139-151.