Expert dispels myths and gives practical tips

Wounds should not take ten, five or even one year to heal, but old-fashioned practices (like applying Betadine- or normal saline-soaked dressings) may hinder healing and mean some wounds persist way longer than they should, says Hayley Ryan, Wound Clinical Nurse Consultant and Director of WoundRescue, which provides wound care education, referral pathways and consulting services throughout Australia and New Zealand.

Here are some key principles to keep in mind when assessing and treating wounds.

Start with a holistic assessment

The dressing is just a tool and should only be chosen after a thorough assessment of the patient and then the wound, Ms Ryan says.

“If you do not have the right diagnosis of that wound, you may not be selecting the right treatment plan to get it on track to healing. That is one reason we see a lot of wounds failing to heal within the normal times we would expect. That can be anywhere from two to four weeks for a basic skin tear, four to six weeks for chronic wounds, and up to three months for an ulcer, as a guide.”

Ms Ryan says important questions include:

• Does the patient have any comorbidities that may impact healing, such as diabetes or obesity?
• Are they on medications that may affect healing, such as anticoagulants, antineoplastic and immunosuppressive agents, corticosteroids, nonsteroidal anti-inflammatory drugs or angiogenesis inhibitors?
• How is their nutrition e.g. are they getting enough protein and essential nutrients?
• Is their fluid intake adequate? This is especially important with high exudate wounds.
• What is the state of the skin e.g. is it dry or is the wound surrounded by areas of hyperkeratosis or oedema present that could dry it out and hinder healing?
• Are additional tests such as Doppler TPI/ABPI scans needed?

Consider the characteristics of the wound

While product suppliers often recommend choosing a dressing based on wound type and stage, Ms Ryan cautions against relying solely on this approach.

“Don’t look at a wound to say, ‘this is the stage of injury, this is what I’m going to put on it,’” she says. “Look at every wound individually and say, ‘What am I trying to achieve with the appropriate dressing?’”

“Look at the symptoms in that wound: Is there a lot of fluid? Is it dry? Is it moist enough that it’s going to achieve appropriate and timely healing? Do I need to put something around the edges to stop it breaking down further, like a barrier cream to avoid maceration?”

Tips for product selection

Ms Ryan offers the following advice for choosing the three key wound management products.

1. The cleansing agent

Before choosing a cleansing agent, think about its purpose, which is to remove surface contaminants, debris, slough, and devitalised tissue. This preps the wound bed to dress the wound. Normal saline is suitable for acute wounds. For chronic and complex wounds, an antimicrobial solution such as polyhexamethylene biguanide (e.g. Prontosan), octenidine or hypochlorous acid (e.g. Grandudacyn or Microdacyn) may be suitable if you suspect a buildup of microorganisms is delaying wound healing.

2. The primary dressing

If the wound is too wet, choose a dressing that will soak up excess fluid, such as an alginate or gelling fibre. If it’s too dry, choose one that will moisten it, such as a hydrogel—unless the wound is ischaemic, in which case further investigation is needed.

3. The secondary dressing and/or fixation

Consider whether you need an additional absorbent dressing and whether a crepe bandage is adequate for fixation and suitable for the person’s age.

“Here’s my biggest tip,” Ms Ryan says. “With a venous ulcer, the quicker you can get that patient into true compression bandaging—and I’m not talking about a TED stocking––then you will see that wound healing as it should.”

She recommends arranging Doppler TPIs/ABPIs to determine the class of compression that is safe to apply.

How much stock should you hold?

It’s essential to keep enough products to manage common wound types, Ms Ryan says.

“If you don’t have the right product to put on at the right time, then it can result in delayed healing.”

Brand does not matter, she adds, suggesting you have the following on hand at a minimum:

• an antimicrobial such as a silver dressing
• basics for abrasions and sports injuries
• some silicon dressings particularly for the elderly or those with fragile skin
• two types of cleansing agents such as normal saline and hypochlorous acid.

Dressings are expensive, she notes, and the Federal Government’s Chronic Wound Consumable Scheme—set to kick off sometime next year—will cover the cost of wound consumables for people aged over 65 with diabetes, and for Aboriginal or Torres Strait Islander people aged over 50 with diabetes.

Follow up care and referral

Follow up care is crucial to keep wound healing on track, she adds.

Tell patients how often the dressing needs changing and when to come back for review, which may be in a week or two, or more frequently if they need help with wound care.

Consider whether they’ll need help to shower to ensure the dressing stays dry and explain warning signs to look out for.

“Patients need to be informed that if there’s any increased redness, heat, swelling, pain exudate, leakage—come back, don’t wait,” Ms Ryan says.

It’s also good to refer people to a wound specialist as early as possible if you have any concerns, she adds.

“When in doubt, get it checked out. Wound specialists exist because we want to help every patient with a wound to get healing on track, with the right treatment, at the right time.”

WoundRescue has staff in every state and territory and will see anybody outside of a hospital. GPs can refer patients to WoundRescue via email or fax.

Finally, remember prevention is always better than cure.

Ms Ryan suggests reviewing a patient’s skin as part of a general consult. Simple things like checking turgor, dryness, and recommending twice-daily moisturiser application can help prevent skin injuries, she says, particularly in people aged over 65 years and in young children whose elastic skin can tear easily.

Key takeaways

• Consider factors that may impact healing, such as medications and comorbidities, as well as the wound itself.
• Choose a dressing based on the characteristics of the wound and the patient, not solely on wound type and stage.
• Use a cleansing agent that is appropriate for the type of wound.
• Apply compression bandaging over venous ulcers as early as possible.
• Refer to a wound care specialist if you have any questions or concerns.

More information

WoundRescue can deliver education for GPs/practice nurses virtually or onsite and offer ‘10-minute coffee break’ training sessions. Email admin@woundrescue.com.au to find out more.