Bandages and Dressings
Bandages and dressings are both used in wound management. A bandage is a piece of cloth or other material used to bind or wrap a diseased or injured part of the body. Usually shaped as a strip or pad, bandages are either placed directly against the wound or used to bind a dressing to the wound. A dressing can consist of a wide range of materials, sometimes containing medication, placed against the wound.
The purposes served by dressings include protecting wounds; promoting healing; and providing, retaining, or removing moisture. Bandages can be used to hold dressings in place, and also to relieve pain and generally make the patient comfortable. Elastic bandages are useful to provide ongoing pressure on varicose veins, fractured ribs, swollen joints, etc.
There have been tremendous advances made in the design and composition of dressings and bandages in recent years. The field is becoming increasingly complex, and there are numerous reports of health care workers applying inappropriate products. Wound-care materials come in a wide variety of product classes, including the following:
- Alginate dressings. These are derived from brown seaweed, and contain calcium alginate, which turns into a sodium alginate gel when it comes in contact with wound fluid. Alginate dressings are available as pads or ropes.
- Biosynthetic dressings. Composites of biological (often animal-derived) and synthetic materials such as polymers.
- Collagen dressings. Made from collagen, a protein obtained from cowhide, cattle tendons, or birds. They are available as particles or gels.
- Composite dressings. These look like Band-Aids, and include an adhesive border, a nonadhesive or semiadhesive surface that is applied to the wound, an absorbent layer, and a bacterial barrier.
- Contact layers. A low-adherent layer of perforated or woven polymer material, designed to stop a secondary absorbent dressing from sticking to the wound surface.
- Gauze. This woven fabric of absorbent cotton is available in a number of formats and materials, including cotton or synthetic, nonimpregnated, and impregnated with water, saline, or other substances. Gauze is sold as surgical swabs, sheets, rolls, pads, sponges, and ribbon.
- Growth factors. These short-chain proteins affect specific target cells. They exist naturally in humans. They can be transplanted from one part of the body to another, or manufactured outside the body.
- Hydrocolloid dressings. Used for leg ulcers, minor burns, pressure sores, and traumatic injuries, these self-adhesive dressings form a gel as they absorb fluid from the wound. They consist of materials such as sodium carboxymethylcellulose (an absorbent), pectin, and gelatin, attached to a foam sheet or a thin polyurethane film.
- Hydrofibers. Similar in appearance to cotton, carboxymethylcellulose fibers turn into a gel when they are brought into contact with wound fluid. They are available as ribbons or pads, and are highly absorbent.
- Hydrogels. These are sold as sheets and in gel form, and are primarily used to supply moisture to wounds. Depending on the state of the tissue, they can either absorb fluid or moisten the wound. An electrically conductive aloe vera gel is available to provide electrotherapy to wounds.
- Hydropolymers. These foamed-gel products consist of multiple layers. The surface layer is designed to expand to fill the wound's contours, at the same time drawing away fluids.
- Leg compression/wrapping products. Designed to apply external pressure to improve blood flow and resolve chronic edema in the feet and legs. Available in a broad range of formats including stockings, compression bandages, or pneumatic pump.
- Polyurethane foam dressings. These are sheets of foamed polymer solutions with small open chambers that draw fluids away from the wound. Some, but not all, of these foam products offer adhesive surfaces. They are available as sheets and rolls, as well as in various other formats suitable for packing wounds.
- Skin substitutes. Also known as allografts or skin equivalents, these are obtained from human cells cultured and expanded in vitro from neonatal foreskins.
- Superabsorbents. These are particles, hydropolymers, or foams that act like the material inside diapers, with a high capacity for rapid absorption.
- Transparent films. These consist of a thin, clear polyurethane sheet that, on one side, has a special adhesive that does not stick to moist surfaces like those found on a wound. They prevent bacteria and fluids from entering the wound through the dressing, but allow limited circulation of oxygen.
- Wound fillers. These can be bought as powders or pastes, or in strands or beads. They are used to fill wounds and also absorb wound fluid.
- Wound pouches. Equipped with a special collection system for wounds that have a high flow of secretion. Designed to contain odors, and to be easily drained.
- Other assorted wound-care products. These include adhesive bandages, surgical tapes, adhesive skin closures, surgical swabs, paste bandages, specialty absorptive dressings, support bandages, retention bandages, elasticized tubular bandages, lightweight elasticized tubular bandages, foam-padded elasticized tubular bandages, and plain stockinettes.
Just as there is a large selection of bandage and dressing products to choose from, there is also a broad range of applications for these products:
- Alginate dressings are used on wounds that exude moderate to heavy amounts of fluid. They are useful for packing wounds, although strip-packing gauze may be preferable for deeper wounds because it is easier to retrieve. Common applications of alginate dressings include treatment of acute surgical wounds, leg ulcers, sinuses, and pressure sores. These dressings should not be used on third-degree burns. Neither are they advisable for wounds that are dry or are secreting only small amounts of fluid, because their powerful absorbing capability may dry out the wound. These are primary dressings that need be covered by a secondary dressing.
- Biosynthetic dressings are used on burns and other wounds. Another application is as a temporary dressing for skin autograft sites. Some patients may be allergic to these dressing materials.
- Collagen dressings are believed to hasten wound repair and are often used on stubborn wounds. They are most effective on wounds that contain no dead tissue. Collagen dressings should not be used in dry wounds, third-degree burns, or on any patient who is sensitive to bovine (cow) products.
- Composite dressings are sometimes used alone, sometimes in combination with other dressings. Deep wounds should first be packed with wound filler material. These dressings should not be cut, and are not recommended for use of third-degree burns.
- Contact layers are designed for use in clean wounds that contain no dead tissue. They are not recommended for infected, shallow, dry, or infected wounds, or on third-degree burns.
- Gauze is used to pack wounds, and also for debridement and wicking. It is especially desirable for packing deep wounds. When using gauze to pack wounds, a loose packing technique is preferred.
- Growth factors. These have highly specific applications against such conditions as diabetic foot ulcers involving disease of the peripheral nerves. Growth factors are heat sensitive and often require refrigeration. Not recommended for patients with tumors, either benign or malignant.
- Hydrocolloid dressings are used for leg ulcers, minor burns, pressure sores, and traumatic injuries. Because they are not painful to remove, hydrocolloid dressings are often employed in pediatric wound management. Because of their absorbent capabilities, they are used on wounds that are secreting light to moderate amounts of fluid.
- Hydrofibers are highly absorbent, so they are particularly useful for wounds that are draining heavily. For this reason, they are not recommended for dry wounds or wounds with little secretion, because they may result in dehydration. Hydrofibers should not be used as surgical sponges or on third-degree burns.
- Hydrogels are often used on wounds that contain dead tissue, infected surgical wounds, and on painful wounds. They should not be used on wounds with moderate to heavy secretions. As with all dressings, it is important to check the manufacturer's directions. In the case of hydrogels, directions on some products indicate they are not to be used on third-degree burns.
- Hydropolymers are typically used on wounds with minimal to moderate drainage. They are not indicated for dry wounds or third-degree burns.
- Leg compression/wrapping products are used to increase blood flow and reduce edema in the lower extremities of the body. A medical doctor should be consulted before using these products on patients with edema. In many cases, topical dressings are used under-neath these products.
- Polyurethane foam dressings are very absorbent and are typically used on wounds with moderate to heavy secretions. They should not be used on third-degree burns, or wounds that are not draining or have sinuses or tunneling.
- Skin substitutes are a relatively new product category, approved for treating venous leg ulcers. It is often advisable to cut slits in the artificial skin, so that wound secretions underneath do not lift the newly applied skin.
- Superabsorbents are employed on wounds that are secreting heavily, or in applications requiring extended wear. A packing material is commonly employed under this product. Superabsorbents should not be used on third-degree burns or wounds that are either dry or have minimal secretions.
- Transparent films are often employed as a secondary cover for another, primary dressing. They are used on superficial wounds, and on intact skin at risk of infection. It is important to remove transparent films very carefully, to avoid damaging fragile skin.
- Wound fillers are primary dressings that are usually used in conjunction with other, secondary dressings. Wound fillers are considered appropriate for shallow wounds with little or moderate secretions. They are not appropriate for use in third-degree burns, or in dry wounds. They are similarly not recommended for wounds with tunnels or sinuses.
- Wound pouches are useful in treating wounds with high volumes of secretion. They are not suitable for dry wounds.
Recommended intervals between dressing changes varies widely between product classes. Some dressings
Health care team roles
Wound-care nursing is a demanding field that can require its practitioners to also be administrators, educators, clinical experts, and researchers. Nurses are the front-line workers in wound care, often working as part of a multidisciplinary team of colleagues from other professions and disciplines. This approach is considered necessary because of the multifaceted nature of wounds. Its importance is especially noticeable in acute care, where 5.4% of hospital patients develop a stage one ulcer. Across the United States, such ulcers in acute care cost more than $839 million a year. Other members of the wound-care team may come from home care, administration, nutrition, geriatrics, vascular surgery, plastic surgery, biomedical, general nursing, pharmacy, materials management, infection control, purchasing, quality assurance, and physical and occupational therapy. Numerous ad hoc members and consultants may also be involved, including representatives from dermatology, trauma, podiatry, risk management, staff development, orthotic specialists, rehabilitation, diabetology, and social services. To be successful, multidisciplinary wound-care teams must establish ongoing communication with primary-care physicians. Nurses are intensively involved in the initial assessment of tissue damage, a responsibility that demands both accuracy and consistency. Other responsibilities may include cleansing and dressing wounds, removal of non-viable tissue, pain management, patient education, nutritional counseling, statistical analysis, and helping the patient cope with the psychological effects of serious or disfiguring wounds. Determining the cause of wounds is often very important, especially the cause of chronic wounds such as skin ulcers. A physician should be advised of any signs of infection or other changes in the wound.
Wound-care nursing is a rapidly advancing field that requires considerable training, clinical experience, and judgment, causing some observers to predict that it will eventually develop into advanced practice nursing or a specialty-based practice. Increasingly, the demands on wound-care nurses are expected to require that they undertake graduate studies. For all nurses working in the field, ongoing education is a must, to keep up with new knowledge, technologies, and techniques. Numerous organizations and institutions offer continuing education courses in wound care management. The Wound, Ostomy and Continence Nurses Society is one such organization. It offers a variety of resident programs at several U.S. centers and also has distance-learning options.
Edema—Swelling of body tissues, caused by collection of excess fluid.
Electrotherapy—The treatment of body tissues by passing electrical currents through them, stimulating the nerves and muscles.
Sinus—In the context of wound management, a narrow hollow in the body extending from an infected area to the skin's surface.
Stockinette—A soft elastic material used for bandages and clothing for infants.
Bryant, Ruth A. Acute & Chronic Wounds, 2nd ed. St. Louis, MO: Mosby, 2000.
The Wound, Ostomy, and Continence Nurses Society. 1550 South Coast Highway, Suite #201, Laguna Beach, CA, 92651. (888) 224-WOCN (toll-free). <http://www.wocn.org>.
David L. Helwig