I have a confession to make. For the first (many) years of my career, I signed the dressing orders that nurses requested without recognizing their significance. Although surgeons and emergency physicians do a lot of dressing changes during their training, internists do not. Not until I attended my first wound healing symposium did I have an inkling of the variety of options for wound care, or the science of appropriate dressing selection (Symposium on Advanced Wound Care)
The basic driver for dressing selection is the condition of the wound bed. For optimal wound healing, a wound bed needs to be free of debris and excess bacterial activity, and must be moist. Wound healing physicians will refer to the “Goldilocks” challenge. The bed should be moist without being too wet or too dry. A wound with drainage (exudate) that is too heavy will wash the healing proteins right off the wound. The white, waterlogged surrounding tissue is called “maceration.” Macerated tissue will not heal. If you have seen a child in a tub or swimming pool with white wrinkled fingers and toes, you’ve seen maceration. RV enthusiasts will be familiar with the maceration process, because it is used to break up the debris in the toilet tank. On the other end of the spectrum is desiccation, or crusting. Crusting traps debris in the wound bed, preventing release of waste from the wound and precluding contact with the cleansing properties of the bandage. Most of the time, a scab or crust should be removed to allow healing to move forward. There are limited situations in which a dry, stable, crust is left in place to serve as a biological dressing. In those circumstances, a simple mechanical bandage is usually recommended to protect the crust from further injury and allow for early detection of drainage as a signal for possible infection.
Dressings provide a clean, warm, stable environment for the cells that move into a wound bed, allowing the new cells to organize in place. The frequency of dressing change will reflect the mechanical and moisture management properties of the dressing, and of course the logistics of the patient’s care. After removing a bandage, the surface of a wound bed reaches room temperature in minutes; it takes 4 hours after reapplication of a dressing for the wound bed temperature to rise enough for cells to migrate into the bed again. Many of our patients arrive to clinic with instructions to change bandages 2 or 3 times daily, unaware that they are losing 8 to 12 hours of healing potential.
Even with the ideal dressing selection, there are other considerations to optimize healing. Daily protein and vitamin supplementation help to compensate not only for increased metabolic needs of healing tissue, but also for the nutrition that is lost from the body in the wound exudate. Elevation and compression garments are necessary to resolve wounds related to chronic swelling. Vascular surgery intervention may be needed for ulcers related to poor circulation. Modification of shoe gear may be needed to change the way feet with nerve damage rest in shoes. Release of tight foot tendons may change how foot ulcers rub against your shoes.
In conclusion, your wound healing provider will help you not only to navigate dressing selection and application, but also to engage complimentary interventions to accelerate healing. Be prepared for questions that may initially seem unrelated to your wound. The more your provider understands about the mechanics of your life, the better your plan can be tailored for you.
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