Sr Barbara Fischer
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An interview with Sr Barbara Fischer, palliative care nurse and stomal therapist with a special interest in wound management.
What are the most important factors in helping our patients cope with a chronic wound?
Basically the dressing needs to contain the wound, drainage and odour but must be comfortable and manageable for the patient, and must be removed without added discomfort. For simple wounds, dressings can be easy and cost effective, ie. Bactigras and Combine. However, as any situation deteriorates, constant re-assessment and innovation can be required - not always cost effective, but comfort and maintaining good family interaction, rather than isolation because of odour or gross appearance, is also an important objective.Are the new dressing products better than the old ways?
GPs can be quite overwhelmed with the plethora of possible cleansing agents and then dressings that can be used on chronic wounds. There seems to be an ever increasing number of expensive products on the market and representatives to tell us how good their products are. But are they really any better than, for example, betadine swabbing followed by antibiotic-impregnated tulle gras dressings?Simply showering over any wound is the cheapest and most effective cleaning. If irrigation is needed warm Normal Saline should be used.
Regular Betadine swabbing usually results in scab formation containing particles of cotton wool and gauze. This can be uncomfortable and also masks what may be happening at the base of the wound. If packing is required for an infected area, prepared Betadine-impregnated gauze is acceptable (gauze wick soaked in solution is unstable, dries and causes discomfort with removal).
Antibiotic impregnated gauze is very infrequently indicated and usually absorbency at the site is impaired by exudate. Also, it may impair healing, cause hypersensitivity reactions and encourage the development of resistant bacterial strains. Systemic antibiotics may be required if clinical signs of infection are evident.
Hydrogels, alginates, hydrocolloids and foams, possibly with activated charcoal, all have their use, but each wound needs to be assessed and treated individually. On occasions a sinus or very heavily exuding wound may need to be covered with a drainable bag. These can vary from small, for a sinus on neck or knee, to large for a dehisced abdominal wound or multiple suppurating lesions.
Can you give some simple guidelines for what to use when?
You mention the benefits of foams, hydrogels, hydrocolloids and alginates, but can you give some simple guidelines for what to use when?When secondary dressings are required, incontinence pads or part thereof conform well to body contours and have a moisture-proof backing. Fixomul or Hyperfic do not harm fragile, reddened skin and are easily removed if oiled 1-2 hours prior to removal.
Sounds good. But what about the cost?
Cost at times can be considerable and has to be considered. Fortunately, really complex situations are minimal - often reduced by being able to use bags as previously mentioned. Hydrocolloids and foams can last up to 5 days and then are cost effective and frequently more comfortable for the patient. Overall, cost effective when properly assessed and the appropriate product used.What can be done to avoid misunderstandings between different doctors and nurses treasting the one patient?
Different doctors and nursing staff seeing a patient with a chronic wound often have differing views of what dressings to use. This often confuses the issue and certainly confuses the patient. What can be done to avoid these misunderstandings?At St Vincent's Hospital we are currently trialing a wound management form, which records dressings currently used, their effectiveness, reasons and date of change. The Richmond Health Service Community Nurses are also using a wound management chart. GPs should be aware of and contribute to these charts where appropriate. This will help to promote good communication amongst all 'players' which is so necessary in good management of chronic wounds.
| WOUND TYPE | AIM | DRESSING |
| Yellow necrotic with high exudate. | Remove slough and absorb exudate. | Hydrocolloid with hydrocolloid paste if deep. Hydrogels. Alginates or enzymatic (elase) removal of slough. |
| Yellow necrotic with low exudate. | Remove slough and absorb exudate. | Hydrogels (rehydrate toaid removal or slough). Hydrocolloids. Enzymatic removal. |
| Cavity wound with high exudate. | Absorb exudate, maintain moist environment. | Alginate or foam cavity dressings. |
| Cavity wound with low exudate. | Hydrate to maintain moist environment. | Hydrogel. |
| Malodorous wound. | Clear infection, reduce odour, absorb exudate, protect. | Systemic antibiotics only if clinical signs of infection seen. Foam or alginate with activated charcoal. Flagyl Gel with caution. |
Dr Andrew Binns abinns@om.com.au
General Practioner
Director, Palliative Care Services
St Vincent's Hospital
Lismore NSW Australia 2477
Discussion
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