That is quite a title, and there is no way we can cover all of these areas in any kind of depth in this article; however, the takeaway message from this is that they do all interlink. You need to understand both the basics behind wound management and the physiology behind bandaging to manage a case well and effectively.
Do not be lured in by the “new dressing which heals all” or the “bandage which never causes pressure sores” as they do not exist. The marketing of bandaging, consumables and wound products is not well regulated, so essentially, they can tell you that the product does anything they want. But when products are used at the wrong time or in the wrong circumstances, they do nothing, or even worse, they exacerbate the situation.
Being able to recognise the phases of healing is crucial to choosing the correct treatment plan and dressing type if required
The most important things to remember and recognise in wound management are the phases of healing (Box 1). Being able to recognise the phases of healing is crucial to choosing the correct treatment plan and dressing type if required. It is also through recognising these phases that you can recognise problems such as a wound stuck in the inflammatory phase, which may suggest a foreign body remaining in the wound.
|Phases of healing|
|Haemostasis – day 0|
Inflammation – day 0 to 4. Extension beyond day 5 would suggest something is “wrong” here as the inflammatory phase is prolonged
Proliferation – day 4 to 21
Maturation – day 21+. It can take a whole year for a wound to be fully healed. When healed the scar tissue present will not have full tensile strength
What is the difference between a bandage and a dressing?
Well actually, quite a lot, and it is important to reference them correctly.
A dressing is the object which goes directly in contact with the wound: normally a non-adherent pad of some form. A bandage is the three-layer protective coating we place over a dressing for protection or support.
It is important to use the correct terminology for either a bandage change or a dressing change. Bandaging is a tricky job and if done incorrectly, it can cause issues such as injuries. But, let’s face it, both at vet school and in vet nurse training there is not much time spent around actually understanding the science behind bandaging. Below are some key bandage-related pointers which should be adhered to.
You should pad the toes with orthopaedic padding, not cotton wool as cotton wool clumps and goes hard once it has been exposed to moisture which can be uncomfortable for the patient. Try it yourself if you do not believe me: put orthopaedic padding between the toes of your left foot and then cotton wool between the toes of your right foot and do a day’s work to see which is the most comfortable by the end of the day!
You should pad the toes with orthopaedic padding, not cotton wool as cotton wool clumps and goes hard once it has been exposed to moisture which can be uncomfortable for the patient
Use the widest bandaging material practical. This all relates to bandage pressures: the wider the material the fewer rotational coverings, and therefore fewer overlaps to potentially “ruck” and “crinkle”, causing points of pressure.
You should always bandage distally to proximally when bandaging a limb and use half-width rotational covers at each overlay of bandage. Finally, you can off-load pressure from bony prominences. This means the use of donuts over areas such as the elbow, to reduce the risk of a pressure-related bandaging injury.
How big does your dressings cupboard need to be?
The true answer is: not that big!
It is easy to be persuaded into buying the latest all-singing, all-dancing dressing material or product that has been over-marketed. Bandaging and wound dressings have become a really “fashionable” area in the last few years, with a lot of companies manufacturing products for this market – a few with some really impressive claims. However, it is important to remember all wounds will heal eventually, but it is our role to speed up this process and to do so in the correct manner.
This may sound a little cockeyed, but manuka honey is a great example of this. Medical grade manuka honey became “fashionable” on the veterinary wound market a few years ago, and people were slapping it on left, right and centre. Now, don’t get me wrong: it is a wonderful product; however, it is not supposed to be used on every type of wound. In fact, if used on a granulating wound, it can cause over-granulation or proud flesh.
So what dressings are for what wound?
The principle to remember here is the moist wound healing principle: a wound will heal 30 to 50 percent quicker if the moist wound healing principle is applied. This means preventing the wound from drying out but also preventing the wound from becoming macerated.
The principle to remember … is the moist wound healing principle: a wound will heal 30 to 50 percent quicker if the moist wound healing principle is applied
Here is a short overview of dressing properties:
- Foam dressing pads promote a moist wound healing environment. They can absorb lots of exudate so they are also good for wounds in the inflammatory phase. Never use these dry on a wound bed as they will suck moisture from the wound and may stick to it
- Silicone comes as silicone sheets and as a covering to foam dressings. These prevent movement of the dressing pad across the wound, therefore minimising damage to scar tissue and the granulation bed, while allowing the properties of the foam pad to remain effective
- Super absorbents, as the name suggests, absorb a lot of fluid so they are good for highly exudative wounds. They are also great for covering the end of a Penrose drain to minimise risk of ascending infection, and to reduce the mess in the owners’ homes
- Perforated polyurethane membranes are dressings such as melolin and rondopads. These have none of the properties to maintain moist wound healing and as such should only be used to cover wounds which are surgically sutured closed
- The properties of hydrogel keep an area moist which is great to encourage granulation and proliferation of a wound
- Medical grade honey (most commonly manuka honey is used) works wonders as a debriding agent due to its high osmotic power. It is crucial that the honey is medical grade to ensure it is treated and filtered
After you have applied your knowledge, selected the correct dressing and applied a bandage, what happens next?
That may sound like a silly question, but our job is not over after applying the bandage or dressing; we have to ensure that the caregiver of the animal is educated on the care needed for that bandage going forward.
I strongly believe it should be protocol in all practices that on discharging a bandaged patient, the owner is given a bandage care form. This will detail things such as what to do if the bandage slips, if the bandage gets wet and if the pet starts chewing the bandage, as well as informing them to monitor for strike through, plus more essential information.
This is crucial for the health and well-being of our patients, and it is important in these times to remember that we need to educate owners, to ensure the safety of our patients. Figure 1 showcases an example of a “home-made” bandage applied by an owner who was not educated on how to care for the bandage or what to do if it came off: you can see masking tape, tied knots and a very uneven bandage, all of which carry huge risks of bandaging injuries.