Journal of Gerontological Nursing

SKIN CARE FOR OLDER ADULTS 

WOUND CLEANSING

Evonne Fowler, MN, RN, ET

Abstract

All wounds need to be cleansed, some need to be debrided. Requirements for wound cleansing vary according to the wound's environment. Whether a wound is the result of trauma or surgery, it can be considered clean, contaminated or infected. Assessment of the wound's appearance, drainage and odor dictates how the wound should be cleansed.

Clean Wounds

A clean wound is one made under aseptic conditions or when the skin remains intact. It contains no gross dirt or foreign materials and for all practical purposes is free of bacteria. Clean wounds require regular cleansing with soap and water. No antiseptics are necessary. A bath, shower or whirlpool bath will be sufficient to cleanse the skin. Skin cleansers are recommended over soaps as they neutralize the body's drainage, emulsify fats crusted on the skin and cut odors. Soaps are usually alkaline and leave a residue on the skin.

Open Wounds

All open wounds are considered contaminated. The difference between a contaminated and infected wound is the concentration and virulence of the bacteria and their ability to overwhelm local defenses causing a systemic response to occur. Open wounds can be cleansed and closed by surgical procedure, but most heal by secondary intention.

Traditionally, antiseptic solutions have been used to clean superficial and deep open wounds. Hydrogen peroxide and povidone iodine (Betadine®) are favorite wound cleansing agents. Hydrogen peroxide is an oxidizing agent and mechanically cleans wounds by its effervescent action. The therapeutic merit of iodine-containing solutions in wound cleansing has been questioned. Authorities and government panels' have concluded that iodine preparations are not appropriate treatments for wounds. Studies have shown detrimental effects of iodine containing solutions in wounds and questional antimicrobial activity in the presence of organic wound fluid and debris. ". . . it offered no therapeutic benefit when compared with control wounds treated with saline solution."1

Open wounds with a pink healthy surface of granulation tissue with no evidence of necrotic debris need only to be washed with soap and water or irrigated with copious amounts of water. Gentle wiping with a soft gauze will not disturb the newly formed granulation tissue.

Open wounds with necrotic debris need to be debrided of all dead tissue. This can be accomplished in several ways; surgical, chemical or mechanical.

Surgical debridement is the most rapid means of removing the necrotic debris. A scapel, scissors or laser is used to remove eschar and slough until healthy tissue is exposed. Subsequent surgical removal of debris may be necessary to prepare the wound for granulation and reepithel ialization.

Chemical debridement or enzymatic agents are used to liquefy the necrotic tissue and Iy se it from the wound. Results can usually be seen within 3-14 day time frame depending on the appearance of the wound. Enzymatic agents need to be used according to the manufacturers instructions. Wounds often appear larger after debridement because all the necrotic tissue has been removed.

Mechanical debridement is the removal of necrotic debris by scrubbing with loosely woven gauze or a brush. Applying wet to dry dressings to the wound is a common procedure used for debridement. The gauze is opened to its largest size and packed loosely into the wound filling only the open wound with the wet gauze. A dry dressing covers the wet one. The dressing is allowed to dry for four to eight hours and then removed. As the dressing dried, it would adhere to the wound surface and, upon removal, debride the dead tissue. This method, however, débrides and abrades viable tissues as well.

Moist dressings (wet to wet) are also used to cleanse and debride open draining…

All wounds need to be cleansed, some need to be debrided. Requirements for wound cleansing vary according to the wound's environment. Whether a wound is the result of trauma or surgery, it can be considered clean, contaminated or infected. Assessment of the wound's appearance, drainage and odor dictates how the wound should be cleansed.

Clean Wounds

A clean wound is one made under aseptic conditions or when the skin remains intact. It contains no gross dirt or foreign materials and for all practical purposes is free of bacteria. Clean wounds require regular cleansing with soap and water. No antiseptics are necessary. A bath, shower or whirlpool bath will be sufficient to cleanse the skin. Skin cleansers are recommended over soaps as they neutralize the body's drainage, emulsify fats crusted on the skin and cut odors. Soaps are usually alkaline and leave a residue on the skin.

Open Wounds

All open wounds are considered contaminated. The difference between a contaminated and infected wound is the concentration and virulence of the bacteria and their ability to overwhelm local defenses causing a systemic response to occur. Open wounds can be cleansed and closed by surgical procedure, but most heal by secondary intention.

Traditionally, antiseptic solutions have been used to clean superficial and deep open wounds. Hydrogen peroxide and povidone iodine (Betadine®) are favorite wound cleansing agents. Hydrogen peroxide is an oxidizing agent and mechanically cleans wounds by its effervescent action. The therapeutic merit of iodine-containing solutions in wound cleansing has been questioned. Authorities and government panels' have concluded that iodine preparations are not appropriate treatments for wounds. Studies have shown detrimental effects of iodine containing solutions in wounds and questional antimicrobial activity in the presence of organic wound fluid and debris. ". . . it offered no therapeutic benefit when compared with control wounds treated with saline solution."1

Open wounds with a pink healthy surface of granulation tissue with no evidence of necrotic debris need only to be washed with soap and water or irrigated with copious amounts of water. Gentle wiping with a soft gauze will not disturb the newly formed granulation tissue.

Open wounds with necrotic debris need to be debrided of all dead tissue. This can be accomplished in several ways; surgical, chemical or mechanical.

Surgical debridement is the most rapid means of removing the necrotic debris. A scapel, scissors or laser is used to remove eschar and slough until healthy tissue is exposed. Subsequent surgical removal of debris may be necessary to prepare the wound for granulation and reepithel ialization.

Chemical debridement or enzymatic agents are used to liquefy the necrotic tissue and Iy se it from the wound. Results can usually be seen within 3-14 day time frame depending on the appearance of the wound. Enzymatic agents need to be used according to the manufacturers instructions. Wounds often appear larger after debridement because all the necrotic tissue has been removed.

Mechanical debridement is the removal of necrotic debris by scrubbing with loosely woven gauze or a brush. Applying wet to dry dressings to the wound is a common procedure used for debridement. The gauze is opened to its largest size and packed loosely into the wound filling only the open wound with the wet gauze. A dry dressing covers the wet one. The dressing is allowed to dry for four to eight hours and then removed. As the dressing dried, it would adhere to the wound surface and, upon removal, debride the dead tissue. This method, however, débrides and abrades viable tissues as well.

Moist dressings (wet to wet) are also used to cleanse and debride open draining wounds. The wet dressing against the wound surface softens the necrotic debris. Recently, absorbent gels/granules with hydrophilic compounds that attract fluid, bacteria and tissue debris and draw it up and away from the wound's surface, have been used for cleansing and healing wounds. These dressings do not adhere to the newly formed granulation tissue and avoid desiccation of the tissue.

Semipermeable transparent films and opaque occlusive wafers are also used to debride wounds. When applied over a wound, these dressings hold the wound fluid which contains living neutrophils and lymphocytes within the wound facilitating phagocytosis and liquification of the necrotic debris. Studies have shown that bacteria proliferate beneath these types of dressings however, large numbers of normal skin flora do not interfere with the reepithelialization of wounds. One must be alert to the possibility of gram negative infections since the conditions in the wound bed beneath these dressings favor the growth of gram negative organisms.

Choosing the appropriate method of wound cleansing is a clinical judgement based on the assessment of the wound surface, color, drainage and odor.

Reference

  • 1 . Rodeheaver G, Bellamy W, Kody M, et al. The bactericidal activity and toxicity of iodine containing solutions in wounds. Arch Surg 1982; 117(Febcuary):l8l-l86.
  • Bibliography
  • Mertz P, Alvarez O, Smerbeck R, Eaglstein W: A new in vivo model for the evaluation of topical antiseptics on superficial wounds. Arch Dermatol 1984; 120(Jan):58-62.
  • Mertz P, Eaglstein W: The effect of a semiocclusive dressing on the microbial population in superficial wounds. Arch Surg 1984; 119 (March):287-289.
  • Yarkony G, Lukanc C, Carle T: Pressure sore management: Efficacy of a moisture reactive occlusive dressing. Arch Phys Med Rehabil 1984; 65(October):597-600.

10.3928/0098-9134-19850801-16

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