World Council of Enterstomal Therapist

Nursing ( WCET )
Ns Asmat Burhan S.Kep., WOC (ET) N
 WORKSHOP
APPLICATION MODERN DRESSING
And Documentation

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HOW TO DRESS

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 Issues in Wound Care
Infection Control
Debridement
Exudate Management
Negative Pressure Drainage
Maintaining moist environment
Pain Management
Odor Control
pH Acidification
SAFETY PRODUCT

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 WOUND MANAGEMENT PRINCIPLES
Control or eliminate causative factor
Pressure, shear, friction, moisture, circulation
impairment, neurophaty
Provide systemic support to reduce existing
and potential co-factors
NUTRITIONAL, FLUID SUPPORT, EDEMA,
CONTROL SYSTEMIC CONDITION
Maintain physiologic local wound environment
Prevent and manage infection
Cleanse wound
Debridement
Moisture balance
Odor control
Eliminate or minimize pain
Protect periwound skin

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 DRESSING SELECTION
What is the action of this dressing?
When should it be used?
Are there any contra-indications to its
use?
Do I know the method of application
and removal?
Is a secondary dressing required ?
If yes which dressing is appropriate ?
The application of an inappropriate
secondary dressing may adversely affect
the ability of the primary dressing to
function correctly.

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 Tujuan pemilihan balutan
1. membuang jaringan mati, benda asing dan
partikel
2. balutan dapat mengontrol kejadian infeksi /
melindungi luka dari trauma dan invasi
bakteri
3. mampumempertahankan
kelembaban
4. mempercepat proses penyembuhan luka,
5. absorbs cairan luka
6. nyaman digunakan, mengurangi nyeri,
7. Proteksi periwound
8. Kontrol bau, .

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DRESSING PROCESS

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HISTORY

Sebelum th 1980 an, kassa

masih menjadi unggulan
balutan
Setelah th 1980, perubahan
dramatis dgn berbagai jenis
balutan yg mendukung konsep
MOISTURE
BALANCE
Saat ini lebih dari 3500 jenis
balutan ada di dunia
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DRESSING / BAHAN BALUTAN
Gauze / kasa
Transparant film
Hidrogels
Hydrokoloid
Calsium alginate
Collagen
Polyurethane foam
Hydrophobic
Silver
Zink cream: Metcovazin
Fixasi

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 CARA MEMBALUT LUKA

BALUTAN BALUTAN
PRIMER SEKUNDER

BALUTAN
LUKA

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 DRESSING
CONVENTIONAL DRESSING EVIDENCE BASE DRESSING

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Description
Alginate dressings are produced from the calcium and sodium salts of
alginic acid, a polymer obtained from seaweed that is composed of
mannuronic and guluronic acid residues. In the presence of exudate the
fibres absorb liquid and swell causing the dressing to take on a gel-like
appearance. This overlays the wound and provides a micro-environment that is
believed to facilitate wound healing.
Whilst in theory all calcium alginate products have haemostatic properties, not
all companies have included this in their information. If choosing an alginate for
this specific property the clinician should ensure the dressing has this licensed
indication.

MANAGE WOUND EKSUDATE AND STOP BLEEDING

ALGINATES Primary dressing for management of heavily exuding wounds,
Warnings
Do not leave on longer than 7 days.
Cavities should be packed loosely - DO NOT pack tightly.
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Description
Hydrogels contain insoluble polymers which swell and increase in
volume, until saturated, facilitating epithelialisation by maintaining a
moist environment on the surface of the wound.
Some hydrogel sheets are available which have a fixed structure.
Indications
May be applied to many wound types including dry, sloughy or
necrotic wounds and are particularly useful for cavity wounds.
May be used for infected wounds (except sheets) - systemic antibiotics
may be appropriate.

HYDROGEL
Contraindications
Wounds producing excessive amounts of exudate may dilute and remove gel from wound onto
secondary dressing. Sheets have limited fluid handling capacity.
Do not use where anaerobic infection is suspected, may support growth of micro-organisms.
Some gel contains Propylene Glycol a potential sensitising agent. Discontinue treatment if signs of
adverse reaction develop.
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Drescription
Allevyn foam dressing consists of a layer of hydrophilic polyurethane foam
bonded to a pink semi- permeable polyurethane film. This pink layer should be uppermost
with cream layer in contact with skin. The film is permeable to moisture vapour but provides
an effective barrier to water. It also prevents the passage of micro-organisms through the
back of the dressing. The wound contact surface of the dressing is covered with a
perforated film preventing adherence to granulation tissue.
Lyofoam consists of a soft, hydrophobic, open-cell polyurethane foam sheet approximately
8mm thick. The dressing contact layer (shiny side) has been heat treated to collapse the
foam cells enabling liquid absorption by capillarity. The dressing is permeable to gases and
water vapour but resists the penetration of aqueous solutions and wound exudate.

POLYURETHANE FOAM DRESSING

Contra-indications
Not indicated for use on dry wounds covered with a scab or necrotic tissue. The necrosis should first
be removed, if clinically indicated, prior to application of foam. 15
Description
NA ultra consists of a knitted open structure made from continuous monofilament viscose yarns onto which has been polymerized a
silicone coating. The dressing acts as a low adherence primary wound contact layer that can be easily removed from wound surface
without causing pain or trauma. The silicone coating does not occlude the pores of the fabric but allows free drainage of exudate from
the wound, thus preventing tissue maceration.
Indications
NA ultra is indicated for the management of clean, lightly exuding, superficial wounds ie leg ulcers, pressure ulcers, burns, cuts and
abrasions. Prevents adherence of dressing to wound bed reducing trauma and pain at dressing change. Its non adherent properties
reduce the risk of damage to new capillary loops of granulation tissue.
Contra-indications
Allergy to silicone (use NA dressing instead).

NON OR LOW ADHERENT DRESSING /SILLICON

Silicone gel sheets are indicated to prevent or improve the appearance of old and new
hypertrophic and keloid scars. 16
Description
Based on Carboxymethylcellulose and other polysaccharides and proteins, i.e. gel
forming agents with elastomers and adhesives. On contact with wound exudates,
the polymers absorb water and swell. A gel is formed which remains in contact
with the wound surface and these moist conditions promote fibrinolysis,
angiogenesis and wound healing without causing maceration. This has a
characteristic odor but is easily washed off with warmed saline.

HYDROCOLLOID
Contraindications
Known sensitivity to the hydrocolloid or its components.
Do not use on clinically infected wounds. Also if the dressing has to be changed more regularly than every 3 days - this is probably
not the most suitable dressing.
Warnings
Inappropriate or too frequent dressing changes may result in skin irritation or stripping. Hydrocolloids may not be acceptable to
vegans due to constituents. 17
Collagen dressings are sheets, pads, particle and gels derived from type I bovine, type III porcine or avian
sources of collagen. These dressings encourage the deposition and organization of newly formed collagen fibers and
granulation tissue in the wound bed.
Collagen dressings are indicated for use as a primary dressing in the treatment of partial- and full-thickness wounds such as skin
grafts, donor sites, surgical wounds, tunneling wounds, infected and non-infected wounds and wounds with minimal to heavy
exudate (depending on the form of the dressing).
Collagen dressings are generally contraindicated for dry wounds and third-degree (full-thickness) burns, and in
patients with sensitivities to collagen or bovine products.

COLLAGEN DRESSING
The following general warnings apply to collagen-based dressings. Always refer to manufacturer information
for Warnings and Precautions for a specific product.
Require a secondary dressing. Not recommended for necrotic wounds. May require rehydration on
removal.
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ZINC CREAM
Topical zinc is widely used in wound treatment although the beneficial effect of zinc has only been
documented in zinc-deficient patients who were given zinc orally. The main purpose of this study was to
investigate the effect of topically applied zinc on leg ulcer healing and examine its effect on some
mechanisms in wound healing using standardized animal models. Additionally, absorption of zinc into
wounds and intact skin treated topically with zinc was studied. topical zinc may stimulate leg ulcer healing by
enhancing re-epithelialization, decreasing inflammation and bacterial growth. When zinc is applied on
wounds it not only corrects a local zinc deficit but also acts pharmacologically.

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 DUA MINGGU YANG BERHARGA
1. MEMBAIK, masih disertai tanda dan gejala infeksi

2. MEMBAIK, tanda dan gejala infeksi berhenti

3. TIDAK MEMBAIK,
STOP penggunaan, evaluasi untuk penggunaan silver dressing
lainnya dengan atau tanpa AB sistemik

SILVER DRESSING

Description
Silver containing products are impregnated with silver metallic ions. When these products are placed on a wound
the silver is activated and becomes antimicrobial. It originally came in the form of silver sulphadiazine cream but is
now available in the form of impregnated dressings. It may act in one of two ways over a period of time:
deliver ionic silver to the wound, targeting bacteria
absorb infected matter and expose it to ionic silver within the dressing
These dressings can be placed directly onto the wound bed. Frequency of dressing change varies between products.
Pure elemental silver is inactive but silver ions are highly reactive. Silver is continuously available when the dressing
is in place. This provides an antimicrobial barrier, protecting the wound.
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Description. Iodoflex consists of individual applications of a cadexomer
iodine paste consisting of a macrogol ointment base incorporating
sterile, yellow-brown microspheres or beads 0.10.3 mm in diameter.
The beads, which are formed from a three-dimensional network of
cadexomer - a chemically modified starch, contain elemental iodine
within their structure. The paste is presented between two layers of
gauze fabric which act as carriers and facilitate application. In the
presence of aqueous solutions or wound fluid, the beads in the paste
take up liquid and swell, slowly releasing the iodine, which imparts
antibacterial properties to the dressing.

Warnings
Iodine is absorbed systemically especially when
applied to large wounds and therefore Iodoflex
should be used with care on patients who have a
history of thyroid disorders.
There is a potential interaction of iodine with lithium
and therefore co-administration is not recommended.
Iodoflex should not be used on dry wounds. CADEXOMER IODINE
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DescriptionSterile larvae for wound management come from the greenbottle Lucilla Sericata. In optimum conditions
they produce powerful proteolytic enzymes breaking down necrotic, sloughy tissue. The larvae subsequently ingest
this degraded, liquefied tissue as a source of nutrient. When initially applied to the wound the larvae are just 2-3mm
in length. On removal from a necrotic wound their size may be increased to 8-10mm in length.
IndicationsSterile larvae are suitable for use on a variety of sloughy necrotic wounds that require debridment.
Infected, malodorous wounds are also indicated as larvae combat odour while ingesting and killing bacteria present in
the wound.
ContraindicationsLarvae should not be applied to wounds close to large blood vessels, bleeding wounds or wounds
that communicate with a body cavity or internal organ.
Warnings If the larvae cause bleeding in the wound the treatment should be removed and the wound reassessed.
Pain associated with the larvae should result in treatment being discontinued.

LARVAE THERAPY / MAGGOTS

Storage
Larvae should be used within 12 hours of receipt. If the time delay between receipt and use is
longer the larvae should be stored in a cool, dark place at a temperature of 8-10 degrees. Sterile
saline should be added to the bag containing the larvae vial for storage to prevent the larvae 22
drying out.
Vacuum assisted closure (also called vacuum therapy, vacuum sealing or topical negative pressure therapy) is a sophisticated
development of a standard surgical procedure, the use of vacuum assisted drainage to remove blood or serous fluid from a wound or
operation site.
A piece of foam with an open-cell structure is introduced into the wound and a wound drain with lateral perforations is laid on top of it.
The entire area is then covered with a transparent adhesive membrane, which is firmly secured to the healthy skin around the wound
margin. When the exposed end of the drain tube is connected to a vacuum source, fluid is drawn from the wound through the foam into
a reservoir for subsequent disposal.
The plastic membrane prevents the ingress of air and allows a partial vacuum to form within the wound, reducing the volume of the foam
and facilitating the removal of fluid. The foam ensures that the entire surface area of the wound is uniformly exposed to this negative
pressure effect, prevents occlusion of the perforations in the drain by contact with the base or edges of the wound, and eliminates the
theoretical possibility of localised areas of high pressure and resultant tissue necrosis.

VAC OR NPWT
Contraindications
Fistulas to organs or body cavities Necrotic tissue in eschar Osteomyelitis (untreated) Malignancy in the wound
In addition, and for obvious reasons, special precautions should be observed when using the technique where haemostasis is difficult,
in the presence of active bleeding or in the treatment of patients receiving anticoagulant therapy.

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Honey is naturally antimicrobial and a preferred treatment application
because it does not possess the same toxicity as ionic silver. Additionally,
MEDIHONEY has been used successfully along with other advanced wound care
modalities, including being used before, during, and after negative pressure
applications, as well as being used as cover dressings for skin grafts and skin
substitutes.

HONEY
MEDIHONEY dressings, a unique line of dressings by Derma Sciences containing active Manuka
(Leptospermum scoparium) Honey from New Zealand, possess unique qualities that make them ideal
for the management of chronic and acute wounds and burns. A strong and growing evidence base
including several large scale randomized controlled studies have shown that MEDIHONEY dressings
are effective on hard-to-heal wounds and burns, in addition to helping to debride wounds and keeping
wound beds clean of necrotic tissue.
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when microorganisms come into close contact with DACC, they
become irreversibly bound to the dressing as a result of hydrophobic
interaction. Once bound
to the dressing these microorganisms are rendered inert and prevented from
reproducing or releasing harmful toxins3. The hydrophobic microorganisms are then
removed with each dressing change, helping to reduce the bacterial load in the
wound bed and leaving the non-hydrophobic microorganisms to stimulate healing3-
7.

DACC (Dialcylcarbamoxyl chloride)

In-vitro testing and studies using a simulated moist wound environment have shown that the use of a hydrophobic
dressing (Cutimed Sorbact) can reduce microbial load in
a wound3. The DACC-coated dressing demonstrated a binding action to common wound pathogens, including
Staphylococcus aureus, Pseudomonas aeruginosa and Candida albicans and was found to be most effective in
wounds with moderate to high levels of exudate3. In addition, Cooper and Jenkins20 have demonstrated a
potential role for DACC in the management of biofilms and multi-resistant organisms.
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Gauze has been used as a wound dressing for centuries, and continues to be the most readily
available wound dressing in use today. A wide variety of gauze dressings are available, with
choices to be made between sterile and non-sterile types, gauzes with and without an adhesive
border, and woven and non-woven gauze dressings. Woven gauzes are manufactured from
cotton yam or threads and woven like fabric. Non-woven gauzes are usually manufactured from
synthetic fibers, which are pressed together to give the appearance of a woven fabric. Gauze may
be used as a primary or secondary wound dressing.

GAUZE
Impregnated-gauze dressings may be used as a contact layer on granulating wounds. Despite the ongoing popularity
of gauzes, these dressings have a number of significant drawbacks. Woven gauze may traumatize the wound bed on
removal, or leave residue in the wound bed that may result in inflammatory response, or the formation of a
granuloma. Finally, as gauze is highly permeable and relatively non-occlusive, gauze dressings may promote
desiccation in wounds with minimal exudate unless used in combination with another dressing or topical agent.
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Transparent filmdressings are thin, flexible sheets of clear polyurethane
incorporating an adhesive coating on one side to allow adherence to the
skin. The adhesive reacts with wound fluid to prevent adhesion to the
wound bed, while allowing the dressing to stick to the dry, periwound
skin. Film dressings are highly elastic and conformable to body contours,
and are suitable for use either as a primary or secondary dressing. The
transparent quality of film dressings allows useful visualization of the
wound bed.

TRANSPARANT FILM DRESSING

They are permeable to water vapor, oxygen, and carbon dioxide, but impermeable to bacteria and water. This
means that oxygen is allowed into the wound to promote healing, while the water vapor and carbon dioxide
produced are allowed to escape. The dressing also acts as an effective barrier to water and bacteria. It is this semi-
permeable nature of transparent film dressings that helps them achieve lower overall infection rates than
traditional gauze dressings. 29
ISLAND DRESSING

Gauze dressings continue to be the most readily available wound dressings in use today. Gauze is highly permeable
and relatively non-occlusive. Therefore, gauze dressings may promote desiccation in wounds with minimal exudate
unless used in combination with another dressing or topical agent. Gauze may be used as a primary or secondary
wound dressing. Gauze dressings are inexpensive for one-time or short-term use. Gauze dressings come in many
forms: squares, sheets, rolls, and packing strips.
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 HIGHLY ABSORBENT DRESSING

GOLD DUST
Gold Dust hydrophilic polymer wound
filler is an exceptionally high absorber.
PREMIUM PRODUCT Recommended only for highly exudating
wounds. Tends to inhibit bacterial
proliferation.
When managing moderate to low
exudating wounds, one must pre-
moisten the Gold Dust granules to
form a gel to avoid over-drying the
tissue. Because of the high absorption
capacity of the product, even the Gold
Dust as a pre-moistened gel can cause
a painful burning or stinging sensation
for the patient. Often the pain will go
away after 10 to 30 minutes. However, in
some cases additional measures must be
used to prevent or reduce this burning
from occurring.

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TAPE - FIKSASI

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GENTLE ANTISEPTIC

The antiseptic agent polyhexamethylene biguanide (also known as polihexanide or PHMB) has been
used for over 60 years in a wide range of applications from swimming pool sanitisers to preservatives
in cosmetics and contact lens solutions. In Europe, it has been available as a wound irrigation fluid for
some time. PHMB is a fast-acting biguanide compound composed of a synthetic mixture of
polymers.The compound is structurally similar to the antimicrobial peptides (AMPs) produced by many
cells within the wound, such as keratinocytes and inflammatory neutrophils, where they are thought
to help protect against infection (Sorensen et al, 2003; Ousey and McIntosh, 2009). AMPs have a broad
spectrum of activity against bacteria, viruses and fungi, inducing cell death by disrupting cell
membrane integrity (Ikeda et al, 1983; Ikeda et al, 1984; Moore and Gray, 2007;). 33
Highly absorbent dressing (Foam)

Menyerap banyak eksudat mempertahankan tingkat

kelembaban luka secara optimalLembut dan nyaman

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 Anti infective dressing
Cadexdomer iodine dressing
Sebagai agen antibakteri dan desinfektan kulit.
Diindikasikan sebagai terapi topical pada luka eksudatif kronik
Memiliki efek samping berupa diskolorasi kulit
Menyerap eksudat, menghilangkan jaringan nekrotik kekuningan (slough),
serta menghilangkan bau
Tidak boleh diberikan pada pasien dengan hipersensivitas terhadap iodine

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Teknologi for Wound Managamen

Infrared
Ozone
Hydropresure
ABPI
Stimulasi Elektrik
Debridement Ultra Sound

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Documentation

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NURSE PRESCRIPTION
PENULISAN
TOPIKAL THERAPY
DALAM BENTUK
NOTA ORDER (
on/ )

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EXAMPLE CASE

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 Kesimpulan
Penggunaan ilmu,Modern Dressing teknologi serta inovasi produk perawatan luka

dapat memberikan nilai optimal jika digunakan secara tepat

Prinsip utama dalam manajemen perawatan luka adalah pengkajian luka yang

komprehensif agar dapat menentukan keputusan klinis yang sesuai dengan

kebutuhan pasien

Peningkatan pengetahuan dan keterampilan klinis diperlukan untuk menunjang

perawatan luka yang berkualitas dengan harapan dapat sesui dengan cost

effective.

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 REFRENCY
1. Hampton BG, Bryant RA. Ostomies & Continent Diversions :
Nursing Management. 1st Ed. United State of America (St.
Louis). Mosby Year Book Inc. 1992. p 42-64.
2. WCET Journal
3. Primary intention international Australian
4. Australia-Canada-Malaysia-Singapore-Indonesian journal of
Wound management
5. Ostomy/Wound Management Journal of extended patient
care management
6. WOCN,WUWHS,AWM Journal
7. Journal of stomal therapy Australian (JSTN)

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