Your browser is no longer supported

For the best possible experience using our website we recommend you upgrade to a newer version or another browser.

Your browser appears to have cookies disabled. For the best experience of this website, please enable cookies in your browser

We'll assume we have your consent to use cookies, for example so you won't need to log in each time you visit our site.
Learn more

Practical issues in the management of highly exuding wounds

  • Comment

Irene Anderson, BSc Hons, DPSN, RN.

Senior Lecturer, Tissue Viability, University of Hertfordshire, Hatfield, Hertfordshire

The management of highly exuding wounds poses a considerable challenge. Manufacturers are responding to clinical need with a range of products that are effective, to varying degrees, as long as their limitations are recognised. It helps to consider the product being used in light of the exudate characteristics - volume, viscosity and direction of flow.

 

The management of highly exuding wounds poses a considerable challenge. Manufacturers are responding to clinical need with a range of products that are effective, to varying degrees, as long as their limitations are recognised. It helps to consider the product being used in light of the exudate characteristics - volume, viscosity and direction of flow.

 

 

High levels of exudate cause anxiety and discomfort to patients. Manufacturers of dressings, drainage devices and skin-protection products have responded to the needs of patients and health-care professionals to a certain degree. Water and fluid handling are the centre of many advertisements for products. Although manufacturers aspire to deal with the problem, dressings are only part of the story. A dressing’s ability, however technologically advanced, to cope with high volumes of fluid remains disappointing.

 

 

This is the third in a series on exudate management. The first (Fletcher, 2002) considered the components of exudate and its presentation and the second (Cutting and White, 2002) detailed the need to protect the skin surrounding wet wounds and the structure of a range of dressings designed to handle fluid. This paper considers the practical aspects of managing fluid. It reinforces the need to understand the tools we have to address it, and to take into account the limitations we inevitably impose on such devices.

 

 

A myriad of wound types and circumstances are implicated in the production of high volumes of exudate - large wounds, deep wounds, fistulae, wounds with a sinus, infected wounds (Dealey, 2000) and those associated with limb oedema. Large wounds may produce high levels of exudate because of their surface area rather than over-production of fluid (Thomas, 1997). High levels of exudate have implications for health-care professionals, patients and their carers (Box 1).

 

 

Professionals
Highly exuding wounds require high levels of care, in particular repeated dressing changes. Whether this is done in a clinic, ward, or at the patient’s home, the economic costs and time commitment are considerable. The challenges of trying to deal with this type of wound also take its toll on the relationship the patient has with the health-care professional. The costs of dressing materials, skin protection, analgesia and possible antibiotics adds a significant economic toll (Robinson, 1997).

 

 

Patients
For patients and carers there is discomfort, skin breakdown, social implications and economic costs, as footwear, clothing and furnishings may be affected. Laundry costs are significant, particularly for people who do not have easy access to modern washing-and-drying facilities. The social implications and quality of life issues are huge and often underestimated (Ryan, 1997).

 

 

Addressing the problem
There is an important distinction between ‘mopping up’ exudate as an end in itself and handling exudate while trying to address the cause of the fluid production. Exudate generally decreases relative to the decrease in wound size as healing occurs (Morison et al, 1997). Similarly, as dependent oedema is counteracted by limb elevation and compression therapy, where appropriate, fluid output from the wounded limb should reduce. In these scenarios high exudate levels are often temporary.

 

 

Sometimes increased exudate levels are a response to clinical infection, which may take some time to control. Appropriate use of systemic antibiotics may be indicated, and in some cases the judicious use of topical antimicrobials such as iodine or silver (White et al, 2001). This has been revisited in recent wound-care practice, bolstered by modern products that exhibit more controlled and controllable release effects, albeit with cautious use (Lansdown, 2002).

 

 

Practical issues
Dressings are the main way to deal with fluid, and understanding how they work can help lead to more rational choices. Some dressings designed for highly exuding wounds rely on simple absorbency. Technology has resulted in a variety of fluid-handling designs, such as vertical or lateral wicking, which maximises the amount of absorbent surface area, or moisture vapour transmission rate, which allows extra capacity by evaporation of fluid.

 

 

Some evidence shows the action of back pressure on capillaries slows exudate production (Thomas et al, 1996). This is because the pressure of fluid building up under the dressing equals the capillary pressure, therefore exudate production is inhibited. But this work was carried out using hydrocolloid dressings, which are not indicated for highly exuding wounds (Jones and Milton, 2000a).

 

 

Health professionals using a product are responsible for familiarising themselves with the instructions for use. This not only ensures patient safety and professional protection, but also optimises the product’s effect. It is unfair on manufacturers and their products if a device is used for a purpose for which it is not designed. Without understanding how a product handles fluid, the user may be disappointed in the outcome, resulting in the dressing not being used again, when in fact it was indicated for a very different wound environment.

 

 

Many manufacturers now have a range of products indicated for different fluid levels, with names such as ‘Lite’, ‘Thin’, ‘Extra’ and ‘Plus’. Just as in the estimation of exudate levels (Fletcher, 2002), ascertaining fluid-handling capacity is a subjective process. Manufacturers rarely place a precise figure on the fluid capacity of dressings.

 

 

Devices such as a negative pressure device with a collection chamber (Banwell, 1999) or a drainage pouch designed primarily for people with an ostomy, mean fluid can be measured with a fair degree of accuracy. Trials that compare the wear time of dressings for highly exuding wounds rarely show clinically significant differences, and are of limited use when comparing different dressing groups. Often, absorbency is a subjective measure by the clinical investigator (Banks et al, 1997). Highly exuding wounds can produce significant amounts of fluid beyond the capacity of dressings (Thomas et al, 1996). Recommended wear times are indicated on dressing pack inserts and often raise wry smiles from practitioners struggling to change dressings three or four times a day.

 

 

Exudate varies widely in its content and viscosity (Fletcher, 2002), which impacts on how it may be absorbed. Practically, bandages, additional padding, clothing and other barriers to fluid evaporation will influence the action of absorption. In the case of a dressing that works by moisture transmission it will only be as effective as the environmental circumstances for that transmission. In the real clinical situation bandages need to be applied, clothing worn and patients must be able to sit or lie as appropriate. As long as the carer is aware of the limitations that must be placed on a dressing and the impact this may have on the performance then the case for ‘blaming’ the dressing for disappointing fluid control is less valid. When the limitations are taken into account then any relative merits of the product such as reduced dressing changes, pain reduction and skin protection must be weighed against disadvantages such as reduced fluid handling.

 

 

Effective use of products
A common mistake with dressing use is to underestimate the effect of applying tapes and additional dressings over primary dressings, which may block moisture transmission (Jones and Milton, 2000a). Another problem is the use of amorphous hydrogel dressings on heavily exuding wounds. This practice becomes apparent when talking to practitioners or listening to questions asked of company representatives. The connection is sometimes made that hydrogels are indicated mainly for use on sloughy and necrotic tissue (Jones and Milton, 2000b). However, if the wound is also wet, then the addition of a product consisting mainly of water will merely add to the fluid levels. This seems rather an obvious effect but often in a rushed and pressured clinical environment such reflection is not always exercised.

 

 

The mode of action of alginates, and other primary dressings, can be affected by the application of creams or ointment directly to the wound bed, or wound edges, as these can block the passage of exudate into the dressing structure. That such elementary mistakes and misunderstanding occur has been the subject of some debate and discussion (Hollinworth, 2002), where the repercussions for patients can fundamentally impact on their confidence in the health professions and can be at odds with professional accountability, which demands protection of patients and positive promotion of benefit (Nursing and Midwifery Council, 2002).

 

 

Secondary dressings
Secondary dressings are particularly important in the management of highly exuding wounds. Many primary dressings used to control fluid, such as alginates and hydrofibres, require an additional dressing. The choice of secondary dressing depends on the clinical circumstances. In the case of very wet wounds the reality is that the dressing will have to be changed frequently even with very effective products. It makes sense, therefore, to select a secondary product that strikes a balance between additional fluid handling and cost. Both of these considerations must be weighed against the imperative of protecting the surrounding skin (Cutting and White, 2002). If a dressing is changed frequently it is less likely to exert a detrimental effect on periwound skin. This is not to advocate routine frequent dressing changes, but rather to promote the targeted use of such a regimen in highly exuding wounds until such times as the fluid levels reduce. Sometimes additional absorbency is afforded by orthopaedic wadding, but it must be remembered that these products are not designed as primary dressings and have no capacity to keep fluid off the skin.

 

 

Dressings that give additional absorbency also add bulk, which may complicate patients’ lives further by interfering with practical issues such as wearing shoes. Secondary dressings such as absorbent pads are generally made from cotton or viscose and these fibres must not be allowed to become incorporated into the wound (Flanagan, 1997). A Value for Money Unit report (1997) found that more than 13 metric tonnes of absorbent cotton are prescribed annually in Wales. This equates to 26 000 rolls of Gamgee padding!

 

 

Thomas (1998) explores a range of secondary dressings, highlighting their usefulness and precautions to be taken with traditional absorbent padding. He also considers the use of modern dressing products such as hydrocolloids and foam dressings. These dressings can sometimes offer benefits in addition to simple absorption such as bacterial barriers and protection to the periwound area, dependent on the characteristics of the particular dressings. The combination of two ‘modern’ dressings would have to be considered relative to the cost/benefit ratio in the clinical area (Robinson, 1997). The use of a simple secondary dressing and creative use of fixings such as light net retention products may enable patients and carers to participate in dressing changes to optimise patient comfort and skin protection.

 

 

There are many skin-care products now available such as barrier films, creams, paste bandages and dressings used as protectants on healthy skin. These products are a useful adjunct to good dressing selection. They do add to the cost of management but offset the cost of dealing with the complications, misery and logistics of dealing with the consequences of uncontrolled fluid.

 

 

Drainage devices
Black (1995) advocated that, when exudate exceeds 100ml in 24 hours, a drainage pouch should be considered (Figure 1). There are several of these and use is governed by the patient’s circumstances (Readding, 2002). The site of the wound is a limiting factor, it must be practical for a pouch to be fitted and have enough surrounding skin area to ensure adequate adherence. The size of the wound may govern the device. If required there are purpose-designed pouches with inspection portals for wounds. The Wound Manager (ConvaTec), for instance, accommodates wound dimensions of 21x21cm (Benbow, 2001). When dealing with highly exuding wounds the weight of the pouch when filled with fluid must be considered. Leaving a bag to fill in order to save visits or cost will result in a heavy, uncomfortable pouch with the risk of leakage and skin damage from pulling, and poor adherence. The bag would have to be emptied regularly. There is an option on drainable pouches to attach the bag to a night drainage system, which may ameliorate some of these issues but will of course be restricting for the patient. In cases where the exudate may be too thick for drainage taps then a drainable pouch closed by a clip will be more manageable and some pouches come with optional drainage methods (Readding, 2002).

 

 

The effectiveness of drainage pouches is dependent on the time and care taken to ensure a good fit. There are various pastes and fillers available to even out surrounding skin to ensure a leak-free seal. This situation illustrates the benefit of a multidisciplinary approach to wound management (and indeed stoma care) as professionals from both specialties work together to ensure effective care and skin protection for the patient (Benbow, 2001). Of course the use of drainage pouches is not practical in all wet wounds; for instance, in the case of an extensive ulcerated area or a sacral cavity wound when a patient is required to sit up for periods of time.

 

 

Cavity dressings
Cavity wounds are often managed by the use of cavity dressings such as foam, alginate or hydrofibre. Instructions for use of these products advocate that wounds are not packed tightly. Anecdotal evidence suggests that this still happens in some cases. These dressing materials absorb fluid by absorption and retention and, in so doing, expand and swell. Tight packing inhibits this action thereby reducing the absorption capacity of the dressing as well as causing unnecessary pressure on the wound and a plug effect as fluid builds up behind the dressing material.

 

 

Positioning and dressing size
As well as understanding the mode of action of dressings and other devices it is also important to reflect on practical issues surrounding product use. Consider the patient - the position they lay or sit in, their mobility and lifestyle. High levels of exudate, which are difficult to control, will result in fluid leaking from the wounded area. The direction of flow of this fluid will vary according to the position of the patient; therefore it would make sense to position the dressing relative to this (Figure 2). The bulk of the fluid-handling area of the dressing should be available to handle this escaping exudate.

 

 

A sufficiently large dressing should be selected to maximise absorption, albeit the size should not be so large that it results in wet dressing material coming into contact with good skin. It is for this reason that manufacturers place such emphasis on fluid ‘handling’, ‘control’ and ‘locking’. Effective dressing selection and use also centres on changing dressings before they leak to minimise discomfort for the patient and reduce the risk of infection due to strike-through of fluid (Morison et al, 1997).

 

 

Documentation
It is extremely useful if documentation captures information relevant to the exudate level and the capacity of the dressing or other device to handle this fluid. In light of the subjectiveness of exudate measurement in clinical practice (Fletcher, 2002) it may be useful to use more descriptive terms (Table 1). This includes the wound dimensions, the size of the dressing and how far the fluid has travelled within the time span. This may aid consideration of the dressing size and the best position to maximise the area of absorption.

 

 

Conclusion
Although there is a plethora of dressing products and devices available to aid in the management of particularly challenging highly exuding wounds, such tools have limitations and it is important to consider mode of action carefully before making a choice. It is important to read the indications and instructions for use, consider the wear time, the dressing/wound size ratio and the indicated exudate level. Position the dressing to take advantage of the available absorbing surface and ultimately take time to prepare the periwound area to maximise wear time of products, reduce costs and promote skin protection and patient comfort.

 

 

Manufacturers have responded to feedback and suggestions from practitioners and it is important that this continues to benefit patients and health-care professionals. In addition, it is vital that there are attempts at defining terminology in relation to measurement of wound fluid (Nelson, 1997) and clarification of the role of exudate and optimal levels within the context of wound healing.

 

 

 

 

Banks, V., Bale. S., Harding, K., Harding, E.F. (1997)Evaluation of a new polyurethane foam dressing. Journal of Wound Care 6: 6, 266-269.

 

 

Banwell, P.E. (1999)Topical negative pressure therapy in wound care. Journal of Wound Care 8: 2, 79-84.

 

 

Benbow, M. (2001)The use of wound drainage bags for complex wounds. British Journal of Nursing 10: 19, 1298-1301.

 

 

Black, P.K. (1995)Caring for large wounds and fistulas. Journal of Wound Care 4: 1, 23-26.

 

 

Cutting, K.F., White, R.J. (2002)Avoidance and management or peri-wound maceration of the skin. Professional Nurse 18: 1, 33-36.

 

 

Dealey, C. (2000)The Care of Wounds (2nd edn). London: Blackwell Science.

 

 

Flanagan, M. (1997)Wound Management. London: Churchill Livingstone.

 

 

Fletcher, J. (2002)Exudate theory and the clinical management of exuding wounds. Professional Nurse 17: 8, 475-478.

 

 

Hollinworth, H. (2002)Professional concerns in wound care. British Journal of Community Nursing 7: 9 (suppl), 36-42.

 

 

Jones, V., Milton, T. (2000a)When and how to use hydrocolloid dressings. Nursing Times 96: 4, 5-7 (Wound Care supplement).

 

 

Jones, V., Milton, T. (2000b)When and how to use hydrogels. Nursing Times 96: 23, 5-7 (Wound Care Supplement).

 

 

Lansdown, A.B.G. (2002)Silver 2: toxicity in mammals and how its products aid wound repair. Journal of Wound Care 11: 5, 173-177.

 

 

Morison, M., Moffatt, C., Bridel-Nixon, J., Bale, S. (1997)Nursing Management of Chronic Wounds. London. Mosby.

 

 

Nelson, E.A. (1997)Is exudate a clinical problem? A nurse’s perspective. In: Cherry, C., Harding, K. (eds). Management of Wound Exudate (Proceedings of the European Wound Management Association and European Tissue Repair Society Joint Meeting, Oxford). London: Churchill Communications.

 

 

Nursing and Midwifery Council. (2002)The Code of Professional Conduct. London: NMC.

 

 

Readding, L. (2002)Stoma appliances: what’s the choice? Journal of Community Nursing 16: 2, 26-32.

 

 

Robinson, B. (1997)The economics of failure to manage exudate. In: Cherry, C., Harding, K. (eds). Management of Wound Exudate (Proceedings of the European Wound Management Association and European Tissue Repair Society Joint Meeting, Oxford). London: Churchill Communications.

 

 

Ryan, T.J. (1997)Is exudate a clinical problem? The patient’s perspective. In Cherry, C., Harding, K. (eds). Management of Wound Exudate (Proceedings of the European Wound Management Association and European Tissue Repair Society Joint Meeting, Oxford). London: Churchill Communications.

 

 

Thomas, S. (1997)Assessment and management of wound exudate. Journal of Wound Care 6: 7, 327-330.

 

 

Thomas, S. (1998)The importance of secondary dressings in wound care. Journal of Wound Care 7: 4, 189-192.

 

 

Thomas, S., Fear, M., Humphreys, J. et al. (1996)The effect of dressings on the production of exudate from venous leg ulcers. Wounds 8: 5, 145-150.

 

 

Value for Money Unit. (1997)A Prescriber’s Guide to Dressings and Wound Management Materials (Revised 1st edn). Cardiff: VFM Unit and SMTL.

 

 

White, R.J., Cooper, R., Kingsley, A. (2001)Wound colonization and infection: the role of topical antiseptics. British Journal of Nursing 10: 9, 563-578.

 

  • Comment

Have your say

You must sign in to make a comment

Please remember that the submission of any material is governed by our Terms and Conditions and by submitting material you confirm your agreement to these Terms and Conditions. Links may be included in your comments but HTML is not permitted.

Related Jobs