Study 2: Staying Power -
Keeping dressings in place is a problem in wound care.
Fiona McGregor and Helena Baxter describe the results of four case studies using tapeless dressings
One of the main difficulties in wound care is that wounds do not always occur in straightforward places. The human body is not flat and its contours and crevices can present a variety of challenges to nurses.
Another problem is that most wounds occur on joints, which can be difficult to dress so that normal joint function is preserved.
Although excellent primary dressings are available, finding a way to keep them in place is a perennial problem. Many dressings are also designed to remain in contact with the wound for days and it is particularly important to keep these in the correct position as they are not checked as often as usual.
Traditionally, bandages or adhesive secondary dressings are used to retain dressings. But if retention bandages are not applied correctly they are at best ineffective. At worst, they can create further tissue damage (Griffiths and Williams, 1997).
In addition, patients can become sensitized to adhesive dressings, creating further problems (RCN, 1999).
Tapeless dressings are made of a hypoallergenic, non-latex, stretchy material that does not require clips or adhesives to secure it to the primary dressing or to the patient.
They are available in a range of anatomically shaped products that conform comfortably to the site of the wound or lesion. The elasticated, non-woven material stretches in only one direction, providing strength, softness and hydrophobicity.
Although they are not sterile, tapeless dressings are washable and reusable. This means that they can be used in community settings.
We carried out a number of case studies to establish whether tapeless products could retain primary dressings effectively and had any effect on general skin condition by, for example, eliminating the abrasions caused by adhesive materials and reducing the frequency of dressing changes.
The study
Tapeless dressings were used on patients whose wounds were difficult to dress. The primary dressing regimens remained unchanged and the secondary (tapeless) dressing was evaluated in terms of:
- The time taken to apply the product;
- The number of dressing changes required;
- The product’s ability to retain the primary dressing effectively.
Materials and methods
On admission to the evaluation programme, the patient’s wound or the site of the lesion was observed and photographed or sketched. All data was recorded on an evaluation form and all primary dressing regimens remained unchanged.
In each case, conventional dressings and tapeless dressings were compared to determine whether there was any difference in the time taken to change the dressings.
The nursing teams involved in each case were asked to comment on the frequency of dressing changes using conventional products compared with tapeless products.
Patients were evaluated over a two week period, at the end of which they were asked to comment on the use of the tapeless dressings.
Results
The case studies suggested that the tapeless dressings were effective in holding primary wound dressings in place on difficult sites, such as the elbows, heels and sacral areas.
The frequency of dressing changes was reduced, which aided wound healing and reduced the amount of direct nursing time involved.
Patients’ skin quality also improved because we were not using adhesives or plasters. There was no risk of compromising or breaking the surface of their skin through the application or removal of adhesives.
The time taken to apply secondary dressings was also reduced.
All the tapeless products used were quick and easy to apply and provided a high degree of patient comfort.
Windows in the tapeless dressings were useful as they allowed nurses to observe the primary dressing without having to remove the bandages. This saved time and reduced patient disruption and discomfort.
First Case study: Dressing a sacral pressure sore
Simon Bronsen, 60, is paraplegic and wheelchair-bound. He presented with a grade-4 pressure sore on his sacral area. It measured 10cm x 15cm.
Areas of the sore varied in depth and degree of wound healing, and a range of primary dressings which were appropriate to the condition of each area, was used.
Nurses dressed the wound twice a day, which took about an hour each time, and Mr. Bronsen dislodged the primary dressings every time he transferred himself from his bed to a chair.
The treatment objectives were to:
- Ensure that the primary dressings were kept in the correct position;
- Reduce the amount of time it took for nurses to change the dressings;
- Reduce the frequency of these changes;
- Improve patient compliance.
It was particularly difficult to keep the dressings in place because Mr. Bronsen was in an agitated state.
Image 1.
Image 1: Gaping wounds in awkward places, such as this sacral pressure sore, can be difficult to dress
Advantages
The tapeless decubitus/pressure-sore dressing held the primary dressings in place for up to two days. It took staff half the time to apply and Mr. Bronsen found the design acceptable. He did not like the net-elastic pants previously used.
Disadvantages
The tapeless products needed frequent washing because of the high level of exudates produced by the wound site, which covered a large area.
Second Case study: Dressing delicate skin
Peggy Nash, 28, with dystrophic epidermolysis bullosa (EB), had superficial blistering over 60: of her skin, mainly on her arms, hands, legs, feet and torso. She was admitted for excision of a squamous-cell carcinoma on her wrist. A friend changed her dressing when she was at home.
The treatment objectives were to:
- Reduce the bulk of the dressings;
- Reduce the time it took to change dressings;
- Make it easier to change dressings;
- Reduce slippage of bandages;
- Preserve skin integrity;
- Promote comfort.
Patients with EB often have open sores and blisters covering a large percentage of their bodies. These require daily dressing. However, all such patients require careful bandaging so as not to cause further damage to their already delicate skin.
This time-consuming and means that patients have to move and turn so that the nurse can apply the bandages, which increases their discomfort.
Tapeless dressings were applied to Ms. Nash’s legs over her usual primary dressings and gauze padding.
Advantages
Appling the dressing required much less patient movement, reducing pain. The process was less time-consuming and the products held the dressing sin place more effectively.
As the bandaging was less bulky, Ms. Nash had a greater range of movement. Most importantly, the tapeless dressings did not cause any further irritation to the skin. The friend who usually changed her dressings felt the tapeless dressings would enable them to spend more quality time together (see Table 1, below).
| Table 1. Comparison of regular and tapeless dressings | ||||
|---|---|---|---|---|
| Product | Site | Time taken to apply | Number of changes over two weeks | Total length of time taken on dressings |
| Retention bandage | Lower limb | 10 minutes | 17 (due to slippage) | 170 minutes |
| Tapeless retention long leg-wrap | Lower limb | Four minutes | 14 | 56 minutes |
Third Case study: Window on progress
Jim Kiros, 60, had a right-sided weakness after a left cerebrovascular accident. He was referred to the clinic with a grade-4 pressure sore on his; left heel and a small blister on his right heel.
The treatment objectives were to:
- Reduce the bulk of his dressings;
- Reduce the time it took to change dressings;
- Reduce the frequency of dressing changes;
- Improve the integrity of the surrounding skin.
Image 2.
Image 2: The tapeless dressing fits securely around Mr. Kiros’ left heel without adding too much bulk.
The necrotic sore on Mr. Kiros’ left heel was being debrided slowly, using a hydrocolloid dressing.
However, the dressing frequently became dislodged when he moved in bed and the nurses had to change it daily, which meant that it was ineffective.
Bandages were then used to keep the dressing in place, but they slipped and it was difficult to observe the dressing for strike-through without removing and reapplying the bandages.
This was a time-consuming task for the nurses and an inconvenience for Mr. Kiros. In addition, the dressing invariably rucked up, inhibiting the debridement process.
Due to the bulk of the bandages, Mr. Kiros could not wear slippers or shoes so his rehabilitation was also hindered.
Image 3.
Image 3: A window in the tapeless dressing allows nurses to observe the progress of wound healing and check for strike-through without having to remove and reapply the bandages.
Advantages
Tapeless heel dressings effectively held the dressing in place for up to four days or until strike-through, which could be easily observed through the window in the dressing.
Debridement was successful and the wound began to show healthy granulation tissue. Because the dressing was less bulky, Mr. Kiros could wear slippers and felt much more confident about beginning to mobilize.
Fourth Case study: Keeping elbows and ankles mobile
Kay Flowerdew, 24, was referred to the clinic after an injury during a skiing holiday. One wound was a superficial graze on the elbow and the other was an ulcer on her malleolus. Ti had been caused by her ski boot and measured 3cm x 4cm x 0.5cm.
Ms. Flowerdew had an active lifestyle and kept dislodging the bandage used to keep the dressing on her elbow in place. The primary dressing then rubbed against the superficial graze, causing pain and slowing the wound healing process.
Image 4.
Image 4: The hydrocolloid dressing on Miss Flowerdew’s ankle tended to ruck up.
Image 5.
Image 5: The tapeless dressing effectively secured the primary dressing and prevented it from sticking to clothing
The injury to the malleolus was healing well but the hydrocolloid dressing rucked up and stuck to Ms. Flowerdew’s clothes.
The treatment objectives were to:
- Allow freedom of movement;
- Promote comfort;
- Prevent the primary dressing from slipping.
Advantages
The tapeless dressings prevented the primary dressing on her elbow from slipping and Ms Flowerdew had a wider range of movement. They also prevented the primary dressing on her ankle from sticking to her clothes. She was able to change her dressings a home, reducing her visits to the clinic.
Image 6.
Image 6: Bandages used to secure the primary dressing on Miss Flowerdew’s elbow tended to be dislodged, causing the dressing to rub.
Image 7.
Image 7: The tapeless dressing kept the primary dressing in place, allowing more freedom of movement.
References:
Griffiths, F., Williams, K. (1997) Bandages: indications for use and drug tariff status. British Journal of Nursing; 6: 20, 1154-1165.
RCN (1999) Clinical Practice Guidelines: The Management of Venous Leg Ulcers. London: RCN Institute.
All the patients’ names have been changed
Fiona McGregor, RGN, DipN, is a tissue viability nurse; Helena Baxter, MSc, RGN, is a clinical nurse specialist in tissue viability, Guy’s and St Thomas’ Hospital NHS Trust
Click here for the print version of the study.