Wound Care: The selection of wound care products for wound bed preparation
The selection of wound care products
for wound bed preparation
Introduction
The healing of an acute wound is usually a highly organised
series of predictable, successive and timely occurrences.1
The phases of healing may overlap, but include the following
three stages, namely the inflammatory, proliferative and
maturation phases.1,2
The healing of a chronic wound, on the other hand,
is unpredictable and complex. In this case factors
that impair wound healing include less active growth
factors, persistent high levels of inflammatory cytokines
and protease, a bacterial imbalance, abnormal cells and
dysfunctional wound matrix component.1,3 Chronic
wounds are caught up in the inflammatory and
proliferative phases, with the result that the wound bed
does not epithelialise and close.
In view of these factors steps have been developed to
ensure an optimum milieu for wound healing in chronic
wounds. These steps are known as wound bed preparation
and this is also known as the TIMES model (Table I).4
The focus of wound bed preparation is to act pro-actively
instead of reactively. In other words, dead tissue is removed
in order to avoid later infection.5
Table I: The main aims of wound bed preparation (the TIMES
model)
T = tissue Viable wound bed without
any dead tissue
I = infection Bacterial balance
M = moisture Moist milieu
E = edges Progressive wound edges
S = surrounding skin Intact skin surrounding the
wound
A superficial infection is diagnosed and managed
timeously before a deep infection and/or osteomyelitis
or septicaemia develops.6 A dry wound bed is moistened
to promote the migration of cells that play an important
Prof Nurs Today
Mulder M, DCur
School of Nursing, Faculty of Health Sciences, University of the Free State.
Keywords: wound bed preparation, wound care products
role in wound healing. Excessive exudate is absorbed to
prevent, among other things, maceration of the wound
edges and surrounding skin and consequent enlargement
of the wound. Wound edges are continuously assessed to
check whether the strategy is effective. The surrounding
skin is protected to prevent skin damage and the possible
development of new wounds.5
Reactive management of signs and symptoms is not
enough. For instance, to treat an infected wound merely
symptomatically is ineffective. Giving pain medication
and using a highly absorbent dressing will not clear up the
underlying cause, i.e. infection.5
It is clear from the above that in-depth knowledge of the
physiology and the underlying pathophysiology of wound
healing, as well as the unique character istics of every
wound care product, are absolutely essential to ensure that
the correct product is selected for a specific patient.
Therefore, it is important to do a comprehensive
assessment of a patient with a wound before selecting
wound care products. The primary aim is to identify
the underlying causes, as well as all the factors that may
influence wound healing.7
The following factors must also be taken into account
when selecting wound care products: 8
• Size, depth, shape and location of the wound
• Amount of exudate
• Presence of an odour
• Presence of dead tissue
• Bacterial load.
The dressings selected must also be acceptable and
affordable to the patient.8
The fluid retention ability of dressings that hold back
moisture only by absorption can be considerably curtailed
by pressure. For instance, if compression bandages are
used, dressings must be selected that remain effective even
under compression.8,9
30 2011;15(6)
 Wound Care: The selection of wound care products for wound bed preparation
New wound care products are continually developed and
launched and therefore there is a large variety of products
available in South Africa. In view of this, and taking into
account the complex and unpredictable nature of chronic
wounds, there is a need for guidelines to facilitate the
selection of the ideal wound care product(s) for a patient’s
needs.
With these facts in mind the Wound Healing Association of
Southern Africa (WHASA) has developed a classification
system for advanced wound care products available in
South Africa (Table II). This may be used as a guideline
for selecting products for wound bed preparation.
Wound bed preparation
Debridement
The primary goal of debridement is to remove dead tissue
that could later stimulate an inflammatory reaction or
serve as a culture medium for bacterial growth.2,6,10 The
bioload of the wound bed is thus controlled by applying
debridement. Wounds containing dead tissue also heal
slowly as contraction and epithelialisation cannot take
place.1,6,11 Debridement therefore ensures a more viable
wound bed.
For the purposes of this article the focus will be only
on autolytic and enzymatic debridement. Enzymatic
debridement comprises the breaking down of dead tissue
by enzymes (see section J of Table II for an example of an
enzymatic debridement agent). This is accomplished by
applying a topical enzymatic agent to dead tissue to digest
and liquify it.6,11 This occurs by breaking down collagen,
elastin and other components of the dead wound matrix.1,6
Autolytic debridement is accomplished by covering the
wound with moist, interactive dressings or occlusive or
semiocclusive dressings. Examples of semiocclusive and
occlusive dressings are transparent films and hydrocolloids
(See Table II, section F). These help to rehydrate dead
tissue and ensure that the enzymes in the exudate do not
digest the nonviable tissue.1
Examples of moist interactive dressings are amorphous
hydrogels, impregnated hydrogels and hydrogel sheets.
Polysaccharides such as honey products may also be
used.12
It is not always ideal to debride all necrotic tissue. A dry
gangrenous toe will, for instance, detach from and fall off
living tissue naturally. However, it is important to refer
the patient to a vascular surgeon, especially if the ankle
brachial pressure index, a measure of the fall in blood
pressure in the arteries supplying the legs is less than 0.5.1
Any attempt to debride such a toe could cause a potentially
life-threatening wet gangrene.
Debridement of dry eschar includes the following steps:9
• Incise in a matrix pattern with a sterile surgical blade
Prof Nurs Today
• Apply an enzymatic debriding agent
• Cover the area with a transparent film dressing
• Remove dressing after two days and remove soft eschar
with sterile forceps
Ensuring a bacterial balance
It is important to differentiate between a superficial and a
deep infection of the wound as their management differs.
The signs that indicate a superficial infection are lack of
wound healing, high exudate levels, a bright red wound
bed that bleeds spontaneously, an offensive odour and
dead tissue in a previously granulating wound bed.1,6,10
Topical antimicrobial dressings containing iodine silver
or chlorhexidine may be used to lower the bioload
(see Table I, section E).6,10,12 Povidone iodine has brief
antimicrobial activity and its action is also diminished
as soon as it is exposed to organic material.12 On the
other hand, cadexomer iodine slowly releases iodine
from its microspheres while absorbing bacteria.6 It has a
threefold action: it absorbs high exudate levels, therefore
simultaneously lowers the bacterial load and debrides
dead tissue. It is also effective against methicillin-resistant
Staphylococcus aureus (MRSA).3
Medicated honey products may also be used. These
products have a dual action – they stabilise the bioload,
and also debride.12
Hydrophobic dressings have a great attraction for
microorganisms, therefore changing the dressings lowers
the bacterial load of the wound.12
An antiseptic solution may also be used for a few days to
stabilise the bacterial load of an infected wound. However,
chronic use is not recommended as these solutions are
cytotoxic.
Deep infections are characterised by a wound that
increases in size, an elevated temperature, new or satellite
areas of tissue breakdown, an offensive odour, visible bone
or bone that can be probed, redness, heat and oedema of
the surrounding skin.6,10
In cases of deep infection the patient should receive
systemic antibiotics. In this case it is essential to take a
wound biopsy or a wound swab to identify the causative
organism and to find an antibiotic to which the specific
organisms are sensitive. While waiting for the laboratory
results, the wound may be treated with antimicrobial
dressings.
The use of metronidazole as a gel on the wound bed
and/or systemically is very effective for the control of
anaerobics and naturally also for the treatment of an
offensive odour.2,13
31 2011;15(6)
 Wound Care: The selection of wound care products for wound bed preparation

Table II: The Wound Healing Association of Southern Africa classification system for advanced wound care products

SURROUNDING SKIN PRIMARY CONTACT PERMANENT SKIN ANTIMICROBIALS Topical antiseptics MALODOUR CONTROL
PROTECTORS LAYERS
• PELNAC® Iodine-based General
Barrier creams Impregnated tulle Cadexomer iodine • Activon Tulle®
• 3M Cavilon Cream® • Activon Tulle® • Iodosorb® • Activon Tube®
• Calmoseptine® • Adaptic® Topical antibiotic • Algivon®
• Atrauman® Povidone iodine • Cerdak®
Barrier films • Cuticell® Classic TEMPORARY SKIN • Bactroban® • Betadine® • Cutimed® Sorbact®
• 3M Cavilon Spray® • Grassolind® • Inadine® • Cutimed® Sorbact® Gel
• Askina Barrier Film® • Jelonet® • AmnioGENtrix®
• Apligraf® Nanocrystalline silver • Cutimed® Sorbact®
• ConvaCare Protective Silicone-based dressings Hydroactive
Barrier Wipe® • Biobrane® Silver-based • Acticoat®
• Adaptic Touch® • Integra® • Melladerm®
• Opsite Spray® • Askina SilNet® antibacterials Bioflavanoid complex • Mebo®
• Silesse Spray® • KeraGENtrix®
• Episil® • Suprathel® • Mebo® • MellaNate®
• Mepitel® • Flamazine®
• NA-ultra® • Bactrazine® Silver-based Activated charcoal
• Silfex® • Cosmopor® Releasing • Actisorb Silver 220®
• Silon TSR® • 3M Tegaderm Ag Mesh® • Askina Carbosorb®
BIOLOGICALS • Silon TSR® Face Mask • 3M Tegaderm Alginate • Sorusol®
EPITHELIALISATION
• Flavonix® DRESSING Ag®
Non-adherent clear • Allevyn Ag®
• Promogran® dressing Physical removal
• Promogran Prisma® • Cuticell® Epigraft • Askina Calgitrol Ag®
• Telfa® Clear
• Urgostart® Hydrophobic Askina Calgitrol Ag
Hydrocolloid/Vaseline®- • Cutimed® Sorbact® Thin® NEGATIVE-PRESSURE
• Urgostart Interface® WOUND THERAPY
based dressing • Cutimed® Sorbact® Gel • Atrauman Ag®
• Urgotul® • Cutimed® Sorbact® • Bactrazine® Foam interface system
GROWTH FACTORS Hydroactive • Contreet Foam® /
Polymeric membrane • Genadyne XLR8
• Regranex® Gel Biatain Ag • VAC therapy
dressing
POINT-OF- CARE • PolyMem® • Elta Silver Gel® • Renasys F/P
DIAGNOSTICS • Flamazine®
• Promogran Prisma® Gauze interface system
Biofilm reduction • Silvercel Non-Adherent®
• WOUNDCHEK™ • EZ-care
Protease Status Cytoflamm gel • Silverlon® • Genadyne XLR8
• Flavonix® • Urgosorb Ag® • Renasys-G
• TNP-assist
Biologicals Non-releasing • Venturi
• Prontosan Gel® • Actisorb Silver 220®
• Prontosan Cleanser® • PolyMem® Temporary abdominal
• Promogran® • Urgotul Ag® closure system
• Urgocell Ag® • ABThera
• Promogran® Prisma®
• Renasys F/AB
Chlorhexidine-based
impregnated tulle Alternate interfaces
• Activon Tulle® foam
DEBRIDING AGENTS • Bactigras® • Cutimed® Cavity
• Legasano Green
Enzymatic Chlorhexidine-based
• Iruxol® solution Gauze
• Hibiscrub® • Cutisoft®
Polymeric membrane
dressing Polyhexamethylene Antimicrobial gauze
• PolyMem® biguanide • Cutimed® Sorbact®
• AMD Telfa® Non-
Second-generation Adherent Dressing Surgical incision
hydrogel sheet • Kendall® Foam management
• Cutimed® Sorbact® • Kendall® Border • Prevena®
Hydroactive
Medicinal honey
Other • Activon Tulle®
• Algivon® • Activon Tube®
• Activon Tulle® • Actilite®
• Activon Tube® • Algivon®
• Cutimed® Gel® • L-Mesitran®
• Cutimed® Sorbact® Gel • Melladerm®
• Intrasite® Gel • MellaNate®
• L-Mesitran®
• Mebo® Anti-biofilm cytoflamm
• Melladerm® gel
• MellaNate® • Flavonix®

Advanced Wound Care Dressings

WHASA

Official classification of the Wound Healing Association of South Africa / www.whasa.org

Prof Nurs Today 32 2011;15(6)

 Wound Care: The selection of wound care products for wound bed preparation
MOISTURE CONTROL
Moisture addition and Moisture balance
debridement
Permeable occlusive film
Amorphous hydrogels dressings
• Askina Gel® • Askina Derm®
• Curafil® • Bioclusive®
• Cutimed® Gel • Episil Absorbent®
• Citrugel® • Hydrofilm®
• Elta silver Gel® • Leukomed® T
• GranuGel® • Mefilm®
• Intrasite Gel® • OpSite®
• Nu-Gel® • Polyskin Transparent
• Purilon® Dressing®
• Spyroderm®
Impregnated hydrogels • 3M Tegaderm®
• Curafil® Gel Wound
Dressing Hydrocolloids
• Curafil® Impregnated • Askina Biofilm
Gauze Dressing Transparent®
• Cutimed® Sorbact® Gel • Askina Hydro®
• Intrasite Conformable® • Askina Thinsite®
• L-Mesitran Net® • Comfeel®
• Melladerm Mesh® • Granuflex®
• Melladerm Mesh® With • Hydrocoll®
Film • Ultec® Pro Alginate
• Tenderwet Gel Pad® Hydrocolloid Dressing
Hydrogel sheets Fibrous hydrocolloid
• Actiform Cool® • Aquacel®
• Aquaclear®
• Cutimed® Sorbact® Acrylic
Hydroactive • 3M Tegaderm®
• Hydroderm® Absorbent Clear Acrylic
• L-Mesitran Hydro® Dressing
• Nu-Gel Sheet® Ionic hydrogel
Ionic hydrogel • Actiform Cool®
• Actiform Cool®
Cera alba
• Mebo®
Specialised postoperative
dressing
• OpSite® Visible
Actively responsive
(absorption/addition)
Second-generation
hydrogel sheets
• Cutimed® Sorbact®
Hydroactive
Granules
• Mellasorb®
• Mesorb®
Polymeric membrane dressing
• PolyMem®
Super-absorbers
• Cutisorb® Ultra
• Cutimed® Sorbact®
• Hydroactive
• Sorbion Sachet S®
• Sorbion Sachet Border®
Other
• Cutimed® Sorbact® Pad
PAIN REDUCTION SCAR MANAGEMENT FIXATION
Ibuprofen foam • Advasil Conform® Elastic adhesive plasters
• Biatain Ibu® • Bio-Oil® • Elastoplast®
• Cica Care® • Leukoplast®
Superficial wound pain • Hypafix® • Tensoplast®
Moisture absorption relief • Mebo® • Dermaplast EAB®
• Phytopain® • Mepiform®
Non-woven fabric Wide-area fixation
Polymeric membrane • Oleeva Clear®
• Leukomed® • Oleeva Fabric®
• Primapore® dressing Non-woven fabric
• 3M Softcloth® • PolyMem® • Oleeva Foam® • Hypafix®
• Oleeva Scar Shape®
• Cosmopor® E • Fixomull®
Betasitosterol • Scarban®
• Cosmopor® Advance • Mefix®
• Mebo® • Scar Science® • Omnifix® Elastic
Permeable film • Silon LTS®
• Leukomed® T Plus Epithelialisation dressing Permeable film
• Opsite® Post-op • Cuticell® Epigraft • Fixomull® Transparent
• Opsite® Post-op visible • Opsite® Flexifix
• 3M Tegaderm Plus Pad® • Opsite® Flexigrid
• Hydrofilm® Plus
Microporous paper tapes
Foam dressings • Leukopore®
• 3M Tegaderm Foam® • Micropore®
• Advazorb Plus® • Omnipor®
• Advazorb Border®
• Allevyn® Microperforated
• Allevyn Cavity® transparent tapes
• Allevyn Gentle® • Leukofix®
• Allevyn Gentle Border® • Omnifilm®
• Allevyn Gentle Border
Heel®
• Allevyn Heel®
• Allevyn Sacrum®
• Allevyn Tracheostomy®
• Askina Foam®
• Askina Foam Cavity®
• Askina Foam Transorbent®
• Biatain®
• Cutimed® Cavity
• Cutimed® Siltec
• Cutimed® Siltec B
• Cutimed® Siltec Sacrum
• Cutimed® Siltec Heel
• Dual Dress 50®
• Kendall® Foam Dressing
• Ligasano®
• Mepilex®
• Permafoam®
• Tielle
Alginates
• Algivon®
• Askina Sorb®
• Curasalt® Sodium
Chloride Dressing
• Curasorb®
• Curasorb® Zinc Calcium
Alginate Dressing
• Kaltostat®
• Melgisorb®
• MellaNate®
• Seasorb®
• Sorbalgon®
Capillary
Levafibre
• Drawtex®
Ceramic
• Cerdak®
Composite
• Alione®
• Combiderm®
• Eclypse®
• Eclypse Adherent®
• Eclypse Adherent
Sacral®
• Eclypse Boot®
• Episil Absorbent®
• Exu-dry®
• Melolin®
Prof Nurs Today 33 2011;15(6)
 Wound Care: The selection of wound care products for wound bed preparation
An offensive odour may be additionally managed with
dressings containing activated carbon. Some of these
dressings also contain silver to control bacterial growth
(Table II, section G).2,13 Dressings containing povidone
or cadexomer iodine or silver are also very effective for
managing an offensive odour.2,13
Should the patient experience pain, dressings may be
selected that promote comfort and reduce pain. Certain
dressings are designed specifically for this purpose (Table
II, section H).
Ensuring a moist milieu
A moist wound milieu ensures rapid re-epithelialisation
since the epithelial cells migrate freely into the fluid
layer over the wound bed.11 A dry environment, on the
other hand, causes dehydration and dessication of the
superficial cells and the formation of a hard crust. In this
case epithelial cells must tunnel through under the dry
crust to close the wound, a time-consuming process that
demands a great deal of energy.11
A granulating, moist wound bed may therefore be covered
with hydrocolloid or permeable film dressings to maintain
fluid balance, promote epidermal migration, keep the
wound temperature constant and to protect the wound
bed against contamination and mechanical trauma.12,14
(Table II, section F)
However, exudate from chronic wounds may also be
detrimental to wound healing.3,15 This exudate consists
mainly of serum with many white blood cells. It serves as
a source of proteases, enzymes that break down protein
and therefore can damage healthy tissue. Excessive
exudate also causes maceration of the wound edges and
surrounding skin.15
If the exudate levels are high, it is important to select
dressings that absorb exudate and restore the fluid
balance. Alginate dressings can absorb a volume of up
to 20 times their weight.11,12,16 Examples are Kaltostat®,
Seasorb®, Sorbalgon®, Melgisorb® and Curasorb®. These
products are developed from brown seaweed and differ
in their composition. It has the appearance of a soft,
fluffy material and forms a gel as soon as it makes
contact with wound exudate promoting autolysis and
granulation.12,17
Highly absorbent hydrophilic foam products may also be
used. Foam and hydropolimer dressings are both made
of polyurethane but differ greatly in design and fluid
management ability. They can absorb moderate to large
amounts of exudate and are available as flat dressings and
cavity dressings.12,14,17
Negative pressure therapy may also be used for wounds
with large volumes of exudate. This type of therapy causes
Prof Nurs Today
a vacuum on the wound bed and consequently suctions
fluid mechanically out of the wound and the surrounding
oedematous tissue.3,17 It also promotes blood circulation,
stimulates the formation of granulation tissue and reduces
the bacterial load (Table II, section F).4
In the late stage of the proliferative phase when
epithelialisation commences, the exudate levels are
drastically reduced and the wound bed is inclined to
become dry. At this stage products that keep the wound
bed moist may be selected, as listed in Table I, section F.
The use of a hydrocolloid or a transparent film dressing
will also ensure that the wound bed remains moist.14
Continual assessment of the wound edges
The wound edges can serve as an important parameter to
determine whether or not the present wound treatment
is effective over time. When the edges of a deep wound
show signs of new granulation tissue formation or when
the edges of a superficial wound is recolonised by visible
epithelial islands, this indicates wound healing.
A wound that does not reduce in size or one that grows
bigger, or whose wound edges are undermined, an
underlying problem, such as an undiagnosed infection or
ineffective treatment, should be suspected.3 In this case
the patient must be reassessed or referred.10
Protection of the surrounding skin
The repeated application and removal of adhesive
dressings or plaster may damage surrounding skin. The
use of bandages or tubular bandages to keep dressings in
place can prevent skin damage.2 Very thin hydrocolloid
dressings may also be used to protect the skin. Adhesive
dressings or plaster may even be fixed on top of these.2,17
Proteases in wound exudate and chemical irritants in
urine and faeces may cause excoriation of the skin. Barrier
creams and barrier spray may be used to protect the skin
against potential damage (Table II, section A).12,14
Conclusion
No single wound dressing is suitable for all types of
wounds and for all stages of wound healing. A patient’s
wounds must therefore be assessed at every dressing
change to determine whether the dressing is still effective
and whether another type of product should be selected.
A thorough knowledge of the action, the indications and
contraindications of all wound care products is therefore
absolutely essential. Without this knowledge ineffective
products may be selected which waste precious time and
resources.
It is also important to treat patients holistically and to
34 2011;15(6)
 Wound Care: The selection of wound care products for wound bed preparation

consider how an underlying illness, nutritional status and assessment form. Wound Healing Southern Africa. 2008;1:16-21.
immunity can influence wound healing. 8. Management of wound exudates. J Wound Care. 1997;7:328-329.
9. Morison MJ, Ovington, LG, Wilkie K. Chronic wound care. A
problem-based learning approach. Maryland Heights: Mosby; 2004.
References 10. Sibbald G, Woo KY, Ayello E. Wound bed preparation: DIM before
DIME. Wound Healing Southern Africa. 2008;1:29-34.
1. Bale S. A guide to wound debridement. J Wound Care. 1997
11. Bryan J. Moist wound healing: a concept that changed our practice.
Apr;6(4):179-182.
J Wound Care. 2004;6:227-228.
2. Mulder M, Small N, MacKenzie J, et al. Basic principles of wound 12. Wound Care Handbook 2008-2009. The comprehensive guide to
care. Cape Town: Pearson Education; 2002. product selection. London: MA Healthcare Ltd; 2008.
3. Schultz GS, Barillo DJ, Mozingo DW, Chin GA. Wound bed 13. Hack A. Malodorous wounds – taking the patient’s perspective into
preparation and a brief history of TIME. Int Wound J. 2004;1:19-32. account. J Wound Care. 2003;8:319-321.
4. Jones J. Winter’s concept of moist wound healing: a review of the 14. Erwin-Toth P, Hocewar BJ. Wound Care. Selecting the right
evidence and impact on clinical practice. J Wound Care. 2005;6:273- dressing. Am J Nurs. 1995;2:46-51
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15. Cutting KF, White RJ. Maceration of the skin and wound bed. 1: Its
5. Fletcher RN. The benefits of applying wound bed preparation into nature and causes. J Wound Care. 2002;7:275-278.
practice. J Wound Care. 2003;9:347-349. 16. Thomas S. Assessment and management of wound exudates. J
6. Baranoski S, Ayello EA. Wound Care essentials. Practice Principles. Wound Care. 1997;7:327-330.
New York: Lippincott Williams & Wilkins; 2008. 17. Vuolo J. Current options for managing the problem of excess wound
7. Naude L. Wound assessment – Incorporating the WHASA wound exudates. Prof Nurse. 2004;9:487-491.

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