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The importance of keeping dressings dry

Nicky Whitfield
RGN NDNCert BSc(Hons)
Tissue Viability Nurse Specialist
Leeds North West PCT
E:nicola.whitfield@ nhs.net

Patients are often given contradictory advice by nurses as to whether they can get their wound wet, depending upon the site and type of wound. Patients with pilonidal sinuses are encouraged to bathe regularly in order to remove any contamination from the wound bed, whereas patients with other types of wounds are encouraged to keep them dry, for example diabetic foot ulcers. This is dependent upon whether the wound is in a site already heavily contaminated by bacteria and upon their risk of developing infection.

To cleanse or not to cleanse?
One of the arguments against the cleansing of wounds is that it reduces the temperature of the wound, which can delay wound healing. One study found that dressings that elevate the temperature of the wound to body temperature promoted wound epithelialisation.(1) A dressing that is allowed to get wet and then left to dry out could lower the temperature of the wound, dry out the wound bed and delay healing.
Most of the research carried out on wound cleansing concentrates on the cleansing solution used. One study found the infection rate in wounds cleaned with tap water was less than those cleaned with sterile saline.(2) Another found that tap water did not contain pathogenic bacteria.(3) Yet another compared the effects of tap water and normal saline on the healing and infection rates of acute and chronic wounds, and found that tap water provides a safe alternative to normal saline.(4) By discouraging patients from social cleansing, we may be increasing their risk of developing wound infection as the increased number of bacteria on the surrounding skin could be transferred into the wound.

Protecting the wound
Some patients attempt to get into the bath with a plastic bag wrapped around their wound, which is not advisable as water usually leaks through to the dressing. They may even try to keep their affected limb out of the water, which is not the easiest or safest activity if the affected limb is a leg and the patient is not very athletic! It is sometimes possible to wrap cling film around the affected area, but there is still the possibility that this will leak. Another alternative is to wash around the wound with the dressing in place, then to change it immediately after the bath or shower. A temporary dressing could be applied after the bath until the dressing can be replaced. The downside of this is that it raises the dressing costs.
Some wound dressings are designed to be waterproof: for example, some of the hydrocolloids and film dressings. However, they tend to be showerproof rather than bathproof. Some dressings have adhesives that are water-soluble and so are not suitable for use in the bath or shower. Nurses may advise patients to apply a waterproof dressing over the primary dressing, which again increases the costs of wound care.
Patients who are able to change their own dressings could be taught how to irrigate the wound with clean tap water and then reapply the dressing. There may be concerns that if the patient cleans the wound themselves they may damage the delicate granulation tissue within the wound and therefore delay wound healing, but then overenthusiastic and unnecessary wound cleaning by nurses could have the same effect.
There are practical reasons why patients who have a plaster cast in situ cannot get it wet, as the integrity of the cast will be compromised. There are several waterproof dressing and cast protectors available to purchase, such as LimbO (Thesis Technology) or Cosy Feet waterproof stockings, which allow patients to bathe with a dressing or a plaster cast in place. They are designed to keep arms and legs dry and usually consist of a waterproof covering that covers the limb and is held in place with a waterproof or Velcro collar. They can only be used over dressings or casts, not over open wounds. These protectors can be reused and can be purchased from pharmacists, the internet or via mail order but are not available on drug tariff. They cost approximately £20.
A new product works on a different principle. Seal-Tight (Autonomed Ltd) has a nonlatex diaphragm, which stretches over the cast or bandage to form a watertight seal, without the use of strapping, pump or Velcro. Autonomed also manufactures Active-Seal, which is designed for use during recreational activities such as swimming, but can also be used to protect casts and bandages while showering. These products are available in different sizes for standard, short and wide arms and legs and in sizes for adults and children. From 1 April a selection of the Seal-Tight range became available on prescription in the UK.
The cast and dressing protectors that are available are for arms and legs only, so patients have to adapt their bathing techniques in order to protect dressings on other areas of the body.

Contraindications
There is a possibility that patients could react to the ­constituents of the collar or adhesive tape, in which case a new dressing or wound protector should be suggested. A bath mat should be used with dressing protectors to prevent patients from slipping and possibly injuring themselves.

Summary
Research into the effectiveness of wound cleansing indicates that routine wound cleansing is unnecessary for many wounds. As Young states, much of the process is ritualistic and could even prolong wound healing.(5) Research has shown that tap water is a safe option for cleaning wounds, so it may be that too much emphasis has been put on keeping dressings dry, which may not have affected the overall infection rate of wounds and may even be detrimental to patient comfort.

References

  1. Lock PM. The effect of temperature on mitotic activity at the edge of experimental wounds. In: Lundgren A, Soner AB, editors. Symposia on wound ­healing: plastic, surgical and ­dermatological aspects. Sweden: Moldal; 1980.
  2. Angeras MH, Brandenberg A, Falk A, Seeman T. Comparison between sterile saline and tap water for the cleaning of acute traumatic soft tissue wounds. Eur J Surgery 1992;158:6-7, 347-50.
  3. Riyat MS, Quinton DN. Tap water as a cleansing agent in accident and ­emergency. J Accident Emerg Med 1992;14:165-6.
  4. Griffiths RD, Fernandez RS, Ussia CA. Is tap water a safe alternative to normal saline for wound irrigation in a community setting? J Wound Care 2001;10:407-11.
  5. Young T. Common problems in wound care: wound cleansing. Br J Nurs 1995;4:286-9.

Resources
LimbO Waterproof Protection
T:01243 573417
W:www.limbo.ws
Cosyfeet
T:01458 447275
W:cosyfeet.com
Autonomed
T:0870 0410150
W:www.autonomed.com
Disability Aids
W:disabilities.co.uk