A vapour-permeable film dressing used on superficial wounds.

A vapour-permeable film dressing used on superficial wounds Frans Meuleneire

Minimising dressing-related trauma and pain

Frans Meuleneire, Wound Care Specialist, Wound Care and Diabetic Foot Centre, Zottegem, Belgium

The importance of considering dressing-related pain and trauma in wound care cannot be underestimated. Statements and guidelines have been published to draw attention to this aspect of care from the European Wound Management Association (2002) and the World Union of Wound Healing Societies (2004; 2007) involving clinicians, researchers, patients and industry. Cutting (2008) has explained that traditional dressings can cause pain and trauma, in particular during their removal, by epidermal stripping of the periwound skin and adherence to the wound, as demonstrated by Hollinworth and Collier (2000). This trauma and pain is often caused by adhesive-related damage and the resulting epidermal stripping can result in inflammatory skin reactions, oedema and soreness; this may then have a detrimental effect on skin barrier function (Dykes et al, 2001). If dressings need to be changed repeatedly, the risk and severity of this damage are increased. Davies and Rippon (2008) found that dressing-related trauma has the potential to increase the size of wounds, exacerbate wound pain and delay the healing process. These problems all increase the cost of treatment by increasing the nursing time, the amount of dressings used and the use of analgesia, as well as causing loss of earnings for the patient (owing to an inability to work) and having a negative impact on the patient’s quality of life (Rippon et al, 2007). Wound pain causes suffering, distress and psychological stress to the patient, delaying healing and reducing quality of life (Acton, 2007; Solowiej and Upton, 2010). Dressing removal and wound cleansing are reported to be the most painful wound care interventions (Hollinworth and Collier, 2000; Kammerlander and Eberlain, 2002). This is emphasised by an international survey showing that 50% of the 2000 patients surveyed experienced pain quite often or more at dressing change; 40% revealed that pain at dressing change was the worst part of living with a wound. Unfortunately, despite the advances in wound dressings and awareness of the problem, 36% of patients felt that there was nothing the clinicians could do to help with pain at dressing change (Price et al, 2008).

Accepted for publication: July 2014

Safetac technology

Key words: Quality of Life

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Wound Healing

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Pain

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Adhesives

A

wide range of film dressings are available to the wound care practitioner. The design of film dressings is generally based on a layer of polyurethane coated with an adhesive layer. The polyurethane layer is moisture and gas permeable; this helps prevent the accumulation of moisture in the wound, so reducing the risk of tissue maceration. Film dressings are used in the treatment of a large variety of wound types, for example, superficial burns, skin grafts and surgical wounds. Film dressings are thin and tend to be very conformable to the wound site so they can be used on difficult-to-dress areas. They tend to be impermeable to water and so can be worn by patients while showering and used as a protective layer to manage incontinence-associated dermatitis and protect peri-wound skin (Guest et al, 2011). A major benefit of films is that they are transparent; this enables clinicians to monitor wounds without having to remove the dressings, reducing the risk of infection, trauma and pain during dressing change. However, this may be less appealing to the patient who would rather not see the wound.

Despite recent developments, some modern dressings may

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© 2014 MA Healthcare Ltd

Abstract

Films are an extremely versatile dressing type that can be effectively used in the treatment of many superficial wounds, such as skin grafts, surgical wounds and superficial burns; they provide an optimal moist environment to promote healing, act as a barrier to bacteria, and afford protection from urine and faecal contamination. Unfortunately, many film dressings are difficult to handle and use traditional adhesives, which can cause trauma to the wound and surrounding skin, as well as increased wound pain at dressing removal. Mepitel® Film is a new, easy-to-use wound dressing designed with Safetac® technology that helps to minimise dressing-related trauma and pain and assist undisturbed wound healing. This article presents case studies that examine Mepitel Film’s use on a variety of wounds, and reviews the findings of research that was undertaken to evaluate the benefits of using this recently developed dressing.

Absorbent dressings can be used in conjunction with film dressings to remove excess exudate. In some dressings, a film layer is actually combined with an absorbent pad, although in these cases transparency is lost (Aindow and Butcher, 2005).

British Journal of Nursing, 2014 (Tissue Viability Supplement), Vol 23, No 15

British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.080 on February 22, 2015. For personal use only. No other uses without permission. . All rights reserved.

also damage delicate wound tissue or peri-wound skin (Cutting, 2008; Greenwood et al, 2000). Wound care is often the domain of nursing staff, and it is vital that they are aware of the many different aspects of wound dressings, so that appropriate ones are selected to minimise or prevent dressing-related trauma. Based on patented soft-silicone adhesive technology, Safetac readily adheres to dry intact skin and remains in place on the surface of a moist wound and damaged skin without adhering to these fragile areas (Morris et al, 2009; White and Morris, 2009). This allows dressings with Safetac to be applied and removed without causing pain or damage to the wound or peri-wound skin (White, 2008; Waring et al, 2011). A significant amount of experimental and clinical evidence has been published that demonstrates the benefit of using dressings with a Safetac wound contact layer; much of this is reviewed by Davies and Rippon (2008). Safetac forms a seal with intact skin inhibiting the movement of wound exudate onto the peri-wound area, thereby preventing maceration (White, 2005). A study by Waring and Butcher (2011) shows that Safetac dressings have good conformability; this property is important because it allows the dressing of difficult areas such as toes and helps to maintain the dressing in place. Good conformability increases the comfort for the patient and results in low levels of dressing-related complications, such as blistering and moisture-related skin damage (Davies and Rippon, 2008). A wide range of dressings incorporating Safetac are now available, allowing wound care nursing staff to select the most appropriate dressings for the many different types of wound and the clinical challenges that they pose.

Mepitel Film Description Mepitel Film is a recently developed wound dressing that consists of a polyurethane film with a Safetac wound contact layer that is supported with a paper frame for ease of application (Figure 1). As might be expected from a dressing with Safetac, Mepitel Film is gentle to the wound and has instant tack that does not exhibit increased adhesion over time (Rippon et al, 2007). Mepitel Film provides a flexible, transparent covering that allows easy Untreated

8

DuoDERM

Mepitel Film

Figure 1. Mepitel Film dressing being applied to an arm

inspection of the wound. The film acts to protect wounds, skin and newly formed tissue from damage by sealing the wound margins from microbial contamination, fluids and other external contamination. Mepitel Film maintains a moist environment even though the vapour permeability allows excess moisture to pass away from the skin, reducing the risk of maceration. The thin film conforms to surface irregularities and body contours. The application system is designed for ease of use and the instant tack adhesion minimises the requirement of having to apply extra pressure over the wound during fixing.

Indications Mepitel Film is designed for use on a wide range of superficial wounds, e.g. superficial skin injuries and superficial burns, and to protect fragile and sensitive skin from damage. It can also be used as a protective cover for open surgical wounds (for example, of the abdomen), and for fixing primary dressings in place by acting as a secondary dressing. Mepitel Film can be used in combination with gels and ointments. Fixation tapes and devices can be placed on top of Mepitel Film, providing protection against the adhesive-related damage and skin stripping often associated with the use of tapes.

Volunteer studies Waring et al (2012) undertook a study involving healthy volunteers to compare Mepitel Film with two other Tegaderm

7

5 4 3 2 1 0

Day 1/Baseline

Day 3

Day 6

Day 9

Day 14

Day of measurement Figure 2. Mean chromameter skin colour measurements (Waring et al, 2012)

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Chromameter ∆∑*

6



PRODUCT FOCUS

3a, Treatment day 1

3b, Treatment day 7

3c, Treatment day 15

3d, Treatment day 22

3e, Treatment day 31


Figure 3. Case study 1

commonly used wound dressings that use alternative adhesives (i.e. hydrocolloid and acrylic) in terms of their propensity to cause skin stripping and impairment of the skin’s barrier function. The dressings were applied, removed and reapplied over a period of 14 days to areas on the backs of volunteers that had been stained with a dye. Skin barrier function was assessed by the amount of transepidermal water loss (TEWL). Skin stripping was evaluated by using a Chroma Mater CR300 (Konika Minpolta, Langenhagen) to measure the degree of change in stained skin colour at dressing removal. Pain associated with dressing removal was also observed. The hydrocolloid dressing (DuoDERM Extra Thin (Convatec)) was associated with a statistically significantly higher loss of skin colour when compared with untreated skin, Mepitel Film and acrylic (Tegaderm (3M)) dressings. Furthermore, Tegaderm had a significantly higher loss of skin colour later in the study, compared with untreated skin and Mepitel Film (Figure 2). TEWL values


after application of DuoDERM Extra Thin increased significantly after day 6 and remained high. After application of Mepitel Film and Tegaderm they remained relatively unchanged. These data clearly show that, of the three dressings tested, Mepitel Film resulted in the least damage to the skin on removal. The subjects evaluated the pain involved in dressing removal, with two dressings being removed simultaneously. All of the dressings performed well, associated with low pain severity scores. The mean values for pain assessment were lower for Mepitel Film than Tegaderm and DuoDERM Extra Thin, but the difference was not statistically significant. The following section of this article presents the findings of a series of case studies that were undertaken in a specialist wound care centre to examine the use of Mepitel Film on a variety of wounds.

Case studies Dressings were applied and removed in line with the manufacturer’s instructions and in accordance with the judgement of the clinician undertaking the evaluation. At the baseline and subsequent assessments, the condition of the wound and the state of the peri-wound skin were assessed. The severity of pain experienced by the patient was measured using a visual analogue scale (VAS) ranging from 0 (no pain) to 10 (the worst pain ever) before, during and after dressing removal. At the end of the treatment period for each case, the clinician was asked to rate the dressing as ‘very good’, ‘good’, ‘poor’ or ‘very poor’ for a series of parameters: dressing sizes available to use, ease of handling, ability to be repositioned/reopened if folded, conformability, patient

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4a, Treatment day 1

4b, Treatment day 4

4c, Treatment day 7



Case study 1 A 90-year-old female patient presented with a 2-day-old skin tear injury to the front of the left shin (Figure 3a); the wound had been treated with povidone iodine gauze. The patient had a history of venous insufficiency. At the baseline assessment, the wound bed was moist with predominantly viable tissue, but the peri-wound skin was moderately dry; moderate levels of wound exudate and a low level of bleeding were recorded.The patient was in continuous pain (VAS=3– 4) causing disturbance to sleep; the pain was treated with paracetamol. Mepitel Film was used as the primary wound dressing to afford protection from external contamination. Over eight follow-up assessments, the condition of the wound improved. The wound bed remained viable and moist throughout with no reported bleeding. Wound exudate levels were low; at the final assessment the wound had stopped exuding. The peri-wound skin exhibited a mild dryness throughout (Figures 3b–e). The patient reported only very low levels of pain at dressing change (VAS=2); pain relief was not required and sleep was not disturbed. At the final assessment the pain score was zero. The dressing was changed approximately every 7 days and no trauma of the wound or surrounding skin was observed at any dressing change. The dressing was rated ‘good’ or ‘very good’ for all evaluated parameters.

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Case study 2 An 18-year-old male presented with a two-day-old traumatic knife wound to the tip of the third digit of the right hand (Figure 4a); the wound had been treated with povidone iodine. The patient had no known diseases or surgical history. At the baseline assessment, the wound tissue was predominantly non-viable; the wound bed was moist but the peri-wound skin was mildly dry. Wound exudate levels and bleeding were low and there was a slight wound malodour. The patient experienced continuous pain (VAS=6–7), causing sleep disturbance; pain was treated with paracetamol. Mepitel Film was used as the primary wound dressing to promote wound healing and reduce dressing-related pain. Over six follow-up assessments, the condition of the wound consistently improved. The wound bed remained moist and wound tissue became viable. The level of wound exudate increased at the initial visit but subsequently reduced; by the fourth assessment the wound had stopped exuding. Bleeding and malodour had stopped by the first and second visit, respectively. Mild maceration was recorded only at the initial follow-up visits, although the peri-wound skin did stay mildly dry throughout (Figures 4b–d). The patient continued to report constant pain, but with lower pain severity scores, at the initial two follow-up visits (VAS=4–5 and 3); by the third and fourth assessments pain was only experienced at dressing change (VAS=2 and 1–2, respectively), pain relief was not required and sleep was not disturbed. The dressing was changed approximately every 5 days and no trauma of the wound or surrounding skin was observed at any dressing change. At the end of the evaluation period, the wound had healed. The wound


comfort during wear, ability to stay in place during wear, ease of removal, ability to prevent trauma on removal, ability to minimise dressing-related pain, ability to maintain most wound environment, ability to minimise risk of maceration, and overall impression of product.



PRODUCT FOCUS

5a, Treatment day 1

5b, Treatment day 2



5e, Treatment day 62

primary wound dressing to maintain a moist environment and protect the wound from external contamination. The wound was assessed over 15 follow-up visits. The size of the wound remained unchanged. The wound bed was moist at all follow-ups and, by the ninth visit, the wound tissue was predominantly viable. Wound exudate levels were moderate at the second assessment but remained low thereafter. Lowlevel bleeding, slight malodour and mild erythema were recorded during the early assessments. The peri-wound skin was mildly dry throughout (Figures 5b–e). The patient reported most pain at the second follow-up visit (VAS=4), at subsequent assessments the pain was lower (VAS=1–2) until the final assessment when it was zero. The dressing was changed approximately every 5 days and no trauma of the wound or the surrounding skin was observed at any dressing change. At the end of the evaluation, the wound had improved and all the primary wound management objectives had been met. The dressing was rated ‘good’ or ‘very good’ for all of the recorded parameters. The problem of fat necrosis, that is commonly associated with this type of wound, was avoided.


management objectives to promote wound healing and reduce dressing-related pain had mostly been met and the dressing was rated ‘good’ for most of the evaluated parameters. The clinician noted that the conformability of Mepitel Film improved as wound exudate levels reduced following the initial inflammatory phase.


Case study 3 A 25-year-old female presented on the ninth post-operative day with a necrotic left nipple following breast reduction surgery (Figure 5a); shortly after the operation there was epidermal lysis and fat necrosis at the nipple. The wound had been treated with Jelonet (Smith & Nephew) for 7 days. At the baseline assessment, the wound tissue was predominantly non-viable; the wound bed and the periwound skin area were dry. The patient experienced pain only at dressing change (VAS=3), no analgesia was provided and sleep was not disturbed. Mepitel Film was used as the


Case study 4 An 88-year-old female presented with a 2-day-old surgical skin graft to the front of the left shin (Figure 6a); the wound had been treated with Jelonet. The patient had a history of unspecified cancer. At the baseline assessment, the wound bed was moist with predominantly viable tissue; the periwound skin was mildly dry. Moderate exudate levels and low level bleeding were recorded. The patient experienced pain at dressing change (VAS=3–4); pain relief was provided with

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6a, Treatment day 1

6b, Treatment day 8




KEY POINTS n Films provide an optimal moist environment to promote healing, act as a barrier to bacteria, and afford protection from urine and faecal contamination n Films are transparent, enabling clinicians to monitor wounds without having to remove the dressings, reducing the risk of infection, trauma and pain during dressing change n Mepitel Film is a recently developed wound dressing that consists of a polyurethane film with a Safetac wound contact layer that is supported with a paper frame for ease of application n The Safetac technology used in Mepitel Film allows undisturbed healing and minimal pain and trauma to the wound during dressing change

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Case study 5 A 48-year-old male presented with a 2-day-old burn wound to the front of his right arm/body (Figure 7a); the wound had been treated with silver sulphadiazine. The patient had no underlying diseases or surgical history. At the baseline assessment, the wound was viable and moist with moderate wound exudate. There were no problems with bleeding or malodour but the peri-wound skin appeared mildly dry. Wound blisters were noted following the removal of the silver sulphadiazine; the patient experienced pain at dressing change (VAS=5) which was treated with paracetamol. Disturbance to sleep was recorded. Mepitel Film was used as the primary wound dressing to promote wound healing, maintain a moist environment and protect the wound from external contamination. Over three follow-up assessments, the size of the wound and its condition consistently improved. The wound remained viable and moist until healed with low wound exudate levels. Pain scores were reduced at the first and second follow-up visits to VAS=1– 3 and VAS=0–2, respectively. The dressing was changed approximately every 4 days and no trauma of the wound or the surrounding skin was observed at any dressing change (Figures 7b, 7c). At the end of the evaluation, the wound had healed and the primary wound management objectives had been completely achieved. Mepitel Film was rated ‘good’ or ‘very good’ for each evaluated parameter.

Conclusion Mepitel Film has been successfully used to treat a wide range of superficial wounds where a film dressing is the preferred method of treatment; and a dressing that is transparent and


paracetamol. There was no sleep disturbance. Mepitel Film was used as the primary wound dressing to promote wound healing and protect the wound from external contamination. Over two follow-up assessments, the wound bed dried but wound tissue remained viable. The wound ceased exuding at the second assessment (Figures 6b–d). Following the first assessment, the patient recorded zero pain. Dressing was changed approximately every 5 days and no trauma of the wound or the surrounding skin was observed at any dressing change. At the end of the evaluation, the wound had healed and most of the primary wound management objectives had been achieved. The dressing was rated ‘good’ or ‘very good’ for all parameters.



PRODUCT FOCUS These characteristics make Mepitel Film beneficial from both BJN a patient’s and clinician’s point of view. Conflict of interest: this article has been supported by Mölnlycke Health Care

7a, Treatment day 1

7b, Treatment day 4

7c, Treatment day 19 Figure 7. Case study 5

conforms well to wound contours is required. The Safetac technology used in the dressing allows undisturbed healing with minimal pain and trauma to the wound during dressing.

Acton, C (2007) The holistic management of chronic wound pain. Wounds UK 3(1): 61-9 Aindow D, Butcher M (2005). Films or fabrics: is it time to re-appraise postoperative dressings? Br J Nurs 14(19): S15-S20 Cutting, KF (2008). Impact of adhesive surgical tape and wound dressings on the skin, with particular reference to skin stripping. J Wound Care 17(4): 157-162 Davies P, Rippon M (2008) Evidence review: the clinical and economic benefits of Safetac technology in wound care. J Wound Care Suppl(Nov 2008): 3-31 Dykes PJ, Heggie R, Hill SA (2001). Effects of adhesive dressings on the stratum corneum of skin. J Wound Care 10(2): 7-10 European Wound Management Association (2002) Position Document: Pain at Wound Dressing Changes. http://tinyurl.com/26unm9q (accessed 24 July 2014) Greenwood JE, Dunn KW, Davenport PJ (2000) Experience with severe extensive skin blistering disease in a paediatric burns unit. Burns 26(1): 82-7 Guest JF, Greener MJ, Vowden K, Vowden P (2011) Clinical and economic evidence supporting a transparent barrier film dressing in incontinenceassociated dermatitis and peri-wound skin protection. J Wound Care 20(2): 76-84 Hollinworth H, Collier M (2000) Nurses’ views about pain and trauma at dressing changes: results of a national survey. J Wound Care 9(8): 369-73 Kammerlander G, Eberlein T (2002) Nurses’ views about pain and trauma at dressing changes: a central European perspective. J Wound Care 11(2): 76-9 Morris C, Emsley P, Marland E, Meuleneire F, White R (2009) Use of wound dressings with soft silicone adhesive technology. Paediatr Nurs 21(3): 38-43 Price PE, Fagervik-Morton H, Mudge EJ et al (2008) Dressing-related pain in patients with chronic wounds: an international patient perspective. Int Wound J 5(2): 159-71. doi: 10.1111/j.1742-481X.2008.00471.x. Rippon M, White R, Davies P (2007) Skin adhesives and their role in wound dressings. Wounds UK 3(4): 76-86 Solowiej K, Upton D (2010) Managing stress and pain to prevent discomfort, distress and delayed wound healing. Nursing Times. http://tinyurl.com/ mkgw574 (accessed 23 July 2014) Waring M, Bielfeldt S, Matzold K, Wilhelm KP, Butcher M (2011) An evaluation of the skin stripping of wound dressing adhesive. J Wound Care 20(9): 413-22 Waring M, Bielfeldt S, Spingmann G,Wilhelm K (2012) An instant tack wound dressing designed to reduce skin stripping. Wounds UK 8(2): 60-7 Waring M, Butcher M (2011) An investigation into the conformability of wound dressings. Wounds UK 7(3): 14-24. http://tinyurl.com/op97d7l (accessed 29 July 2014) White R (2005) Evidence for atraumatic soft silicone dressing use. Wounds UK 1(3): 104-9 White RA (2008) A multinational survey of the assessment of pain when removing dressings. Wounds UK 4(1): 14-22 White R, Morris C (2009) Mepitel: a non-adherent wound dressing with Safetac technology. Br J Nurs 18(1): 58-64 World Union of Wound Healing Societies (2004) Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. MEP Ltd, London UK. http://tinyurl.com/l3zm3sb (accessed 23 July 2014) World Union of Wound Healing Societies (2007) Principles of best practice: Minimising pain at dressing-related procedures: “Implementation of pain relieving strategies”. Evidence informed practice. WoundPedia Inc. Toronto. http://tinyurl. com/q95287h (accessed 23 July 2014)

About the book

Skin problems are one of the most common reasons for people to seek help from a nurse or GP in general practice. This handy reference guide is the essential collection of common dermatological cases encountered in everyday practice with concise content on the aetiology, diagnosis, management and prevention so that healthcare practitioners can effectively treat their patients. Importantly, this book also examines other issues that impact patient care, with consideration for how social and psychological factors impact patients and treatment of skin conditions.

This practical, user-friendly book is made up of articles from a popular series in Practice Nursing and covers: the aetiology, diagnosis, management and prevention of most common dermatological cases; social and psychological factors and their impact on patients and treatment of skin conditions This book comprises updated articles from a long running and highly popular series published in the Practice Nursing journal on the differential diagnosis of dermatological conditions. It has been highly illustrated with colour pictures provided throughout to aid diagnosis. The chapters have been presented in a user-friendly format making this a highly practical text for nurses and GPs.

Dermatology Differential Diagnosis

Helping nurses treat common skin conditions

Dermatology Differential Diagnosis

Dr Jean Watkins is a retired GP and remains an active member of the Practice Nursing Editorial Board and, in April 2004, was awarded a Fellowship of the Royal College of General Practitioners.

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About thepublication author ISBN-13: 978-1-85642-401-1; 297 x 210 mm; paperback; 200 pages; 2010; £29.99

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Transparent polyurethane film as a catheter dressing.

A comparative study of colostrum dressing versus conventional dressing in deep wounds.

Alkali-treated konjac glucomannan film as a novel wound dressing.

Efficiency of microbial cellulose dressing in partial-thickness burn wounds.

Natural and synthetic polymers for wounds and burns dressing.

Effectiveness of Woven Silk Dressing Materials on Full-skin Thickness Burn Wounds in Rat Model.

Solubility studies on ethyl cellulose used in film coating.

A tie-over dressing using a silicone tube to graft deep wounds.

Novel technique for skin grafting parastomal wounds using a negative-pressure dressing.

In situ production of a synthetic barrier dressing for burn wounds in rats.

Use of tissue adhesive as a field expedient barrier dressing for hand wounds in disaster responders.

Effects of limited access dressing in chronic wounds: A biochemical and histological study.

Efficacy of a new multifunctional surfactant-based biomaterial dressing with 1% silver sulphadiazine in chronic wounds.

On-Demand Dissolution of a Dendritic Hydrogel-based Dressing for Second-Degree Burn Wounds through Thiol-Thioester Exchange Reaction.

Powdered Wound Dressing Materials Made from wild Silkworm Antheraea pernyi Silk Fibroin on Full-skin Thickness Burn Wounds on Rats.

The Effect of Virtual Reality Distraction on Pain Relief During Dressing Changes in Children with Chronic Wounds on Lower Limbs.

Antimicrobial Activity of a Novel Vascular Access Film Dressing Containing Chlorhexidine Gluconate.

Physical, morphological, and wound healing properties of a polyurethane foam-film dressing.

Erratum to: Comparison of hemostatic dressings for superficial wounds using a new spectrophotometric coagulation assay.

Comparison of hemostatic dressings for superficial wounds using a new spectrophotometric coagulation assay.

Beneficial effects of silver foam dressing on healing of wounds with ulcers and infection control of burn patients.

Antibiofilm Efficacy of DispersinB(®) Wound Spray Used in Combination with a Silver Wound Dressing.

Amazing Topical Protocol and Novel Powder Dressing Combination Formula in Treatment of Diabetic Foot Wounds.

Physical and biological properties of a new synthetic amino acid copolymer used as wound dressing.