Chapter 11: Dressings and Postoperative Care

THE PURPOSE OF WOUND CARE

Mother Nature has been able to repair damaged integuments for at least half a billion years. Scars and scabs are evident in the fossil record since the beginning of terrestrial life.¹ So why has there been an explosion of interest in wound care since the last World War? Quite simply, because of faster and better healing. Smugly one-upping Mother Nature, modern dressings are an entire paradigm shift from the standard approach taken since time immemorial.

As there are hundreds of dressings, bandages, and wound-care products available, the purpose of this chapter is not to catalog the daily changing varieties, but rather to provide a compendium of wound-care classes in order to understand their advantages and disadvantages.² These products include specialty items marketed for leg ulcers, decubitus ulcers, burns, and stoma care, which may have crossover potential for postsurgical skin care, especially for granulating surgical defects.³

In the United States particularly, nomenclature may be confusing. A dressing is generally something placed directly on a wound, whereas a bandage supports that dressing, while being external to it and the wound. The purpose of all wound coverings, including scabs or crusts, is to provide a barrier between the internal and external world. Presuming that there is no infection, many consider the most important function of this barrier to be wound hydration or at least anti-dehydration. However, an ideal covering will also protect and support the wound, provide hemostasis and analgesia, absorb exudate, debride slough, regrow what is missing, will be easily applied and removed, and be inexpensive.⁴ Exudate absorption is a close second in importance to wound hydration. Dressings absorb exudate by capillarity, which is defined as the sum of the hydrophilic surface forces that cause liquid to move along the surface of a solid, like watercolor paint between the hairs of a paintbrush. Wound debridement is also important. There are four types of debridement: autolytic, mechanical, chemical, and surgical. The latter two are exogenous and, although part of wound care, are generally not a part of wound dressings. Autolytic debridement occurs naturally when a dressing hydrates a wound, and it is yet another reason why moist healing is so important. Wounds are mechanically debrided when dry adherent dressings are removed, taking bits of crust with them.

CHARACTERIZATION OF WOUNDS

Wounds may be described as acute or chronic, full thickness or partial thickness, endogenous, such as vascular wounds, or exogenous, which may be infectious, surgical, or traumatic wounds. There is also a surgical classification of wounds. Class I are clean wounds or a clean surgical site sparsely colonized with bacteria; Class II are clean-contaminated wounds or a clean surgical site heavily colonized with bacteria, such as the groin. Class III wounds are contaminated, either due to unclean technique or colonization with bacteria before surgery, such as from trauma. Class IV wounds are ...