N-TERFACE® Material

Karyn Weller, RN, ET
Nurse Clinician
University Hospital, Shaughnessy Site
Vancouver, B.C. Canada

Presented As An Abstract At The Sixth annual Clinical Symposium On Pressure Sore & Wound Management St. Charles, Illinois, September 12-13, 1991

INTRODUCTION

Desiccation and subsequent stripping of viable epithelium is a recognized problem in wounds healing by secondary intention. The premise behind this statement lies in the observation of the use of traditional gauze dressings. Dry gauze is the most difficult to remove if stuck to the wound bed and will do the most damage to viable tissue. ⁽⁸⁾ Initially, the dressing is placed upon the wound moist, but subsequent coverage with an absorbent outer dressing wicks away the moisture content of the gauze. Coupled with this is the fact that today's theories of moist wound healing, and terms such as "occlusion" and moisture-retentive" are not commonplace nor in wide practice in those institutions that have not embarked on a comprehensive wound management program. And, despite the abundance of literature and research to support these theories, traditional approaches continue to be the mainstay. It is estimated that up to 60 percent of dressings continue to be saline soaked gauze with a dry topper. It has been shown experimentally that re-epithialization of wounds occurs more rapidly under moist conditions than dry. ^(1,5,8)

Patient care providers who have not been introduced to the newer methods often, unknowingly, subject the patient and wound to needless trauma and pain. Very little time is required for the gauze dressings next to the wound to dry out. Dressing adherence can impair wound healing by disturbing or destroying partially healed tissue at the time of removal. Removal then becomes a painstaking procedure, delicately trying to lift the firmly adhered gauze, while liberally soaking the area with more saline to ease the removal, in an effort to prevent pain and wound bed trauma. One of the most important features in an ideal dressing is non-adherence to the wound. ⁽¹⁰⁾

Having continued to observe these practices, and in light of the fact that the introduction of new theories and practices and even the concept of wound management itself will be a long and tedious task, we would simply work alongside tradition. In our efforts to introduce the new theories and dispel the old, we chose to introduce a non-adhering wound contact material, in an attempt to demonstrate the needless detrimental effects of dry gauze directly on fragile new epithelium, thereby achieving compliance of newer practices through the consistent use of presumably wet saline dressings. Gauze dressings permit tissue drying. These dressings are highly permeable to water vapor expelled from the wound and have delayed wound healing in partial and full thickness wounds.

CLINICAL PROCEDURE

Securing wounds was not a difficult task, as those described as either chronic or surgical were consistently ordered to be dressed with saline soaked gauze, although the frequency of change varied.

Most wounds selected were clean and granulating. Dressings changes had been ordered only on a once-per- day basis.

In-service was carried out, either on one on one or in small groups, as observation of the wound was necessary. Nurses were encouraged to observe the dressing change procedure on two consecutive days. Wounds were initially dressed with saline gauze only. Attention was focused on:

• degree of difficulty of removal
• pain/discomfort to the patient
• bleeding at the wound bed
• discussion of time utilized

Larger group in-services were then assembled, describing the normal healing process and factors that impede healing.

The introduction of the non-adhering layer material (N-TERFACE) was then commenced; thus adherence of the gauze dressing could be avoided.

The non-adhering wound contact layer material (N-TERFACE) has previously been demonstrated to be efficacious in dermatological burns and skin grafts to permit painless and bloodless dressing changes without disturbing the healing process. ⁽⁶⁾

Nurses were once again assembled to observe the same dressing procedure, this time using the non-adhering wound contact layer.

The wound contact layer material was placed directly into or on the wound bed, overlapping the wound margins, followed by the saline soaked gauze.

Nurses were once again encouraged to review the same parameters as with the saline gauze only dressings.

RESULTS

Our efforts in demonstrating that basic wound care could be improved and simplified were overwhelmingly successful. The old cliché, "seeing is believing," was very appropriate. The introduction of newer theoretics and methodologies - by enhancing the traditional - was very positive.

Our nurses described using the non-adhering wound contact layer as a necessary step in basic wound care. As their knowledge of wound healing has expanded, they can no longer accept the traditional methods as status quo.

Their observations, anecdotal recordings and continued use of the
N-TERFACE Material demonstrate an effort to understand and actively participate in wound care today.

Prior to using the non-adhering wound contact layer the dressing change procedure was a long and tedious process, often times traumatic to the wound bed. These conditions were particularly evident in wounds where the gauze had adhered to the wound bed. After the addition of a non-adhering wound contact layer (N-TERFACE) to the procedure, gauze does not stick, and can be easily removed from the N-TERFACE layer. The procedure is brief and the patient is comfortable. After irrigation through the N-TERFACE Material layer the healing progress of the wound bed is easily observed through the N-TERFACE "window on the wound". Cleansing and redressing the wound were quickly and easily carried out. The N-TERFACE Material was often in place up to 72-96 hours without obvious adherence or bleeding.

SUMMARY

These results have been based on clinical observations where traditional saline soaked gauze has been used.

The purpose was not to abruptly change dressing procedures currently being used, but to demonstrate that by simply adding a non-adhering wound contact layer, pain and trauma to the patient could be eliminated. As maintaining the moisture content of the saline dressings is not always a certainty, we can hopefully prevent and avoid lengthened healing time due to needless wound bed trauma. Also, wound care is provided by a wide variety of caregivers who may as yet be unfamiliar with the process of wound healing. Therefore, adding this simple step to our wound dressing protocol ensures compliance and consistency, as our wound management program develops.

Application of the non-adhering wound contact layer material is to be applied to all wounds described as either chronic (pressure sores, leg ulcers) or open surgical wounds - healing via secondary intention, where saline soaked gauze is the prescribed dressing.

The frequency with which the dressing is changed is determined by the nature of the wound and the function of the dressing. The inclusion of the N-TERFACE Material in the dressing procedure allows for the painless and nondisruptive removal of gauze dressings.

1. Wounds - Heavily Exudating

Thoroughly irrigate wound with normal saline. Choose the appropriate size of N-TERFACE Material to sufficiently line wound cavity and overlap wound margins. Lightly pack wound with saline soaked gauze. Cover with secondary dressing.
For prescribed changes (possibly T.I.D. or Q.I.D.) remove gauze dressings. Dependent upon exudate and debris in wound, wound may be irrigated with the N-TERFACE Material left in place. If the slough is tenacious, after irrigating through the N-TERFACE Material, remove the N-TERFACE Layer, repeat irrigation, and apply new N-TERFACE Material. Recommended N-TERFACE change is q 24 hours.
2. Wounds - Small to Moderate Exudate

Thoroughly irrigate wound with normal saline. Choose appropriate size of N-TERFACE Material to sufficiently line wound cavity and overlap wound margins. Lightly pack wound with saline soaked gauze. Cover with secondary dressing.
For prescribed changes (possibly B.I.D. or Q.I.D.) remove gauze dressing. Irrigate wound with normal saline, while N-TERFACE Material remains in place. The wound bed will then be visible through the wound contact layer material.
Recommended N-TERFACE change is q 24-72 hours.
3. Wounds - Clean, Granulating

Gently irrigate wound with normal saline, after removing the saline gauze dressings, while leaving the N-TERFACE dressing in place. In this instance the N-TERFACE Material may be left in place up to 96 hours while saline dressings are still being utilized. These saline dressings are generally changed q 24 hours only.

Bibliography

1. Winter GD: Formation of the scab and rate of epithielization of superficial wounds in the skin of the young domestic pig. Nature 193:293-294 1962


2. Hinman CD, Maibach HI, Winter GD: Effect of air exposure and occlusion on experimental human skin wounds. Nature 200:377-379 1963


3. Rovee DT, Kurowsky CA, Labun J, etal: Effect of local environment on epidermal healing. In: Maibach HI, Rovee DT. Epidermal Wound Healing. Chicago, Year Book Medical Publishers, 1972 pp 159-181.


4. Rovee DT, Linsley CB, Bothwell JW: Experimental models for the evaluation of wound repair. InMaibach HI, Animal Wounds in Dermatology. New York, Churchill-Livington Inc.,1975 pp253-266


5. Hinsley CB, Rovee DT, Dow T: Effects of dressings on Wound inflammation and scar tissue. In: Dineen D, Hildick, Smith. The Surgical Wound. Philadelphia, Lee and Febiger, 1981 pp 191-205


6. Salasche SJ, Winton GB: Clinical Evaluation of a Nonadhering Wound Dressing. J. Dermatological Surgery Oncology 12:11 Nov 86.


7. Bolton L., Pirone, L., Chen, J., Lydon, M. Dressings' Effects on Wound Healing. Wounds: A Compendium of Clinical Research and Practice, Vol. 2, #4, July-Aug 1990, 126-134.


8. Noe, J.M., Kalish, S. The problem of adherence in dressed wound. Surg. Obstet. Gyneco. 147: 185-188, 1978.


9. Dyson, M., Young, S. Pendle, L., Webster, D., Lang, S. Comparison of the effects of Moist and Dry Conditions on Dermal Repair. The Society of Investigative Dermatology, Inc. 1988 pp 434-437


10. Malone, W. Wound dressing adherence: a clinical comparative study. Archives of Emergency Medicine, 1987, 4, 101-105.