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Building bridges in wound management.

Building bridges is the theme for the New Zealand Wound Care Society's conference in Wellington on April 6-8 (see p14). The importance of the theme is reflected in the challenges clinicians confront in caring for, or preventing, wounds. New information about tissue repair and regeneration is generated at an extraordinary rate, and advances in technology have resulted in a plethora of dressings, devices, pharmaceuticals and an increasing number of bioengineered tissue substitutes. Advancing technology has provided wound clinicians with so many choices that decision-making has become more complex, and, for some, confusing. Trying to eliminate confusion, the more informed seek direction from emerging science, while others seek solace in ritualised practices or in therapies outside mainstream nursing. The art of wound care has evolved down the ages, while the science of wound healing is a relatively late phenomenon. Many ancient civilisations have bequeathed to modern man (sic) a legacy of treatments that have undergone a recent resurgence in the search for a panacea for heating chronic wounds. For example, the ancient Egyptians used honey, silver, milk and resin adhesives in their wound heating armamentarium. The use of adhesives in modern wound care is well entrenched. However, the use and therapeutic value of the former three modalities have only been substantiated in more recent times. A revival in the use of honey owes much to the work of New Zealander, Peter Molan. (1) Growth factors obtained from milk whey have been found to contain a variety of cytokines and growth factors that regulate tissue repair. (2) And the interest rekindled in the antimicrobial properties of silver knows no limits.

Silver has been used for its therapeutic and preservative properties for centuries. Ancient civilisations stored their water and milk in silver containers to prevent them from spoiling. (3) Early American settlers placed silver dollars in their water barrels to maintain freshness. (4) Silver and copper metals are stilt commonly used in water towers to destroy bacteria and fungi. (4) The ancient Egyptians, however, are credited with the first use of precious metals in wounds. In 1884 silver nitrate solutions were used for their anti-microbial properties in the treatment of ocular infections. (5) The use of topical silver waned with the advent of sulphonamides and antibiotics. During the 1960s, silver nitrate and silver sulfadiazine cream were employed as antimicrobial agents in the treatment of wound infections. (6)

Effectiveness of silver

Silver is known to be effective against Gram negative, Gram positive, anaerobic and aerobic bacteria, yeast, fungi and viruses. It is also effective against antibiotic resistant strains of methicillin resistant staphylococcus aureus (MRSA) and vancomycin resistant enterococcus (VRE) (5), (7) Some silver impregnated dressings have also been demonstrated to be biologically active in the wound environment. (8) These findings and attempts to reduce the dependency on antibiotics have led to the addition of silver to an ever-increasing range of dressings. But at what cost? Silver impregnated dressings are among the most expensive. Of greater concern is the ongoing debate among scientists that focuses on the best methods of delivery and therapeutic dosages for topical silver. (9,10) Significant concerns have been expressed in regard to the potential risk of developing bacterial resistance to silver, mimicking that developed to antibiotics. (9,10) This discussion highlights the urgent need to bridge the art/science gap in wound management. The great challenge is how best to do this, in tight of the fact that rituals in wound care still abound. Consider for instance, the rituals associated with wound cleansing and dressing procedures. Many of us could chant the indoctrinated steps we were taught for using "clean" and "dirty" instruments when cleansing and dressing a wound. In light of the abundance of evidence to the contrary (11,12) it is surprising, if not inexcusable, to find such rituals till taught in many schools of nursing in Australia. Is this also the situation in New Zealand? Less than optimal heating outcomes and subsequent waste of resources is compounded by lack of comprehensive education. We need to bridge the theory/practice gap early in our professional journey. Unfortunately, the tendency has been for many undergraduate programmes to adopt a token approach to teaching students the science and art of wound management. One can appreciate the demands on undergraduate programmes but the care of the integument and prevention of its injury is fundamental to art nursing practice. There appears to be an expectation that students and new graduates, as if by some metamorphic process, will absorb all they need to know in the clinical setting. Such educational naivete does not prepare novices for the clinical challenges ahead and it reinforces less than optimal wound management. Is this also the situation in New Zealand? If so, it reinforces the significance of events such as the Building Bridges conference, for such events advance our understanding of the fact that wound management is not just the application of a dressing. It requires an informed, multidisciplinary approach to the assessment and management of the person, their wound and their healing environment. To do this well, we nurses need to keep abreast of the science and draw upon the evidence and examine our practice in light of that evidence. This indeed is a bridge to success.


(1) Molan, P. (1999) The role of honey in the management of wounds. Journal of Wound Care; 8: 8, 415-418.

(2) Cox, D. (1994) Milk growth factors. Journal of Wound Cure; 3: 1, 47-48.

(3) Baranowski, J. (1997) Colloidal silver, the universal germicide. Nexus; Dec, 39-42.

(4) Ovington, L. (1999) The value of silver in wound management. Podiatry Today; Dec, 59-62.

(5) Burrell, R. (2003) A scientific perspective on the use of topical silver preparations. Ostomy/Wound/Management; 49(5A Suppl), 19-24.

(6) Kucan, J., Robson, M., Heggers, 3, & Ko, F. (1961). Comparison of silver sulfadiazine, povidone-iodine and physiologic saline in the treatment of pressure ulcers. Journal of the American Geriatrics Society; 24: 5, 232-235.

(7) Wright, J., Lain, K., & Ko, F. (1998). Wound management in an era of increasing bacterial antibiotic resistance: A role for topical silver treatment. AJIC; 26: 6, 572-577.

(8) Landsdown, A. (2002). Silver 2: Toxicity in mammals and how its products aid wound repair. Journal of Wound Care; 11: 5, 173-177.

(9) Silver Symposiums presented at 2nd World Union of Wound Healing Societies' Meeting. (2004) Paris, July, 8-13.

(10) Silver Symposium (2005) Perth, WA; September 7.

(11) Ellis, T. & Beckmann, A. (1997) The wound field concept: A new approach to teaching and conceptualising wound dressing. Primary Intention; 5: 2, 28-32.

(12) Ellis, T. (2004) Understanding the act of contamination in wound dressing procedure. Collegian; 11: 3, 39-41.

Keryln Carville, RN, PhD, is Associate Professor Domiciliary Nursing, Silver Chain Nursing Association and Curtin University of Technology, Western Australia.
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Article Details
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Title Annotation:tissue repair and regeneration trends
Author:Carville, Keryln
Publication:Kai Tiaki: Nursing New Zealand
Article Type:Editorial
Geographic Code:8NEWZ
Date:Mar 1, 2006
Previous Article:Events 2006.
Next Article:New nursing era may prove detrimental.

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