-Is this common or rare?

- Any procedures where this is more likely to happen?

- Any place I can get more detail on this?

When it does happen, is the problem related to the skin wound not closing or something else?

Alice, RN student

unsigned

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To hold the dressing on, try using surgical netting. You can take a large size, and cut a couple armholes to make a vest. That might help
the dressing hold on better. You could use something like a hydrogel to avoid sticking.

Renee C., MSPT, MPH, CWS

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Pat,
Also try Allevyn thin- breathable foam dressing.
This is if there is not a lot of drainage like scant
or minimal.
You put pressure around the edges to
make it stick and when you remove it, you merely
lift and pull on one corner to remove the dressing;
not as traumatic to the surrounding skin when
removing. I find this useful on high friction areas.
Maria Carunungan, DPT, CWS

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Hi Pat,

This is Beth RN from Bangor, ME. What about using a mepitel with a telfa over it and secure with some medipore.

Mepitel would prevent sticking and the medipore seems to adhere without causing irritation. Just a thought. Hope all goes well.

Beth RN
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Pat-
Most of the time when the resident is picking at the dressing something hurts or itches, I would try Domboros Solution.
It is indicated for minor burns, insect bites, and rashes. But a oncologist I have worked with in the past loves it on cancerous lesions as well as deep radiation burns... and it's easy to use, saturate a 4x4 with the solution apply it directly to the wound and leave it for 15 minutes, then remove TID. You can cover the wound with Xeroform or telfa between treatments, but everyone I have used it on swears it helps with the itch and the pain related to the wound.
Tina (LVN, Treatment nurse)

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By using a prodiuct such as Aquacel, you would be able to leave the dressing in situ for longer periods of time - often in such wounds this is preferable as the dressing change may involve pain or discomfort. Aquacel, for example, is very absorbant and can be left for several days dependant on the drainage, if the Aquacel did stick to the wound one only has to moisten it with NaCl and it will become a gel which one can then easily remove without causing trauma to the fragile wound. If there is bleeding, an alginate such as Kaltostat can be helpful in controlling the bleeding and is also a very absorbant dressing.

Both of these dressings need a secondary dressing to secure them. In patients who pick at their dressings, often Opsite is a good choice as it is more difficult for the patient to find the edge of the dressing. You may need to protect the skin from potential damage related to long-term, multiple applications and removal of adhesive dressings - there are several products on the market such as SkinPrep, or Cavilon No Sting Film Barrier which are applied as a skin barrier with the additional benefit of allowing the dressing to adhere better to the skin.

Good Luck, Kay RN
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I would use a wound gel under the telfa, to prevent the sticking. Duoderm probably wouldn't work on a fungating tumor, will be too wet.
To keep a non-adhesive dressing in place, you could consider using a flexnet/tubular bandage.
Dawn, RN, CWOCN
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I am only a CNA but have been doing alot of private care and i just had a lady who had a bad ulcer that became very fungal. I mixed zinc oxide paste with nyistat cream I used this to put around the outside of the sore after cleaning the sore. My method was to clean the sore with boric acid i bought the powder boric and boiled it 1Tablespoon with one cup saline solution then put it in a clean spray bottle , I cleaned the sore with it then used wet to dry in the sore on the outside of the sore is the place i put the mixture of zinc and nyistat, it worked wonders. Even if you dont use the wet to dry you can still use the other s i mentioned I also would do Oxygen treatment , I devised a funnel and we cleaned it after every use I would put the oxygen tube up through the hole in the funnel and then put it by the sore and left it on for about 10 to 20 minutes . I know that alot of this is not medical but it worked for me and the boric acid is a great antifungal. I hope this helps .Crystal

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Hydrofera Blue has worked well with an elderly patient I had with fungating breast tumor.
The dressing kept the wound moist and offered significant reduction of pain.
You can secure by wrapping her upper torso and axilla with kerlix. unsigned

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we had a patient like this as well. Eventually drained tremendous amounts. How about adaptic, 4x4, abd pad and secured with stockingnette?

unsigned
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Due to the fungating mass it will be difficult to keep proper dressings in place especially if there is a lot of discharge . You could pack the ulcer
with Aquacel / Aquacel Ag ( if there is infection onboard) from Convatec and close with Mepilex from Tendra ( it has soft silicone lining and doesn't adhere to the skin ).

HARI MD

Christian,
Spider veins are actually varicosities
when veins lose their integrity and remain
distended. E stim will not cause these.
Standing for a long time frequently and weight gain can also predispose you to spider veins. Might need to check with your physician about compression stockings?
Maria Carunungan, DPT, CWS

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It is highly unlikely that e-stim would cause spider veins. Research tells us that e- stim increases blood flow to the local area, how ever there may be an underlying problem with your circulation in both extremities. I would recommend a vascular consult to rule out PVD.

Tim Biggs PTA

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“Proud flesh” is generally the term used for hypergranulation, which is treated with silver nitrate stick or swab, or with compression dressings, whatever is appropriate to the situation.

Vicki, MSPT, CWS
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Proud flesh, or hypergranulation tissue can be treated with silver nitrate sticks. You can help prevent hypergranulation tissue by properly stabilizing the tube. A loose, dangling tube will irritate tissue and cause hypergranulation tissue. The tube should be allowed to come straight out of the opening and not pulled off to the side.
Dawn, RN, CWOCN

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As mentioned a quick swathe of silver nitrate,has been effective inthe past.Non use of cytoxic topicals peri-otomy,good skin care with pre-made "trach"dressing daily!?!
Wayne A.Best ,LPN,W,C.C

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Treat the proud flesh with Silver Nitrate sticks but more importantly to keep proud flesh from returning you MUST achor the tube to keep it from moving. Mobility of the tube is what causes the proud flesh. There are several different anchoring devices on the market, both Hollister and Convatec make fairly good ones. It will depend on the size of the pt and their abdominal contours around the tube. Good luck.
Chris Berke RN CWOCN

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a few more emails came in mentioning silver nitrate.

Allan

Tina

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Tina- technically yur are correct. The wound is unstagable until a depth can obtained. However, in the Sub-acute universe, for the purpose of MDS
completion, this type of wound would be staged as a IV. For updated information on wounds go to the CMS web site.

Kim
LPN/Wound Care Nurse

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Tina-
Necrotic tissue is necrotic tissue, you are right.
The problem is that if you are treating the wound you can't bill Medicare or Medicaid with out staging, if your billing is based on the MDS (Medicare) the caption next to stage IV ulcers says Stage IV or necrotic, however a T.I.L.E. (Medicaid) says no stage no pay. Check into your facility policy, the policy at the facility I work in says you chart necrotic wounds are staged as "unable to r/o stage IV" while debridement is being done and as "unable to stage" if no treatment is happening. It's just a play on words to ensure we are paid for the treatment.
Tina (LVN, Treatment nurse)

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At least 10 more replies came in to Tina's question, but they were consistently saying the same thing as the postings above...so I didn't reprint them.

Allan

unsigned2

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Always get a second opinion. Also check with a wound care facility.

unsigned

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You are definitely right about colostomy attracting more problems to an elderly patient in her early 80's. Nutritional and degenerative changes can constitute further stress that can wear her down; holiestically speaking. I suggest a more pragmatic and conservative approach and colostomy as a last radical resort.

Ahmed Sabo

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 I how the use of a colostomey could enhance healing, but alot of in-between information is missing. Who is caring for your mother, how often is toileting/incontinence care being done, and what is her nutritional ststus are just a few off the top of my head. I did want to say the if a colostomey is preformed, you might as well ask about the feasibility of usiong a wound-vac as I've seen alot of success with their use in recent months.

Respectfully,

Chuick D. R.N.
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If it were my mom I would ask about rectal bags before letting them do the colostomy. unsigned

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If a pt. with a coccyx ulcer has frequent incontinent stools, a diverting colostomy is not unusual. In fact, the diverting colostomy is a good way to help keep the wound area clean, since there is no stool contaminating the area. It is not extremely aggressive or inappropriate, in fact it is very appropriate if incontinent stools are causing increased exposure to potential infection of the wound. A diverting transverse colostomy is a relatively low risk, albeit major abdominal surgery, which could be worth the risk, to get the stool out of the wound, which would also be a risk for wound infection.
Dawn, RN,, CWOCN

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There are multiple considerations for colostomy.
One is the chronicity of the wound. How long has
she had the wound? Is healing not progressing due to infection from frequent fecal soiling from the anus?
There are multiple factors other than fecal incontinence which can contribute to delayed healing which can be medications which slow healing, hydration, nutrition, pressure, etc. Also, colostomy is reversible (or some are)
and are usually reversed once a wound is completely healed. Just ask your physician nicely if the other factors have been looked at also. Sometimes, even what one eats, or any existing problems with digestive system can affect bowel movement- like frequent diarrhea. These
have to be addressed as if they aren't, then even with colostomy, some wounds will not heal. Colostomy is usually considered when the wound had not healed for a considerable amount of
time and with fecal incontinence/soiling as "the" major limiting
factor. Good luck,
Maria Carunungan, DPT, CWS

Betina,

You should call your surgeon and ask him/her what you should do. Each one has different protocols, and it will depend on how much take the graft has. Call them today.

Renee C., MSPT, MPH, CWS

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Typically the surgeon will tell you to let the donor site (your thigh) "dry out", wash with antibacterial soap and water daily and call who ever did the procedure if you believe it is getting infected or you are having complications.
Tina (LVN, Treatment nurse)

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Betina,
Check with your physician if he wants the area
dressed all the time. There is what you call:
"skin prep" which you can apply to the skin
which will not irritate the skin but makes the adhesive stick better and protects the skin from the trauma of later taking adhesive off. This is a commonly used item at clinics and hospitals.
Maria Carunungan, DPT, CWS