Karen RN, BScN

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How often you treat an infected wound depends on what you are treating the wound with. Topical antibiotic ointments or creams are usually qd and up to qid, most silver based dressings (not ointments) are usually ordered qod or even q3days. Personally I believe that if the wound is infected it needs to be seen at least daily for documentation purposes.
Tina (L.V.N./wound care nurse)

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Vicky,
The need for dressing change depends on the amount of drainage and the choice of dressing also depends on the wound characteristics. There are dressings which are used for min, mod, heavy drainage. There are also dressings which have antimicrobial ability like the silver dressings which now come in an absorbent form also like those with Smith and Nephew- Algisite with silver, then another from Convatec like the Aquacel Ag. Usually these can be left on for 2-3 days (for alginates with silver) depending on the amount of drainage.
Those with minimal drainage and wound needs kept moist, you can use semi-occulisives like the Allevyn plus an acticoat pad. I usually look more at what the wound needs based on appearance, drainage, then choose my dressing and not get so stuck on one particular line. If you are doing an inservice, try to contact these companies and others and ask for samples.
They'll give you brochures to describe the capabilities of each dressing type. Other antimicrobial might be modalities like
UVC and a form of high volt pulsed current can also help with infection.
In addition, some silver dressings can usually be left on for up to 7 days, that is, if drainage is minimal.

Good luck,
Maria Carunungan, DPT, CWS

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Infected wounds should be cleaned and dressed daily to promote decrease in bacterial load. I love to use the new silver dressings for those wounds. Depending on the wound characteristics, a silver alginate (for heavy drainage) or a silver gauze can be used to knock down bacterial load. Also, my favorite all-time dressing, Polymem foam, now has a silver-impregnated version. Also, any necrotic tissue should be removed ASAP as this provides a good environment for bacteria. As soon as the wound is cleaned up, the drainage should subside, and you can go to dressings that can be left in place for more than a day, such as films, foams, etc.

Vicki, MSPT, CWS

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There have quite a few advances in dealing with infected wounds:

1) Ascertain if your wound is truly clinically/systemically infected (there is a host response i.e. temp, elevated WBC, malaise, etc.) or if the wound has become critically colonized meaning it a high level of bacteria w/o host response.
2) If there is a host response, culture wound appropriately so the physician can prescribe antibiotic therapy
3) For a critically colonized wound, implement a 10 day trial of a topical antimicrobial such as silver (Acticoat) or cadexomer iodine (Iodosorb)
These new technologies are sustained release, meaning they have bacteriocidal activity up to three - seven days depending on the amount of exudate in the wound. They are broad spectrum and kill all bacteria, fungi, virus of clinical significance without harming fibroblasts which are responsible for granulation tissue formation.

Hope this helpful!
Ellen Williams BA, LPN, CWS

There is such a huge variation in wounds, even wounds of the same etiology, that it is not possible to cover the bases with specific standing wound orders. The only standing orders that would be truly effective would be something like "Wound Care Team to evaluate and treat as indicated" or "Wound management team consult and make recommendations."

Bryan G., MSPT, CWS
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Deb,
I am actually in the process of creating house protocols for different wound types (decub stages 1-4), venous stasis, arterial, diabetic ulcers. We are doing this in my facility to bring on more continuity in care and avoid unnecessary interruptions in care when we are having to wait on physicians who are at times difficult to contact. The protocols will need to be reviewed by our medical director first and presented to the physicians who see our patients. Protocols would include both patient and wound assessments, labs and tests, and treatments including patient education (from position changes, relaxation techniques, lymphedema exercises, vascular exercise, smoking/caffeine cessation, nutrition,
hydration,etc.) Hopefully too, we can achieve a "24 hour wound care" because our protocols will spell out standard procedures during each shift and will direct staff on procedure for referral or consultation should there be an issue at any shift. You can e-mail me at MDCarunungan@aol.com
around end of February to see our progress.
Maria Carunungan, DPT, CWS

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Stage 1 and 2
Xenederm q shift open to air
CBC. transferin, Prealbumin, Albumin, Total Protein
Vitamin C i po q day
Zinc Sulfate 220mg i po bid
PT to screen and evaluate

Stage II
Panafil if granulating
Accuzyme if necrotic with moisten gauze dressing
Same labs

Stage III or IV
Same labs
Granulating wounds Panafil
Necrotic wounds Accuzyme

Draining wounds cover with Aquacel or Aquacel Silver
Minimal draining wounds dry gauze

If too moist and draining excessively Mesalt or Kaltostat

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Most standard protocols call for tub cleaning between every use, the manual for the tube will tell you which cleaners can be used safely in the type of tube you have... wound infection known or not.
Tina (L.V.N./wound care nurse)

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Leonard,
Because of the many disadvantages to whirlpool
including the risk for cross contamination, and the time it takes to prep patient/equipment and do aftercare, the use of whirlpools in most healthcare settings have dwindled. There are benefits like wound cleansing, debridement, stimulation of circulation. However the
disadvantages almost nullify or minimize the benefits. It encourages venous congestion which slows healing; after warming comes wound cooling, which results in reduction of or absence of cellular activity for 3-4 hours post treatment, then sometimes the pressure from the turbulent waters actually drive bacteria into the wound.
MRSA is a tough one, so maybe even more need to stay away from whirlpool. If the patient has completed antibiotics and becomes colonized, it is best you continue to use antimicrobials in dressing form instead. Having been used to whirlpools when I first got into wound care 18 yrs ago, it was hard for me to let go of this modality, even up to 5 years ago, I had those temptations
as it does clean up the wound fast. But I found that some things are actually as effective if not more effective such as irrigating with water pick, or a syringe (8 psi), using pulsevac after maybe using a chemical debrider for a few days to 2 weeks, then switching to a dressing that will keep the wound moist and warm for optimal
healing. Then there are these wonderful antimicrobial dressing now (silver based) which you can also use for antimicrobial purposes and they might even come in other forms which also combine absorptive properties.
Maria Carunungan, DPT, CWS

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Leonard,
Some facilities actually use UVC to
quickly disinfect surfaces. However, we still
have turbines and other crevices which we might not get UVC exposure. Check with your Infection Control Officer and he will usually have a list of cleaners which will address pathogens as drug-resistant and resistant pathogens like MRSA. Most health regulators will want to see the disinfecting capability of your cleansers
anyway and it usually is better to use the same one as the facility's.
Maria Carunungan, DPT, CWS

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In our clinic, we are able to successfully treat the large majority of our MRSA or VRE wounds without the use of whirlpools. This is often by bedside irrigation/debridement with either syringes or pulsatile lavage, depending on the wound. However, pulsatile lavage has been shown to aerosolize the pathogens, thus conaminating nearly everything in the room, so if that choice is used, appropriate PPE must be used to avoid carrying it on the clinician to other places. As far as whirlpools that are used with MRSA pts, the usual protocols for cleaning them should be effective against all pathogens, including MRSA and VRE. The real issue is the cross-contamination of other equipment and items in the whirlpool room. Both the Tech and the PT must be acutely aware of everything they do and touch, to avoid cross-contamination. All used items that are not disposable need to be isolated and cleaned by the tech, again with appropriate PPE, with alcohol or another approved surface disinfectant.

Bryan G., MSPT, CWS

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Try immobilizing the foot to minimize movement and also apply "gentle" pressure with the flat surface of your thumb over the exterior of the dressing so as not to contaminate the wound. You can also secure it with mild compression from pressure bandage over the primary dressing provided your doctor has checked out the foot and cleared it of any circulation problems first. This extra tissue is "hypergranulation" or what is known more as "proud flesh" or even "angry flesh" and  Calcium has some effects on formation. Sometimes, the healing proceeds rather too quickly. If it persists, you can use silver nitrate to minimize the hypergranulation. If it is too much that it mushrooms, then it needs to be removed surgically. What dressing protocol
are you currently using? Good luck,
Maria Carunungan, DPT, CWS

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Bacitracin ointment to the hypergranulation should help.

unsigned

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When the initial excision was done, was the excised tissue sent for histopathological examination? Has an x-ray been done of the foot? Recurrence of hypergranulation suggests a stil existing underlying causative factor. pressure, I believe should help but the underlying casue must be found and only then can the problem be tackled appropriately.

kumkum

Positioning your resident so that sliding is more difficult will help eliminate the sheering problem. For chair positioning I have become fond of Broda chairs... they look like lawn chairs on wheels and have a tilt in space type feature (but much cheaper). Side to side positioning in bed makes it more difficult for the person to use their legs to slide all over the bed, and provides pressure relief to an already compromised area. As far as treating the "itch" have you tried an anti-anxiety med? Sometimes with the elderly scratching is more of a nervous tick then a sign of a skin condition. To treat it if (s)he is incontinent I would keep going with a barrier cream; Baza makes a great anti fungal barrier crm, my personal favorite barrier crm if you are sure it's not fungal in nature is Xenaderm.
Tina (L.V.N./wound care nurse)

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Cindy,
How is her hydration? If the skin is dry, she
will probably keep scratching. Perhaps the
behavior of sliding is pain and discomfort related.  If it is goulded and inflamed, I would apply cold compress three times a day over the Allevyn mostly for pain relief and slow down conduction along the nociceptors just so to keep her from scratching. This is probably the primary goal. Usually you'd like a warm, moist wound  but in this case unless we reduce the irritants, she'll keep  scratching and the more she scratches, the more she activates histamine which will perpetuate the process.
After she calms down, maybe try Acticoat with your Allevyn for anti-microbial for a few days to a week...then switch to EPC (has zinc and some vit A). During this time you would have also discontinued the cold compresses as now we would like to proceed from inflammatory to the next phase. Hopefully at this time too, your anti-histamine (which is anti-inflammatory) can be discontinued so healing can proceed.
Good luck,
Maria Carunungan, DPT, CWS

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My favorite treatment for superficial breakdown or scratches to the buttocks is Xenaderm ointment. You don’t have to apply a dressing over it unless needed. I believe Healthpoint manufactures it.

Vicki, MSPT, CWS
 

Teri

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Terri,
This is recognized practice. We use silver
nitrate a lot on hypergranulation. I wouldn't
advice applying it yourself unless your physician knows and had observed you doing this yourself over a few applications. Another way too is gently applying pressure (flat surface of your
thumb) on the ulcer (that is first covered with a clean dressing) for 5 minutes per time. It is the amount of pressure you might use to check your wrist for a pulse, and not any more.
Good luck,
Maria Carunungan, DPT, CWS

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I have had the same problem my entire life and they are miserable. And yes you can do it at home. Your physician can probably get you some of the sticks or swabs, or help you with getting them.

Vicki, MSPT, CWS
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Has any thought been given to using Vacuum Assisted Closure? We try to use VAC for stage 3 and 4 pressure ulcers. Not only does it reduce the trauma to the resident/patient as it is only changed 3 x/wk or prn, but it also
reduces time spent by registered staff foing treatments for the same reasons. The only thing used with this type of dressing usually is
Acticote, a silver dressing, adn only if needed. Generally, we just use the VAC alone. The company we use to get the VAC is KCI Canada. I know KCI is in the States as well. It's a great tx and can have great and quick
results.
Pat K-S RN, Skin Care Co-ordinator, Ontario, Canada

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Pam,
It is bothersome. A safer and easier option
is using a silver-based alginate rope to pack
the wound and also address drainage absorption. The silver is of course anti-microbial. If you have the tunneling / undermining, need to culture for anaerobic and aerobic pathogens. Regardless, unless there was any signs of infection in the wound and periwound, treatment would still be the same as using the silver based product. You can get these through Smith and Nephew has algicite plus silver ropes, and also Convatec has rope (Aquacel Ag- hydrofiber plus silver). The wound bed is pink so healing should proceed as long as the wound is moist and definitely reducing bacterial load from even a colonized wound is a big plus.
Maria D. Carunungan, DPT, CWS

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I would rather use an alginate on granulation tissue. If there is substantial drainage, the wound may be colonized and a silver alginate might be the choice.

Vicki, MSPT, CWS