Thanks,

Alfred MD

---

I would use Aquacel on your wound. It has slight maceration to the wound edges. Too moist. My mentor alway said, if your wound is too moist, dry it, if too dry maintain it moist.

Maria - LVN student

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You might try one of the silver dressings, perhaps one of the foams. It will absorb the drainage, doesn't have to be changed daily and the silver will aide in preventing infection and will promote healing. I have seen good success in similar wounds using the silver dressings.

Monica RN,C
Director of Nursing

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Where is the wound located? and its chronicity? The wound bed is dry and from the appearance of the wound and periwound, might even have an infection. I would suggest hydrating the wound using a semiocclusive and silver combination (like Acticoat 7 which is silver released over 7 days and you do not have to change dressing as frequently minimizing trauma from dressing changes, especially as it is lightly draining only, then covered with a semiocclusive like Allevyn adhesive or a Versiva semi-occlusive. Surrounding area definitely has to have skin moisturizers and choice of this also depends on where the wound is located.
Maria Carunungan, DPT, CWS

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I would try a foam dressing such as Polymem. You want to keep the wound bed moist but not wet. I would also want to keep it clean. The other option would be using a hydrogel with a cover dressing like a Combiderm. Looks nice and clean, just need to maintain a healing enviroment. Jennifer PTA

akhoff02@msn.com

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Letty,
Sometimes hypergranulation appears around those tubes. If the patinet is otherwise asymptomatic, its probaly ok, just keep it clean, of the yellow drainage with normal saline. Sometimes this whole response occurs when the patient is Latex intolerant and a latex tube is used. Sharon Mendez RN CWS

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Hi Letty,
Before you try anything you need to have the area cleansed and a culture done of the drainage that can be excreted with a little pressure from aroung
the tube. You also need to contact the physician that either inserted the tube or the primary care physician to let him know what's going on. The
culture result will dictate what treatment will be needed. Sometimes when a tube is allowed to constantly go in and out of the body it creates an
irritation that ends up causing over-granulation of the tissue and you end up with the tissue growing above the skin line and up the tube. In any
event, contact the pcp for evaluation and if referred back to the GI doctor that inserted it for follow-up. Continue to cleanse and wait for the culture
results. Putting an absorbent foam like mepilex that will absorb the drainage but not macerate the tissue. A skin barrier like Calmoseptine
ointment that has calamine and zinc oxide will soothe the area and protect the intact skin from the drainage. No-sting skin prep should be used at
every dressing change where the adhesive and skin contact eachother. When the dressing is removed, the protective barrier will be removed, not the sensitive skin layer. Good luck and congratulations for asking for help.
Kathy RN (wound care nurse)
---

 Hello,

Maybe you should try culturing the site, that way the sensitivities would gice you a better idea on what to use with this wound. Do not be suprised if the wound is infected with some type of MRSA or VRE.

Respectfully,

Chuck DiTullio R.N.
---

Leety,
Try Hydrofera Blue. It's a polyvinyl alcohol foam impregnated with gentian violet and methylline blue. It will absorb the drainage, it's antibacterial and antifungal. Dressing change would be BID for 2-3 days until drainage decrease and then daily. Will help decreas inflammation as well.
It's an awesome product. You can learn more about it by going on web site www.hydrofera.com.
Good Luck,
Sharon RN, WCC

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Letty,
Look up Hydrofera Blue.
It has anti-infective properties and absorbs drainage.
Tina (L.V.N., wound care nurse)

---

Letty - You might try a moisture barrier cream to peritube tissue; maybe an antifungal cream if it appears to be fungal, if not i would suggest 1/2 A&D ointment mixed with 1/2 zinc oxide cream. This combo works wonders on mildly irritated skin and is easy to remove. In addition I would try Calcium Alginate to the hypergranulated tissue at tube site. It will absorb drainage and help decrease tissue granulation. If wound appears to be infected or colonized, yo might try Acticoat Absorbant to the tissue instead. It has bacteriocidal properties even against VRE and MRSA. Good
Luck.
Kim, LPN

---

Letty,
I suggest getting a CBC done because the drainage as you described sounds like it's purulent that there is infection and where is it at? deep seated in the jejunum or somewhere in the GI tract versus from the stoma only? Patient may need to be on antibiotic. The protruding wound is most likely hypergranulation which is very common around stoma especially from
a gastric and a jejunum tube. You can use silver nitrate to reduce this. Then cover with an "Aquacel Ag" slit in the center to to make a hole for the tubing. The Aquacel is hydrofiber which will absorb exudate and the silver is released/activated
by the exudate, is good to use for reducing bacterial load. Then you can use a secondary dressing over the Aquacel to secure the Aquacel and also for extra absorptive power. I would also suggest you get a BMP due to the heavy amount
of exudate. If patient is also having weight loss with the heavy drainage, you need to watch against protein malnutrition.
Good luck,
Maria Carunungan, DPT, CWS

---

Letty,
I forgot, try also asking around about "wound pouches." These let you collect excess drainage and measure these as well. When you use a wound pouch, you have to use a
skin protectant to protect the healthy skin around the wound from breakdown from the wound drainage. So your choice of between pouching versus using Aquacel Ag+ secondary
dressing depends on how much the drainage is. Again, I suggest looking at asking for a CBC/BMP also.
Maria Carunungan, DPT, CWS

---

Dr. Ronald Sherman of the University of California at Irvine is regarded as the nation's foremost expert on biotherapy. Check out his website at http://www.bterfoundation.org for information on biotherapy of all kinds.

Thanks in advance,

Mark Rickard
---

Yes, I do. I am Pam Mitchell on the Board of Directors with The BTER Foundation. We are just now starting our workshops in areas across the country. We just had our first one in California, January 29, 2005. Please visit our website for all the information you need. You are among many who are just now finding out all the benefits of these amazing maggots.

bterfoundation.org

---

Dear Anne,
I use Maggot Debridement for my in patients and outpatients and wrote the policy and procedure for the treatment in my hospital. I am also a member of the Board of Directors for the BTER Foundation. You can visit our web site and use the Policy and Procedure that is there as your own, or you may use it as a guide. The board members contact information is there for your support. www.bterfoundation.org
Sharon Mendez RN CWS

---

You might try The Maggot Therapy Project from the University of California
at Irvine.
Kim. LPN

---

Maggot biodebridement therapy (MDT) is an excellent way of managing chronic non healing ulcers ranging from wounds from burns, diabetic foot ulcers, ostomyelitis etc. It involves the use of appropriate medicinal fly larvae eg phanacia serricata, to clean non-healing, infected and necrotic wounds. Its use suffered a setback in the 40s because of the advent of antibiotics which was thought to produce better result alone or in combination with surgical debridement. With the the benefit of hindsight we now know better. MDT is clearly superior in terms of cost, efficiency and safety to the patient. Maggots secrete proteolytic enzymes that specifically bind almost exclusively to non viable(dead) tissue. Aided by movement they liquefy the necrotic tissue in a feeding process and also ingest microbes. Maggot factor is currently being studied for possible use in new generation of dressing material materials and we might have the equivalent of hirudin from leech in maggots. It is ethically sound and can get approval from most authorities in good number of countries of the world. Visit maggot therapy homepage for more information.

Ahmed Mohammed Sabo,
MBBS, MSc (Physiology)
Dept of Human Physiology,
University of Jos, Nigeria.

---

Go to www.woundcarejournal.com. Maggot
therapy was recently featured complete with
info on reimbursment and treatment parameters if I am not mistaken.
Maria Carunungan, DPT, CWS

---

Linda,

Where is the wound? Some types of wounds heal slower than others depending on location and the cause of the wound. Also, there could be other things to consider that can delay wound
healing, like your nutrition, hydration, medications you take, etc. Labwork can be helpful as these give you information on your nutritional level too, any infection, or might point to other things which
can delay healing. What other treatment were used before papain urea?

Papain Urea is actually an enzyme derived from the tropical Papaya fruit. It is used to degrade protein to soften devitalized ("dead") tissue as
you cannot have healing if there is dead tissue. How long it is used depends on how much devitalized tissue you have. If it is thick, it takes
longer to clean the wound of this tissue. You would see the dead tissue soften and become cheesy like and the wound will smell and look
like it is infected. This is the papain working. When you get the dead tissue down to a small amount and have more healthier red/pink tissue, it is usually discontinued. As the Papain debrides or "cleans" the wound of dead tissue, once this dead tissue has been removed, you will see a slightly larger and looks like deeper wound. Its use can be anywhere from a week to several weeks depending again on the amount of dead
tissue the Papain need to debride.

Since you just have been started on Papain, suggest you wait and see what happens for another 1-2 weeks.

Maria Carunungan, DPT, CWS

---

The length of time before you start seeing results will vary depending on what the wound looks like.
If you are in a hurry to get rid of slough, I would try Acuzyme before Pananfil. But if the wound is pale pink, no slough, you might want to check and see what kind of supplements (nutrition) your pt. is getting. If the wound is screaming that it is ready to heal make sure that the edges aren't curled under and be patient, over all Panafil is a good product... give it 14 to 21 days before you change the product.
Tina (L.V.N., wound care nurse)

---

Is your ulcer caused from venous insuf. or other problems.? I have good results with using Unna Flex by Convatec and secure with a 4" Coban for compression. This would not be a good solution if there is an arterial problem. It may be easier to answer if there was more info. Jennifer PTA

Mack

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Mack,
What problems are you having with the VAC foams? How deep is the wound? What is in the wound (color tissue)? The alternatives really depend on what problems you are having with it? Is the foam sticking to the wound is the problem? or infection?
Maria Carunungan, DPT, CWS

---

Blue Sky has a product that is not only less expensive than Kci’s vac, but you can use your own supplies as well. I have had great results with this. Sue, CWS
 

RDawson

---
 

Hi, I work in LTC and a stage II is about as deep as the height of a nickel, more than that is as stage III. Only on the MDS can up-staging be used. DMS

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The definition of a stage III is through the dermis completely. The depth depends on the thickness of the skin. That might be very shallow,
but will never been thicker than about 3 mm. The key is to see if dermis is present or not. The depth of the crater is not terribly relevant. For example, a stage III on a hip might be over a centimeter
deep, but a stage IV with bone involvement over the malleolus might be a mere 1 mm.

Renee Cordrey, MSPT, MPH, CWS

---

I would have the doctor stage the wound and also include photo. unsigned

---

Rose, You have to follow the NPUAP (National Pressure Ulcer Advisory Panel) guidelines on staging. If they are going by your documentation of depth then the location of the ulcer is the next question. A stage lll over the maleolous is not as deep as a stage lll over the sacrum. In my facillity the staff can measure, describe, etc., but only I or another certified nurse stage. This eliminates discrepencies. Sharon Mendez RN CWS

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If your wound appears superficial but has some yellow necrotic tissue or any type of yellow on it (not collagen tissue) Your staging is a three, regardless of the drainage and depth. You do not know what is under that yellow tissue. Best to Stage higher then to under stage. The only thing to do, is stage it and document that the wound is a 3 for your notes and your MDS.
Maria LVN 8 yrs wound care

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Rose,
Clinicians follow the NPUAP guidelines on
wound staging. Go the their website www.npuap.org.
Staging depends on the layers of skin
involved (depth).
Stage 1 is skin alteration observable by redness which is relieved by
removal of pressure. (Skin may feel boggy also).
Stage 2 is partial thickness which means it involves epidermis and
part of the dermis; presents as an abrasion or blister, or open with a shallow crater.
Stage 3 is full thickness with a deep crater but does not extend as far as the fascial layer.
Stage 4 is full thickness with extensive destruction of tissue exposing bone as muscle and fascial layers are destroyed.
For it to be a pressure ulcer, it must be over a bony prominence or on areas where pressure was used for prolonged periods (example under a brief line, etc.) The MDS coding is different from the NPUAP coding as NPUAP does not allow "reverse staging" as a wound heals. Like a stage 4
wound as it heals and gets shallower is per NPUAP described as "healing stage 4" versus downstaging to a stage 3 or a stage 2.
However, for MDS purposes where you have to show the extent of involvement as time progresses, you would code a healing stage 4
wound as perhaps a stage 2 or 3 instead of saying "healing stage 4."
Example:
You have coccygeal decub: Stage 2 is perhaps a blister or open blister over the coccyx area.
Stage 3 is perhaps a 0.4 cm.
Stage 4 is perhaps a 4 cm and the coccyx
bone can be seen due to destruction of muscle/fascia over it.
I suggest also, you ask your facility to obtain a MDS manual as it gives you guidelines on coding wounds for MDS.
Good luck,
Maria Carunungan, DPT, CWS

---

Rose-
You have to love the world of what your taught vs. what the MDS says... the only advise I can give is when you are documenting on the wounds that are healing, use words like "granulating stg III" that will help explain to the paper nurses that the wound is deeper then it appears. Never back stage the wounds, the damage to the tissue is still there after the granulation has started.
Tina (L.V.N., wound care nurse)

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The traditional eggcrates are really not effective for pressure reduction. You need a minimum of 4 inches of good foam for any reduction. Most facilities have gotten rid of eggcrates entirely. If
you have a replacement mattress, then the eggcrate will totally eliminate that benefit.
Renee Cordrey, MSPT, MPH, CWS

---

Eggcrates are no longer acceptable according to Medicare (They are not medicare reimburseable) Try gel overlay, APP, or Group I mattress replacement. These are only used for prevention. If a patient is very high risk (in facility) or already has stage III or IV consider a Group II support surface.
Convolutes side up to allow body parts to fall betwwen crevices, therefore decreasing pressure. If you have it with flat side up you can increase risk for friction and shear when moving the patient in bed. Support surface is my specialty.
Good Luck,
Sharon, RN, WCC

---

I was taught to put the convoluted side down also. The convolutions could cause venous congestion, particularly in someone with edema, and this could lead to ischemia of the tissue. The other issue would be if the patient is bottoming out on the "eggcrate" mattress overlay. Is the foam even dense and stiff enough to provide an appropriate static surface support? There needs to be more than an inch of support between patient and regular mattress to provide any positive outcome. Check out the AHCPR Clinical Practice Guideline book.
Kim, LPN
---

Ms. Cotton,
I am not aware of any literature but you may want to check instead with the manufacturer who will usually have info on why which side is against what.
Maria Carunungan, DPT, CWS

---

Ms. Bowen,
Dehiscence (reopening) can at times be due to infection. Your Hodgkin's is also a consideration. Then it's location makes it more prone to infection plus it is an area where movement occurs.
Watch the drainage also and your protein levels. You lose a lot of protein from a heavily draining wound. And it if is usually clear drainage then becomes yellow, brown, or bloody, consult your physician right away. Ask about a wound vac which helps pull drainage from a wound and
also helps with closure by using negative pressure (vaccuum pull).  There are portable vacs now.
Good luck,
Maria Carunungan, DPT

Jill

Sharon Mendez RN CWS