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Key Benefits

• Coats wound bed, filling crevices and undermined areas
• Remains in contact with wound regardless of patient activity
• Unique osmotic action cleanses the wound
• Promotes autolytic debridement
• Protects developing tissue by providing a moist wound environment
• Absorbs excess exudate

TBright
 

wound will not heal the epitheal cells cannot cross because they are rolled. silver nitrate to the edges should get it started closing
Sandie wilke rn cwocn

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I would suggest you culture the wound.
Also do a CBC, BMP. If she is not eating she may be dehydrated and not have the essential elements to heal the wound, nor the hydration. If however, she is eating but very thin as you described her, look at skin turgor and if poor, has had weight loss, I would at least get a pre-albumin. If she hasn't been seen by a dietitian
yet, I would get a dietary consult right away and would likely also suggest these labs. If she has COPD, CBC will show if she may be anemic. What are her O2 sats? In hypoxic conditions, you are more predisposed to infection.
Maria Carunungan, DPT, CWS

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Dear "Unsigned":

A non healing wound in the upper extremity requires a closer look at your blood circulation. I urge you to see a vascular surgeon. A chronic wound care center is good place to start as they usually have vascular surgeons on staff.

Thomas A. Sharon, R.N., M.P.H.
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Before going anywhere with topicals or other treatment regimens, I would rule out osteomyelitis... sounds pretty textbook on this one. The pinpoint comment and lack of healing is so typical, especially in an area where bone is so superficial.

Jim Patrizi, PT, CWS

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Sounds like you have some sort of bug in there or you have osteo. Have you tried Dakins 1/4 strength x5 days, then a product called hydroferra blue or aquacel AG. (Both antibacteriostatics.) I just healed an elbow ulcer admitted to us that was previously unhealed in less than one month using hydroferra blue.
Cheryl Nichols LVN
Sub acute care unit wound care

Leah

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The poor circulation is probably the reason it isn't healing, has the patient had a vascular consult?

WoundOKC

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We usually think of PVD in the lower extremities, however in this case vascular studies needs to be done.

Tim Biggs P.T.A.

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 I had a similar problem with a patient, and what finally worked for me was Silverlon packed/laid gently into the wound, and finally convincing the patient that he HAD to wear a simple molded brace to keep him from bending his elbow all the time. The wound could not granulate and close with him continually rolling the tissue back and forth across the bone. One more thing, you say no infection, does that also mean this pt has been checked for osteomyelitis??

Vicki, MSPT, CWS
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What is the eitology? Factors that delay healing intrinsic and extrinsic.. Has a bone biopsy been done? Rule out osteo....Perfusion, what other meds is patient taking that might delay healing. Food for thought.
Hope this helps.
Jesse M. Cantu, RN, BSN, CWS

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As you seem to have tried several things with no improvement, you might try powderd comfrey leaf sprinkled on the area. S.L.Willis
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A pale wound bed would suggest to me that you need to address some nutritional issues, have you checked a CBC, COMP, and Pre-albumin lately. You need to know if she is anemic or dehydrated (CBC), COMP will give you over all health but pay more attention to the albumin (your looking for long term protein deficiency) and the renal functions (you don't want to start her on a lot of protein if her renal functions are impaired), the pre-albumin will give you more current protein deficiency perspective. As far as your rolled edges, you MUST get rid of those, the wound may believe it is healed... silver nitrate sticks are wonderful for that. And finally for a treatment... you may want to look at Xenaderm. If the center is not bone but slough it will clean it out and it will help with the poor circulation. I have used Xenaderm over bone before without harm... good luck.
Tina (L.V.N./wound care nurse)

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You mention one important factor with the wound that the wound edges are rolled. In that case the wound thinks it has healed itself. I would use silver nitrate around the wound edges to promote granulation again then return back to saf-gel if there isn't any necrotic tissue on the wound bed. If the wound bed has yellow necrotic tissue I would use panafil which is and enzymatic debrider and works great. Also, you mentioned the patient is thin it is very important to promote proper nutrition because a wound takes several calories to heal themselves also. Ensure might be a healthy habit for the patient to start.
C.B., LPTA

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You might try Panafil. It is made by Healthpoint. It has a tendency to stimulate circulation in a wound bed. It will help keep slough under control in the wound bed. It has healing properties. I have had some excellent results with the use of Panafil.

Monica Miller RN,C

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my friend was on a wound vac and then ended up fianally in Boston where she belonged and they where horrified that she even had it on. the best i can tell you from a lay persons perspective is go to links maybe beth isreal deaconess medical center maybe they have a web site becuase between my girlfriend and my husband local treatments were not working .most are not sure how to address non healing wounds even if they call themselves wound centers..... cover a wound especially infected with a vac defies common sense good luck not sure where you are from. unsigned.

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Seen these,does pt lean on elbows as in using a walker?Is this COPD pt on prednisone?Waste no time,get an orthopedic consult.The olecranon bursae are right below this anatomy.Any plain films or bone scan or other diagnostics?You just may be looking @ the tip of the "Iceberg".
Wayne A. Best,LPN,W.C.C
VAMC
Gainesville,FL..

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XRAY THE ARM AND R/O OSTEOMYELITIS

Amparo (Amy) Pastor RN
Certified Wound Specialist
Manager of Clinical Practice

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The one area you have not mentioned is the patient's nutrition. When you can't find any other cause like obvious pressure or infection you have to consider the fact that they may not be getting enough protein or vitamins to grow new tissue. If the person was even a past smoker that is a likely cause for seeing no improvement. Have you read the story in the Nutrition section of this website? It might explain a little better what I'm trying to say. Hope it helps. Yvonne Asay LPN

Hello.
Have you consulted with a podiatrist? I would
suggest "total contact casting" to offload the
pressure area while healing proceeds. You could
even use a silver based dressing over there wound before the first layer (eg. "Acticoat 7"). Once healed, start stretches to lengthen the dorsiflexors and toe extensors.
Podiatrists might have orthotists who can custom-make shoes for off-loading for diabetics.
Also, have you looked at leg length
and pelvic assymmetry? I had some patients who
had callusses on the foot of the shorter leg and genu valgus on the longer leg.
Maria Carunungan, DPT, CWS

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The way I look at it, the reason for the wound in the first place is the bony deformity. If the patient won't non-weight bear on the foot voluntarily, I would try to take control of the weight bearing issue more aggressively. The presence of serosanguinous exudate tells us that trauma is occuring, so we must eliminate the trauma. Have you tried a total contact cast? It has worked very well for me for these types of cases. You need to find an ortho tech, PT, orthotist, podiatrist, etc. who is skilled at fabricating these cast, as they are quite different than a standard cast. I will assume the patient doesn't have osteomyeilits, or any other infectous process at the moment. The topical treatment within the cast is less crucial than the fact that you must eliminate pressure/trauma. The callous will also be minimal without the trauma. Once the wound is healed, shoe wear is crucial, to transfer the forces to more appropriate weight bearing structures. Good luck.

Jim Patrizi, PT, CWS

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Have you tried regranex and total contact casting? unsigned

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WHAT STATE ARE YOU IN? MAYBE SOMEONE CAN RECOMMEND A VET

Amparo (Amy) Pastor RN
Certified Wound Specialist
Manager of Clinical Practice

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I am with you, most of my work has been on the speices that walk on two legs, however I had a friend with a simular situation and her horse, while the wounds were infected we treated them with Tea Tree Oil (you can get it at any health food store) after the infection had cleared we started treating to horses ears with Granulex spray 2-3 times a day. Just spray and go.
Tina L.V.N./wound care nurse

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When you say the dog has been on antibiotics, have these been oral or a liquid flush? As with humans, are the wounds being covered with anything, or are they drying out to the air? My Lab often gets ear infections, and we use Malaseb, which has a Miconazole base with Chlorhexadine Gluconate (found in most antibacterial hand washes), and we flush her ears bid with it, which works well. You may need to use a topical that will keep the wounds moist.

Jim Patrizi, PT, CWS

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Has flushing of ear canals been tried and
tubes to drain the ears? The wounds around the
ears may not be due to the antibiotics but
the heavy bacterial load. I would contact
Johnson and Johnson and Smith and Nephew,
Convatec and ask if silver-based dressings have
been used on canine wounds before. On humans, the silver-based dressings work wonderfully in keeping bacterial load down. Otherwise, I would suggest you look for a PT who is skilled in using UVC for bactericidial effects on wounds. I'd hate for your dog to lose his ear canals.
Good luck,
Maria Carunungan, DPT, CWS

Hi Helene

I am a registered nurse, level 1 working in the UK, working with acute confused patients. I have recently completed a course on wound care from Queens University in Belfast, Ireland. This was a remarkable course to which I really enjoyed, and got a lot of good knowledge. As part of the course you were issued with a wound care book that gives all this information that you need regarding the wounds and types of dressings to use. If you are willing to give me an address I can photocopy the information and send it to you. Alternatively, I can type the information on to my PC and send it via the e-mail system to you. If you want the address of the university just let me know and I will see what I can dig out.

Look forward to hearing from you soon, Helene

Regards,

Ritchie Watters

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Hi
I had a professor tell me on wounds.
1. If it is too moist, apply a dressing that will dry the wound up.
2. If it is too dry, try a dressing that will maintain it moist.
3. Try your dressing, and find the one that works for you.
4. Try the ones, that your facility approves off.
5. Not all wounds react the same, so experiment and find what works for your wound.
Maria V.
LVN/ wound care nurse
6 years
Work long term/skilled facility

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simple way to remember what to do if it is wet make it drier (absorbent dressing) if it is wet make ir moist (deposit moisture) There is a book published by springhouse authored by C. Hess that covers the topic very well
Sandie Wilke RN,CWOCN

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The question you are asking could take weeks to answer. I suggest that you find a continuing education course that covers basic wound healing principles, and goes over the many classifications of wound healing dressings. You can also find wound healing texts. I like the most recent edition of Cathy Thomas Hess's book, I'm note sure of the title, I think it's "Wound Care". It has much good basic information, and has a listing of the hundreds of wound care products on the market today. Good luck!

Jim Patrizi, PT, CWS

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I've applied hundred of Unna boots in the past, and never went longer than 7 days between changes. I'm wondering why you're using a hydrocolloid (Duoderm)? Is it draining much? There are so many pieces of information needed to answer your question well; do you have much edema? Is the wound infected? Does your periwound tissue tolerate the adhesiveness of the hydrocolloid? Do you have venous or arterial insufficiency? Unna boot is a very mild compression wrap, and works well with the appropriate patient. If you need more aggressive compression, there are other products out there to use. Looking forward to your answers!

Jim Patrizi, PT, CWS
jimpatrizi@aol.com

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Unna boots are changed weekly at the clinic in which I work. 3 weeks seems a very long time to leave one in place.
Sue, RN

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I recommend you see a wound specialist. Go to www.wocn.org or  www.aawm.org to find one near you. Unna boots are usually changed
weekly. However, there is a better type of compression wrap available, the multi-layer wraps (eg: Profore, Proguide, Dynaflex, etc.). Unna
boots don't provide much active compression, and lose what they do offer quickly. The multi-layer wraps maintain their compression over
the week.
Renee Cordrey, MSPT, MPH, CWS

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Hi RN!
Sorry to hear your plight. I first want to say that an Unna Boot is not to be left on for more than a week. Have you had any vascular studies that
pertain to your current circulatory situation. Have you had an ankle - brachial index done to determine what level of compression you should be treated with? Are you watching your salt intake and have you had an A1C and
albumin or pre-albumin level done. Alot of studies have to be done to determine what treatment would be the best. When was the last culture?
Compression will be your treatment for life, during and post healing. Getting rid of the edema is of first importance. Finding out if there is an
infection is the next step. But as I mentioned in the beginning, vascular studies are in order. If you have had them, let me know the results and I
can then go further with my recommendations. Hope to hear from you soon.
Kathy B.i Rn,WCC,CHT

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I personally never leave an Unna’s boot on more than a week. If the wound is worrisome, suspicious for infection, etc, I usually change 2 or more times a week, just depending upon the specific wound’s characteristics and what I am trying to do. Also, if this wound is suspicious for infection, an occlusive dressing like a duoderm probably is not appropriate. An Unna’s boot is usually used for wounds due to venous insufficiency. Do you have swelling in your legs and/or hemosiderin staining (the purplish discoloration) indicative of venous insufficiency? If not, I would question what the Unna’s boots are supposed to be doing. Also, wounds on legs can be from arterial insufficiency, and they should not be treated using any kind of compression!!! If you can get to a wound specialist, that would be wise.

Vicki, MSPT, CWS
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Dear R/N,
I think you should see a Vascular Surgeon. No offense to your Dr.! The history makes me think of a venous problem. The vascular surgeon will be able to assess via a Doppler the circulation. If your wound has a venous underlying you will benefit from compression bandage. Daniela Chrysostomou,Wound care R/N South Africa

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Hi
If there is not any necrotic tissue involved that needs to be removed I have had great success using iodosorb (as long as you do not have any allergies to iodine.) It works very well with ulcers on the lower limbs.
Cheryl LVN Tx Nurse

Leah
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The Diapulse Wound Treatment System is available electromagnetic therapy that is covered by Medicare part B and provides complete healing of chronic wounds in people with diabetes. Go online at diapulse.com to call the company and find out if there is access to this technology in your area.

Thomas A. Sharon, R.N., M.P.H.