sweetangel35127@aol.com

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Karen,
Do get an MDS manual. It will tell you how to
properly code wounds, etc.
Good luck with your new unit!
Maria Carunungan, DPT, CWS

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This assessment was designed to meet all of the wound care documentation requirements for Medicare, feel free to print it and use it if you like. You only have to fill it out once a week and put it in the nurses notes... I tape an actual tracing of the wound to the document. Just lay seran wrap over the wound and trace it with a sharpe.
Tina (L.V.N./wound care nurse)

P.S.

I am looking at Stage 1 and Stage 2
I am looking at all the items in the list below, except surgery, which would not be indicated for Stage I and II. Thank you for your assistance.
Karen Whitmore

- product
- nutritional support
- support surface
- nursing time
- hospitalization
- antibiotics

Each case is different to some degree depending on comorbities, mobility status, etc. However, you might try working from the Braden scale
interventions list. You can find the scale and interventions at www.bradenscale.com. Good Luck in your search

Kim
LPN, Wound Care Coordinator

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Karen,
The cost of treating a wound depends in part to
the setting you are in. It is easier if you were merely in an outpatient setting or utilizing part B Medicare or private insurance as billing is simpler. If you are in an inpatient Medicare unit,
you consider other things and reimbursement depends on other factors about the patient so it is harder to pin down cost of wound care only. In an outpatient setting you don't get reimbursed for the labor cost and dressings can be iffy also. Billing is by CPT code which is based on procedure
(some you can bill by amount of time spent and some has flat rate regardless of time spent in delivery). You could be for instance debriding a wound using a G code and it is a service-based code which means you get reimbursed 1 flat rate
no matter how long it took you to complete the care. The only measurable cost is the cost of dressings regardless of setting. You can check with purchasing on how much the dressings on your formulary cost and check with Business office on the profit margin. Labor cost, the cost of other interventions such as support surfaces
(special mattress) in an inpatient Medicare setting does not matter much as again you don't bill by time spent on wound care alone.
Maria Carunungan, DPT, CWS

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According to my sources, the cost is anywhere between $6500.00-$65,000.00…..CDN

Karen Barratt, RN, BScN
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At one point I questioned an oncologist about "drying" wounds and was told that when a superficial cancerous lesion is removed that you don't always know if you "got it all" and if you let the wound dry the top layers of the dermis will "die" and slough off... maybe your dermatologist has the same idea in mind.
Tina (L.V.N./wound care nurse)

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A wound is a wound. Period. And moist wound healing has been shown many times over to be the most effective way to heal. I have never heard of “dry wound” healing being effective and it usually leads to scarring. Perhaps you could show them some of the multiple studies that have been done on moist wound healing or contact a wound care specialist and/or rep for a wound company that would do an in-service or some type of education. A lot of the MD’s I have worked with still stick to the “old ways” of wound healing but once they see how great it works, are more than willing to use more modern methods. Good luck, I know it is tough to change their minds! Sue, CWS
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Unfortunately dermatologists are not wound care experts, but want to think that they are. There is plenty of evidence to support moist wound healing, but whether or not you can convince a physician is another matter.
Dawn, RN, CWOCN

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hi there im a wound care nurse working in one of the big hospitals in the UAE
regarding what you have mentioned..such wound are realy wet...and they exude continously ...the aim is to manage exudate by absorbing them (and there they say drying them)..as nurses we learned that wounds should be kept wet..and in such pateint they are already wet,,thats the time we go into removing such exudates that might damage othe tissue. cancer wounds are realy hard to manage cause some times you dont know what
to do,,,they smell(manage the odour)..they leck(manage exudates...they have slough (autolytic debridement) high tendancy to have infection(p[revent infection) and all these things can be present in one wound.
wish you all the best
regards
laila

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Terri,
Can't understand it either. We use Mesalt
for ulcerating metastatic lesions and we need
to keep these moist. Drying up a wound to heal it is as you say "old world, as the studies over the year found to dry up the wound actually leads to increased healing time because epithelial cells migrate down versus centripetally due to lack of moisture. It fools the untrained person as
it looks like the wound is healed because it is "sealed" by a "scab," without the person realizing that the healing' continues and takes longer under the scab. The only rationale I could think of is someone would actually want to slow healing due to the known rate of activity of cancerous cells (they work fast and replicate fast). I am interested in others' thoughts on this subject.
Maria Carunungan, DPT, CWS

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Try covering the wound with plain gauze or a calcium alginate (if you are worried about desterbing the wound bed). I know you said that it has minimal drainage, but if you moisten the alginate it can't absorb as much drainage. I have noticed that a lot of the time if the cover don't fill the wound but lays over it you are more likely to have the edges roll.
Tina (L.V.N./wound care nurse)

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You are describing epiboli or proud flesh. This is a condition where the epi cells have curved inward and prevent the cells from migrating to the center. The cells then pull the new forming cells to the edge, causing a rim of thick, almost keloid like tissue. To prevent this you can use a saline gauze scrub each treatment to irritate or renew the acute phase to encourage epi and granulation cells to form and migrate. Run the wet gauze around the wound edges and across the center. Just make sure your patient has had proper meds for pain. You can also get an order for a silver nitrate swab. This also causes irritation by burning the epi cells causing a return of the acute phase. I use the guaze scrub tech during every treatment to keep the epiboli from forming and it also works when the line has already formed, just be persistant. Hope this info helps.

Kimberly G Cash LPTA in VA

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It sounds like you have something called “epiboly” happening with your wound, which is when the epithelialization gets ahead of the granulation. You can wipe it off sometimes with some aggressive wiping with dry gauze. Also, silver nitrate can be used to burn it back.

Vicki, MSPT, CWS
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Have you tried hydrofera blue? This will stimulate granulation and help unroll the edges, secondary to negative pressure the product offers.
It is also very cost effective. Contact your local rep. to get more info www.hydrofera.com

.-Sharon, RN, WCC NY

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Hi Joan
Consider getting rid of the Telfa, tends to cause too much maceration to the wound edges and use ABD of 4x4s depending on depth and drainage, may consider using Calcium Alginate, then consider Silver Nitrating the edges daily for a couple of days to prevent the inward rotation.
Cheryl Nichols LVN
Wound Care

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What you are describing is called rolled wound edges, and when the edges are rolled, healed is stalled. I'm not aware of any way to prevent this, but you can intervene by using silver nitrate sticks. Silver nitrate is chemical cautery, and what you doing is basically burning off the rolled edges and re-starting the inflammatory response of wound healing. Roll the tip of the silver nitrate stick over the edges until all the silver colored material is gone. Repeat 1-2x/week until the rolled edges are gone.
Dawn, RN CWOCN

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This is called epiboly, and I usually address it with silver nitrate application. It can also be surgically excised.
Renee Cordrey, MSPT, MPH, CWS

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Dear Joan,

It sounds like you've done a lot of things well, per your description of the base. The fact that the edges have epithlialized under tells us that we need to get rid of that border... debridement is the answer. If you don't have access to a surgeon to either come into the facility, or send the patient to (to pare back the edges), then you could try using Silver Nitrate sticks, to essentially "chemically burn back" the edges. If you've never used them before, they look like long matches, and are encased in a white tube. The material on the end of the stick will chemically interact with the moist tissue at the transition zone from wound to skin. You will likely need to use several for this wound. Just rub the stick along that border, and the tissue will turn grey to black. You are creating a partial thickness wound by using this technique. (Silver Nitrate is often used to stop small bleeders also). Dress the new border with a dry dressing, and use your usual wound dressing (I like Panafil a lot, and have often used it to complete healing with wounds as you describe; some people stop using it once the wound is well granulated).

Anyway, I hope these ideas help. Looking forward to your outcome!

Good luck,

Jim Patrizi, PT, CWS

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Joan,
If the wound is clean and there is granulation tissue in wound base, you may need to look into trying something else other than Panafil. It is used best if you need some debriding (minimal as in small to moderate amount of slough loose slough) as papain is a potent debrider of denatured
proteins. Curling of wound edges can also be due to some infection, or to constant trauma around the wound edges, especially Panafil requires twice daily to daily changes. Switching to an alginate wound filler which you can leave in the wound for
3 days since drainage is minimal, plus a secondary dressing like Allevyn might work. Be careful with Alginate as they can dry up the wound. Another alternative is hydrofiber like Aquacel rope. This also comes silver-impregnated (not as much silver as Acticoat) but if there is not signs of inflammation around the wound, plain Aquacel might work and Aquacel with silver is to
ensure lower bacterial load. Like Alginate, you need a secondary dressing like Allevyn. Remember to pack loosely if you are using
the ropes. Watch after the first dressing change. If the wound is dry with the use of absorbent, you can try a wound filler like Solocyte then a secondary dressing semi-occulsive.
Maria Carunungan, DPT, CWS

Joan,
Also, might you also consider changing the dressing and not using the Hypafix. Hypafix works well in adhering and securing the dressing. However, it adheres so much, there is so much trauma during dressing changes, especially as again with Panafil, it is usually BID to QD dressing changes. The Panafil/hypafix combination is the culprit to me at this time. It may have been appropriate to use it in the more severe stages when the wound still needed debridement.
Also ask about the patient's nutritional status.
Is he getting enough protein, hydrated well?
Maria Carunungan, DPT, CWS

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It would really be helpful if I have more information about this wound such as Patient diagnosis, cause of the wound, measurement, onset of wound, and patients mobility, continent?. Anyway I will try to give my two cents. If I have a wound like you have described, here's what I would do. I will cauterize the wound edge using silver nitrate, this will jump start the epithelialization process. To keep the wound edge from maturing prematurely, every dressing change the wound edge needs to be swiped gently around using a gauge. Continue with this procedure until the wound cavity is filled with granulation tissue. I would like to use hydrogel for this kind of wound then cover with 4x4 gauze, if you get a strike through on the next day then use more gauze or use abd pads or change dressing bid. Use modality such as E-Stim, SWD or US, this will help justify you being skilled services.

Dex Bayani, PT

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Hello,

If the wound is 100% granulating panafil may not be needed any longer. Curasol soaked nu-guaze strips packed into the wound after cleansing and "sanding" down the edges. Yes "sanding" that's what I said LOL! An emory board oe even a very fing grade sandpaper rubbed along the edges before claensing may help stop the "curling" your talking about. There is a specific term for what your describing, but right now it escapes me. Anywho, I have treated the same type of wound you described the exact way (above) and had much success. One of the more important factors is to be able to keep perfusion to the area thru walking (if able), turning(if in bed), and repositioning(if W/C bound) (the Pt.) strictly, this can be the biggest challenge in a LTC facility. You'll have to really develope a relationship with the nursing staff to be able to accomplish this effectively.

Respectfully,

C. DiTullio R.N.
 

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Hello Simone, There are several resources available. There is WCEI ( Wound Care Education Institute) The web site is www.wcei.com. They offer classes throughout the US. The course will offer certification as a wound care nurse. Check out the site. Cheryl Wilkerson BSN, WCC, DAPWCA

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You could start by attending the best wound care class available thru Wound Care Education Institute. Not only will you get the information you need but you can become certified in wound care. It will be the best investment in your education and wound care training that you will ever spend. I am also a LPN who spent 10yrs specializing in wound care. Even though I had training and was very proficient in wound care strategies and had excellent outcomes my collegues did not take me seriously and often questioned my plans of care, so I took the leap and it has changed by life for ever. You can get the information on the course at www.wcei.net . Once you are certified then your collegues will listen to you and your career will soar. Good luck ...
Janalene Wilder Eaton, LPN, WCC, HT

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Go to the American Academy of Wound Management's website for a good list of
wound courses, www.aawm.org.
Vicki, MSPT, CWS

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Try this web site, not only is it educational, but it gives you free CEU's.
Tina (L.V.N./wound care nurse)

http://www.thewoundinstitute.com/

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Visit the WOCN web site, www.wocn.org. They have a list of courses that are offered. One option is the WOCN annual conference, offered in June. This year it's in Las Vegas. You don't need to have any specific credentials or education background to attend.
Dawn, RN, CWOCN

The term Mersa refers to MRSA which is Methicillin Resistant Staphylococcus Aureus. You can go onto the internet and find more about it. The way to determine if you have an MRSA would be by your having an C & S test ( Culture and Sensitive Test ). I don't think you have a MRSA from what you are describing.

unsigned

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MRSA is a bacteria. It actually stands for methicillin resistant staph aureus. By squeezing the bumps, you could have inadvertently introduced the bacteria into your system. We all have staph aureus on our skin but what makes MRSA difficult to treat is that it is resistant to a lot of antibiotics. The bactroban cream is commonly used to treat MRSA as it is usually effective against it. Did your doctor take a culture of any of the wounds? A culture would show what bacteria is in the wounds. Maybe you also have another organism in the wounds that have not healed. The alcohol and the peroxide would not have killed the MRSA and the triple antibiotic cream could have made the MRSA more resistant. I would suggest a culture of the areas that are still open and then treatment according to the results. In the meantime, you should continue with the bactroban cream, cleaning the wounds gently first and if they are deep, you should cover them with a dressing to protect them. You should wash your hands thoroughly before and after doing this. Good luck. Sue CWS
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Part of your confusion is what you have is not "mersa", it's M.R.S.A.
"Mersa" is slang, M.R.S.A. is a drug resistant staph infection. The Bactroban is the topical treatment of choice. It comes in two different forms a cream that is white and an ointment that looks like a cloudy version of triple antibiotic ointment, the doctor probably gave you a sample of the cream and the pharmacy filled the prescription as the ointment. You may want to call you doctor and see if he could call you in another prescription and this time specify that you want the cream.
Tina (L.V.N./ wound care nurse)

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Hi,

Just wanted to inform you that Mersa is MRSA.( Methicillin Resistant Staphyloccus Aureus). Its a type of infection not a wound type. Basically your doctor feels the infection will not react to any type of medication with penicillin in it. The type of scar you will get will be based on the depth of the wound and how many layers are affect by the infection.

If you truly have staph, it is serious and contagious. PLEASE get a second opinion!!!!

unsigned

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Hi,

I am guessing that the “mersa” you spoke of is really the MD’s way of saying Methicillin-resistant staphylococcus aureus, which is abbreviated “MRSA” and called “mersa” sometimes for short by some healthcare providers. It is a bacterium, “staph” as most laypeople might recognize that term. However, it is a very aggressive form of staph that is resistant to multiple antibiotics. It is usually addressed by the use of Vancomycin (antibiotic) and good wound care; I like to use the new silver-containing dressings that have been shown to be capable of killing this form of staph. Find a wound specialist who can help you, or try another MD who knows more about wounds, would be my advice.

Vicki, MSPT, CWS
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What you are calling mersa is probably methycillin resistant staph aureus (MRSA), which is often called 'mersa'. This means that the bacteria causing the infection does not respond to methycillin (an antibiotic). Staph aureus is an organism that usually lives on our skin, but if there are too many of them it's an infection. There are no 'pictures' of MRSA. Scarring depends on how deep the wounds were to begin with, and have nothing to do with if it's MRSA or not. The first cream that you had was probably silvadene, or sulfamyelon, which are effective against more organisms that cause infections than bactroban. You may want to ask for another prescription for the first cream that you got, since it seemed to work better than the bactroban.
Dawn, RN, CWOCN
sdwocn@yahoo.com

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You really had a trying time and it sounds like you still are. First, stop with the peroxide!!! Throw it away and never use it again. Secondly, did your doctor culture the site? without doing a culture, it is difficult to determine if it is MRSA or another bacteria. That would help with the course of treatment chosen. Since you are computer literate, try looking up MRSA, methicillin resistant staphylacoccus aureus. You should be able to find a wealth of information. MRSA is very serious and very contagious. Cheryl Wilkerson BSN, WCC, DAPWCA

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You probably are talking about "MRSA" or
methycillin-resistant staph aureus which is an
infection that can be found in any other kind of
wound. You could be scratching and infected the
wounds which were originally allergic rash. Wounds can be cultured to know what was the infection, then your doctor usually prescribes the antibiotic depending on what infection there is. Bactroban is also used for MRSA.
Suggestion too is not to use peroxide and alcohol.
These hurt the good tissue and latest studies suggest the wound can be cleansed well with saline or sterile water alone. Suggest too you see a dermatologist to put your mind at ease about your wound or a wound specialist in your area.
Good luck,
Maria Carunungan, DPT, CWS

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Hello, I hope that by the time you'll get my message you are completely well. To answer your question, MRSA stands for Methicillin- resistant Staphylococcus Aureus. MRSA is a type of staph bacteria that is resistant to certain antibiotics. These antibiotics include methicillin, oxacillin, penicillin and amoxicillin. The bacteria will cause an infection to the wound making it difficult to heal. Visit this web-site, this will tell you more about MRSA. Have a good day.

God Bless

Dex Bayani, PT

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MERSA is a abbreviation for Methlicillin Resistive Staphylococcus Aeuras,in laymans terms a staph infection. It is spread from one open area to another by what we call cross contamination (surface) or systemic transmission (through the blood)  The best way to prevent further spread is to start with good hand washing. When applying the topical medication the physician has prescribed to the areas use a cotton tip applicator or Q-tip and be sure not to touch one sore and then touch another sore with the same Q-tip. If the sores are not improving with a topical treatment then you may need to talk to your physician about an oral antibiotic treatment. If the physician has not cultured the areas infected that are not healing, they might want to do so to see what organism is causing the infection to be sure the medicaiton that was prescribed is appropriate. I am not aware of any specific photographs of MERSA that would be helpful to you as the appearance of infection is different in each wound and each individual. The scarring effects are also different in each person as some people heal with no scarring at all and others scar significantly. If you continue to have problems you might want to seek out a wound care center as they are very up to date on wounds and infections and can help you get on the right track for healing with minimal scaring. I hope this information is helpful.
Janalene Wilder Eaton, LPN, WCC, HT

unsigned
 

When an ulcer gets to the point of a stage 4, in wound care terms it is as bad as it can get, unless it grows and won't heal. At that point surgery is the last option and yes sometimes they do fail. But that is a risk with any kind transplant procedure. When someone has a "flap" done the surgeon removes healthy tissue from a "donor" site and puts it where the body can't seem to grow it on it's own and has for so long been fighting infection. To the body this procedure is not much different then having a kidney replaced. Sometimes the flap is rejected, it's discouraging but happens and it doesn't always happen right a way. Really wish I could be more encouraging.
Tina (L.V.N./wound care nurse)

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Any surgery will potentially fail. Before any surgery, I would explore the capability of the surgeon and find out what their track record is. Some surgeons have better overall outcomes than others. If the surgeon is worth their salt, they will have that information readily available for you. If they don't, that is a red flag.
When you are dealing with pressure ulcers, a major part of the treatment should be pressure relief over the affected boney prominence. If pressure is not adequately relieved, the wound will probably re-occur, and will require more surgery. You and your husband should have been educated about pressure relief products, including a prescription for a wheel chair cushion, and techniques to help prevent recurrence of the pressure ulcer.
Dawn, RN, CWOCN

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There are many causes of infection. It is difficult for a tunneling wound which may leave tracts that you don't see on inspection. We'd know of patients whose wound on the sacrum closes up
and a tract was not seen and formed a
communication with the pelvic cavity where
infection usually sets.Infection can also be caused
by different conditions such as when someone's resistance might be low, low oxygen conditions and of course infection is always a risk after any surgical procedure. Infection can also come from other sources. Wounds close to the perineum are notorius sites of infection as the site is easily reached by feces or urine. Ask about nutrition and even vitamin supplements as good nutrition and sometimes additional vitamins help you ward off infection.
Maria Carunungan, DPT, CWS

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Unfortunately there are times when flap surgeries fail for one reason or another. The cause of failure can range from the patient not having proper nutrition to help with the healing process, Continued pressure to the area being treated, undetected infection at the surgerical site, etc. Before healing can begin infection must be treated and alleviated. Since your husband has had several failed surgeries you might consider seeking to see if he would qualify for Hyperbaric treatment following surgery to help the grafts to start healing. Consult a nutritionist to be sure that he is getting the nutrition he needs for the healing process and be sure that no pressure is being applied to the area that is trying to heal. If you are looking for a second opion you might want to seek out a wound care center as they specialize in the treatment and healing of chronic wounds and will be able to help get the healing started. Hope this information is helpful, hang in there, there is light at the end of the tunnel.
Janalene Wilder Eaton, LPN,WCC,HT

unsigned2

I did home health for 4 years and taught wound care to many pts/caregivers, and now do so as an outpt therapist. The effectiveness of pt/caregivers providing wound care varies greatly, as you would expect. I found that most laypeople are not as aggressive at cleaning wounds as healthcare professionals are. Another concern I have is the clean or “sterile” technique (of course there is no true sterile technique in the home) being used, as laypeople often just did not think twice about touching clothing, table, etc then touching the supplies or wound again. I would say that there could be a place for kits as you speak of. With home health, of course, the agency should provide the supplies the staff uses. What I am now seeing, with doing outpt wounds, is that my patients sometimes get frustrated trying to get together all they need for dressing changes between outpt visits. Also, they cannot find specialty dressings such as Acticoat, Silverlon, alginates, Polymem (some of my favorites) very readily.

Vicki, MSPT, CWS
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Judy,
Wound care is never just limited to dressings.
The better clinician would constantly monitor
other areas as hydratrion, nutrition, assess the
wound as during the different phases of healing, it may be necessary to change to different dressings or different dressing frequency. Caregiver education is important especially in teaching them clean techniques and including nutrition/hydration/skin care. However,
the nurse should always check the wound for the
reasons I mentioned. Depending on what the wound looks like, it may even be necessary to request labwork at times.
Maria Carunungan, DPT, CWS

unsigned3

You don't just measure a wound to prove that it is healing. When documenting a chronic such as stasis wounds you are also verifying that the wound isn't getting worse, having a non-healing wound be stable is just as good and important as having a healing wound close.
Tina (L.V.N./wound care nurse)

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I am vascular surgeon with a great deal of interest in venous disease. First you need to make sure this is the result of stasis. Then you need to identify whether this is the result of superficial or deep venous insuficiency. Primary treatment for stasis ulcer is to avoid vertical positions as much as possible and use of multi layered short stretch
bandages such as unna boot (non elastic compression bandages). For superficial venous insufficiency the veins can be ablated with surgery, laser, radiofrequency and/or sclerotherapy.
unsigned

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Definitely, I measure these wounds. I use a simple length, width, depth (these wounds are usually shallow, of course), and since venous stasis ulcers typically have irregular margins, I use the longest,widest measures. Another method that can be good for irregular wounds is tracing on a transparency. These wounds can be healed many times with proper treatment. Venous stasis ulcers need compression dressings! Arterial, of course, do not.

Vicki, MSPT, CWS
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A stasis ulcer is one of the easiest ulcers to heal. Compression is the key. When you have a wound compression can be provided with a zinc paste boot (pt. must be ambulatory) or a 3 or 4 layer wrap (pt. can be non-ambulatory). The problem with stasis ulcers is that they frequently re-occur, if the patient doesn't have long term compression. Long term compression is provided by a stocking.
In regards to your question about measurements, the standard in the industry is to measure weekly. If you are doing appropriate treament, the wounds should heal, and the measurements are not a waste of your time.
Dawn, RN, CWOCN

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Venous ulcer DO heal, when treated appropriately. My patients close typically in 4-8 weeks. Once you clear the arterial supply, you need
to use compression therapy to address the etiology. Measurements are very valuable. In fact, I find my VLUs have more change occurring in a
week compared to deep pressure ulcers.
Renee Cordrey, MSPT, MPH, CWS

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Measuring is necessary to determine how well the wound is responding to treatment. Even with chronic wounds like venous ulcers, you would see a measurable change if you are using the appropriate dressing. Healing also
depends on nutritional status and hydration. If a wound shows no measurable signs of healing within 2 weeks, the treatment is re-evaluated and areas such as nutrition, hydration, medications, etc. are looked into. It may also be due to infection. I know it's tedious but necessary.
Maria Carunungan, DPT, CWS

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Wound measurement standards are a minimum of weekly. Wound measurement is very important in the assessment process to determine is the treatment you are providing is effective or not.Yes they are very time consuming but also very necessary. When you have a wound that you are treating worsen or become larger (determined through measurement) then that is the signal that you need to further investigate the reason behind the stalling or decline. Stasis ulcers are the result of a disease process, but with proper nutrition, compression therapy ( for venous stasis ulcers only) and appropriate wound care, these ulcers will heal. Teaching the patient about their disease process, the cause of the uclers and what the patient themselves can do to prevent further occurence of these ulcers( through lifestyle changes, good nutrition, controled blood sugars, etc. ) is the very best care you can provide for your patient. If the ulcers are arterial in nature, then referral to a neurosurgeon will be necessary, because until the circulation problem is addressed the ulcers can only worsen and the treatment you are providine will continue to be ineffective. Hope this information is helpful to you...Good Luck
Janalene Wilder Eaton, LPN, WCC, HT