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Paul,

I know this may have already occurred to you…. But I have to ask if you have ever been evaluated by a wound care specialist to help you identify

What type of wound this is and why it has been present so long ? Is it possible that this may be a pilonidal cyst or some other type of wound given it's

Chronic recurrent nature ? Just food for thought.

Sincerely,

Gregory J. Redmond, PT, CWS
Shreveport, LA
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I would want an expert opinion on whether it was truly a pressure ulcer or some underlying pathology or infected pilonial cyst? anyway, one way to get
better if it is a chronic problem; you might want to contact a plastic surgeon to do a skin graft. There are a couple types of grafts. See what he/she says. The point of pressure could be better off with the new skin.

Deborah Harris, BSN, JD, RN, CWCS
Louisville, KY

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All the tissue that was lost to the ulcer (muscle, adipose, bone?) never returns. You cover the area with collagen. When you have completed the collagen reformation process (as much as 2 years after wound closure) you will only have 80% skin integrity in this area (at best) and it will have no elastin. Therefor (as you have experienced) this tissue is thin, weak, has no elasticity and is prone to sheering forces. The best you can do to minimize your ongoing discomfort is to keep the skin well moisturized and minimize sheering forces. That means posture is vitally important. Many people are inclined to weight bear against their sacrum as opposed to on their sit bones.
Michelle PT, CWS

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I doubt you have a decubitus ulcer just because it is
located over the coccyx. Chronic ulcers run the risk
of malignancy, Please get it examined by an experinced and certified general or plastic surgeon. Good luck
KT Kishan, a vascular surgeon
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Just wondering - do you have adherent scar tissue there? If you do, scar mobilization may help.

Also, any chance it is a pilonidal cyst?

Sara, PT, WCC

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Paul,
Since you are active and working and I am not aware of any physical limiitation you might have it sounds like the type of wound is not a decub as those are formed from pressure. However since you have had this chronic wound for quite some time there seems to be an underlying factor that some how has been over looked. I have worked in Wound Care for the past 12 years and it has been my experience that when I run into cases such as yours the investigation begins. It is not uncommon when a person has a type of infection in the bone for a wound to persistently reoccure in the same area.This can occur during the first time a wound was in a specific area and had the opportunity to find a place to hide. Have you had a MRI to rule this possiblity out? Second many people carry a form of staph infection in their systems that when the body's immune system is stressed or low will give it the opportunity to surface which in turn causes reoccuring breakdown in the area in which the infection lays dormant. Have you ever had your wound cultured during a time when it is open. Since you are in the medical profession I would recommend that you consult a wound care clinic or center as this is their specialty and they may be able to find a solution to your problem.
Janalene Eaton, LPN,WCC, HT

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Xeroform is a petroleaum soaked gauze dressing. It is packaged in foil to prevent drying out and ease of removal. the advantage is it promotes moist wound healing by keeping the wound moist for 24 hour intervals. It is also easy to cut the size you need by cutting the foil. You can keep the dressing relatively clean and handle with ease this way because you simply peel off the foil after cutting it. In my opinion the great disadvantage is that it macerates tissue surrounding the wound and promotes bacterial growth in draining wounds. It was meant to be cut to the exact size of the wound and used only on dry wound beds(scant to no drainage). You must also have a cover dressing with it. I hope this has answered your question and if you need further information I will be happy to help.

Sincerely,
Marilynn Feltner, DPM, CWS

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I love xeroform for several uses in particular. It is a yellow petroleum impregnanted gauze. I used it specifically over skin tears and then I apply
a telfa dressing and wrap or apply a film dressing over it. Or if you have an almost closed wound you still want to maintain moisture until healed, or
a wound that is dry and you want to soften up to debride. I have also used it on a condition called bullous pemphigoid where you have big weeping
ulcers and what I have done is treat the underlying condition and then apply silvadene and xeroform and gauze and wrap with kerlix and coban or ace
bandages. They heal up nicely without any scarring.

Deborah Harris, BSN, JD, RN, CWCS
Louisville, KY

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Xeroform is an impregnated gauze, occlusive non-adherent dressing it works well on skin tears.
Xeroform is contraindicated for draining wounds.

R Czapiewski LPN

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Xeroform is a petroleum impregnated gauze... best used on the wounds that other dressings tend to stick to or areas where a cancerous area has been removed. I would not recommend using it on wounds with heavy drainage.
Tina (L.V.N./wound care nurse)

Kathy McCasland, Infection
Control Practitioner

All wound care should subsist of at least the clean, no-touch method of addressing wound care. That means wash hands before & after, use gloves to
remove, change gloves after removing dressing and before applying dressing. All dressing supplies should be laid out initially after washing hands on
clean surface without anything touching the surface - for example open the sterile gauze, but leave in the package. Do not let anything that touches
the wound bed touch anything else. I must say that there are only a few minor studies as to the meaning behind what is clean, asceptic, sterile etc.
and what practices constitute adherence to each of these. The AHCPR or AHRQ as it is now called has a description used for pressure ulcers. There is
some literature out there with opinions, but there have been no extensive studies in terms of numbers of wounds, risk of infection comparing one to
another, definitive practices as to what each one means, etc. In other words, there is no evidence-based research to back up what they or anyone
else says all the way back to Florence Nightengale. That is the bane of our practice at times. We just do what works and hope it is the best practice
until proven otherwise. I hope I don't sound too cynical. There is hope for
us all.

Deborah Harris, BSN, JD, RN, CWCS
Louisville, KY

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The Center of Disease Control is the source for infection control standards. It is well known that wounds are not sterile environments and can therefore be safely managed using "clean technique" in most cases. There are exceptions, primarily related to the setting in which the wound care is being conducted. At the very minimum clean technique should be used. In acute care settings the organisms residing there are "foreign" to most patients and because the problem of cross contamination in that setting can be a problem sterile technique for acute wound management wound be required and clean technique again for chronic wounds is likely to be acceptable. Hand washing saves lives...gloving is common sense. Good luck.

Brenda D. Brown, DNS, RN, CS, CWS
 

Your help will be appreciated.

Regards,
Mills

Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS

You are opening up a big can of worms there. LTC is on the PPS system, meaning prospective payment system. So if a patient is admitted with the wound, they will put up bigger bucks from medicare for care all dependent on treatment modalities, rehab, etc., if the admitting nurse documents on the MDS correctly. However, the facility can choose or not choose to use the
funds as they see fit. As long as the treatment nurse is instructed on the particular treatment and is competent, she can do it unless the facility has
policies preventing it. Depending on exactly what you are talking about, Physical therapy might be the ones to implement. Home care is different and
can get reimbursement thru medicare part B if it is an approved technology - and believe me all the sales reps know if it is a covered treatment or not.

Deborah Harris, BSN, JD, RN, CWCS
Louisville, KY

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This is a physical therapy modality and need to be provided by a physical therapist. There is special training for this including the study of electrophysiology related to wound
healing, etc. As with any discipline, if a clinical personnel provided a treatment which is outside the scope of your practice, this is considered inappropriate and if any one bills for a treatment like this, can pose legal issues as it can be looked
at as yourself misrepresenting the treatment given as one provided by a personnel trained and certified to do so when you are not. Therefore you may not bill for the treatment. There are some
electrotherapy modalities the use of which can be taught to a non-skilled personnel including patients, provided the patient has the capability to learn and operate the equipment. An example is the use of home TENS unit which carries less risks
for injury and does not need as much monitoring and hands-on as modalities for wound treatment.

This is similar to providing ultrasound treatments for instance. You can be shown how to move the ultrasound transducer head on a person's skin but there is more to ultrasound treatment including proper dosing and monitoring of treatment responses.
Hope this info helps.

Maria Carunungan, DPT, CWS

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The only coding for reimbursement that I am aware of is for application of wound care estim that is performed by a Physical therapist.
Janalene Eaton, LPN,WCC,HT

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If you are referring to electrical stimulation used in treating wounds, Medicare B pays for it in long term care facilities provided you have tried other, more “traditional” methods of wound care for at least 30 days with no progress in the wound. In the state of Massachusetts, electrical stimulation therapy has to be done by a PT. I don’t know if it is the same in other states. If you are referring to some other type of therapy, such as ultrasound or warm-up therapy, Medicare part B does not cover these in long term care. If the patient is accessing his or her Med A benefits (100 days skilled), any type of wound care and treatments would be paid for by the facility under PPS. Hope this helps. Sue, CWS
 

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Those are all excellent questions and the answer is yes. Even a healthy person would need more protein intake to heal a wound, let alone someone who is debilitated thru any other medical condition going on concurrently. I would definitely worry about weight loss under all circumstances and that
should be investigated. THere are guidelines as to how many proteins and calories it takes to heal a wound, but it is all dependent on what that
patient's bloodwork shows. For example a physician or NP might want to order a prealbumin, a CBC, transferrin level etc. Dieticians can usually calculate patient's weight, their need, their labs together to come up with the exact
caloric and protein need.

Deborah Harris, BSN, JD, RN, CWCS
Louisville, KY

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Caloric intake should be increased for any patient
with wounds. This does not mean eating more but more of eating right. If a patient is losing weight but is eating, need to look at what happens to the food ingested.Certain tests can show this such as pre-albumin and albumin. Pre-albumin has shorter half-life so is a better reference for metabolism. There is always need for increased protein especially as one has a stage 3 wound that will take time to fill in. If there is inadequate protein one will not heal. If there is inadequate protein support (as in protein is being broken down as they are formed), the wound will not heal. Some medications as taking steroids
at certain doses can delay healing and this effect is counteracted by increasing certain vitamins such as vit C and A. A basic metabolic panel (BMP) can provide information as to a patient's metabolism and can help predict the patient's ability to heal.  There are other nutrients needed as fluid intake, vitamin and mineral supplements like vitamin c, a, zinc, calcium, magnesium, copper, B vitamins. Vitamins C and A provide protein support.
Remember that included in granulation tissue (red tissue filling in the wound), are new microcirculation. Vitamin C maintains the
integrity of these vessels as well as increase the strength of collagen (the primary protein in healing tissue). Also, if a wound is draining, we need to watch that the wound is not leaking so
much protein. If it is, what are we doing to replace the protein lost? If we are providing more protein, are we also encouraging fluid intake? I suggest you talk to the physician about lab tests
and consult with a dietitian who can plan a diet to meet the needs of a patient with wounds, especially one with a stage 3 ulcer. Of course, it is even more helpful to have a wound specialist involved as there may be other issues with the patient which can be delaying healing. Good luck,
Maria Carunungan, DPT, CWS

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There is definitely a need to increase calories and especially protein for a person with a wound. If a person is losing weight, there is definitely something wrong. Without adequate nutrition, a wound will probably worsen or not heal at all. There is a formula to determine the correct amount of calories for someone that depends on his or her weight and also a formula for calculating the increased protein needs. Your best bet would be to consult a dietician if possible who can figure this out for you. You can increase protein by using a supplement like Ensure or Instant Breakfast and take a multivitamin with minerals, but the best way is through an adequate, protein enriched diet.

Sue, CWS

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One organization I am a member of is www.wocn.org - you can look up each
state and see who is certified and where they work. There is one other organization that board certifies, but I will leave that to them to answer.

Deborah Harris, BSN, JD, RN, CWCS
Louisville, KY

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Go to the www.wocn.org site and look of wocn certified programs - I think there are about 6 that do the wound, ostomy, continence and 1 that does the
wound alone. Now there is also distance learning with much of them and a lot can be done online with clinicals arranged locally.

Deborah Harris, BSN, JD, RN, CWCS
Louisville, KY

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Go to the WOCN web site and inquire.

Brenda D. Brown, DNS, RN, CS, CWS

This wound sounds like a good one for a KCI wound vac. Unless infected this should heal the wound quickly and it is reimburseable through Medicare. If you don't want to go that route and since you do have some slough, cover the wound bed with Santyl, gladase or Panafil. Always include the undermined area. and cover with a cover dressing. A wet to dry dressing is only recommended for short term useage. If wet to dry is done properly, you remove the dressing dry, which pulls off good healthy granulation buds, is extremely painful to the resident and prolongs healing. In the long run a wet to dry dsg treatment is more costly.
Darlene Etchberger BSN RN, Wound Care Manager

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If this is a terminal patient and healing the wound is not a reasonable goal then the focus of the treatment needs to be comfort and quality. Your dressing NEEDS to be able to prevent infection, control odor and minimize pain. I am concerned that a kerlix packing would increase pain, increase risk of infection and does not address odor. Perhaps you can find a dressing that does not need to be changed daily and can be cost competitive from that stand point (less material and less man power). An alginate with or without silver? Or the wound can be lined with a product like mepitel (a inexpensive- thin- perforated silicone sheet that can be put on the base of the wound and your kerlex over that. The silicone sheet does not need to be removed so there is no disturbing of the wound base.) Kerlex does have a very inexpensive product that is impregnated with a powerful antimicrobial that will add pennies to the cost of the dressing but prevent pain from colonization/infection and medical complications from infection. I am uncertain the name of chemical name but it comes in the same packaging as regular kerlex with purple writing on the package. I am sure you will be able to locate this product with the above information
Michelle PT, CWS

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Iodoform is used usually in the presence of infection. There are however other dressing/packing options. The wound is draining and you need an absorptive dressing like alginates. However, there is also necrotic tissue like slough which need to be debrided before a wound heals. This wound, and "this patient" has other issues/needs. Priority should be in determining what factors may be contributing to the worsening of the wound
especially a tunneling wound. The most common cause is infection. Suggest culture of the wound for anerobic organisms, and also wound biopsy. If there is clinical infection, the physician will decide and might order systemic antibiotics. Then you have the slough, What is the patient lacking to cause tissue breakdown leading to necrosis as with slough. Is the patient eating enough? This patient seems like she needs vitamin supplements  vit C and A to support protein production for healing. Also, iodoform will not debride slough, but other
preparations like Gladase (papain urea) will help debride the wound. The presence of necrotic tissue is a foci for infection to set it.
Are staff making sure the patient has adequate "pressure relief systems?" (as the use of support surfaces like specialty mattress, or being turned frequently, etc?). If the pressure is not relieved, would will not heal and will further deteriorate.
Suggests tests like pre-albumin, BMP especially if
the patient's wound is draining and continuing to
break down. Anemia can cause delay in healing,
infection can, poor nutrition can, inadequate hydration can. Some medications as steroids, cancer medicaiton, etc might also cause delay. Is the patient losing weight?
As bone is exposed, may need to check for osteomyelitis as well. I strongly recommend you consult with a surgeon on this one, especially if the wound is tunneling as you need to know the extent of the undermining. Also ask about switching to Gladase C plus an alginate dressing
(debrider is Gladase and alginate will absorb drainage) then covered with a foam dressing may be more appropriate while the patient continues to have slough. As you get more red tissue, and the patient's wound is still draining, you can try absorbent dressing with silver (silver is an
antimicrobial) like Acticoat absorbent or Aquacel Ag. then a foam dressing or consult physician about wound vac I realize your patient is a hospice patient. I am not sure what your policies are. I know for sure at least, that if hospice care is to provide comfort as well, that not using the appropriate dressing or not adequately following the
patient and his wound will eventually lead into more
discomfort for the patient. Look up a wound specialist in your area. The best advice is from someone who actually sees the patient,
the patient's wound, and has had the opportunity to
review lab values and other tests. If it was me, I would immediately consult a wound specialist and a surgeon before I change anything.
Good luck to you and your patient,
Maria Carunungan, DPT, CWS

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Could this patient perhaps have a Kennedy Terminal Ulcer? You can research this type on the Internet.
Pam LPN

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The use of Iodoform packing is to keep the bacterial load down in the wound which will keep the patient from developing infection as a secondary complication. The disease process itself has the body compromised from all aspects. Even though a patient is diagnosed as terminal and wound care is pallitive, it is our responsiblity to provide optimal care to prevent infection, which in the patients compromised condition could rapidly lead to septic and thus hasten their death. When a patient is terminal keep in mind that the minimal standards of wound care still apply and are the standards that you are held responsible for.
Janalene Eaton, LPN,WCC,HT

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Iodoform packing strips are pretty inexpensive and I can’t see that you would save much money by switching to kerlix and abd pads. They are all pretty inexpensive compared to other wound care products. It seems to me that a dressing that can stay on longer, reducing the amount of pain and discomfort to the patient, should be the priority here. Packing the wound with a calcium alginate and covering it with a foam dressing such as Allevyn would allow the dressing to stay on for several days. In the long run, it would probably be more cost effective and also reduce the nursing time required for dressing changes. Sue,, CWS