I am an RN, BSN and have worked long term care for 12 years. I have seen a lot of pressure ulcers. A few questions, how is his nutrition? Is he on a stress tab c/ zinc daily? How is his prealbumin/albumin? Is he a candidate for Arginaid powder mixed in 8 oz of water bid for 60 days, or is his lab values such that he would benefit from Prostat 101. Prostat 101 30 cc mixed in spirit is like a cherry cola.
It's time to stop the Xenaderm, especially in a stage III/II. I would try Calcium alginate. It will help with the underlying bleeding, although the perfusion is good to bring nutrients to the site. I would cover it with Verseva dressing. It comes in different sizes, and you don't need to add a dry drsg between the Calcium alginate and verseva. I would use skin prep prior to the Verseva, protects the skin and the Verseva will last longer. If it is draining so much that it is causing maceration, then change it every other day, and try applying Xenaderm to the intact skin to prevent harm.

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Suggestion:
Change mattress to lateral rotation surface which will turn patient as often as programmed Have you tried hydrofera blue on the wounds? It's bacteriostatic, relieves pain, and results are awesome!!!
www.hydrofera.com
Good Luck

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Hello,
You have a complicated treatment plan.. First I haven't had that much experience with xenaderm? But gaining popularity and will probably try it on minor wounds. The stage 111 now a stage 11 should other than point of reference should not be down staged because of damage left behind and to alert others of it severity. This does sound difficult I would suggest talking to a wound consultant. But the blood underneath could be due to small blood vessels breaking down and to be watched carefully because something internally might be happening. Hoping that's not the case if its not open, it should heal by itself, maybe from pressure and friction blood vessel tears. One thought is try using a very thick foam dressing and cut a hole in the middle apply the normal dressing then the foam over that. This may help relieve pressure to the area and promote circulation since his turning options are limited to non existent.Hope this idea can help. Good luck.
Terry wound care nurse

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I am also a wound care nurse at a long term care facility so I understand the frustrations of surveys. I have used topical ointments (calmoseptine, Xenaderm) that do not require dressings, in fact dressings are not even recommended for use with these types of ointments. I use these on a consistent basis and our facility has never been cited for this. I would have done the same thing you did with the wound you described. If the skin is intact with no drainage or infection, it does not require a dressing. I have seen where people have placed tegaderms or duoderms on intact fragile new skin and have seen the wound get worse and open up due to keeping the wound too moist under the dressing. I would think that you could go to any wound care site on the internet or in medical/nursing journals to find documentation to back up your actions. Good luck!

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You need to get a copy of "Clinical Practice Guidelines" for Pressure Ulcer Treatment by AHCPR. You can request your free copy by calling 800-358-9295 or write to: AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.
Even though the particular area you are discussing is not a "pressure ulcer", the understanding of wound healing is all the same.
The surveyors, as well as attorneys look to this book as the "standard" of care for wound healing. On pg. 53 is states that a dressing should be applied to "protect the wound, be biocompatible, and provide ideal hydration".
Hope this helps.

Dianna Guidry RN, BSN, CRRN, WCC
Director of Nursing

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I agree that a G tag sounds excessive for this type of wound. It sounds like it was almost healed. I know the surveyors check to see if you are following facility protocols for this type of wound. Perhaps it was not documented well enough by the staff as to what type of wound and the treatment and the progress of healing. Even if the doctor ordered it, I know it is not acceptable anymore to just do what he ordered. It is the facility’s responsibility to make sure treatments follow accepted standards of care and the surveyors will hold you liable for this. As far as all wounds having to be covered, there are instances where you would not do so, such as applying skin prep to a necrotic heel ulcer and then elevating it off the mattress. You also could have had a surveyor with little wound knowledge. I have run into this many times in my 12 yr’s of wound care. I think you would have a good chance of appealing and winning this one. Good luck...
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First, I am sorry for your site for a 1cm size wound that sounds like it is healing. The surveyors are given some information on wound care but you cannot replace the efforts of a professional for their expert opinion. I, too, work in a long-term care facility and we just had our survey and they really zoned in on wound care but they decided to pick on us in other areas. Now, if a wound is closed - no open areas, I see no reason to cover it. If the wound is open - then you would need to apply the principle of moist wound healing and cover it. Because it was on a finger - it does have more of a chance for contamination. However, the scab that was on it was a cover as well. I don't know what type of lotion you use but I would be careful about using lotion on an open wound. If you have Stage 2 ulcers on the buttocks, Xenaderm or another good barrier can be used and no dressing needs to be applied. There are lots of unanswered questions - how did it happen? Was it present for any length of time? Do you have measurements, pictures, and good documentation? How is the patient's nutrition? Labs? I would supply a picture of the before (when first received) and after (as it is now) when submitting for an IDR. Maybe the surveyors didn't see got follow through and that is why the site was given. At any rate,you need to prove that your interventions helped and didn't harm the patient. It seems to me that the surveyor is being nit-picky but without seeing the wound it does leave that question in the back of my mind about the healing qualities. Lastly, get yourself a copy of the AHCPR guidlines because that is what the surveyors use for information. God bless on your results! Cindy, RN WCC

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Send your assessor back to school in the real world!

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Actually, xenaderm ointment is appropriate to use on wounds and leave open to air or cover

unsigned

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Hard to say why this wound won’t heal without more info. How long has he had it and how large is it? Have you considered that he may have osteomyelitis in the wound? Is he on an adequate alternating pressure mattress and is it set at the correct pressure? How is his nutrition status? Has he been evaluated by the dietician and extra protein provided? How much time is he spending out of bed and what is he sitting on while OOB. Is he being repositioned as he should with the HOB down as much as possible? The wound vac works very well. If you are having problems healing with this, you need to look for other possible causes of non-healing. Sue, CWS
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The vac is most likely the proper choice. Are you using their silver impregnated sponge with the vac? This may be what you need to do. Is the person on any suppliments? Juven is a good choice and Vit c and Zinc.? Silver will help jump start the healing. Call their rep and see what he suggests.
de RN BSN

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Try placing collagen into the wound bed, then apply the wound vac.
Sometimes the wound reaches a point , that it thinks it is healed, if you stimulate the wound bed a bit this will remind the wound that it is not healed.
Michal Meaders LPN MSS CCT

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I am an RN and have worked on long term care for 12 years. We have used wound vacs with some success. How deep is the wound? any tunneling? Are you using black or white foam? Has the pressure been altered to stimulate the wound? Keep cutting the foam a little smaller than the area. Be sure there is no infection in the wound, and if suspected, then go to white foam.The company has been trialing a silver foam, maybe the rep could assess and give you a sample. Is the dressing staying on all three days, or is it being sheared off with turn and repositioning? Have you tested the Hgb, albumin/ prealbumin? How is the nutritional status? Make sure they are on stress tab c/ zinc daily, and Arginaid powder one packet in 8 oz of water bid for 60 days to jump start the body to stimulate healing. If they are a diabetic, be sure their HgbA1c is in order and the accu checks are managed. I would be sure to have them on routine pain medicine, so they are comfortable and reduce the risk of restlessness.

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Any treatment you are using needs to show improvement with in 2 weeks. You state you are using a “Wound VAC” you might want to clarify if it is a proven system.

Alice, RN
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Ability to heal is determined by many factors. a wound VAC is a great modality IF the wound is fairly clean of necrotic tissue, appropriate positioning is being used, pressure relieving support surfaces, diabetic management of glucose levels below 200 (preferably below 150) and nutritional needs are being met. may need a nutritional lab work to determine albumin, prealbumin, transferrin, hemoglobin, hematacrit, vitamin levels, zinc levels. Protein needs when there is a significant wound increase dramatically. Please do ensure all factors are being address to optimize potential.If then there is not the expected outcomes you may need to pursue having a wound biopsy to rule out any osetomylitis or a carcinoma.
Good luck, Michelle PT, CWS

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Wound that wont heal may be a sign of infection. Perhaps getting some lab work done like wbc, for s/sx of infection. Albumen to check his protein and nutritional status and H&H, and ESR to start. Although not always indicative of anything other than surface contaminants a wound culture can sometimes pick up things like MARSA. Xrays and labs can r/o osteomylits. All these factors can interfere and prevent wound healing. In vac cases infection is contra indicated unless on a appropriate antibiotic which can aid in directing the antibiotic to the site to expedite the healing. If you do the wound culture cleans the area as well as possible and pick the healthiest tissue possible, because dead tissue will give you nothing you don't already know. Regards.
Terry wound nurse Calif.

janzyarrow@comcast.com

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For wound cleansing a spray bottle would be ok. When you are cleansing a stage 3/4 wound then you get into the psi number because you are usually irrigating the wound. Sea clens by Coloplast is very good as well as Dermal wound cleanser by Smith/Nephew.
de RN BSN

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Hi. We have a video called "Taking care of your wound" that might help. It is designed for patients, families, friends, and health professionals. It covers the basics of wound care. You can see it free on our website--- www.thinairproductions.ca . Hope this helps. Chris.

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Blairex normal saline spray

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 As long as the bottle is set on spray, and not stream, the psi should fall in the lower portion of that range and be safe to use. However, by guidelines, the bottle must be labeled and can only be kept for a certain amount of time, as the bottle can eventually begin to grow bacteria as well. Some pharmacies will print you a label if you have the correct md order for the solution to be placed in it.
But this seems like a lot of trouble!! Have you considered using a wound cleanser? (such as saf-cleans, or elta?) Most all companies which manufactor wound care products will have their own version of this, although they are pretty much the same. They will already have a label, the psi will have already been checked and approved, and are relatively inexpensive, so when it is empty it can be thrown away without the worry of having to pay a lot for another. Another good thing is that the cleansing agent will have a cytotoxicity level approved to effectively manage bacterial load within the wound, but mild enough that it is not damaging to good tissue.
I recommend you check into this. Hope I was helpful!!!!