Wound Email - November 1, 2006

Wound Care Information Network

November 1, 2006

Automated removal instructions are at the bottom.

Sponsor's message:
"Change your life in one week"...Wound Management Certification Seminar

Wound Care Education Institute presents
Wound Care Certification Course
One week seminar, CEU's, and exam
for "WCC" Wound Care Certified Credentials.

click here for details

mention code EDU0401 for your
$ 100 discount

"...One of the best educational experiences I have ever had"
Carol K. RN, Aurora, IL

Submit your new question to the group right now: wounds@medicaledu.com
Sign up with our Email Service to see replies.

Previous email questions & their replies are listed below. Remember, replies have not been validated for accuracy or truthfulness.

I have recently been made aware that if a patient is put on an air mattress that their fluid intake should be increased. Does any one know what the equation is to figure the fluid increase or if there is a standard that dieticians use. I feel really inept that I didn't know this before. Thanks. Cyndy S., RN	“Air mattress” is a very vague term. High air loss or air-fluidized mattresses may increase loss of moisture, and if I was on one I’d increase my fluids, but I don’t think a patient who is drinking “normal” amounts would be in danger of dehydration on these mattresses. Low-air-loss helps to dissipate some heat and moisture from the body, but not to the extent of dehydration. Closed air mattresses don’t pull any moisture, unless the vinyl makes them sweat just because it’s vinyl. Still, the amount of sweat would have to be very significant to lead to dehydration. I’ve never heard of an equation for figuring out increased fluids on “air mattresses”. Laurie M. Rappl, PT, CWS Clinical Support Manager Span-America ---- If it is a "low air loss" mattress you would want to monitor hydration status, they aid in moisture control, which can also dry out the skin. Hydration status can be determined by lab values. If you are using an "alternating air mattress" without the low air loss, the mattress has sheets applied just like any other bed and there is no dehydration risk. R DeLaney LPN, CWS, FCCWS
What is your opinion on using HealthLight - LymphaCare home unit to help heal wounds? Thank-you Nancy Carpenter	sorry, no replies
My mother is in bed with Parkinson's disease. She is cared for by medically unskilled, but very intelligent, loving people. She is almost immobile. She does get into a wheelchair, and eat at the table, and is washed and taken to the bathroom. She is now at risk for pressure sores. Heel pressure sores are our number one risk right now. What is the best boot, splint, pad, etc. that you recommend. What place has a good selection of these. I live in the Broward area north of Miami, if you have local knowledge. Sincerely, Alexander Jacobson	Hi Alexander, I’m sorry to hear about your mother. She is lucky to have someone like yourself who is looking at preventative strategies to manager pressure ulcers. Ulcers typically develop on the bony parts of the body where there is little tissue between bone and skin, such as heels, elbows, back, shoulders and buttocks. Moisture, Shear (internal bone, muscle & tissue movement), and Friction (external movement of skin against interface surface (i.e. mattress) are all contributors to the occurrence of pressure ulcers. Commonly, some form of padding or underlay is used. It's important that this underlay 'breathes' so as not to trap moisture, is able to be hygienically cleaned to hospital standards, provides the level of resilient comfort needed to cushion the body, and of course, addresses shear and friction. We have found that Shear Comfort Australian Medical Sheepskin (AMS) is the only product that allows us to address all of these aspects as part of a preventative strategy at a relatively low cost per use. Shear Comfort products meet the Australian Standard 4480-1 (textiles for healthcare facilities and institutions). This means they provide a product range of overlays and foot care products that can be laundered at 80oC (176oF), therefore eliminating cross infection bacteria all while holding shape and characteristics. Further, Shear Comfort AMS have a fibre density of 4,000 to 6,000 per square centimeter offering proven pressure relief. Shear Comfort® is the only company globally, manufacturing with the Airtec™ process, which is an introduction of a matrix of small holes into the sheepskin allowing enhanced airflow to help patients’ skin regeneration. AMS are utilized throughout the world as part of the standard of care for those at risk, and are recognized by the following: TGA - Therapeutic Goods Administration (Australia) FDA - Food and Drug Authority (USA) CE – Mark 1 MDA – Medical Directives Administration (UK) Techno Aid – Japan HMS – Scandinavia DVA Listed (Canada – covered by department of veteran’s affairs). US Medicare Medicaid Register RAP Scheme. While sheepskins of the past have a bad reputation due to their inability to be laundered, disinfected, varying performance and lack of standards (i.e. anything from synthetics to decorative rugs being called "sheepskin" with varying pile/fiber height and density), the new technology is resonating well with OTs, Nurses, Physiotherapists, and other healthcare professionals due to their proven clinical benefits. Best regards, Holland Patton, RN -------- There is no one "right" device for everyone. She may also need a special mattress or overlay and a wheelchair cushion to reduce her pressure ulcer risk for her pelvis. I recommend that someone evaluate her for these devices. It may be a physical therapist or nurse with knowledge in this area, or a wound specialist. Ask your doctor about referring her to someone for this. It's great that you're thinking about prevention. Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS ---- Alexander, My first concern would be her immobilization and use of heel boots (heel protectors), Multipodis boot (with a heel lift suspension), or any other boot, while she is in bed without constant monitoring. When a patient is in bed and they can turn, reposition, or if they move a lot, you then have to be concerned about the boots turning, sliding etc... which can cause other areas of concern (pressure ulcers in other areas, trauma to the lower legs, or if she has foot drop the strap of a heel protector can cause a pressure ulcer). Another thing to keep in mind is that "heel protectors" are just that, "heel protector", and once there is a problem such as soft heels, red heels, or pressure ulcer, you want to avoid heel protectors. Many people do not understand that if the patient has heel protectors on, and the heels are on the bed or the foot rest of a geri chair, the couch, or any firm surface, then the heels still have "PRESSURE", therefore you are not eliminating the pressure. I would recommend the safest measure would be to consider offloading/floating her feet at all times. What that means is you would put a pillow or pillows under her lower legs (supporting up to the knee, lengthwise) so her heels hang off the end of the pillow, not touching the pillow or any surface (floating), that means she will have no pressure to her heels, which will eliminate the problem. Healthpoint makes a wonderful product called "Xenaderm" that you can get by prescription from the MD that aids as a barrier and increases blood flow, and aids in wound healing. Hope that helps. R DeLaney LPN, CWS, FCCWS ----- Bless you both. Multipodus splints when OOB and when she is in bed float the heels on pillow rolls. One flat underneath the calves and the second pillow folded over and placed under both heels to float them. Splints, when in bed, can cause further breakdown especially the achilles area. Teresa Q. LPN, WCC --- Your best defense against pressure sores is good nutrition - especially adequate protein such as a protein supplement drink and vitamin supplements focusing on the skin vitamins like E and C. I would suggest you study on this area of her care and be sure she also drinks plenty of water. I would also suggest good range of motion to her arms and legs to maximize her oxygenation. Yvonne Asay LPN --- There are a variety of medical companies that have great products to help decrease the risk of pressure sores. Look for a product that helps the heels “free float” while she is in bed. Sammons and Preston and AliMed all have good products and all can be found on-line. You can also use the web to find a medical supply store in your area. Good luck! Chris Beigel,OTR/L --- The very best method to prevent pressure sores at the heel is to float them. Place pillows underneath her calves so that there is no contact at the heel, therefore there is no pressure. They also make booties that can be worn, but at any beginning signs of pressure, like a red area at the bottom of the heel, especially if it doesn't blanch (stage 1), float the heels. Justin, PT Austin, TX --- The cheapest way would be to place a pillow under her calves but do not allow the pillow to be placed under her knees because that will imped her blood flow. Sherry Adkins, LVN --- I am the Wound Care Manager of a 99 bed long-term skilled facility. We use EZ-boots for heels that are high risk or for pressure ulcers on the heel. It keeps the heel off the bed and open to air. We order them from our provider, but I am sure you can order them from any medical supply place. S.Bejrowski, RN.C.
My husband (71 years old and hernia prone) had abdominal mesh installed to repair multiple incisional hernia June 15, 2006. Developed infection July 21 due to internal suture exposed. Hospitalized for 10 days. Abcess below the mesh cultured showed SA. Abcess above the mesh cultured MRSA. Has been on daily IV therapy since July 31 after being discharged. IV daily .75 gram vancomycin over 1 hour every 12 hours. Wound sides are granulating but mesh is still visible and can't seem to get a tissue bed. Last culture (early Sept) did not grow MRSA but did grow light S Schleiferi. Was doing daily wound therapy including saline irrigation and repacking since July 31. Wound healed to about the diameter of a pencil but continued exudate and had to be incised because of tunneling. Healed again to the same point but continued exudate and was enlarged to accomodate wound vac (Sept 27) with silver foam. Is now about the size of a quarter. Surgeon is not happy with healing. Mesh was still exposed on the last Dr appt (Oct 6). IV was discontinued after AM dose Oct 6. Dr is intending to give wound vac another week before possible surgical intervention which may have to include mesh removal and reconstructive abdominal flap. Any suggestions of what we can do to help healing and avoid more surgery would be much appreciated. Bee	It sounds like you need to turn some of your focus on his nutritional status and his immune system including his bowel function for good absorption. He needs adequate protein and vitamin intake to grow new tissue. Is he getting a protein drink supplement and enough vitamins associated with healing like C, E and zinc? He may need a probiotic or to eat things like ypgurt with a active culture in it. This is always a basic place to start when tissue growth is needed. Yvonne Asay LPN --- This is a very complex situation and would be best handled by a wound specialist after an in-person examination. You can find certified clinicians at www.aawm.org and www.wocn.org. Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS
Thank you for an informative web site. I am an ED nurse with a particular interest in Wound healing. I have been reviewing the current literature on the most effective cleaning methods, analgesia for cleaning and wound dressing products for patients who present with superficial abrasions. I have not found any reference to the most effective method and least toxic to remove bitumen/road tar from these abrasions. Would you have any information that could assist. Many thanks Mary-Anne Spence Staff nurse Waikato Hospital Hamilton New Zealand	Mary-Anne, If you go to www.worldwidewounds.com and do a search there is an excellent aricle (with pictures!) of removal of road tar and care of the burns associated with the hot tar. Butter was used to facilitate the tar removal! Myra Badger, BSN, RN, BC, WCC --- Mary-Anne, Just a thought, but if you could use mineral oil to soften and remove the tar, then you could concentrate on cleansing once the tar is removed. R DeLaney LPN, CWS, FCCWS
Apart from the waterflow score, what other pressure risk assessment tools are there? What do they mean by shear? Teresa	The Braden Scale (www.bradenscale.com) is probably the most common one. The Norton and Gosnell scales are also used. You can find more info on pressure ulcer risk scores in any pressure ulcer prevention guideline (www.guidelines.gov). Shear is movement between layers of tissue-epidermis on dermis (a skin tear), or skin against subcutaneous tissue, such as when someone slides down in the bed, but their skin stays on the bed, bunching up in the upper trunk while their frame moves down. That leads to large sacral ulcers as the capillaries can't stretch that much. Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS ---- Teresa, The National Pressure Ulcer Advisory Panel has a form called the "P.U.S.H." tool (pressure ulcer scale for healing). Their web site, I think, is www.npuap.org. Shearing is a horizontal force perpendicular to pressure. That means that there is the interaction of both gravity and friction against the surface of the skin (the body slides down in bed or chair), the skin remains stationary, and the underlying tissues and bones moves, which tears the underlying cappillaries and blood vessels. Shearing also causes underminning on pressure ulcers that are located on the buttocks, coccyx, sacrum, and back from the patient constantly sliding down in the bed or a chair. R DeLaney LPN, CWS, FCCWS --- Hi There is the Braden Score & the Norton Score. Shearing is like Friction only the limb etc is continually moving. Jeanne --- There is the Braden Risk Assessment tool that is pretty reliable. It is composed of several questions, regarding the whether the patient is experiencing any numbness or tingling, whether they are incontinent or not, their level of activity and/or mobility, nutritional status and also whether they are at risk of friction or shearing. Based upon how the questions are answered, there is a number score given, and then the score is totaled up at the end, and then if the person falls below a certain level, they are considered to be at risk and certain precautions should be taken to prevent any pressure sores, or worsening of an existing sore. Hope this helps-- Brenda, RN
I work in a residential setting with an aging population of mr/dd adults. Many are wheelchair bound. I’m hoping to find some type of color handout showing and describing what pressure ulcers look like. The majority of staff have no medical training and don’t know what to look for. Any suggestions would be helpful. Thanks, Toby Allen RN	Many of the dressing companies have that type of educational materials they can provide you. Also, any nursing text or wound text will have pictures. Look at www.guidelines.gov for pressure ulcer treatment guidelines for more options. Lastly, go to www.AdvancingThePractice.org, and click on the education tab. You'll find some on-line resources as well. Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS ---- Toby, Just do an internent search for pressure ulcers staging or pressure ulcer pictures. I have gotten great pictures that way of actual staged ulcers and then diagrams of pressure ulcers with cutaways showing depth. Myra Badger, BSN, RN, BC, WCC
My husband has been on VAC Therapy (portable unit) for ten weeks now, following complications from an umbillical hernia repair. He started with the drape supplied with the dressing pack, then progressed to Duoderm as he began to get an allergic reaction to the drape in the form of fluid filled blisters. The wound nurses were very careful not to pull tight over the skin, so the layers of skin were not separated. They have also been using Cavalon on prior to the Duoderm but he seems to be developing a reaction to that also. We are in the process of seeking a second opinion as the VAC is now on an open wound due to re-operation to clear out the infection from the first op. In the meantime, can anyone tell me if there is anything else that can be used instead of Duoderm? Thanks Jo	If the wound is too exudating, Hydrocolloids may not be sufficient enough to absorb try hydrofiber dressings (aquacel/ Ag) or foam dressings ( Biatain,Allevyn,etc) meantime, VAC therapy is also good snd works well. Dale WOCN Manila, Philippines ---- Try hydrofera blue, bacteriostatic foam dressing which offers a natural negative pressure of about 60mm Hg of pressure. I've had wonderful results with it. Good Luck!! Sharon --- It's hard to say without an in-person examination. To find a specialist for your second opinion, go to www.aawm.org or www.wocn.org. Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS --- The problem you are experiencing MAY not be a reaction to the dressings. I do love the wound VAC but I find a tendency for the tissue around the wound to develop a red raised 'rash' that can breakdown into a excoriated tissue. The majority of the time it turns out to be a fungal infection, like candida,and resolves quickly with the application of nystatin powder on the skin. After the powder is lightly applied a skin barrier should be dabbed on to seal the Nystain to the skin and provided a base for the drape to seal to. It would be worth asking those involved with this wound care if they think this may be a fungal infection. Good luck! Michelle

Please note that this email summary page was compiled from emails submitted to the Wound Care Information Network. It is simply a forum for people to discuss wound care cases, treatments, products, etc. Email replies included in this forum are not evaluated for accuracy or correctness. Please verify all information presented with your own sources of information, such as; doctors, nurses, manufacturers, published literature, etc. We do not know who the authors of the email replies are and their stated credentials have not been verified or validated. Read the disclaimer below.

Disclaimer - Acceptance and publication by this email and/or web page of an advertisement, news story, or letter does not imply endorsement or approval by the owner of this website of the company, product, content or ideas expressed in this email. Any medical condition should be evaluated and treated by the appropriate healthcare provider. This email is for informational purposes only and is not a substitute for competent human intervention. The owner of this email list and web site does not check for accuracy or legitimacy of ideas expressed by the individuals who post messages.

Automated removal Instructions shown below.