Our first Who knows better than you survey revealed quite interesting results.

The product we looked at was from DP Wound Care and received a total score of 7.44 (out of 10) from participants. Take a look at the results for yourself.

Click here to see the results.

First I would recommend to assure her protein intake is between 1.5 to 2.0 grams/Kg/of body weight and that her total caloric intake is sufficient to meet her BMI needs. Remember if her intake is not sufficient the protein she is receiving will be converted to energy (ATP's) Second pull a Pre-alb.
to assure her protein stores are not depleted. As I review residents particuliary in LTC this is usually the cause for non-healing wounds.

Second, Rule out any bone disorders/infection.

Third, the treatment recommendation would be to implement Aquacel AG in case you have a bacterial load. Cleanse wound with sterile water, dampen the Aquacel with the sterile water before application to activate the silver Change treatment QD. Use rope for the tunnels.

Fourth, Eliminate any sheering/friction forces. Use gel cushion on wheelchair, Turn and reposition client every 2 hours, and use air fluidized bed.

Fifth, check for any epibolie. If present you must correct and pack wound assuring all edges are contacted. (This is the second most common reason for non-healing wounds I see)

Last, if the wound continues to not heal check for MRSA in the wound bed.
Stage 4 in LTC/Acute hospital stays has shown significant probability of colonization. If evident change treatment to Acticoat Absorbant and change every 3 days.

Although this treatment regiment is slightly expensive the long-term effect will offset the expense.

This is my 1st line of approach with non-healing wounds.

Let me know if she does better.

Jerry Hunsicker, RN, ADNS, NHA, WCC

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What is the albumin level (more definitively a pre-albumin)? Often co-factors can impede healing. Assessing what extenuating co-factors are involved and addressing those would be a first step. How long has the Bactroban been used? Antibiotic therapy (even topical) should be used for a limited time , usually two weeks. With the 50% slough and 50% granulation tissue and no signs of infection (as we know, it is colonized), I would recommend Panafil SE and collagen to the entire wound bed to promote more granulation tissue and help reduce the slough, then add Xenaderm to the periwound (which aids as a barrier, promotes healing because of the vasodialation component, and it decreases pain) then completely secure with a waterproof dressing and change daily. I have used this combination many times with great success. Gently pack the tunnel as well, make sure it is tunneling and not undermining (often the two are confused), undermining is destruction of tissue under the skin edge, which means the ulcer is larger at the base than at the skin surface (usually caused by shearing with the HOB elevated i.e. peg feeder), and a tunnel is a passageway under the skin surface that only extends in one direction. Another treatment to consider would be a silver gel and collagen to the wound bed, that also has much success for increasing healing rates. Remember turning and repositioning the resident and eliminate pressure in the coccyx area, this includes positioning devices such as pillows, which also if placed on the coccyx causes pressure. I hope this helps.
R DeLaney LPN, CWS, FCCWS

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 Hello,

With a tube feeding you can check her labs including PAB and if they're alright ask the MD for her prognosis. If its more than six months, debride the slough (mech. or chemically) and try a wound vac. Actually there are any number of approaches you can institute but optimally something that you only have to change every three days or so to give the wound the best chance to heal. If your facility can manage, there's a number of wound care consulting firms with all the best type of treatment modalities that will best heal the wound

Respectfully,

Chuck

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First of all are you removing the cause ? The surface would need to be looked at and assure that you are removing pressure. The second issue would be to remove all slough . Use of sharp or enzymatic debridement to remove the slough would be good . If the patient is having much pain it will take a little longer with the enzymatic debridement but would be the right choice for the patient. At the same time remember to fluff not stuff the dead space tunnel).
If you don't have any clinical signs of infection remove the bactroban gauze and use an alginate rope or silva impregnated rope to keep any bioburden down while at the same time providing a moist /warm enviroment. The secondary drsg selection could be changed to decrease the amount of time you are exposing the wound. You could us a silicone base drsg that can stay in place for 5-7 days or until it is 100 % saturated. This will decrease the time you drop the temp of the wound and with the minimal exudate this will decrease the cost of the drsg and the time spent BID in changing the drsg. Be sure to note if no improvement with any plan of care if its not working in a 2 week period or the wound starts to go south then re-look at the picture. If dietary is not involved they need to take a look at the patients nutrition and maybe even some labs to see if the tube feedings that the resident id receiving is meeting the needs for the wound to heal. The last suggestion would be also if after making the enviroment just as we have discussed in the beginning since you do have tunneling I would be assured with a culture (aerobic and anaerobic) to make sure you have all of your areas covered. I hope this will be of some help.
TJollyRNWCC

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A couple of suggestions. You need to know how much protein is in the tube feedings. What is the res albumin level. You need to get rid of the slough before you can expect healing. What type of bed is the res on. How much time does the res spend on the affected area.
Good luck
Cheryl Nichols Tx Nurse

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Have you tried Alginates to pack the wound? I think Bactroban impregnated gauze is not necessary anymore since you said there is no sign of infection.

Thanks

Dale WOCN
Manila Philippines

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You have to get rid of the slough to heal the wound. Can it be debrided by the MD or can you use something like Accuzyme? Is she getting enough protein through her g-tube feeding? Has the dietician evaluated her and recommended any supplementation? What is she on for a mattress? Is her time out of bed limited? Depending on the length of time she has had the wound, has she been checked for osteomyelitis? I have healed wounds like that in the past with elderly advanced Alzheimer’s patients, but it takes a combined effort of all disciplines at the facility. Good luck, Sue CWS

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This person is need os seeing a wound specialist. There are too many things going on here to make a judgment without having more information. Please take a look at her nutrition - is she getting enough calories and nutrients for her to heal? What else is going on in her body - does she have diabetes, heart disease, etc. I would ask her doctor if she had any labs recently - are her iron, glucose, lytes, CBC, albumin, prealbumin levels WNL? How is her kidney function? My last question is - How old is she and is she declining? Would your goal be more for comfort rather than cure? You didn't share if you were a nurse, therapist, or family/friend, but these are all heavy questions that need answers from her physician and a wound clinician. God Bless!!
Cindy R, RN WCC
 

Vivian

This patient needs immediate eval by a vascular surgeon for debridement and possible amputation. Pt. has a high risk for osteomyelitis. This is not a wound dressing issue but a circulatory issue

SRS RN

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Has this patient had arterial Doppler's or an ABI? There could be an arterial insufficiency. If there is an arterial involvement it could be a whole different ballgame. I would monitor for osteomyelitis and treat accordingly. This would be a first step to determining what treatment options are available.
R DeLaney LPN, CWS, FCCWS

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 This patient has Obviouse signs of OsteoMylitis, and this appears to be traveling ( as Observed by the Erythemia)
Dr. should be notified and x rays will help determine extent of the damage
Devota

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Sounds like the pt needs an xray of her rt foot to exclude/diagnose osteomylitis, a swab to be taken to establish if an infection is present, and an appropriate course of antibiotics if indicated. Has a doppler been done? to establish circulation problems. The dressing I would use is sorbsan - as this helps reduce slough, with allevyn over to protect/absorb exudate. Pt should have high protein diet to replace protein lost through exudate.
Hope this is some help
Mary - Practise Nurse, Devon, England.

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Has she been assessed for osteomyelitis? If not, get that checked first. If positive, will be treated with IV antibiotics and possible surgery. Then you go from there. You didn't mention is she were on a specialty bed. Negative pressure might work after checking out osteo. Silver is a good choice and can be used with negative pressure also. Good luck. Debbie Harris, CWCN, Louisville, KY

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Sounds very probable that this wound has osteomylitis. it would be contraindicated to promote wound closure at this time. Please refer her to a surgeon for evaluation. meanwhile, your treatment should focus on managing the surface bacterial load with a silver dressing, promoting comfort, and nutrition.
Michelle PT, CWS

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I'd send her to the ER, sounds like Osteomyelitis! Has she had a bone scan? Whats her ABI's? unsigned

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Vivian,

Regarding your nutritionally compromised patient with bilateral pressure ulcers on her feet, I would have to ask what your treatment goals for her are -to heal the wounds? or palliative care? I have to commend you for your interest in helping this lady, that speaks highly to your nursing integrity. Your patients are more fortunate than they realize having you for their nurse.

I am sure that you've addressed the need for a labs, nutrition consult, floating the heels and good basic nursing care. With exposed bone in a wound as you've described, you can almost guarantee osteomyelitis. If present, the wounds will not heal. Since there are many other variables to consider, I would request a consult with a wound specialist nurse to help you weigh the pros and cons of treatment options. Aggressive treatment could involve bone & tissue cultures, surgical debridement, PICC placement, IV antibiotics and hyperbaric treatments coupled with the same wound care as you're now doing. Once the wounds are "clean", the use of a wound vac would not be out of the question.

On the palliative side, you could consider fortifying the nutritional intake with a supplement called "Arginade" which I've had some favorable experience with in the basically healthy population. A simple tissue culture, p.o. antiobiotics specific to the culture sensitivity, which may help a bit with pain, an enzymatic ointment for debridement, an alginate, preferably with silver such as what you're using now along with the Allevyn- for exudate management and a barrier film for the periwound area (I prefer Calmoseptine) are all good choices for basic palliative care. I would investigate whether or not she may be a Hospice candidate on the outside chance she may be going into generalized multi-system failure -just a thought if palliative care is what the goal is.

All in all, you've got a toughie! I wish you lots of luck!

Blessings,

Lori McCarthy, MS RN CWCN

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This poor woman needs to see a physician and have some debriding done. Again, with LTC, how is she care planned? Are we looking at healing or comfort? At this stage of the game, maybe a good debriding will help her feel better and keep the infection process from getting any worse. With all the bone issues that she has she most likely has osteomylitis. Please get her to a physician (surgeon) quickly.
Cindy R. RN WCC

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Please check with any of your vendors. Thsy have this done for you and are happy to share

Tracy Reed-Wilson, RNC, NHA

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In response to your mail I am a RN who was working in ICU for 10 years acting as a Tissue Viability Link Nurse for my colleagues. There is a need for your colleagues to update them selves in wound care and its management.
I put together a wound care manual soley for ITU staff.I designated a month which was "October Wound Care Month" where teaching took place for all staff to attend and by popular demand the ward staff attended also. I re-designed the hospitals standard wound care chart, just for ITU use only, which is now being used Trust wide, so that the continuation of care can continue straight from AE-admission through to Theatre Wards and ITU. It was a mammoth task but was needed and evenually implemented. I am now a Tissue Viability Nurse and it is a challenging role but very rewarding. My advise is to join the Pressure Ulcer Association and any further association that focuses on wounds.
Good Luck
Jules England

Try Lyofoam, it can be cut to fit the base of the wound as well as the areas of undermining. It is a good dressing for wounds that are very moist. Cover with a hudorcolloid dressing and change Q 3 days and prn. I assume that your patient is has a F/C and is on an air bed. Good Luck

Carol RN

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If the wound has a clean base, VAC therapy would be your best option. If not ,the patient needs debridement then VAC therapy. A plastic surgeon could then rotate a flap if the pt. is a surgical candidate. Your local VAC rep could assist with management of a VAC in the peri-rectal area.

SRS RN/BSN Wound Resource

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The amount of drainage would be a concern as well as the dressing being soiled by urine or feces. A recommendation to absorb drainage, fill the wound cavity, and provide a bactericidal, would be to use silver calcium alginate fluffy rope. This is easily applied and has multiple uses. For those patients that are incontinent and dressing adherence is a problem, I have recommended to use a foam then secure the foam entirely with mefix tape then reinforce over that with pink tape (which makes it a waterproof dressing and soilage can be cleansed without changing the dressing, because it will not penetrate) and change daily. I have not heard of a topical that aids in pain prevention. I have used Xenaderm (made by Healthpoint) to the periwound as a barrier, due to drainage, to prevent maceration and it does have the benefit of helping reduce pain as well as a vasodilator to promote healing and epithelialization. Hope this helps.
R DeLaney LPN, CWS, FCCWS

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There are prescriptive formulas that can be made for topical pain, however, Regenecare by MPM has 2% lidocaine as well as collengan to help heal wound. What is her eating status and pre-albumin levels? Does she need a continence diversion appliance like a fecal manager or a fexi-seal or zassi? Also negative pressure might be a consideration. If interested in negative pressure, I also represent a national company - you can check us out at www.medastat.com Has a specialty bed been a consideration? We carry those also. Debbie Harris CWCN, Louisville, KY

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This does sounds like a complicated situation. I would start by ensuring he has the optimal pressure relieving mattress/bed. If he is on a alternating pressure mattress or a low air loss mattress for at least 30 days and the wound has not improved he would qualify for a clinitron bed (Hill-Rom is the company that helps me with this process). Second, anything you can do to improve nutrition will help. Emphasis should be on protein and vitamins. Protein needs increase to 2.0grams of protein /kg of body weight with this kind of wound.
Next, the dressing itself. There are many dressings that will work to minimize fecal exposure and the contamination from fecal exposure. An antimicrobial dressing like Aquacell Ag will decrease bacterial/viral/fugal levels and absorb drainage. Similar absorbent silver products would be Contreet by coloplast or Acticoat Adsorbent. The silver dressings are designed to remain in place for up to three days which in itself decreases pain associated with dressing removal, provides thermal insulation, and is proven to be cost effective treatment. A secondary dressing like tegaderm or opsite will keep a clean/impermeable surface. I personally prefer Mepilex border because it is so gentle on removal yet keeps an effective seal. Another alternative would be a topical perscription ointment made by health point called xenoderm. Xenoderm is indicated for BID application and does not require a secondary dressing. It increases circulation by up to 50%, provides a barrier against incontinence, and maintains a clean wound. Because of the depth (? drainage) you may find you still need a secondary dressing. Xenoderm is a good option if the patient has nursing care already in place to apply this medication BID or with each incontinence episode.
Regarding topical pain relief, I use 4% xylocaine frequently with wound care. Its limitation is that is applied after the dressing is removed to permit sharp debridement therefor it is not a good means of routine/lasting pain control.
Hope there is something here that proves useful!
Michelle PT, CWS

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There are multiple issues to be addressed in this patient. First of all, the patient’s nutritional status needs to be evaluated. He is losing a lot of protein out of that wound. If he is eating very poorly, the chances of healing that wound are slim. Supplements are in order here. Also, what type of mattress is he using? Is it good enough to provide proper pressure relief? Has the wound been evaluated for osteomyelitis? There are new products out on the market that can manage fecal incontinence quite nicely. The heavy drainage and undermining are troubling. That wound needs to be evaluated by a wound specialist. There are many, many products that can control the drainage such as Allevyn foam or a calcium alginate but it sounds like something else is going on there. Pain can also be a sign that there is infection present. Good luck, Sue CWS
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I would recommend a calcium alginate rope for packing. The alginate will help absorb the heavy exudate, is easy to fluff and place in the tunneled areas and fill the dead space, and can stay in place for 24-48 hours (check manufacturer reccomendation). Expect the rope to liquify in the wound and don't over stuff "fluff only". Use a good coverdressing that can be wiped clean if soiled from feces or urine, I use Combiderm and it is great, costly but it stays in place and I have healed stage IV wounds without anchoring a f/c. As far as pain, what about the p.o route, especially prior to a dressing change. P.S. the wound must be irrigated between dressing changes to ensure that the rope is irrigated from the wound.
Yolanda, RN, WCC

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Hello there, I work LTC and had a patient very similar to the one you are describing. Those ulcers are the worst in the world to keep clean. My advice would be to clean it BID with 1/4 strength Dakins solution. Irrigate the wound well and clean out any slough that you see. The 1/4 strength will NOT harm the wound and will aid in healing, contrary to what some say. We have treated huge stage IV wounds and healed them because we used the Dakins to clean. With the amount of drainage that you describe, what infection process is going on? Is these feces in the wound? After cleaning, you can impregnate a moist Kerlix roll gauze (you need Kerlix - it doesn't leave fuzz or pieces in the wound bed like some roll gauze will do.) Fluff the Kerlix, impregnate with "Triad" Hydrophilic wound dressing by Colorplast and pack the wound. Probably will need to do BID if dirty. Then cover with anything that will stick!!! Prep skin first, however.
Cindy R. RN WCC

It's hard to give an answer without seeing your scar. If it's just a large scar, the silicone scar treatments you can get in the drugstore can help reduce the appearance. If it's a keloid on the other hand, which it might be, you don't want to cut it out. That will make an even bigger scar. See a dermatologist for treatment, which may include injections of medication into it. I'm not aware of any evidence for or against ultrasound at reducing an old scar (or keloid). And, regarding your fatty liver, imaging ultrasound can reach that deep, but is not therapeutic. Therapeutic ultrasound only penetrates an inch or two tops.

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

Some (including some manufacturers) advocate staying with a debrider to remove the ongoing fibrin formation as it moves through the healing process. One former manufacturer had the line "start with, stay with." Personally, I move away once clean. At that point, the wound usually has other needs that the debrider can't meet-exudate management, adding moisture, etc. There is one topical, papain-urea-chlorophyllin creams, that have a little debrider in them while containing an ingredient purported to promote tissue growth.

I think you need to establish a policy, based on evidence as available, and stick with it. It gets really confusing for staff and patients to keep switching. And, it's expensive. And, surveyors will wonder what's going on if they look at that chart.

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

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It is fine to continue use of any debriding ointment after the removal of all devitalized/necrocic tissue. At this time I am not familiar with any "debriding ointment" that can harm healthy tissue. If will serve simply to maintain a moist wound environment (like a hydrogel, petroleum, or whatever the base is in the product you are using). In the past we did have to remove the debriding ointments after compltetion, but not anymore!

Jerry Hunsicker, RN, ADNS, NHA, WCC

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As I understand it, wounds with neucrotic tissue require a debriding agent, once the neucrotic tissue is gone and there is evidence of healing tissue the the medication should be changed to support the growth of the new tissue. I am sorry that you work in a non-supportive situation. Good Luck

Carol RN

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You are in a position that all wound care nurses find themselves in from time to time - more often than any of us want to be. I am a nurse practitioner in wound care and I also fight the same battle. The answer is to look beyond all of the political issues at your facility and look at the patient and how you can bring them the very best care possible. When there is an issue with a product being used, go to the source and get the straight answers. Every product has a company rep. that will give you the answers you need. They will talk to you on the phone, they will give you web sites to go to, they can even send you printed information if that is what you need. Perhaps you need to talk to more than one from different companies to compare different products. Just the fact that you are looking for answers on this web site says you are not satisfied with just going to work and coming home and forgetting your patients' care. The company reps. are part of your own personal resource group and have much more value that just free lunches and free ink pens. The companies want their products to be successful and you want your care to be successful, it's up to you to put the two together for your patient. unsigned

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Collaganese ointment can be used for up to 2 weeks AFTER the wound has healed without adverse effect. unsigned

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Well first things first, everyone needs to be on the same page and working towards what is best for the patients.
Secondly, debriders are what they say they are: debriders. Debriding accomplished, change product. Some debriding agents actually cause harm to viable tissue once slough or eschar has been removed.
Cheryl Nichols Tx Nurse

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You are correct. A debriding ointment is used for the purpose of removing necrotic tissue. Once the wound is free of necrotic tissue, the plan of treatment should be re-evaluated and changed. Continuing to use the debriding agent will not harm the viable tissue, but is no longer necessary and as well as prohibited by your policy and procedure. You may consider using a healing agent, like Panafil for example to speed closure, or just choosing an extended wear dressing that will maintain the proper wound environment, decrease the frequency of dressing changes and minimize disturbance of the wound bed.

Bill Richlen PT, WCC, CWS

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There are enzymatic debriding medications that are approved for use until full wound closure, and some that are for necrotic tissue only. The two I am most familiar with is Accuzyme and Panifil (both made by Health point). Accuzyme has a higher concentration of the component that digests necrotic material and is indicated for a wound containing devitalized tissue. Panifil has a lower concentration so it is somewhat less aggressive but also has another component (copper-???). this component is what makes panifil green. it is a nutrient that feeds the wound and helps facilitate new tissue growth. This is FDA approved for use till full closure. My personal position on this is that once the wound is clean, it may be okay to use panifil to closure but there also maybe something more appropriate for that specific wound. each wound (regranex, prisma, a silver dressing...). Each wound needs to be individually addressed to create its ideal environment.

Michelle PT, CWS
ps. Consider calling health point for an in service. they have several great products and our rep was a wealth of valuable information!

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Sounds like the main issue here is not wound care. One can continue to use a debriding agent like Accuzyme once the necrotic tissue is gone, but what is the point? Wound care must be specific to the type of wound you have. If it is granulating, then use a treatment made for that type of wound. If it is necrotic, then it needs to be debrided. Sue, CWS
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I don't know what particular enzymatic debriding agent you are talking about? Is it Santyl? If so, I have been using santyl oint for many years (10), and it does work until the wound is closed and does not harm viable tissue. Santyl has healed many of our wounds from stage IV to stage II's. Keep in mind that santyl and accuzyme's ingrediants work differently. Now if you are talking about accuzyme, I stop using it after the wound is free of eschar and slough and the go to another dressing and on occasions I go to santyl. I will never knock santyl, I've seen how well it works.
Yolanda, RN, WCC
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It really just doesn't make any sense to keep using since the enzymatic debriders are to remove slough, not prevent it. It is specific to nonviable tissue.
Beth WOCN