There are a multitude of "silver impregnated" dressings available today.
These are an ionic silver that will kill most every microbe but is not cyto toxic. Some brand names are Silverlon, Acticoat, Aquacel AG. Try to google silver impregnated wound dressings.

Bryan

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Hydrofera Blue
Contains gentian violet and methylene blue
together rendering an analgesic effect within 24 hours

S Cohen

***

A dressing with Analgesic properties?

It may depend on the type of wound you are placing it on.

Is it a burn? Silvadene cream is great, and it can be used for other wounds also.
Here are a "couple" reference sites:

National Wound Care guideline: www.guidelines.gov Wound Care Institute: www.wcie.net Wound Management.net www.Info.com - enter wounds in Search box will provide pages of information.
Try also Convetec, they have some very good products.
If you can reach the rep in your area, and discuss what you are looking for, sometimes they will give you a product to trial.

Also keep in the back of your mind: reimbursement issues. It may depend on the environment and insurance provider in how you document the need or if it is a covered item, or limitations to quantity.

Good Luck
Please post your results

CE, RN,CWCN

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Im Alaa selme,R.N in M.O.H of jordan.
I hope to be connect, lf you need any thing im ready.

Eileen

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the info that you have provided is lacking in detail.
I suppose it was a crush degloving injury. What was the site of injury (below knee, just above the ankle)? Was it circumferential or just on the outer/ inner/ front/ behind aspect? What is your basic complexion?
By and large skin grafts differ in colour from the surrounding skin. However the colour-match is better in fairer complexion.
The swelling is possibly due to injury to the local autonomic nerves. This may be helped by alternating hot and cold compresses (provided your sensations are fine of else you may burn yourself). You could also use pressure socks.
If the injury was circumferential, the edema could be due to the damage to the lymphatics.
The intermittent pain suggests lingering sensory neuropathy. This may be benefited by frequently tapping lightly with your hand along the route of the culprit nerve.
Kumkum

***

It sounds as though the area closed with scar tissue, and the color would not be the same because there is no pigmentation in scar tissue. I would recommend going to a plastic surgeon, it can possibly have a graft from another part of your body that would come closer to matching the surrounding skin color. Hope this helps.
R. DeLaney LPN, CWS, FACCWS

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Eileen:

I don't know if this suggestion will help you, but since it is your foot causing all this havoc, I suggest checking with either an Orthopedic surgeon or a Podiatrist who does advanced wound care and surgeries.

If you lived here in Florida, I would highly recommend a Podiatrist I like.

Hope this helps, or at least shows you options.

Frances J. Jessup, RN, BSN

***
I would definitely have it looked at. It is possible you may have osteomyelitis, bone infection, but most likely the off and on pain is arthritic in nature. Plastic sx is an option, another ? for your MD. The discoloration may be due to disrupted tissue, that wound specialists see alot with venous stasis wounds or CVI, which allows leakage of erythrocytes, red blood cells, into the interstitial area. A trip to a good MD with knowledge of wound care is your best bet. I would look for one with CWS credentials, many Podiatrists have this and since it is the foot they would have great knowledge of the anatomy and physiology of the affected area.

Bryan K. Luster, PTA, CWS

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Hello Francine, autoytic debridement I would say falls under selective debridement. Uses the body's own enzynmes to dissolve necrotic tissue within the wound. Using occlusive or semi-occlusive dressing. Using code 97597 if wound size is <20 cm or 97598 if wound is >20cm. But you should document clearly in the the minimum weekly, especially on medicare pts. as to why it takes a therapist to apply for this procedure ( I supposed you are a therapist since your dealing with codes)

Dex, PT WCC

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There technically is not a code for “autolytic debridement” since that is the body’s own mechanism for debriding wounds. 97602 is used for “Non-selective debridement, without anesthesia (e.g, wet-to-moist dressings, enyzmatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care per session”. 97597 is for “Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel, and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area <20 cm2”.

Bill Richlen PT, WCC, CWS

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You cannot use either code for autolytic debridement and it is considered nonskilled. in most instances.
97597 is for selective debridement and you have to use sharp instruments (scalpel, forceps, scissors, etc), however I agree that autolytic is selective. If you look in your CPT code book it will give you the exact defenition of the code. But again, you cannot use 97597 unless you are removing devitalized tissue with sharps or pulsed lavage or such.

97602 is used for mechanical debridement and again I will defer you to the CPT code book. Mechanical debridement is defined as more of wet to dry or removing devitalized tissue mechanically with gauze.

Remember, when using either of these codes as a PT/RN, you need to document why skilled services are needed. I believe (but not quite sure) that if you bill 97602 there is $0 attached to for physical therapists billing it. However, if you bill the facility component and are in a hospital based OP wound center, you may be reimbursed about $20. Hope that helps and best of luck. In that case you may be better off billing an Evaluation and Management Code.

Lisa PT, CWS

 

Orzi

sorry, no replies received

Vivian

You can use silver nitrate sticks to remove hypergranulation. It can also be surgically debrided off. Keep in mind that a critically colonized wound may have overgrowth that appears to be hypergranulation but isn't, so anti-microbial therapy can help. You should also look at using a more absorbent dressing, as over-hydration can lead to hypergranulation. Compression therapy can help prevent it as well.

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

Vivian:

The hypergranulation should be addressed by either sharp debridement with appropriate dressings afterword, or if the patient is a home health patient who does not go to a wound clinic (should go), use a foam dressing.

Frances J. Jessup, RN, BSN

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Hypergranulation is a sign of "overhydration of wound bed and periwound area. It means that the dressings used are not absorbent enough for the amount of drainage. Two things need to be done: change your dressing material to one that’s appropriate, i.e. foam perhaps, or a combination of foam and calcium alginate. Meanwhile, the hypergranulated area is treated with Silver Nitrate sticks - you'll need a physician's order for this and he can determine the frequency of application.

Estrella C. Mercurio, R.N. G.N.C.(c),
***

The two most common methods for addressing hypergranulation tissue is the use of a foam dressing wrapped with kling or kerlix to put pressure against the tissue or silver nitrate pencils, or a combination of both can be very effective.

Bill Richlen PT, WCC, CWS

***-

Hypergranulation tissue is usually caused by increased drainage or such. You can use silver nitrate to cauterize the hypergranulation tissue. Also you can use an absorbent dressing and apply pressure (foam under compression). Another option is using something like Mesalt, that has worked for me in the past. The most important thing is controlling the drainage and bioburden and that will in turn affect the hypergranulation tissue.

Lisa PT, CWS

***

Hyper granulation Tissue?

Sometimes you may hear it referred to as "Proud Flesh".
The overgrowth may result from the wound bed remaining too moist through the healing process.
Options:

1. Use a Silver nitrate stick to reduce the over growth.
Dependent on the Size of tissue, and where the wound is in the healing process, You may have to use the stick a couple times. After the first use, re-eval site in 3-5 days. Keep site dry.

2. Use a type of Foam dressing that will provide some pressure to the wound, and secure with a 2" tape.

Keep reimbursement issues in mind along with your documentation for need.

Please post results!

CE, RN CWCN

***

Hi Vivian,

There are several things that you can do. Our most common intervention is chemical cautery with silver nitrate. We also use electric cautery with a "Bovie" although this is for more extensive areas and can be somewhat painful but not always. We will sometime use a topical xylocaine prior to use.

Other intervensions used are:

more frequent dressing changes to reduce the amount of time the drainage is on the granulation tissue iodoform as first-layer or betadine-soaked gauze

I hope this helps.

August Stierwald RNBSN

***

We have used Silvernitrate stick (40%) or sharp debride then haemostat. - depending on the area and size. Need to consider the underlying problem (aetiology) Is there infection?
Julie Miller
Podiatrist
Melbourne Australia

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Hi, I'm a tissue Viability Specialist in South Africa. Hypergranulation tissue is easily treated with hypertonic saline wet to dry dressing, or silver nitrate (be careful you know how to use it) The wound moisture balance should be moved to slightly drier. Epidermal calls cannot migrate over a wound if the angle is greater than 45 degrees, hence hypergranulation will not epithelialize.

***

There are two things that I know that work well. One is a compression dressing, make sure there is no blood flow issues if the hypergranulation is on the lower extremity before applyig compression. The second thing that has been useful is silver nitrate sticks. Hope this helps.
R. DeLaney LPN, CWS, FACCWS

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Vivian,
I have had great results with a silver nitrate stick. Makes the wound look really bad almost instantly, but dont be alarmed, this knocks back the tissue as well as sanitizes the wound. Also, sometimes it will restart the wound cascade to the inflammation stage and the wound will begin to heal properly. After the first application, monitor for hypergranulation and use it again if warranted, be aware however that if it continues to hypergranulate at an alarming rate, or continues to not heal, you may want to take a tissue biopsy to rule out cancer.

Bryan K Luster, PTA, CWS

***

Overexuberant granulation
(1) Surgical excision with sharp scissor or tangential excision with blade followed by a haemostatic dressing

(2) Chemical cauterization using CuSO4 crystals or AgNO3 stick -- wash off excess chemical immediately with saline or the damage may be deeper than required
(3) on limbs a pressure dressing will help prevent its recurrence
Kumkum

***

1. Surgical intervention
2. Silver nitrate
3. hydrofera blue foam dressing

SCohen

***

Sometimes using Hydrasorb will help with hypergranulation. Brenda Gladfelter, RN, WCC

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Silver nitrate helps reduce hypergranulation. CTisack, WCC

***

Wounds that have a hypergranulated bed can be treated w/ silver nitrate. I've also seen topical lidocain used in a wound clinic prior to MD debriding w/ a scalpel. Mesalt can also be effective. The wound bed may be too wet, which will encourage hypergranulation, so consider how effectively the exudate is being managed.

Beth CWOCN

You'll find a list of great texts at www.advancingthepractice.org/resources.htm Most have what you're looking for. If you're looking for info on specific topicals you have already, read the package inserts for a lot of information. You can also talk to the product reps for more info.

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

Dana,
I also practice PT in Arkansas, Jonesboro to be exact, so Hey! Kovia comes in 3 different strengths if I am not mistaken. I have used both and have not noticed a big difference, but you may not have the same strength as Accuzyme. Check that out, I think the highest strength has some yellow on the tube, and not all white. If you have a lot of slough or eschar I would recommend sharp debridement, followed by a good enzymatic like your using.

Bryan Luster, PTA, CWS

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I also am working with Kovia and it does work, just not quite as fast as the accuzyme. iI work as a wound acare nurse in a subacute facility. Unsigned

***

Kovia is a generic of Accuzyme, and does have the same type of active ingredients (however the rest of the ingredients are different or different doses). I have used both and can tell you that we have had much better results with Accuzyme. If you talk to the Healthpoint rep they can probably give you more specifics (may be a little tainted though). You will see that a lot with generics, that they don't tend to work as well as the actual product. Best of luck.
Lisa PT, CWS

***

I agree that kovia accuzyme is not as effective, Coaty RN,CWS. Alex. La.

unsigned

Regranex isn't indicated for pressure ulcers, and the research doesn't support its use in your husband. There's a lot more wound healing than what goes onto the wound itself. He needs to have good nutrition. He needs to keep the pressure off his ulcer as much as possible. He may need an special mattress or a new wheelchair cushion. There may be a high bioburden (number of bacteria), without having an infection. Electrical stimulation might help. I recommend you see someone certified in wound care. You can find someone at www.aawm.org and www.wocn.org.

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

***

You are asking a lot of complicated questions, but let me see if I can provide some insight. My first question would be does he have an infection of the bone and has a bone biopsy, sed rate and C reactive protein been done or even an MRI? If your husband is sitting on the wound throughout the day, no matter what you use the wound will not close. Does he have a pressure cushion and pressure redistribution mattress? and even if he does he should not sit up for more than an hour a day (maximum)-easier to say than actually follow. As for the wound, has it been cultured, is there a bioburden which may require the VAC silver foam? I think Regranex is terrific and a great adjunct to all therapies, but it seems the etiology or casue of the pressure ulcer and lack of progression should be addressed first.

Lisa PT, CWs

***

Hi I'm a Tissue Viability Specialist in South Africa.

Your husband's problem will continue for as long as he lives. He has scar tissue in the area of the pressure sore which is poorly vascularized. Over time the blood supply to the scar tissue decreases and the slightest amount of pressure with cause the pressure sore to reoccur. I suggest to get him to a good reconstructive surgeon for a "Rotation Flap". In this procedure, they cut the scar tissue out around the pressure sore and rotate the gluteus muscle over the pressure sore to close the cavity. This provides good soft tissue cover with good blod supply to the area.

Healin pressure ulcers with dressings (called secondary intention) should never be attempted when dealing with insensate patients since they will re occur. Surgery is the only long term solution for a long term problem.

***

I am charge nurse in a nursing home and we have these types of pressures sores every so often. What we use is 1/4" nugauze dipped in normal saline.
Place it into the wound using the stick end of a long qtip. Pack it lightly.
Then we cover it with allevyn foam or any foam type dressing. You could probably even use 4x4's. and then we use mefix tape which really sticks to the bottom if you make sure the area is really dry. We sometimes have a problem getting tape to stick if the person is incontinent. You could probably use paper tape if your resources are the drug store. If his skin is real moist in that area, using some type of skin prep first and letting it dry before putting the tape on helps alot. Don't pack the wound tightly.
Just a tiny bit of nugauze goes into the wound. Nugauze is a type of sterile strip. It comes in a plastic jar. Change the dressing every day. We have a lot of success with this dressing. I have never used a wound vac on this type of sore. You want to keep the wound moist to promote healing. But not too moist. Try to keep the pressure off as much as possible. Can he stay in bed a little longer every day just for a while so he can be positioned off of it? Hope this helps.

Karen Tucker RN

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Sounds like you have a difficult wound to heal. From the information gleaned from your post, I think the two major reasons the wound is having trouble healing is deinnervation due to the paralysis and pressure/shear from location, Im thinking sacral or ischial tuberosity area. Regranex is a good product if used on the correct wounds, but if the wound is not missing the ingredient Regranex replaces it will not be effective. I think the VAC should heal the wound with correct management of pressure relief which is probably your biggest obstacle. 125mmhg should be sufficient pressure, not sure if your using KCI, Blue Sky or what brand, Im familiar with KCI's VAC and have always had great results with 125. Remove the cause of the wound and it should heal if not infected, which would be pressure relief. I understand the dilemma with this situation but would need more information to further instruct as to how I would address the pressure. Shear could be a big factor and occurs a lot while actually in bed with the head of the bed raised 45 degrees or more, especially if the wound is sacral, if it is more ischial probably re-injuring with sitting, wheel chair push ups, often, if possible depending on the SCI level, etc.

Bryan K Luster, PTA, CWS

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Please read the story under the Nutrition section on this website. This could be your problem.

Yvonne Asay LPN

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Hi there,
why did this occur in the first place? sounds like the
problem is the weight. could be skin shear as a contributing factor. depends on how he is assisted to transfer. got to shift the weight, spread the weight, relieve the pressure, frequent turning, side lying, cushioning, hard work, time consuming, must be carried on way past apparent healing to allow full thickness regrowth and need to change the arrangement to position so it will not come back
good luck
Brian NZ

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hi.
I am a wound ostomy care student nurse. I have been working with wounds for 5 years now and I am very familiar with this kind of wounds you are describing.
I assume you are using good pressure relief devices for your husband. There could be one or two problems: The wound edge or VAC resistant wound. If the wound edge is all curled up. The wound healing process will stop. The wound acts as if it is healed and will not respond to any other intervention. If this is the case, a wound care doctor will have to scrape off the wound edge with a scalpel and recreate an acute wound to restart the wound healing process. If this is not the case then, sometimes holding the VAC for a few days and using other types of dressing like a moist aquacel will help with the healing.
good luck. let me know of the outcome.

Margo, RN, BSN
 

sorry, no replies