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There are a number of texts available to provide resource material on cleaning wounds, from Mosby or Springhouse. A Wound Ostomy Continence Nurse Consultant maybe able to direct you also. If there are no wocn's in your area, you can look on the wocn website for referrals, i.e. www.wocn.org. or the National Pressure Ulcer Advisory for additional information.

PC, MSN, RN, CWOCN

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I am a firm believer in polymem foam dressings if the wound isn't draining all that much, it can be left in place until 70% saturated or 5 days. They make a polymem silver which I use initially to decrease the bioburden. It also provides some padding since it is a foam. I don't generally use any debridement ointments unless it is a yellow sloughy wound, and even then I have better outcomes with polymem. Hot tubs or any "soaking" of an open wound just causes capillary edema and messes things up.
I have used polymem with pink zinc tape over it, and it remained waterproof. Hot tubs are petri dishes of bacteria unless properly maintained. No way if I was a diabetic with a wound would I go in one. Huge risk of infection.+
unsigned

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I am a Physical Therapist and have seen some amazing healing results with cold laser therapy. The research with laser on wounds is very good. they have been using in the UK for more than 20 years. Just approved here in the US last couple of years. I treated and gentleman just recently with infected dog bite. Foot was swollen, site was red and inflammed and toes had blue tinge from swelling. 1 treatment to lymph nodes and wound site. 24 hrs I couldn't believe my eyes. The swelling was gone, the foot was a normal color with mild redness over wound area. 24hrs!! amazing. If all else fails with convential approach wound care treatment we must reach outside the box. There is something for everyone.

unsigned

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I dont know what Carasyn contains, but if it is a desloughing agent, it is a waste to apply it once there is no more necrotic tissue in the ulcer base.
Your second question suggests that the ulcer is not being washed during the bath. Today the trend is to wash wounds well with a mild bath soap and tap water as many times in a day as necessary (depending on soakage / external soiling / odour) and then dressing it appropriately. Also in this particular case, 'neupopathic ulcer', the surrounding skin may be dry and would benefit with application of vaseline or some other moisturizer applied soon after the bath.
If you are concerned about contaminating the bath tub, 'Opsite' could be applied but recurrent peeling off of the adherent opsite could harm the skin.
Kumkum
 

An E&M code is the only one you can bill for changing a dressing. Lisa PT, CWS

Debora

Yes! This is a common problem. The low airloss mattresses are a bit like and air hockey table. There is a small amount of air that comes out f the mattress. This is great to keep skin dry, This decreases moisture and friction. if needed a cotton draw sheet works, don't put plastic backed bed pads/ chucks. You are decreasing the effectiveness of the mattress.
Michelle, PT, CWS

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Each bed has its own specifications when it comes to the use of incontinence pads. The air mattresses usually require special pads that allow air to flow through them.

Darla RN, BSN
 

You would call these blisters partial thickness wounds. You only use staging for pressure ulcers due to shear and friction. Hope that helps. Lisa PT, CWS

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HI,, No you dont count diaper blisters as stage 2 they are not a pressure ulcer. it is diaper rash plain and simple. the ONLY thing you stage is pressure ulcers. katy L RN WCC

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It depends, if a brief causes a fluid filled blister over a bony prominence, it is absolutely a stage II. I don't like it either, but the brief possibly caused friction or was too tight and caused pressure which then lead to stage II. I also consider where the blister is, is it on the abdomen (not on a bony prominence), if it isn't over a pressure point, I do not count it as pressure. The clinician must be the judge, but NEVER cover up a stage II. Don't forget, if you are certain that the blister is from the brief, the brief must be resized, or staff inserviced. I've experienced residents with weight gain where it wasn't the brief that was the problem, but the pants were too tight. So, the stage II must be investigated.
Yolanda, RN, WCC

Yates

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Yates,
If you have a stage IV over your ankle, first and foremost make sure pressure has been removed at all times and that no pressure is causing this to remain open. Immunosuppresives will cause your wound to heal very slowly, so that is expected. If the infection MRSA and osteomyelitis is all removed, but the wound still probes to bone, consider using the VAC again to continue to get granultion tissue. KCI has a silver foam you can get too if the facility writes a letter of medical necessity noting infection is present. When the wound is almost at skin level, consider another Apligraf or skin substitute or Regranex (platelet growth factor gel with a collagen such as PRISMA). Best of luck. Lisa PT, CWS

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have you tried hyperbarics?

rosalind hinton

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Hi My name is Pam Mitchell and I am on the board of directors for the BTERFoundation.org. I am not a health care professional but am a former patient of maggot therapy. I too had been on immunosuppressants for twenty years(kidney transplant) and a diabetic 45 years. I had an ulcer down to bone on heel with osteomyelitis. My doctors wanted to amputate after trying two years of all conventional treatments. Maggots worked quickly and much cheaper than anything man can come upon with. They are FDA approved. They eat only dead infected tissue, excrete enzymes to promote healing and kill all the bacteria. They also cleared up the osteo. Please do the research and become you own patient advocate and save your limb. Feel free to contact the foundation or myself through our web site.

Good luck,
Pam Mitchell
 

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You can not heal a wound that has untreated osteomylitis. Therefore, unless the bone infection is addresses your goal is inappropriate. Your goal, considering the choice that was made by the person holding power of attorney, should be to manage the drainage, control pain, prevent further skin breakdown and/ or sepsis, and decrease cost of expensive dressings. It is very important to set appropriate goals for patients in light of whole medical situations ( ie: severe PAD with DM may have that same gaols as above or a cancerous lesion, or a terminal patient who is more concerned with comfort and odor then healing.) That being said, please pout away the expensive high tech dressings and consider matinence dressings. This is were a wound cleaner like daikins or hydrogen peroxide are good to use. Normally they prevent healing as they are cytotoxic but in this case, that does not matter because we already know it will not heal, we just want to prevent cellulitis and sepsis. Then you can use a gauze dressing which again is cost effective way to manage the drainage.

Now, there are non surgical ways of addressing the osteomylitis that may be considered (like aggressive iv antibiotic therapy or maggot therapy) If this is done then the goal to support wound healing would be appropriate to consider. If you can support your treatment with an appropriate goal and be able to explain it comfortable you will have nothing to fear on inspection.

Good luck, We all feel the pressure of scrutiny in the current skin care climate!
Michelle PT, CWS

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The bright green is probably our friend "pseudamonas" You need to use a silver product - silvasorb gel, aquacel ag, polywic silver etc.
Patricia RN BSN WCC

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Kim,

It has been my experience with wounds that bright lime green usually will be Pseudomonas. The best thing that works with this would be acetic acid solution and a physician needs to order this. This type of dressing can be interchanged with other NS dressings if the wound is packable.

Darla RN, BSN

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Kim,
You have a tough wound on your hands. It sounds from what you said that the hip really has to be removed or even opened and drained-if you chose to be agressive. At this point the green drainage is probably pseudomonas, but you will also know when you get your culture back. I don't think anything is going to heal your wound short of surgery and likely offloading (probably due to pressure). Without having any more information, I would pack something lightly into the tunnel, probably a silver or iodoform dressings, you don't want to pour something into a septic joint. Keep monitoring this persons white count and pre-albumin. Good luck Lisa PT, CWS

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Hi Kim my answer is pretty much the same for Yates. Maggot therapy can work for this type of wound. They can get in where a scalpel or surgeon cannot. They can work on the osteomyelitis as they did with my wound. They are FDA approved. They can get way in but will NOT stay or get lost. They are ONLY interested in the infection and nothing else. They then will come right out after doing their job. Please do the research on learn how well they work and what they can do. They are also cost effective and covered by insurance, Medicare/Medicaid.

Good luck,
Pam Mitchell

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Be Aggressive, protect the resident from septicemia. Cover yourself and the facility you are working for. Is the wound clinically infected (induration,fever,edema, erythema, odor, increased drainage, purulent drainage, pain)at least four of these would indicate infection. Speak to the family and primary doctor and find out what they expect. My expectation would be (seeing your patient has improved and no longer hospice) that the surgeon who performed the surgery follow-up. Don't forget to document everything. In the mean time, irrigate the wound well with a wound cleanser and use a silver ionic dressing that is effective against multiple organisms (VRE,MRSA, psuedomonas, Ecoli etc.)Remember what AHRQ says about betadine, and in the future consider the use of betadine prior to using it (unless your goal is to maintain dry arterial wounds).
Good-luck!
Yolanda, RN, WCC