Rees

Janice

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There are several reasons this ulcer could be difficult to heal. Without knowing more about his age and general condition, the thing I would most suspect is that he has an infection in the bone underlying the wound. If he can tolerate it and afford it, the bone should be biopsied and surgically debrided, then a long course of antibiotics. Alternatively, a long course of antibiotics, like 6 weeks and usually IV, can be effective.
Patti, RN, CWOCN

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That area is sometimes particulary hard to heal because there is very little tissue covering the bone. If this is the case it is a shearing effect not allowing the wound to heal. Be careful with positioning and transferring and try not to perform movements that will slide the skin over the malleolus. It also may have some arterial component to the wound and the compression would then be contra-indicated. I would recommend an ankle brachial index be performed to rule out arterial problems. Also it could possibly be osteomyelitis of the underlying bone, with this sometimes the wound will heal or almost heal and then reocccur. A bone biopsy would confirm this and if possitive the hyperbaric treatment and IV Vancomyacin is usually the
course of treatment.

Bryan , PTA, CWS
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Is this a dry wound or wet wound? Just wondering if Venous and Arterial studies have been done? If a wound is not getting adequate blood flow it will not heal. Has adequate off loading of the area been accomplished to relieve pressure. Another thing is to have a wound culture done, and MRI for osteo. If unable to undergo a MRI a 3 phase bone scan could be done, but is not as efficient for detecting Osteo as a MRI. Fibracol Plus, Promogran and even Prisma (if alittle Silver is needed) with a cover dressing could prove to be useful depending on the wound bed. Another option would be to see if this wound would be a canidate for Apligrap application.

Theresa RN, WCC

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Unna boots would not be beneficial to a paraplegic. It only compresses when you are ambulating. At rest there is no compression. Make sure you are offloading that area. At night is there pressure on the area? Have you ever been checked for osteo (bone infection)? Wounds will start to heel and then reopen. If there is osteo, then 6 weeks of antibiotic therapy should be tried to eliminate the osteo. Also, a TCOM should probably be checked to see if there is adequate oxygen to the area. If there is adequate oxygen, no osteo or other infection, you may want to try an oasis application. Good luck.

Diane--wound care nurse

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An una boot is only effective in ambulatory patients. I use polymem max silver or fibercol. Patricia

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Please be careful with compression therapy like the use of Unna boot. I think it is important to find out if there is an arterial problem in this case. You mentioned though that the patient is diabetic and if the diabetes is in its advance stage there is a tendency of blood vessel calcification resulting to decreased circulation in the area. Although paraplegia results to loss of muslce pump mechanism sometimes ishcemia to the limb causes intracellular edema. With decreased oxgyen supply the sodium pump mechanism of the cell is lost causing the cells to swell up. IF this is the case, applying compression therapy on the leg will not be a good intervention. I suggest consultation with a certified wound specialist in your area.

Saturn B Dagwase, PT, CWS, FACCWS

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I am a Director of Nursing and I really enjoy wound care. It seems like you have a stagnant wound. If the patient has a PVD or any circulatory problem it might be hard to heal the wound. But for a stagnant wound I have used "collagen" dressing. Collagen is the protein that gives strength to the skin and is ideal for wounds that are slow to heal or stalled. This dressing can be left for up to 7 days. It's worth trying.

Josephine RN,BSN,CDONA/LTC

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Any kind of pressure relief will be advantageous - both in and out of bed. I have not heard of that kind of boot. Also important to check for underlying arterial disease which will impede healing, and also if infection present.
Julie Miller
Podiatrist
Melbourne, Australia

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I used Hony as dily dressing for such ulcers ,with control of the blood sugar and infiction.
Best regardes
Dr.Ahmed M.Abdullatif
FRCS

Polaroid made grid film. But, they're getting out of the film business, so you won't be able to find it for long, if at all. Personally, I don't like grid film. I find that the lines obscure the image, hurting more than it helps. The benefit of the grid was to be able to grossly approximate the wound size if the camera was held at a fixed distance. A better way is to place a ruler next to the wound (paper and disposable, preferably), so the scale is in the wound and the image is clear.

Renee C., PT, PhD(c), MSPT, MPH, CWS

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Mary:

whenever you fiind this wonderful camera, please send the information to me RNFrankie@AOL.com.

We have a small "tag/label" that we place as close to the wound as possible, and that does help. But the camera you are lookiing for would be most excellent assistance for any wound care clinic/ nurse/ facility.

Looking forward to hearing from you

Frances J. Jessup, RN, BSN
 

I AM A HOME HEALTH NURSE IN ARKANSAS, I AM TRYING TO FIND OUT IF THERE ARE ANY CELLULOSE DRESSINGS BESDIES EPIMAX AND EX-CELL DRESSINGS.

Sherry

Yes, there is a cellulose silver alginate made by Reliamed. I have found it to be very effective for Moderate to Heavy Exudating Wounds. I own three wound clinics and we do use this product.

Wound Care Resources, Inc. carries this product. If your patient is a Medicare Part B beneficiary they can also bill Medicare for your patient at no charge.

Their phone number is 1-731-287-9797. I would suggest asking for Donna.

FYI - A couple of other products my clinics have used are Medihoney and Anasept. Anasept kills all Bioburden in 30 seconds, is used for minimal to moderate exudating wounds.

Hope this helps.

Susan G Davis
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Prisma and Dermagran work well.

Bryan Luster, PTA, CWS
 

Is the wound infected?? How much drainage? Is there any slough? You can use an alginate with silver that will decrease any bio-burden and decrease any infection. I also have used AMD moist with NS you must warm the NS slightly (this helps improve healing) the AMD will heal the wound completely all by itself if you don't want to use expensive products, if infected use silver cream inside and then pack loosley with AMD. I have one whole hospital that uses this exclusively. Hope this helps.Obviously I am not an MD only RN and you need orders, Take care, Patty my email is: AbusyRN2go@mac.com

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recently I had a similar resident whom had refused vac therapy as well. I had used Algicell AG roping (dermascience) covered with a duoderm with change schedule Monday, Thursday and prn. The wound had healed within 4 weeks.

Connie , RN, WCC, DAPWCA

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First of all, "drying up" a wound is not desirable, unless it's closed. Moist wounds heal better than dry ones. There are many, many factors to consider with wound healing, so a solid recommendation can not be made without further assessment. I would make sure she is on a pressure-reducing surface in her chair and bed, that she's being turned often and kept off the wound, and is well nourished. Also, make sure you're limiting or even avoiding friction and shear in bed and during transfers.

Find a wound specialist near you to consult. www.WOCN.org or www.AAWM.org

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

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If you've tried many different wound care then either there's an infection (or osteomyelitis in that bony area) or the patient is not off-loading in that area. If the latter is the reason then nothing will heal it, not as long as the patient's on his back.

Amy Pastor RN, Director of Nusing/
Wound Consultant

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VAC would be a good treatment, but there may be some osteomyelitis of the underlying bone which will cause a tract from bone to surface and if this is so hyperbaric tx and IV Vancomyacin would be the next step. This can be diagnosed by a bone biopsy. Also, it could just be critically contaminated and using a good silver dressing will help. A lot of good beefy wounds stop healing due to this and usually resolve easily with silver dressings like Silverlon, Aquacel Ag, etc.

Bryan Luster, PTA, CWS

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I first would be sure that the patient is eating well - especially protein as this will help with healing. Also consider adding a multivitamin, vitamin c, and zinc as this may also help. As for dressings, I have had good luck with Aquacel Ag - will absorb any drainage and help keep bacteria at bay. Cover with Allevyn foam as this will help with drainage and also provide the nice warm wound environment that is needed for healing. I would try and change the wound every 3 - 5 days - changing a wound exposes it to cold air and it takes about 4 hours for the wound to warm up again, thus leaving the dressing on for a few days is a great idea. Hope this helps - there is no one way to trweat a wound, sometimes it is just trial and error.

C. Royce RN, BSN, CWCN, BC
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Have you done the "basics"? Mainly, does the patient avoid pressure on the area. An air mattress of some sort, side lying most of the time, avoid lying in bed with the head elevated, an excellent whelchair cushion. An air mattress covered with a thick layer of incontinence pads is no help. The incontinence pads negate the benefits of the pressure relief mattress.

If he/she is still putting pressure and shear on the area, no dressing will help. If you can relieve all pressure, just about any dressing will work, if the patient has adequate nutrition for healing and there is no underlying bone infection.

You say the patient has refused the VAC which makes me suspect he/she may not be compliant about other care, like pressure relief. I assume you have tried a number of dressings. If you are sure that pressure and shear are not the problem, underlying bone infection is ruled out or unlikely, and the wound has been around awhile, look into "biofilms". You might try a short (1-2 dressing changes) course of Dakins or Betadine dressings with scrubbing of the wound bed, then go back to more healing dressings, calcium alginates, silver dressings, etc. Be sure you only pack the wound loosely, tight packing just increases pressure.

Good luck,
Patti RN, WOCN

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Try a collagen called Promogran. Cover it with a bordered foam dressing.
Patsy McAuliffe LPN CWCA

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cut a small piece of polywic silver (smaller than wound) cover with polymem max, because it is a sponge it wound increase capillary pressure and cut off your blood supply to your wound - wound vac heals faster than wet-dry NS - but not nearly as fast as polymem products.

I don't even use wound vacs anymore they are
a pain for the patient and I found they don't heal as fast as other products

Patricia RN BSN WCC CDE
 

Hasna

sorry, no replies

Michele

I think VAC therapy is individualized when it comes to the effectiveness in any patient. I know what you mean about the VAC war I have the same issue.

Josephine Girandi RN,BSN,CDONA/LTC

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Hi Michelle
I am so glad you asked this question, it's more valid than you think! Blue sky is a great product!  As with any dressing, it is only effective if the wound and patient assessment have been done accurately and you are sure the wound is appropriate for NPWT. Secondly, all NPWT must be correctly applied at the right time with no leaks. All necrotic tissue should be sharp debrided and other principles (T.I.M.E.) should be adhered to for satisfactory results.

I am involved in the pre launch trials of Blue Sky (called Ezcare in SA) and I find it is easier to use for the practitioner and easier for the patient to manage because it's simpler. It costs about 60% less in SA than VAC does. I know different countries have different trading policies, in SA, the trading policy also favours the patient.

Try it for yourself.
Liz
Wound Healing Specialist ( cum laude with 20 Yrs experience)
South Africa

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VAC is also NPWT. Negative Pressure Wound Therapy is a generic term for this category of modality. There are now several brands, including KCI, Smith & Nephew, Medella, and some others. The main differences are that the VAC uses a foam for the wound filler, and the machine has lots of bells and whistles. The other devices use a gauze and drain filler, and generally don't have the bells & whistles, including safety alarms. There is more to the decision than just the cost. Which is easier to use? I've heard people say each type is easier than the other. Are safety alarms important to you? Do they work equally well? If one doesn't perform, it's not saving you any money, but wasting it. I have not seen any studies comparing the two styles head to head and showing any type of equivalency. (Only marketing materials claim equal efficacy.)

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

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Blue sky was recently purchased by Smith /Nephew! They are doing a great job in education concerning the product! Inservice free! Lynn karsky RNC

Lynn

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I have used both Vac for many years. KCI is agressively marketing, they do have more actual research regarding wound healing than Blue Sky they are both very expensive. The only prob I have seen with Blue sky is the dressing does not work well with obese patients or multiple wounds. But I HAVE seen them work well. I use KCI more I guess because I am very comfortable with their vac, but I think we as nurses should be able to use which ever one WE think is more approp for that particular wound. Patty

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You will be seeing even more brands of NPWT. I saw a couple of new ones at a trade show.Your blue sky reps need to be talking to the doctors in your area! I think only time will tell which devices work better and I suspect that each will find it's own niche! I have talked with nurses on both sides of the issue and the Blue Sky brand does seem to work ok.
Patti RN, WOCN

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Thankfully, we don't have these dramas in Australia - YET !!!
KCI has a monopoly with V.A.C. and everyone seems to love it. We are seeing some good results when used correctly and as indicated.
Julie Miller
Podiatrist
Melbourne Australia

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I've used both systems and we now only use the KCI product based on results. The explanation I was given for the positive results acheived from the KCI Wound VAC is so logical. Our rep, who is an RN provided this explanation and it really made sense to me, the first thing you see with KCI Wound VAC is the contraction of the wound. This starts the cellular reaction going. The granufoam transfers the negative pressure to the entire wound bed bottom, sides etc. and in doing so, it places stress on the individual cells in the wound. Stress and strain on cells leads to mitosis! Gauze cannot do this. In addition, gauze is meant to be absorptive while granufoam is actually designed to only hold as much moisture as is necessary to keep the wound bed moist. Unlike gauze, every opening in the granufoam has an exit. The gauze is more similar to a kitchen sponge!
The Doc's all recognize this which is why they're so adamant about using KCI.
Pat RN
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I'll solve your problems - don't use either. Nothing heals faster than Polywic caviety filler and polymem products. I have had numerous non-healing wounds from wound care centers that I healed in under 6 weeks.
The product was made by an engineer in Chicago and until he died 5 years ago- pretty much no one knew about the product . I brought it to Florida when I moved 11 years ago, and word spread - now it is being marketed. I have used this product for 15 years - I have tried every new product on the market. I keep going back to polymem. Patricia
 

Barbara:

Your husband should be seen by a certified wound specialist, WOCN , etc. this wound appears to need good packing in order to heal from the "bottom" up to the surface. A good wound care nurse would be able to assess the wound and suggest the proper wound care.

Best Wishes

please consider my suggestion.

Frances J. Jessup, RN, BSN

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I'm sorry that he's having to deal with this for so long. Laser is not approved for wound healing in the US because research does not show that it works. Both the US and the UK technology assessment agencies have made that conclusion. There are many things that need to be assessed in your husband. The wound might need to be opened more to allow it to fill in, not close over a cavity. I highly recommend you find a wound specialist in your area for a consult. This can be a very challenging type of wound to treat. www.WOCN.org and www.AAWM.org can help you find someone near you.
Renee C, PT, PhD(c), MSPT, MPH, CWS

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Since brother is a PT have him look into Electrical Stimulation and Ultrasound combination for wound healing.

Carrie Sussman has written many articles on this subject. I own three wound clinics and have a 90% healing rate. The best machine on the market for wound healing in my opinion is the Dynalator 811 which has both electrical stimulation and ultrasound. This machine maintains a uniform HVPC without spiking and is excellent to reduce pain.

Second most important thing is proper wound dressings. Have you tried a Hydrofera Blue with perhaps a EpiMax as a primary dressing or a Medihoney alginate. Wound Care Resources, Inc. is where my clinics get all their dressings. Their number is 731-287-9797. They also take most insurances which can help the patient. I would ask for Donna, she is excellent.

Hope this helps.

Susan D.

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I would rule out osteomyelitis of the underlying bone with a bone biopsy, if it is positive HBOT and IV Vancomyacin would be the course of action.

Bryan Luster, PTA, CWS
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It sounds to me like he has an underlying infection, probably in underlying bone. Regular "rounds" of antibiotics won't cure bone infections. It takes high doses of IV antibiotics and/or surgical debridement of the bone itself to cure. Because bone has very poor circulation, normal doses of antibiotics don't get to the site.
Patti RN, WOCN

I forgot to say, ask his doctor for a referral to a wound care center or an ET (CWOCN) nurse.
Patti
 

maytroftg@gondtc.com

sorry, no replies

I think you're asking if someone can go into a whirlpool (maybe a therapeutic pool?) with stitches/staples. That is a contraindication. Even with a transparent film dressing, there is the potential for leaking and contaminating the surgical site, which would be very bad. What is the whirlpool being used for? If the surgical site, there is no need. If for another wound, whirlpool is an outdated approach and greatly increases the infection risk to the wound.

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

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You need to check with your doc usually you do not want a patient in a whirlpool or spa or tub because of chance of infection esp when the sutures
are still intact. Patty

I've heard of using a dish of charcoal, vinegar, kitty litter, or cut onion in the room. But, I've also read recently that they aren't as effective as metronidazole. Crushing a tablet to sprinkle the powder over the wound can be effective as well. O/WM had an article on that recently. I've also used Dakins wet to moist dressings to reduce bioburden, and therefore odor.

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

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I have had good luck with washing the wound with vinegar then using dressings soaked with vinegar alternating when necessary or every 1-2 weeks with Dakin's solution used the same way. I have heard that maggots will clean the wound well and destroy the odor, if the patient is willing. You can get more information about using maggots at the BTER foundation. They have a website and contact information.
Patti RN, WOCN

Patti Worley RN, CWOCN

Sorry, I missed the "rural, indigenous" part. If you don't have Dakin's solution, you can make a similiar solution by adding a teaspoon of bleach to a gallon of clean water. But vinegar by itself works well.
Patti

Brea:

You need to get orders from your physician for wound care from a wound care nurse. would be nice if she is certified, but nevertheless, it sounds as if your wound will not heal as the orders stand now. You need different packing and there are many types that do not pull the new tissue as gauze would. PLEASE get orders for a wound care Home Health (if you stay home and don't work or for attendance at a wound clinic.

If this wound were mine, I would want this done immediately, if not sooner.

Sincerely,

Frances J. Jessup, RN, BSN

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Ask your doctor about using AMD gauze it is medicated we use it a lot in all
of our wounds, you can ask about a silver gel to apply to the gauze to get rid of any bacteria. But ask your doc, if he is not familiar with AMD gauze find a wound care specialist who WILL know about it. Just a thought, good
luck Patty
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There are many possible options for treatment. Wet to dry saline gauze is not the current preferred approach for the reasons you stated. Ask your doctor to refer you to a wound specialist in your area. www.WOCN.org and www.AAWM.org can help you find one.

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

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Absolutely! Gels would work in your wound. Ask your doctor if you could clean the wound with saline solution, apply "hydrogel" (ie: Intrasite, Solosite or other gel) into wound gently with qtips, then moisten gauze with saline and insert it into the wound, cover with a foam dressing (if you have a lot of drainage) or gauze, or ABD pad if you're not draining so much. Upon removal moisten the gauze that's inside the wound, wait a minute or so and it should slide right out. Hydrogels keep the wound moist and keeps the moisture in th egauze also, so it should not be so painful. I hope you get better!
Amy Pastor RN, Director of Nursing/
Wound Consultant
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Wound VAC would be my choice.

Bryan Luster, PTA, CWS

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A possible option for treatment would be a negative pressure therapy. We have had excellent results with Wound V.A.C. (Vacuum Assisted Closure) with healing wounds including complicated surgical wounds. The VAC has a sponge that is placed in the wound and sealed with an adherent layer (looks like clear contact) than attached with tubing to a piece of equipment that when turned on causes a suction to occur on the sponge aiding in the removal of wound secretions and stimulating growth of wound tissue. The VAC is not painful and requires dressing changes every other day to two times a week. Home health can be involved in dressing changes and families can be taught how to use the VAC. At our wound clinic patients are seen on weekly bases and the wound is debrided of necrotic or non viable tissue to promote healing. The machine is small in size (carried like a pocket book or fanny pack), battery operated (making it very portable) and patients are able to return to work or near normal lifestyle as tolerated.

Theresa, RN, WCC

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polywic silver into wound cover with DSD, then when fully granulated use polymax pink. change when 70% saturated. Trust me I can heal anything and have with these products

Patricia

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You could Calcium Alginate rope, there are several brands. They are more expensive than gauze and you will only find them at a medical or surgical supply store, or online. The tissue won't grow into them.
You could also temporarily change the dressing every day, then the tissue will not have grown into the mesh so much. Changing the dressing more frequently will slow down the healing some so, once the pain is lessened, you should go back to every other day.
Also, it may help to know that as the infection goes down, it will become much less painful.
Good luck,
Patti RN, WOCN

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I would talk with the surgeon about discontinuing the gauze with saline/iodine treatment. I see no good indication for the treatment as the wet to dry dressing removes healthy tissue and iodine is cytotoxic.

I recommend using "Hydrofera Blue" as wound packing. This material, which is wetted with sterile saline, can be easily packed into your wound and it is gentle, non-cytotoxic and bacteriostatic.

Ron Carson MHS, OT

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Brea,
Hydrogel silver impregnated gauze covered by a bordered foam. It will keep the wound moist, it will not stick and the silver helps keep infection down.
Patsy McAuliffe LPN CWCA