Try contacting the WOCN Society. www.wocn.org


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

I wish I had the answer to that, and would love to find out from you IF someone has the answer. I have wanted to become WOCN for a very long time, but the cost and the lack of any financial help has delayed any further venture for me.

Frances J. Jessup, RN, BSN

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As long as your STATE medicaid covers PT as a benefit - there should not be a problem obtaining authorization for PT weekly in the home. Medicare will pay for skilled visits as long as visits meet medicare criteria.

Russell Darrow, BS, RN, WCC

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Thom:

The transportation to the wound clinic is an essential trip. The wound(s) are assessed and any changes in the wound care are made at that time. The physician and the nurses at the wound clinic are all advanced wound care experienced. Very often, a WOCN is involved in this assessment.

Please do not discount this step as a financial hardship - as I mentioned, this is an essential step in the healing of the wound(s).

Frances J. Jessup, RN, BSN
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I have found that thin duoderm placed onto the excoriated area will gradually heal the irritated area and also give you a smoth base to apply the wafer or flange. Make sure the duoderm is secure prior to applying the wafer or bag. I gained this method from MD Anderson-Houston. It really works.
 

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First lay down a piece of duoderm to cover the irritated skin. Cut a hole for the opening of the ostomy. You can place the other piece over the duoderm so you won’t irritate the skin and it will heal by the use of the duoderm.

David & Kathy

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If the surgeon is not available, perhaps he has a partner or nurse who could take a look at the situation. Ideally it would be a certified ostomy nurse. To heal the skin around the stoma, cleanse with plain warm water and pat dry gently. 'Puff' a small amount of the karaya powder onto the skin and gently dab it in with your finger. Then apply the wafer and pouch. The karaya powder is meant to work with ostomies and ostomy appliances and should not interfere with adherence as long as you don't cake it on. I also suggest you contact the manufacturer of your wife's ostomy appliance and look at the United Ostomy Association of America's website www.uoaa.org. Good luck!
Meagan, RN, CWON

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the karaya powder wont hurt the stoma at all.
you want to cut the hole the size of the stoma to protect the surrounding skin. you can sprinkle a light dusting of karya powder on the irritated skin, brush away the excess, and spray 3-M Cavilon no sting skin prep over the powder, then appy your wafer on top.
An extra barrier ring , such as a Convatec eaken seal stretched around the stoma, can be placed over the powder, skin prep and then the wafer can be applied on top of the eaken seal
the eaken seal is good for the skin and helps prevent leaks

c. orzolek MSN, CNP, CWOCN

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Here are some helpful tips I have learned along the way providing ostomy care and suggestions from E.T. Nurse. Trust these will be helpful.

Cleanse stoma site as necessary. Allow to dry well.

There are products to protect skin around stoma. 3M is non-sting barrier that prevents the fluids from irritating the skin if fluids flow over this. Allow to dry.

Mycostatin powder with an order if warrants.

Stomadhesive powder.

There is adhesive paste that can be applied to the perimeter of cut wafer—apply like toothpaste-or new recent instructions; place a small dab of adhesive paste at 3 and 9 o’clock on the body outside of stoma.

Next cut Eakin Seal in half, warm in hand and roll like a snake and place on pouch perimeter. Allow to air for a couple of minutes.

Place pouch on a slant onto body and warm with hand for a few minutes as body heat helps keep a good seal.

Place the other Eakin ½ Seal wrapped in own packaging into a glove and tie for next change as these will dry out and are expensive.

Careful not to get glove powder and creams/moisturizers on these seals or around stoma as will break seal.

I find 4 days is a good length to not change a pouch but may be stretched to 5 days.

My clients have two squeeze bottles. One with a mouth-wash/water mixture for odor control and one with water and cooking/vegetable oil for rinsing stool out of pouch as everything slips out clean.

Movements are controlled nicely with Lactulose—with an order. Reduces strain with movement.

All the best.
Barbara

sorry, no replies

Wounds that are not able to be staged have to be coded as a IV on the MDS if you are in the skilled setting. The wound care is a skilled service. Medicare covers services which require the daily skilled services of therapy or a licensed nurse.

Susan M. Howard
Clinical Education Specialist

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By NPUAP guidelines, wounds with eschar cannot be staged.
Check out: http://users.erols.com/airsuprt/wo04000.html
and http://www.span-america.com/medicare_e0373.php
Use other tools such as "Braden scale score," "PUSH" to justify need for special mattress/surfaces. Request a letter from the patient's physician and address these scores
too when appealing to consider coverage.

Maria Carunungan, PT, DPT, GCS, CWS

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No it is never safe to assume. It would be classified unstageable.

lynn
RN
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A wound which is completely covered by slough or eschar is now listed under the new criteria as unstageable because it is impossible to determine how much tissue damage lies beneath the eschar.

Thank you,

Glenda Landskroner-Black MSN, ARNP, CPNP
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While it is likely the wound may be a stage III or IV once the eschar is removed, as long as the eschar is present you cannot stage it other that unstageable. I know this doesn't help in the reimbursement side, but if we stage pressure ulcers incorrectly, that affects future reimbursement changes. Sue, PT, CWS, FACCWS

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a wound that is over 20 percent is an unstable wound

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Jim:

One can not stage a wound covered with eschar. As the wound heals under the eschar, the eschar will shrink. Some want the eschar to be removed, so order Accuzyme to slowly remove it. This does work. I had a patient with both heels covered with eschar (one was larger than the other). The MD insisted that accuzyme be applied. One visit several weeks later, the eschar "fell off" revealing her calcaneous. This infuriated me because now the patient was upset with this besides fighting breast cancer ! I do not like the accuzyme route because of this experience. One can not know just how deep the pressure ulcer is until the eschar is gone therefore, staging a pressure ulcer covered by eschar is impossible.

Frances J. Jessup, RN, BSN

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It is impossible to make good recommendations without more information and an in-person assessment. It sounds like you have tried many advanced options. Is his nutrition adequate? If not, it will not heal. Since he is on hospice care, it might be possible that physiologically he does not have the internal resources to heal. It's good that he's on an air mattress. You may want to find a someone certified in wound care to see him. You can look at www.wocn.org and www.aawm.org


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

Has anyone suggested using KCI's wound VAC? I have seen great results using it. Hopefully, his mattress is a pressure relieving one and he is turned off of the wounds?

Frances J. Jessup, RN, BSN

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Dawn,

I feel for your father and your family. The type of ointment you put on will depend on what the wound looks like, what it is doing (if draining and how much or what is on the drainage). When wounds look infected, the wounds may be covered with antimicrobial agents and the patient might also be put on antibiotics. If the wounds need cleaned (as if they are covered with necrotic or dead tissue), debriding agents such as Accuzyme or Santyl, etc. might be used. There are other factors to consider in choosing a dressing that is most appropriate. Try looking up and including the help of a wound care specialist (someone certified). Check out the aawm.org website so you can see who is the specialist closest to you in your area.

Other items which need looked at which can influence wound healing include: nutrition, immobility, circulation, pain, other diseases (heart disease/lung disease/diabetes/ hypertension, cancer, etc.), medications, etc. There are labwork which can be done to check nutritional status and need for nutritional support. Pain can stress a patient can hormones released which delay healing. Bacterial load can also affect it, as well as fluid build-up, continued pressure, poor circulation due to poor mobility and other causes. Some medications like steroids can also affect the wound. When these other factors are not addressed, wounds will not heal despite the best dressing.

Good luck,
Maria Carunungan, PT, DPT, GCS, CWS

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Pressure ulcers are caused by pressure. It doesn't matter what product you use, because it is not the product that will promote healing. It is removal of the pressure. What is his albumin? Does he even have adequate protein stores for a foundation to be laid?

Lynn
Rn
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is this area with black necrotic tissue or open with red drainage.

If with black necrotic tissue you could attempt surgical debridement if with red draining how about a wound vac.

do you have a wound clinic in your area? if so pursue that

Lynette Flick, RN

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I use Hydrafara Blue Foam dressing on several of my wound patients with stage IV 's one that had a wound vac for several months prior to me treating his wounds with slow healing results. I found this Hydrafera Blue Foam and it is wonderful with great results. He's wound's are now stage l and two are stage ll . He's wounds are on bilateral buttocks and one the the coccyx , I really think you should talk to your Doctor and ask if he thinks it would work on these wounds. It really works and it is easy to use . soak in normal saline and squeeze out excess saline and apply to the wound bed cover with 4X4's and secure with a island dressing. You will need to cut to fit wound areas before soaking in saline. you change the dressing every one to three days depending on the amount of drainage you have. when you change the dressing you will see that the blue foam maybe white that is a good sign that it is working by pulling out the infection in the wound. I really like it and I've seen it work to many times It's wonderful. Contact your Doctor and request to give it a try. Write back and keep me posted on the results Good Luck!!!! Lawyana LPN LTC

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Hi Dawn I am not a health care provider but I am the patient advocate for maggot therapy. I am greatly concerned for your father. I feel you should never give up on anyone till it is over. I was surprised to see that you have tried maggots. Can I ask you a few questions. I am sure it was once and you have to do maggot therapy at least three or four times to know if it is working or not. The correct number of maggots for the area and correctly applied, also. I know that often none of these things are done correctly. You can find more info on our web site at BTERFoundation.org or please email me at Pamsmaggotinfo@aol.com and I would be glad to talk to you and offer suggestions or answer any questions you may have. Please feel free to contact me at anytime as this is my mission to help others. I too had severe stage lV ulcers down to bone with bone infections which the maggots took care of and healed up the bone infection and closed my ulcers. BUT they were done correctly. Good luck with your dad

Blessings
Pam

Nancy,

Have they tried debriding agents such as Santyl,
Accuzyme, Collagenase, etc. I am not particularly fond Dakin's solution. Most cleansers do clean the wound and reduce bacterial load, but they can also harm good healthy tissue (the pink and red tissue). So sometimes as you clean the wound with these cleansers, they kill good tissue which will continue the cycle. The use of debriders is helpful because they remove dead tissue. How they work is they break down protein in dead tissue so they eventually loosen from the base of the wound, and carried off from the wound as the dessing is changed. The wound will look worse as you will see gooey yellowish stuff, and sometimes even green drainage depending on the debrider you use. As the dead tissue is cleaned off, naturally the wound will even look larger and deeper. You need to get down to red tissue to proceed with healing. There are however other factors to look at as your nutritional status, medications you take which problems in these areas can also delay healing. I suggest asking your physician about consulting with a certified wound care specialist. Some specialists are called specialists because they deal with a lot of wounds, but are they board-certified? A CWS will look at the big picture also, like your physician and look at all other issues which may be contributing to how your wounds are. Good luck.

In addition, if any wound needs packed. It does
not need to be packed tightly as this will slow
healing. Again, I am not fond of Dakins solution-
may not be the best for the wound. If it is due to
infection, there are other dressing which can reduce bacterial load and not harm the wound or the patient sometimes is prescribed antiobiotics.
Maria Carunungan, PT, DPT, GCS, CWS

Kelly,

This is definitely way too long for a wound to heal. If there is no appreciable improvement in a wound in 2 weeks, the wound care technique is usually reviewed as it may not be the most appropriate. Other factors also need looked at as checking for infection, nutritional problems, use of medications which may affect healing such as steroids, etc. Consult a wound care
specialist in your area. Go to aawm.org.

Maria Carunungan, DPT, GCS, CWS