Priscilla

Jen

Rachael

Pam

Yvonne

Note: I've asked Yvonne to author an article on her experiences with nutrition.

Dr. Allan Freedline

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Moist wound healing is definitely the way to go. A couple other things to consider. With the longevity and the depth, has osteomyelitis (a bone infection) been ruled out? It would be likely after this time. Secondly, if you've had you cushion for a while, it may be time to change it. See a vendor who can pressure map you. No one cushion is best for everyone. You may wantto consider the Isch-Dish by Span-America. It has a cutout around the sacrum/coccyx and ischial tuberosities, the main pressure locations in sitting.

Renee C., MSPT, MPH, CWS

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I think it would be wise for you to investigate the V.A.C. Dressing. It is a Vaccuum Assisted Closure. As long as the wound is 75% free from Necrosis, no Cancer, no Osteomyelitis you can use this technique. I am not to sure if it is covered by all insurance companies but it will decrease the length of time it takes to close the wound.
Keith

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See Tim. T's reply to Diane B. below. He sent you the same message.

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You might get your wound assessed for a VAC treatment. If appropriate, it can help with granulating the wound to closure. It works by pressure like a vacume seal and the best part is the dressing changes are only every other day and it is very comfortable to use. Long term you need a seating assessment by a qualified OT. There are things even beyond a rojo now, though that is pretty good. You can get seating mapping dowm with a computer now that can help identify the pressure and show you how to relieve it.
Wendy M. Nurse Clinician

Cathy LSW

unsigned

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Favor

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Sounds as though an infection not responding to
antibiotics may be responsible. Is the Wound vac
helping? Is it possible there is a fistula involved?
They can sometimes be hidden in abdominal wounds which may explain the high amounts of drainage. If you are using a vac, check to see if a higher pressure setting may be appropriate to move the fluid away faster.

Icarus

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It sounds like your patient has had her body compromised by all the antibiotics and now can't deal with the stress of the infections. I had a patient that had osteomylitis last summer as a result of 4 years of dealing with surgery and repeated infections in a pressure sore. We tried everything and finally turned the corner with nutrition and a product called Optiflora from Shaklee. He had to have IV meds for 7 1/2 weeks before the last surgery and this time we did great with vitamins and protein drink before during and after the surgery.

unsigned

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We see a lot of abdominal wounds in our clinic (C-sections, hysterectomies,
etc.). We've had great success with pulsed lavage. It cleans out the wound
thoroughly, even the cavities, and the mechanical forces stimulate tissue
growth. It can help rinse out bacteria to reduce infection risk. Try not
changing the bandage so often. Find something that can stay for 1-2 days, like
Aquacel, or Iodosorb (we use a lot of that too). That lets the body's healing
agents (WBCs, fibroblasts, growth factors, etc.) stick around long enough to
do their job.

Renee C., MSPT, MPH, CWS

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Favor:
If you are still using the VAC see if the MD will try silver underneath the infection (i.e., Acticoat) using a single this layer of the silver under the VAC sponge. I've seen this work really well.
Good luck.

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Blueskymedical.com provides suction therapy as well.

Karen C. RN

Mohamed

Pam

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Mohamed, this is very challenging to treat. Please try contacting Dr. Gary Sibbald at the University of Toronto, Canada, Dermatology.
Wendy M. Nurse Clinician

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If the heel does not have a wound and you are using the EZ boot for prevention, then no you should not be wrapping it w/ anything. The idea of the boot is to alleviate pressure by having the heel "floating" or suspended in the air. Perhaps by excessivley wrapping it, the kerlix is pushing on the boot thus causing pressure. However, if it is a red area, you may want to cover it w/ a tegaderm type clear film so that you can see the progress of the skin and have your protective barrier.
Now, a wound is either a stage II or III, it can't be an "in between". Remember your definitions and appropriately stage your wound. Why are you packing w/ ca alginate? Is the wound excessively draining? Calcium alginate's purpose is for a heavily draining wound, it does not have any "healing" factors. If the wound is not heavily draining, then switch to moist (with saline) packing guaze.
Other tx's to try: get your P.T. dept involved, they could do electrical stimulation to help bring the wound to closure.
Evelyn C. MPT, CWS

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Hi! Diane i am a wound care nurse in long term care at present and i also work for a Wound care/ vascular surgeon. I'm not sure how deep your tunneling is on your wounds but it seems as if your wounds are healing from the outside in when they should heal from inside out which is probably why your wound re-opened . However the calcium alginate should work for the
tunneling with light packing if the wound is deep. If you pack to tight this will prevent wound contraction. If your tunneling is not that deep try Iodosorb gel its very good in healing wounds with a small amount of depth (
1cm and under). Also, i have to agree with the nurse who uses bulky protective dressings with the boots. I am a stickler for this.

Good Luck! Elaina

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Xenaderm on a stage II or III that is tunneling is not appropriate tx. If you are using the Ca alginate that is ok. But do not put the Xenaderm on the wound bed. Is the wound draining enough for alginate? That is the other question I have. I would suggest making sure you are offloading the areas of pressure, assess for drainage amount to select your dressing, and make sure the pt. nutrition is ok. Arginaid is a good supplement for wounds but is expensive. There are a lot of other drinks and foods you can bulk up his diet with. Wrapping the heels is not necessary. If they are red you need to offload. Xenaderm has been effective to the heels. Good luck C. Adams LPN, WCC

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Hi Diane.

In regard to EZ boots, remember that this type of protective device does not relieve pressure, they reduce it. There is a big difference. As for the nurse loading up the heels with Kerlex, this is not necessary and could cause shearing depending on how tight the wrap is and how mobile the resident may be. Pressure is measured in mm/hg. EZ boots do not prevent pressure ulcers.
Although, interventions are individualized, I find the best intervention is to float heels off bed surface with bed pillows or a venous pillow.

Arginaid is a wonderful source of protein, if you have the budget for it. It is expensive here in Florida.

As far as the wounds you described, what is this resident's dx? Are there underlying factors to hinder healing? I have always been taught, you must loosely pack "dead space" for healing to take place. Have you tried this? Is complete pressure relief consisent at the wound sites?

Just my thoughts

dawn P
Certified Wound Specialist

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You should never wrap the heels with anything when using EZ boots. That defeats the purpose of the EZ boots. EZ boots are a wonderful product to prevent heel ulcers when used properly.

Gerry M.

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Diane,

1). Make certain your patient has an ample supply of protein onboard for healing. Has there been an albumin drawn lately? Also, if the protein (albumin) level drops below a certain low level, the oncotic pressure changes, allowing the fluid to escape from the cells causing edema, which will further hinder healing.

2). Your heel protectors, I do not know them by that name. We use L-nard splints, which cradles the entire heel, and a single pair of socks will help protect the heel, plus keep the foot of the elderly resident warm. Remember, even if moon boots or something like it is used, it is still important to lift those heels off the surface of whatever it is the patient is laying on (mattress, gerichair, etc.). Per square inch, the pressure is the same for a padded heel resting on the mattress as it is for a naked heel resting on the mattress. Put a pillow under the ankles and allow the heels to hang loosely over the edge.

3). Remember to turn and reposition every 2 hours or less. This is most important! Keep those areas free from further breakdown by keeping the pressure off as much as possible. Keep the resident dry, and the skin clean. Wipes that are furnished with depends (or other diaper type products) are not sufficient for cleaning the skin after an incontinent BM. Soap and water is STILL the best cleaning products to use. Rinse and dry well. It sounds as if you are losing ground, so I would consult a wound care expert to aid with the tunneling problem.

Karla, RN, MSN, FNP

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Diane B. LPN
The ulcer that you feel is getting away from you could have multiple problems. I just came thru a carotid wound and when it looked like I was loosing I quit packing it and just kept it open with a q-tip and flush with saline approximately every 8 hours. Two weeks later I removed 4 4X4 bandages that were left in by the hospital. The wound has to drain and it has to be infection free to heal. Please have a culture done before you set your plan of attack.
Good luck it took me 11 months,
Mike P.
Caregiver-EMT

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Hey Diane, I'm sure your pt. is on some kind of pressure relief mattress to help the wounds, that would be the first issue to address. With tunneling and sinuses, it can sometime mean an infection. If your pt's wounds were so close to healing, then 'broke out' again, it could be a sign of osteo., even in the sacral area you can develop osteo. Hopefully your pt is taking Vit. C. and zinc supplements along with the protein supplement. As far as the heels, I don't see wrapping them up with kerlex would help. The E-Z boots do a pretty good job by themself!
I also used xerderm on a pt with a stage III, but didn't have much luck. I'm now using just a plain wet to dry using SNS and getting good results. Good Luck!
Donna

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Diane wrapping the could cause more pressure. The coccyx wound you might have packed too tight. This will cause the wound edges to close before the tunnel fills in. I like xenederm. We use it on stage 1 & 2's . I would not put it in wound bed before packing. Have you tried the wound vac. They work great on tunnels. We use argiment and vitament. You mix with 8oz water bid.

Delores R. lpn

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Hi Diane,
With regard to your question about resident who has 2
stage 2-3 ulcers - you don't mention what you are
doing to reduce pressure. Consider whether resident's
position in chair and or bed is aggravating healing
and re-opening wound. Also consider whether resident
is also eating well in general or not which would
require dietary consult for help.

Nancy

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 Dear Diane,
I read you quetion with interest and hope I can give some help. I'm not aware of the specific product (EZ boot) you refer to but would suggest that wrapping the area could be detromental to the site by increasing relative skin humidity, trap moisture against the skin and cause epidermal cells to swell through reduced transpiration, leading to an increased risk of shearing forces and infection if skin becomes excoriated.
In the U.K. alginate dressings are mainly used for their haemostatic properties as cadaver studies have linked them to fibre shedding and prolonged inflammitory response, we tend to use hydrofibre dressings eg.
Aquacel. Does the dressing need to be changed daily? Unless there is a very high level of exudate the dressing will not gel in that length of time. If exudate is low try leaving the dressing intact longer a if nessessary
irrigate the wound with warmed saline or water to remove debris. Silastic foam could be benificial as could V.A.C. therapy. A patient here would probably be on an alternating or low airloss mattress to aid healing and a
seat cushion if up to sit.Hope this of some use and that you carry on the good work.
Stuart RGN BSc.

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DEAR DIANE

I'M 40, BEEN HURT 21 YEARS. C-5 QUAD. SITTING ON A ROHO. I HAD THE EXACT SAME WOUND APPEAR AFTER A SPIDER BITE KILLED THE TISSUE. MY WOUND MAY HAVE CLOSED- IN A LITTLE MORE THAN YOURS BUT STILL WENT TO THE SACRAL BONE. AFTER 2 YEARS OF PACKING THE WOUND. THE WOUND SHAFT HAD EPITHELIALIZED. THIS MEANS THE WALLS OF THE WOUND HAD TOUGHENED UP JUST LIKE A EAR RING HOLE DOES. THEREFORE, THE WOUND WOULD NEVER GROW TOGETHER.

MY SOLUTION CAME FROM A SURGEON, WHO IS A D.O. SHE CLEANED OUT THE WOUND, REMOVING THE EPITHELIALIZED TISSUE ALL THE WAY TO THE BONE. THEN SHE SUTURED IT SHUT FROM THE INSIDE OUT AND SENT ME HOME WITH A "WOUND VACUUM" ON THE WOUND. (VACUUM-CONTROLLED ASSISTED CLOSURE) I STAYED IN BED ABOUT A WEEK, THEN WAS ABLE TO GET IN MY CHAIR USING THE PORTABLE VAC THAT HANGS ON THE CHAIR. IT PROBABLY TOOK 6 MONTHS TO CLOSE BUT I HAVE NOT HAD ANY SACRAL TROUBLES SINCE. HOPE THIS GIVE YOU SOME HOPE.

GOOD LUCK, TIM T.
PENSACOLA, FL
 

Thanks, Arlene

While it is absolutely impossible for anyone to give you any sound advise without evaluating you properly, there is a condition called NLD which does sound very similar to the problems you are describing on your shin. I'll list a few web resources for you:

Article 1

Article 2 (with pictures)

Dr. Allan Freedline

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I have a similar condition on my knee caps. I am type II diabetic. I had a biopsy done by a dermatologist. Said they were benign and probably caused by neuropathy balling up the collagen under the skin and the irritation of my paints rubbing my knee caps.The following does not work for me: steroid cream. topical antibiotic cream, antibiotic shots. I am trying to treat this problem as scar tissue by applying a chemical that tends to smooth out collagen bumps. There are over the counter scar reduction creams. They all seem to contain as the active ingredient a chemical extracted from onions. I am using onion pulp. Either way they say it takes about 12 weeks to notice a change. I am on my first week.

Warren

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arlene, you need more than your GP can give you. You should see a dermatologist, you need to have a full lower limb assessment, neuropathy, vascular status.

Wendy Nurse Clinician

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Hello Arlene, My name is Muna Swairjo I'm a physical therapist, I've been treating patients with diabetic wounds and none healing wounds resulting from other medical conditions. My approach includes Low Level Laser Therapy. this modality is a non invasive techniques, no medications involved or any sensory irritation and no heat associated. Low Level Laser therapy boosts the tissue immune system, and increases the cellular protein synthesis which is the building block for a healthy tissue. I don't know where you are residing. to assist you locating a provider.

Muna

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Hello,

Its hard for me to tell just by a description, but it sounds like your problem may be vascular insufficiency. In other words, "poor circulation" if you're not used to medical terms!! Specifically, I'm suspicious of your veins being the culprit. If the discoloration is a brownish-reddish-purple, that can be hemosiderin staining, and is associated with the venous insufficiency. Also, if you have problems with too much fluid in your legs, or cardiac circulatory problems, it can make the problem worse. Ask an MD about this, and if that's what the diagnosis is, you need to ask about support hose and keep your feet up with sitting.

Good luck
Vicki F.  MS PT, CWS

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Hi Arlene !
I'm not a medical professional, just a co-patient who would like to use my bad experiece to help you and assist you in avoiding a repeat. Cortisone was used on my ankle 20 years ago to treat arthritis. A scar at the joint exploded in an allergic like reaction and I was told by other doctors that cortisone cannot be used on diabetics (Type I anyhow) as it encourages infection by lowering the resistance. Please get another doctor's opinion anyhow and talk about alternatives to the cortisone. I strongly recommend not proceeding with the doctor until you are provided with a diagnosis and medical treatment plan. Good Luck !
PS I'm doing ok, but was just hospitalized for 3 weeks for a complication of that wound caused by the cortisone 20 years later !
Janet

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Hi! Arlene. Try Zinc Oxide ointment for this im pretty sure this will work. I have a great success rate in using this for patients with lesions of various sorts on the legs especially with erythema surrounding the lesions.

Good Luck, Elaina

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I have a Home Health patient that I had trouble with the disc coming off of the dressing. I now make sure that the hole is about the size of a nickel in the sponge and drape, then apply the disc trac, I then cover the whole disc trac system with another drape and secure down the tubing. I then cover the disc with 4x 4 gauze and medipore tape. Her wound is on the abdomen and she has to have the tubing secured to her leg also, so it does not put tension on the disc. I use the gauze and medipore tape because my patient has twiddler syndrome, you know pulls and messes with the dressing constantly. This has stopped the disc coming off and the machine from beeping every weekend and night. My KCI nurse gave me this suggestion and it worked for us.
Deborah RN

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Have you tried placing the suction disc in a location just adjacent to the wound? The skin surface may be flatter and less likely to be disrupted once the patient changes position or ambulates. As long as the underlying intact
skin is well protected with VAC drape (the clear plastic dressing), then you can use a small bit of sponge to bridge from the sponge the suction disc sits on over to the wound bed sponge. It should suck down fine as long as all pieces of sponge contact sponge. Another trick is to use an extra liquid skin sealant wipe (what you are
supposed to use to prep the surrounding intact skin before applying the VAC dressing)and run this wipe around the edges and seams of your finished dressing plastic prior to turning on the VAC. Sometimes this can be enough
to seal up the little nooks and crannys that typically occur and often account for some leaks.
I'm not sure from your question how long that this has been going on for, but I would make sure that you try a dressing pack from a different lot
number to ensure that there is not a problem with the batch. Have you tried another type of VAC unit? If you are using the ATS, would you
be able to access a "classic" VAC that has the tube suction tip instead of the suction disc? Maybe that would be more sucessful for you.
Hang in there. The VAC can be a very useful tool in dealing with these wounds.
Best of luck.
Allison RN,ET.

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You will need to cut a strip of the black foam and connect this piece to the black foam in the wound. Be sure you have drape underneath the black foam you are bridging. then you can put the tack disc and apply it to the bridged piece above the wound so it will be in an area that will not have any tension on the tubing. We also have used Mastisol for better adherance to the skin. Hope it works

Laura RN

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I am a Wound Care Specialist from Israel and I have a very good experience in wound healing with Terraquant - it is magneto-infrareded-laser device.
Cathy

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Will, the optimal unit for wound healing is the DynaLator 811 by DynaWave. $5,200.00
Yes, I sell them and have for over 15 years (25 years in the the physical therapy business)-- but read on: the ultrasound is best used for diabetic wounds as it breaks up the occlusions blocking the vascular system. For open wounds the DynaWave stim is best $4,000.00. The DynaLator 811 has both ultrasound and stim. We have true double-blind studies showing healing in all cases in nine weeks done at Milwaukee V.A. Do a Med-Line search for Prof. Luther Kloth, or Jeff Feeder as authors..
I have worked on several paraplegics with 9 inch wounds on the low back deep enough to see the spine. Have seen them all heal in 8-9 weeks. True tissue growth from bottom up to skin. Simple protocols that do not require undressing the wounds. 45 min/day, 3x's /week. Have list of satisfied users. Many hospitals and long term care users, too.
Hope this helps
Barry Ziebell