Mavis

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Thanks Jeff

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Concerned Daughter

Darlene

Thanks. Kelli

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Dr.  Richman (podiatric physician and surgeon / diabetic foot care specialist)

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Always find the causative factor and then alleviate that if possible What cause the wound in the first place Pt has arterial insuff so that tells me that the pt. is probably not getting sufficient blood supply so until they do a bypass you will have problems closing the wound 2+ edema needs to be address You do not want to use full compression because of arterial disease but you could use ace wrap before he gets out of bed in AM The increase pain on elevation is very common with pts that have arterial disease very hard to get blood circulation to the furthest distance from the heart giving pt pain on elevation of leg If the wound is dry HYDRATE if the wound has copious amts of drainage ABSORB and CONTAIN ie ALGINATE or MESALT Please read literature on the proper use To protect the surrounding skin use an ointment (Barrier) This will prevent the irritating drainage to lie on intact skin
Janet G. RN/ET CWCN/COCN
 

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Hi,
I would suggest using skin prep around the wound bed. This helps keep the drainage from macerating the surrounding skin by keeping a barrier on the skin. I usually use at least 2 preps, letting them dry before the next application. I use these often and they work great. Be careful not to get it on the wound bed, as it may sting. also exerderm helps. Good Luck!

Cyepye LPN, wound care consultant

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My name is Terri R.N.

Have you tried skin prep skin barriers to the
periwound skin? They are made by 3M and provide an invisible barrier. This will prevent sheering, maceration by the exudate, and provide protection from tape. The barrier will come off instead of the skin.

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I like to use Aquaphor (made by Eucerin) as a moisture barrier........really prevents maceration/ breakdown. It is also great to use on the patient's skin...........quite sold on it. Looks like vaseline------don't be fooled--------- it definitely isn't. Comes in a jar for about $12.00.

Frances Jessup, RN, BSN

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 We often have the same problem, you must make certain that the "drainage" is not from third spacing, or sipping from the skin, if so, what you can use an absorbent dressing, and change according to demand. If the drainage comes from the wound bed and it is from an infection, you must eliminate de infection ( you are trying that), but, meanwhile, you can protect the skin with a skin barrier cream, using it on the periphery of the wound to keep the exudate from irritating the healthy skin tissue. These techniques have worked well for us. There is a great risk of this infection becoming systemic. Arterial ulcers are difficult to heal; many will never heal, depending on the degree of arterial occlusion. The main goal is to keep the infections out. What are you doing right now? Was the degree of arterial occlusion determined? Do you have a vascular surgeon involved with the case? Do you have a nutritionist involved?

Ed L. ,RNC
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Have you tried sprinkling powdered comphrey on the wound? I find the root to be more potent than the leaf powder and have also found it to be highly antiseptic. Using this substance every other day, alternaing with cleansing and leaving the wound open for a day has helped me heal some otherwise difficult injuries.

S Willis
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hi, i am an lpta in home care and soon aim to be certified through wcei. The first product that came to mind was aquacel,the hydrofiber that can manage copius drainage but has the "blocking" feature so that the drainage cannot continue past a certain point and therfore it may help prevent maceration, if indeed maceration is your problem.

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Have you tried Xenaderm, it is a barrier as well as promotes healing.
Lee Ann, LPN
Wound Care Nurse

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You might try alginate on the wound; it will absorb lots of drainage. Also, there are different types of skin protectant that will help keep wound perimeters from macerating. Some are wipe-on and some are sprays. And, you may know this already, but don't use occlusive dressings on infected wounds; they should be used with caution on any arterial ulcer anyway, due to the decreased ability of the body to get bacteria-fighting cells to the area.

Vicki, MSPT,CWS

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Hi Nancy,
is your mom being seen by a doctor on a regular basis? Does she have home health coming to her house to manage this wound? Sounds like this toe is a dangerous problem. Dakins solution is "bleach" watered down. Its been around for a long time and a lot of docs still use it, but its cytotoxic and shouldn't be used anymore. There's just too many other wound cleansers and antibacterial cleansers on the market to help the infection and control odor. If she doesn't have a home health nurse, check with the doctor about ordering home health to do wound care, and they can teach you how to manage the wound also.
Iodosorb is a good product for infected wounds and also actisorb silver is excellent for wound healing. Ask the doctor about these products, which would be what you would put on the wound after using a cleaning solution like saline or wound cleanser, not Dakins! Hope this helps.......cyepye LPN Wound care consultant

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She needs a stronger antibiotic.

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You can try magnesium sulphate and hydrogen peroxide. The hydrogen peroxide you use to clean and mgso4 for dressing.

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Your mother's situation is very serious due to the fact that she has diabetes. For what you are describing, she is experiencing tissue death, she is at great risk for loosing her toe, and, if nothing is done soon, she can progress to having to undergo amputation. The tissue is dying for lack of blood supply. The ideal would be for her to be seen by a vascular surgeon, there are other alternatives for anesthesia. Meanwhile, you must keep the toe and her entire lower leg very clean. In Brazil we make a solution of neutral pH dish detergent, 4-5 liters of water at room temperature, one cap of a 2 liters Coke bottle full of bleach, and with this solution, we clean the infected wound very well (very well) by soaking the entire foot on this solution and using sterile gaze as a “brush” clean the toe very well using soft circular movements at first, and them at last, using a bit more pressure, but, taking the care to go from the top of the foot to her nail this direction will keep you from injuring the good tissue, but at the same time will remove some of the dead tissue. Do this 3 x/day to start then 2x/day for one to two weeks, after each cleaning, dry it well, then you can use sterile wet gazes over the wound, top it with dry gazes and secure it with a bandage. Do this for a while until you can remove all dead tissue. Keep the wound clean and well dressed, keep her foot and lower extremity warm, make certain that her capillary blood “sugar” is at the value it should be, get her to a family practitioner, or a diabetes nurse ASAP. Good luck Nancy.

Ed Leme-Brazil

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Nancy, If your Mom does not have sufficient blood flow to the foot to support healing, I would recommend NOT keeping the sore wet but to try to dry it up by painting it with 1/4 or 1/2 strength betadine and covering with a dry dressing two times a day. Until the sore dries, you may have to moisten the dressing with saline* to gently remove it. Dakins can be used judiciously to remove dead tissue from a wound but only if the goal is to clean the area up and promote blood flow, which in your Mom's case does not appear to be possible. Have you tried electrical stim by a Physical Therapist? I have had success with this treatment with some diabetics as it promotes blood flow through the smaller blood vessels. Also consulting with an ET nurse may be helpful - call your local hospital to see if they have one on staff or sometimes Home Health agencies will have an ET nurse.
*Recipie for Making Saline: 1 quart (4cups) distilled or boiled water. 2 teaspoons table salt. Place water and salt in storage container which is clean (washed with soap and water and boiled for 5 minutes). Mix well until the salt is completely dissolved. Cool to room temperature before using. This solution can be stored at room temp in a tightly covered container for up to 1 week.

B. DeSantis, PT

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Hi Nancy I am not a health care provider but I am a patient advocate. As I myself am a diabetic for 40 years. I had diabetic ulcers on both feet. They were Stage IV and I also had osteomyelitis.(Bone infection) The doctors wanted to amputate my feet. I talked them into trying Maggot Therapy. The maggots eat just the infected skin (they don't touch the good) they also excrete enzymes to promote healing. It worked GREAT. My feet are totally healed up and have been for a year. I am promoting Maggot Therapy. Here is a web site for more information. Maggots are extremely cheaper than amputation. The doctor in the web site sterilizes and sells them throughout USA. Good luck!
Pam Mitchell (patient advocate) Dr. Sherman's Maggot Information
Trying to help diabetics know their options!
 

Linda

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Linda, you don't give much information regarding the wounds and their cause. However, in general, I don't use whirlpool much for any wound care anymore. Only if the wounds are really "dirty" and then only for a few times to clean them up and then we move on to more "state of the art" approaches. Moist wound care is the treatment approach of choice in most cases, however, there are always exceptions to the rule. If there is not sufficient blood flow to the foot to support healing, then keeping the area wet may be contraindicated. Has there been any arterial testing done such as arterial dopplers to determine ABI's or at the very least, are there palpable pulses in the foot? Also, in general, if an approach does not bring about measurable healing within 10-14 days, it is time to take a different approach. Good luck. B. DeSantis, PT
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Whirl pool is indicated for many types of wounds, it would be important to know what type of wound you are talking about. To me it appear to be of a vascular nature. Vascular wounds are very hard to heal, some never do! The whirl pool works well to reduce colonization of wound bed and to remove dead tissue, wet wrapping is also used to remove dead tissue. Wounds are very dynamic, and the treatment changes according to the stage of healing.

Leme- Brazil

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Whirlpool has its pros but it also has its cons. The school of thought is leaning away from whirlpool treatment for many reasons: IT can definitely be used to cleanse the wound if there is necrotic (dead tissue) present. But once the wound is clean and pinkish red in color, then whirlpool should stop. There are many more reasons as to why one should or shouldn't use whirlpool. There are many other alternative treatments available that don't have as many "cons", such as HBO (hyperbaric oxygen), Ultrasound, Electrical stimulation, etc. Do some more research and always ask you doctor or healthcare provider for other options.
As far as the moist dressings go, yes the wound should be moist but not soaking wet. You can put a "moist" gauze covered with dry gauze. Optimum environment for wound healing is moist not dry.

Evelyn MPT, CWS

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Dear Allen,

The treatment regimen with cortisone is clinically indicated. Many say that one should not disrupt a blister, since it helps to keep the fragile regenerative environment sterile, in your case it occurred accidentally, but for what you have described, you have a good healthy tissue underneath it. In my Practice in Brazil I treat similar wounds with creams that in US are known as skin barrier ointment, they have a combination of good healing components such as vitamin A, zinc oxide and others, you can purchase them over the counter. You must place enough of the cream over the affected area as to keep the gauze from sticking to your skin, or use a non-sticking dressing, protect the area against friction, and keep it clean, use sterile gauzes, and a good bandage to secure it, change 1 to 2 x/ day or more if it becomes soiled, try this for a few days, always wash your hand with liquid soap before reapplying the cream, if you do not see an improvement, see a Dermatologist.

Ed Leme, RNC-Brazil
 

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If all you have is ecchymosis it is not stageable because there is no skin loss. I am glad you mentioned that you are checking the boot every shift and more often. Such boots are known to cause ulcers when not checked frequently because the foot tends shift within.

Thomas S. , R.N., M.P.H.