Lisa

Jill

Frank

lisa, RN

Mavis

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You need to get your Apligraf rep in to discuss proper follow up care with your surgeon and the facility staff ASAP. Usually the docs will be more receptive to treatment suggestions if they come from "outsiders" and the reps with whom I have dealt from Novartis are very well spoken and versed on the proper application/care of Apligraf. That is a very expensive treatment and results should be optimized by proper follow up care in order to justify the cost in this ever shrinking world of reimbursement. You also need to start giving your surgeon some "state of the art" articles on moist wound care. You may want to give him a copy of the AHCPR guidelines (http://www.ahcpr.gov/) and mention that lawyers use these guidelines as the standard of care when prosecuting physicians for bad wound care outcomes. Good luck. B.DeSantis, PT

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I am a caregiver for a guy who had an Apligraf a couple years ago. I believe we had to leave the dressing on untouched for at least 1 week and possibly 2 weeks. It was applied with staples. We went back to the doctor and they changed the dressing but there was no real wound care involved other than just checking for signs of infection. Hope this helps.

Yvonne Asay LPN
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To whom it may concern,

I manage a wound care center in New York, we use Apligraf. Apligraf is a wonderful product. In order for Apligraf to work you need a clean wound {bacteria free} You need to have a good surgical debridement also. Apligraf is applied in a sterile matter, it is meshed before being applied to wound site,after applied, xeroforn is applied then a N.S. dsg applied, DSD applied and tape. If used for venous stasis ulcers Compression Dsg is recomended. As for a follow up, no debridements for a while, Pt should be assessed on a weekly visit. DO NOT clean wound with Peroxide thats a big NO NO in wound care, cleanse with NS but just rinse no rubbing, Alpigraf healing outcome should ve done after 1 month after application, and no debridements in-between. Each week re-apply xeroform , Ns dsg, dsd and tape. GOOD LUCK!!

MaryAnne Alessio R.N.
Victory Memorial Hospital WCC
Brooklyn NY,

Click here for larger image

Thanks Jeff

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My first question would be, "What diagnostic testing have you had at this point?" Have you had imaging studies to rule out osteomyelitis (bone infection)? Any wound that can be probed to the bone, none healing, should be considered suspect for bone infection. Have you been treated with several rounds of an antibiotic? If you have, and the infection keeps returning, this is considered "chronic refractory osteomyelitis". If this were the case, you would be a candidate for adjunctive hyperbaric treatments in a hyperbaric chamber to assist in fighting the infection. Oxygen given at pressures greater than one atmosphere can assist in combating bone infections that have not responded to other treatments.

Douglas Ross, RN, BSN, ACHRN, CWCN
Center for Hyperbaric Medicine at Virginia Mason Hopital
Seattle, WA

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Jeff, I am sure you are going to be asked this question multiple times in the replies - but do you have co-morbidities such as diabetes; have you had your foot checked for osteomyelitis (bone infection) and your arterial status checked (i.e., ABI testing where they put blood pressure cuffs around various levels on your leg to determine blood pressure/flow in your leg). Also has your albumin/pre-albumin blood level been checked? Without answers to these questions it is difficult to determine why your wound is nonhealing. Your foot looks swollen which is another impediment to healing. Final thought - are you compliant with what the doctors/wound care specialists tell you? Sometimes we are our own worst enemy because we don't follow instructions.

Becky, PT

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Have you tried an enzymatic debrider. Your wound appears to have necrotic/sloughy tissue black and yellow and in order for it to heal you need to have all of this dead tissue debrided. A cream such as Panafil or accuzyme would be a good start covered with 4x4's and changed daily. You would need a doctor's prescription for the medicine. We have had a lot of success with this in our facility.
C. Brewer, LPTA

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Dear Jeff,

I read your letter, you have this wound for a while, I have a few question for you 1) Has x-rays or a bone scan been ordered to R/o Osteomylitis
2) Have you been to a wound care center or wound care specialist
3) Do you go for debridements
4) Did you have Cultures done to see if there is a bacteria growing.
5) Did you have PVR's done {circulation test}

Jeff a non-healing wound can have many reasons, such as, bacteria, prro circulation, osteomylitis. Please have these tests done, and SEE A WOUND CARE CENTER OR MD Good Luck

MaryAnne A. RN
Victory Memorial Hospital WCC

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Poor circulation is due either to a main artery obstruction or narrowing of the smaller blood vessels and capillaries. If it is the former, a vascular surgeon would be the one to recommend whether to remove or bypass it. If it is the later, then electromagnetic therapy with Diapusle has been very successful in improving circulation and promoting healing even in people with diabetes. Additionally, hyperbaric chamber treatment has had some success, although to a lesser degree (50%)

First, before anything, see a vascular surgeon to diagnose the circulation in your leg. Then you will be able to know what treatment would be best. If you don't know how to access such a specialist, go to the nearest wound treatment center (a good one would have a vascular surgeon on staff). I don't know what type of doctors have been seeing your foot, but after more than a year, it is time to get a fresh start with another physician group. If you live near a university medical center with a vascular department or chronic wound center go there as soon as possible.

The information on Diapulse is available at www.diapulse.com It is available only with a doctor's prescription, so you would have to show it to your treating physician.

I hope this is helpful to you.

Thomas A. Sharon, R.N., M.P.H.

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Hello Jeff,

I couldnt see really well on my screen, but it looks like the wound has some yellow fibrin debris. It therefore needs to be cleaned up and encouraged to granulate fully. Depending upon your state of health otherwise, that could be done by outpatient whirlpool/debridement or by appropriate occlusive dressings (if there is any indication of infection, occlusive dressings shouldnt be used; occlusive dressings are ones such as duoderm, opsite, etc). Once the wound is fully red and healthy, then appropriate dressings could be used to encourage it to stay moist but not wet, and heal over. Since you've had a really hard time with it, you might find someone with wound expertise and ask about the VAC (vacuum-assisted closure) device marketed by KCI (that's an I as in "ink", not an L).

A word about whirlpools, they are overused sometimes. If you have poor circulation in your leg/foot, the whirlpool might not be appropriate. Also, if you have a bone infection, the whirlpool might not be appropriate, especially a very warm one. Find a wound specialist you trust who will explain things to you.

Vicki, MSPT, CWS

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Have u had an MRI to check for osteomyelitis?

unsigned

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It's hard to assess without seeing you in person. Here are some things to consider: If your bone is exposed, you probably have osteomyelitis, a bone infection. Have you been treated for that?
How is your circulation into your foot. Are you able to stay off your foot? You may want to find another wound specialist and try something different. Try www.aawm.org and www.wocn.org for
people who are board certified wound care specialists.
Renee C., MSPT, MPH, CWS

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You might think about getting a bone scan to see if you have some infectious process going on that is keeping it from closing.
Yvonne Asay LPN

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Always remember to wash your hands before you put on your gloves and after. The community box of gloves causes a lot of contamination. You might want to keep a box for yourself to cut down on the risk of infection for your patients. Hope you have a long and fruitful career.

Yvonne Asay LPN

unsigned2

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So very excited to see more Nurses interested in Wound Care and wanting to make a difference. I have three Web Sites for you to visit where you can get information on pertaining to your interest. :-))

www.wcei.com, www.nawc.com, www.woundconsultants.com.

Good Luck,
Cecelia LPN, WCC

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Start with your representatives from the supply companies Smith & Nephew,
Johnson and Johnson most of them will give you information about their products and several have protocols already made up. that way you can pick and chose and they will provide inservices on products and give you
educational material.

Edna Hawkes RN

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My recommendation right off the bat is to provide a wide range of nutritional information which is the foundation of all wound healing and should be the first consideration even before the dressing/treatment. I would be happy to help you in any way I can with info or whatever you need. Yvonne Asay LPN

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Hi,
Great idea! I did the same for a hospital (the Sihanouk Hospital Center of HOPE) here in Phnom Penh, Cambodia. I came here a year ago and was shocked that hydrogen peroxide was being used on almost every wound. We are a nonprofit hospital providing absolutely free health care to the Cambodians and amazingly have lots of donated wound care supplies. But, the problem was that noone knew how to use the products so they would sit in the warehouse (in 100 degree + weather) and become ruined. So, I started awound care committee (WCC). I am a nurse w/ only 3y. experience from the states in a few different types of units including an ICU, so I was not sure what to do... I just started w/ 1) a few nurses from each area (we have a surgical ward, medical ward, and ER), 2) I gave them copies of the first chapters of this book that I have Acute and Chronic Wounds by Ruth Bryant and have had them read it (their English is not so good, so it has been slow but the book is easy to read), 3)created a dressings book w/ samples of each type of dressing in plastic, transparent holders and grouped by types of dressings 4) I taught the few nurses how to use the dressings and now they are educating the rest of the staff by doing 10 min. inservices at the beginning/end of the shift to help everyone understand how to use the different products... 5) and started a WCC communication book so that the members of the committee are able to give/get advice and keep up on what is happening and new supplies that we have etc...

So far it has been good. I have also had to teach the doctors alot about wound care. Still lots to do, but every day we learn. I wish you good luck. Maybe you can't start a wound care committee but you could at least do some inservices on your own and give people handouts to read on their own time or down time at work.

Good luck!

Amy Schelin, RN BSN

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Hi,
I was just wondering if you have tried to apply duoderm at the site (after applying a skin prep pad to help it adhere to the skin since the area has a lot of sweating). Duoderm wound maybe keep the chemical damage from incontinence down but for the pressure I am not sure. The wound sounds like it is due to constant pressure of the skin folds and the incontinence/moisture. Turning (positioning) and keeping pressure off of the area would also be necessary to prevent a recurrence.

Hope it helps.

Amy Schelin, RN BSN
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Lynette,

Health Point has a great product called, "Xenaderm". It's great for partial thickness wounds and Stage I/II wounds. It's also perfect for those areas where dressings are impossible to stay intact.

Good Luck,
Cecelia LPN, WCC

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What are u doing for pressure and shear?

unsigned
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Good basic old fashioned nursing. Turn her every two hours and provide meticulous skin care. There is no substitute or magic bullet.

Thomas A. Sharon, R.N., M.P.H.

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Re: Lynette

Recommend a strict schedule for repositioning and for cleansing for bowel incontinence. Is pt. using a pressure relieving mattress and wheelchair cushion? What is her nutritional status? Is she on routine multivitamin? You may want to try Calmoseptine. It serves as a thicker skin barrier, helps prevent itching, may decrease any shearing caused by repositioning. You may want to use some A&D oinment to help remove the Calmoseptine when cleansing.

Kim
LPN/Wound Nurse
 

unsigned

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Iodosorb is like any other dressing, it can be used appropriately or inappropriately. If the diabetic ulcer has the characteristics that indicate iodosorb, then it would be appropriate, but you're right in questioning it's use on ANY wound that isnt drainaing much in my opinion.

Vicki, MSPT, CWS

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Iodosorb needs exudate to work. It absorbs the exudate, swells up, and releases the iodine. If it's too dry, then it doesn't work. If you're concerned about bacterial load, a silver product
may be better on a drier wound, since you can wet the dressing.

Renee C., MSPT, MPH, CWS

Concerned Daughter

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What is causing the wound and where is it located? If it is a pressure related sore, you have to find a way to relieve the pressure, friction, or shear that is causing it. Does she have a fever (does not sound like it.. ) but if she does, she probably has an infection and you would want to have more tests done. How is her diet? is she diabetic and if so, are her blood sugars controlled? Is she getting enough protein and vitamins (some people believe a supplement helps). As for the dressing, I think you could just continue to clean w/ normal saline (not necessarily needing the soap) and then apply a calcium alginate (rope type) that fits into the wound and not around the borders so as to keep the moisture from getting on the skin around the wound, and cover w/ gauze, changing as often as every 6 to every 12 hours if it becomes soaked. If it becomes soaked over 24 hours then change every day. Perhaps the calcium alginate will help to stop the maceration and allow it to heal.

Good luck.

Amy Schelin, RN BSN
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If a wound is healing, don't rock the boat is my opinion. However, if the wound is not healing but remains clean from the duoderm's successful debridement action, then you might try an alginate (one of those dressings that look like fiberglass insulation, if you're not familiar with the names of dressings) to absorb the drainage that was macerating the wound, and cover with a duoderm, tegaderm or any other occlusive dressing. Change the dressing as needed, when you can tell there is drainage saturating the dressing. The alginate will turn into a gelatinous "glob" when saturated. If it sticks to the wound, irrigate it gently.

Vicki, MSPT,CWS

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She probably doesn't need the sulfa, and dial antibacterial soap is really pretty harsh on the skin (very high pH). The antibacterial properties also damage the fragile growing cells. On something like this I may use either a foam dressing (to keep it from macerating) or even a film dressing with a barrier film around the wound to protect it.  I like films for
re-epithelialization; I find them very effective.

Renee C., MSPT, MPH, CWS

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My mother has had the same problem. She has had a small ulcer on left heel that refuses to close after a year and a half of treating it. We alternate with a debrider, Accuzyme or Santyl, to remove dead tissue and a hydrogel, we are using Amerigel, to heal it. Mom also sees her podiatrist every 6 weeks and she removes any hard scab that builds up. There has been a lot
of healing from underneath, her ulcer went to the bone and it has been slow process. When things look a little too moist we back off and use a dry dressing for a few days. We also use Dial and saline. It was recommended by
the podiatrist to scrub the wound daily, as much as she can tolerate, to try to remove dead tissue and promote healing. We are careful of elevating the foot and legs. Something that must be done long after the wound heals over since the tissue is so fragile. Doing these things we have been able to ward off infection and decrease the size of her ulcer dramatically. Good luck.
Another Concerned Daughter

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Ask your doctor about an alginate type dressing they absorb lots of exudate
and keep the wound at body temperature so better healing results the best
thing is to keep the wound slightly moist.

EH RN

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I’ve used a Clearsite dressing on small wounds. It’s a touch padded and keeps the wound covered. Not cheap, however.
Steven M, Attorney

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Peroxide is not the best thing to irrigate a wound with. It destroys healthy tissue. If your mothers wound is forming granulation tissue, the peroxide can destroy it and deter healing. In my facility we generally use an ointment called dermagran for stage II ulcers. This is effective for most. Cleanse the wound with either normal saline or soap and water, then apply the ointment and a clean dry guaze dressing.
We use duoderm occasionally to debride wounds that are either necrotic or have yellow slough in the center (stage II's and IV's). I've not found it to be effective in treating stage II ulcers. If the wound has depth (progressing to a stage III) and the wound bed is clean (red granulation tissue present), I would recommend cleansing with saline or soap and water and using a gel such as multidex or intrasite and cover with a guaze dressing. If the wound bed is yellow, this is slough and it is now a stage III. A stage II wound will not support slough. In this case, Santyl ointment applied daily and covered with guaze will work the best as it removes the slough but will not harm healthy tissue. It can be used up to healing and is very effective.
RN DON and wound nurse at a LTC facility

Darlene

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Xenaderm manufactured by Healthpoint is intended for stage 2 ulcers or partial thickness ulcsers therefore has no debriding ingredient in it according to the Heallthpoint reps I had talked with. I have used this on several cases and find it a very good product.

NanaCWS

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Xenaderm is a product made by Healthpoint that is used for wound care primarily with wounds of stage I and II type (pressure ulcers).
This ointment has been tried and used with some success in my inpatient and outpatient patients. It can reduce the macerative effects of light to moderate drainage due to it's skin protectant in the cream and it can promote wound bed vascularity. It can be used on other types of wounds under the proper care and supervision of a clinician and physican's order. This cream is a prescription item and requires medical evaluation. I hope this helps.

Greg Redmond, PT, MS
Shreveport, LA

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xenaderm is an excellent moisture barrier, has balsam peru and castor oil which increases blood flow to the wound. works well with stage i and 2 ulcers, use BID., don't need to cover with dressing. (made by healthpoint)

lisa CRNP

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Do you mean Xenaderm, by Healthpoint? If so it is not a debriding agent it is a healing agent> It contains Balsa of Peru, Trypsin and castor oil. You should get ahold of their product information it has been successful and is a barrier as well and stays on for a long time. Their "800"# is 800-441-8227.
JODY CWOCN-Denver

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Xenaderm is a new product from Healthpoint. It's a new type of moisture barrier (I've encouraged them many times to package it alone, unmedicated) with the old Granulex ingredients in it. It's a prescription product marketed for the red bottoms. Here's the website for more info: click here
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Renee C., MSPT, MPH, CWS

Xenaderm is the ointment version of Granulex spray.
unsigned

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Xanaderm is basically Granulex, but in a tube and at a premium price. The amount of trypsin in either of these products is not enough to make them very effective as initial debriding agents, but rather to help prevent the wound from renecrosing after initial debridement has been completed. The primary function of these products is to promote capillary circulation.

Rhonda Wilson, NP, CWCN

Thanks. Kelli

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Hello Kelli,

Good for you to be concerned and aware of the poor state of wound care sometimes being performed!!! I have a favorite book, by Luther Kloth and Joe McCulloch - "Wound Healing, Alternatives in Management"; FA Davis publishers. There are national wound meetings that are great; Im about to attend the Advances Symposium in Chicago in October, but it is expensive. There are others. If you note that the instructor is a certified wound specialist or ostomy nurse (CWS,WCC, CWOCN) then you might have a better shot at getting progressive information.

Good luck, we need more like you!!!
Vicki, MSPT, CWS

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elli,
I commend you on your dedication.  There are some good sources out there. This link will give you guidelines from various organizations that havepassed muster, including the AHCPR prevention and treatment of pressure ulcer guidelines.  Some texts I recommend are (authors listed, since I don't remember the exact titles, but a search of author and wound will show them) Sussman and Bates-Jensen have a
great book with lots of photos and step by step instructions. Bryant's Acute and Chronic Wounds is a classic.  Chronic Wound Care 3 by Krasner, Sibbald, and Rodeheaver is a wonderful resource, but more on the knowledge side, not hands-on technique. There are many others, but these are the first three that come to mind.
Renee C., MSPT, MPH, CWS

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Hi Kelli,

Go to www.wcei.com. Wound Care Education Institute educates and certifies LPN's, RN's, Nurse Practitioner's, Physical Therapist and MD's in Wound Care.

Good Luck,
Cecelia LPN, WCC