Debra

Vik

Thank you, Nancy

---

Horse Chestnut is sold in the US as Venastat. You can buy it over the counter in any Rx. It is used extensively in Germany for vascular health.
JHulse, CNS.

Jill

---

If the patient is not compliant with off-loading or during transfers, it likely won't heal. Have you checked the patients nutrition level, notably albumin and transferrin. At our wound center, we have had success with plastic surgeons using tissue expanders and then flapping the area. If the patient's only issue is not healing the wound, I would notify a plastic surgeon for surgical closure. Hope this helps.

Lisa Goodfriend, PT, CWS

---

Hi Jill,

I work in a long term facility and many new patients that come to us have ulcers. I have seen many of them heal with a very simple treatment.

Once debrided, apply a skin barrier over top like a skin prep (made by 3M). Then we applied bacitracin covered with vaseline gauze. Lastly we applied a gauze pad over top and changed 2 times daily. We significantly reduce a huge venous status ulcer with this treatment.

The theory with this treatment was simply once clean, the bacitracin provided a protection from infection while keeping a moist wound to allow for tissue growth. Please remember to use the skin barrier though. The bacitracin and drainage may moisten surrounding skin and cause maceration and further skin breakdown.

Good luck,

Sincerely,

Theresa RN

---

Jill- The wound may be colonized. I would try a silver/alginate dressing like Acticoat as a primary dressing, with an absorbent secondary dressing, change the dressing every 5 days and PRN. This will help if colonized and should also provide some debridement. Be sure to lightly fill in the undermined area with the primary dressing. Is resident on a protein supplement (i.e. Prosource)? Is MVI also included in regimen? Encourage fluids and of course encourage Q2H repositioning. You don't mention is wound is at all epibolized. If it is, you may want to use some silver nitrate to reopen the prematurely closed area.

Kim

---

I would suggest one of the silver dressings as the wound may be infected and certainly is contaminated with all kinds of garbage. Bacteria compete with fibroblasts for oxygen and therefore will cause a wound not to heal. You can use something like Arglaes which is silver and alginate powder or even
Silversorb packing dressing. They should help. Janet Hulse, CNS

---

Hi Jill,

I once had a pt whose hip wound was granulated,not infected, but would not heal and tended to be undermined like you describe. She was a home care pt of mine, very slim. I could not understand what the problem was, because I felt like the family was taking good care of her. Finally one day I saw them turn her and they were pulling on her, stretching her skin to create a shearing effect at the wound. When we stopped that with education, the wound healed. Just a thought for you...

Have you considered the VAC? And what about her nutritional status?

Vicki, MSPT, CWS

---

My first thought was the wound V.A.C. since wound bed is clean . I wonder what else is preventing closure. Could nutrition be a factor? What about infection?

unsigned

---

how long has the patient had the pressure ulcer?
there many be a chronic underlying soft tissue infection and/or osteomyelitis so you'll need to ask for a referral for investigations......MRI for example.

Is the patient being nursed on an alternating pressure air mattress? It is important to prevent further damage while you are trying to heal the ulcer.

Do you know whether the serum albumin level (the best marker of nutrition) is normal? All wounds lose albumin which in turn delays or prevents wound healing. A blood profile is a good place to start then advice from a nutritionist.

The VAC (for Vacuum assisted closure) from KCI may help to close the wound. Hope this helps.
Kate Sharp, Founding Member & President, Wound Care Association of New South Wales, Sydney Australia

---

Hi Jill - It sounds as though you have been using appropriate dressing techniques but the first thing just about everyone is going to ask is whether or not the patient is compliant with pressure relief in this area. Secondly, how long has it been open? As long as there is undermining you won't get good healing. Perhaps the area needs to be excised by a surgeon to restart the inflammatory phase and begin the healing process anew. Granulation tissue becomes ineffective in a wound that has been open for a significant period of time. Good luck. Becky, PT

---

A the home health agency I work for we have had much success with using 2 different products to heal wounds.

1). Multidex Powder: Great for healing stubborn wounds, used las week on a pt with a stage 2 decub on coccyx, went back on Sun and saw him and wound was healed. You can even use as packing. If opening large enough, just pour into wound and then add your packing. I have also sprinkled powder on NSS moist nugauze packing with success. You can learn more about Multidex on line. Change dressing QD for gauze covering or if using a specialty drsg such as Thiele, change QOD.

2)Silvalon: comes as 4x4 gauze or as a packing "rope. Esp good for deep wounds and/ or infected wounds. DO NOT us NSS with this product. Must be moistened with sterile H2O before application. then covered with DSD. The beauty of this is that the Silvalon only needs changed Q7D. We change the cover dressing QOD. This has also been very successful. Not sure if I spelled Silvalon correctly, but there is also info on line about this product.

Hope that helps.

Truth Topper RN
----

I have had very good luck with Mesalt. It comes in a sheet or a roll and you cut the mesalt to fit directly into the wound. Mesalt is a Monlyke product, cover with Alldress which is also a Monlyke product. It is to be changed
daily and PRN if drainage is indicated.
Hope this helps.
MIchelle, PTA

---

As far as I know, there is no regulation. There is great controversy over patient consent (whether you need a separate one for photographing or your standard patient consent covers it as part of eval/treatment), and of course you wouldn’t put anything in the photograph that would identify the patient. The trend seems to be toward photographing, making sure a measurement tool is in view for perspective and measurement. Many lawyers say the photos can be used against you so don’t do it. But ultimately a case will focus on documentation, and the photos should back up your documentation of good wound care practices, methods tried, progress made, reasons progress was not made. Dr. Courtney Lyder who sits on panels for HCFA, presents photographing wounds as a positive thing to do.

Laurie M. Rappl, PT, CWS

---

At a recent conference for Florida Podiatrists, a speaker (attorney) was asked 3 questions about wound photographs:

1) is it true that a photograph of a wound will 'shock' the jury so it's better not to have one? Answer: No, the photo is a good thing to have. We can demonstrate to the jury that this is good wound care, regardless of how they may first react to the photo.

2) what about the issue of 'manipulating' digital images. Answer: while the issue might exist, he's never heard of it being brought up in court. You obviously shouldn't manipulate the image.

3) Sometimes, the image on screen (or printed out) just doesn't really look like the wound. Answer: be sure to use appropriate lighting and have a good angle of the wound. Be satisfied that your image is a good representation of what the wound looks like clinically.

Dr. Allan Freedline

With a history of amputation on the opposite foot, I caution you to be very careful about this ulcer. You want to make sure that your doctors and nurses are watching you closely, monitoring for any infection. Please do not try to treat yourself. Consider going to a local wound care center.

Dr. Allan Freedline

---

I would recommend going to a good Wound Center where you can get physical therapy and nursing care by people familiar with wound care. Call your area hospitals and ask them if they can refer you to a wound center. Or call some home health agencies and ask to speak to their ET Nurse in charge of wound care. Electrical stimulation in the form of high volt pulsed current may work well for you - this is offered by physical therapists. Sorry I live in the Pittsburgh area so can't make any referrals. Good luck. Becky, PT

---

Have you tried an air cast? Has air pockets in that you deflate/inflate to support the leg thus removing pressure from the foot. You could deflate if got too tight and inflate again. hope this helps

JB (ET Nurse)

---

Steve,

You could use a PROFORE 4-layer compression dressing or the Circaid Velcro compression dressing. Elevate your feet as much as possible...it can never be too much. Pump your feet while they are elevated. You need to work at getting the swelling down. Is the ulcer on the leg or foot?

You need to see a different foot care clinic if all they offer is the cast.

JODY RN, BS, CWOCN

----

Pam wrote a reply which spoke about her success using maggot therapy. Here's a link.