Email - February 14, 2004

Wound Care Information Network

February 14, 2004

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New questions sent by readers. Please e-mail your answers. See previous questions and answers below.

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If you have a patient with a leg ulcer, what tests would you run to see if it was venous in nature? I'm looking for reliable diagnostic tests as opposed to a visual exam. Thanks, Alfred, MD	Archives messages can't be replied to.
I'm looking for documemation guidelines on surgical wounds for /in home health. Thank you for your assistance. Brenda Cruickshank
Hi there I am looking for information regarding what to do with bleeding surgical incisions immediately post surgery. Our nurses use different practices. Some change the whole dressing, others reinforce. Thank you Lauren Wolfe Clinical Resource Nurse
I am a visiting nurse with an elderly female patient who has gotten a wound on right lower leg. She has extremely brittle skin. rubbed right leg with left shoe and has a appx. 3"x3" wound. Has taken top layer of skin off. She has a DNR so I am unable to take her to hospital for wound attention. Must do the best I can with over the counter supplies. Have put antibiotic cream on and applied a pressure dressing. Wound was on Fri. Last night I started wet and dry dressings. Any suggestions on how or what to do to help healing. Sincerely Dottie G
hello I have recently been asked about Granulex topical spray as a debriding agent, instead of accuzyme, and the others listed. I have no experience with granulex. Can it be used on hard, shiny eschar? Susan Hoban
Should arterial ulcers be evaluated with the same "stages" criteria as pressure ulcers? unsigned
Hello, I have a 1.5X2.0cm wound, about 0.5cm deep on the top of my left foot 5cm above the fourth toe. It was cultured on 1-30-04 and came back MERSA positive. Since I have had a MERSA infection before, my foot doctor told me to start taking Zyvox again (1 500 mg tab a day), wich I have taken before and have been told the oral med is just as effective as the IV dose. I was also told that since I was MERSA before, I will always be MERSA and as long as the wound was not showing signs of infection (redness, swelling, drainage, odor etc.) that I shouldn't take the Zyvox and chance becoming resistant when I didn't need to. Right now the wound is being treated with cleansing by antibacterial soap and water and application of Silvadene and a DSD. I am a very slow healer. I don't have Diabetes. I have another wound (3X1.5X0.1cm) on the lateral edge of my left big toe. It is a surgical incision wound from 8-1-03 that has still not healed. I have had Rheumatoid Arthritis for over 30 years. I am a 55 year old Cauc. male. Any advice? Thank you, Gary Snyder
Are therapists and nurses re-using pulsed lavage guns multiple times for one patient or single use? Is any one having problems with the Dept of Public Health accepting multiple use (on same patient) for the pulsed lavage guns? Is anyone attempting to clean the guns between use? Carol DiPrima, PT

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Previous email questions & their replies are listed below. Remember, replies have not been validated for accuracy or truthfulness.

Three weeks ago I was assaulted resulting in a 2cm wound. The wound was cleaned with saline by an EMT and he placed a band-aid. Unfortunately he neglected to inform me that I need stitches, so I returned home. When I woke up the next day I removed the bandage and notice that the wound was deep and required stitches. I had to wait 5hrs in the ER before I was sutured. The total time between the time of injury and the wound being sutured was about 16hrs. I'd like to know what impact this had on the wound healing properly on a scale of 1-10 1 being little impact and 10 being profound impact. Presently the wound in understandably red. I can see a pin line scar forming with redness surrounding it. What is the redness due to? I am using band-aid brand silicone strips and I understand this will help it fade. Is there anything else I could do to lessen scarring? What do you think about dermabrasion? Thank you. Jim	Dear Jim: 16 hours from injury to suturing is not an inordinate amount of time, so I would not worry about it. Redness is a sign of inflammation and you should expect some redness because it is a response to trauma. There were two traumatic episodes - the initial cut and the suturing. Look at the redness and determine whether it is an "angry" red or just moderately red. If it is the former, check the surrounding skin to see if it feels hot, hard and tender to touch. This would be a sign of infection and you would need medical intervention. You didn't say what part of your body was lacerated, but because you are very concerned about scarring I assume the injury is to your face. I don't know about silicone strips for reducing scar formation. Silicone is a substance that has been less than beneficial and is a possible irritant. Aloe Vera gel and Vitamin A&D ointment might be a better bet for superficial skin healing. However, if you ask ten people you will get twelve opinions. Remember there is no pat answer for minimizing the scar. Everyone reacts differently. My best advice is for you to consult with a cosmetic surgeon. If you are concerned about coverage, a post trauma consult and scar or wound revision from a plastic surgeon is included in most health plans. I hope that it heals well. Thomas A. Sharon, R.N., M.P.H. --- If your scar is almost 3 weeks old, you should be able to feel a hard ridge when you palpate the scar. If you don't feel this firmness, your wound edges have probably not healed together properly. If you do feel this firmness along the entire length of the scar, it has probably healed together and you don't have to worry. KR RNBN --- Sounds like you are doing everything that you can. Watch the redness. So long as the redness is near the wound only it's probably just healing redness. If it starts to spread then there may be some type of infection. Whenever you have a wound requiring sutures you will end up with a scar. So long as it's thin there's not much else you can do. If it were bulging,ect then a plastic surgeon would be your best option. theresa rn
My colleagues and I are investigating the possibility of setting up some in vitro experiments that would represent a wound with exudate, possibly spiked with bacteria-the point we are particularly interested in is the production of lysozyme within an infection. I am assuming that putting some exudate on a petri dish, which we need to monitor for a number of days for lysozyme will not represent what would be happening in a wound as there is no immune response. Do you know of any in vitro model systems that are used for this type of thing? Thank you Debra	sorry, no replies
Hello, I work in a PT clinic in Virginia and my co-workers and I were wondering how other facilities are billing for Wound care services ie:whirlpools, dressing changes, etc. in Virginia Any information would be helpful!!!! Thank You, Katie Brown	I'm not in Virginia, but it's pretty much the same everywhere. You can bill the whirlpool code for whirlpool, but you can not bill sharp debridement (97601) at the same time. Dressings are wrapped into your other treatment charges. 97602 covers it, but it's a non-reimbursed code. It's bundled into 97601. 97601 covers sharp debridement and pulsed lavage, which is almost always a better option than whirlpool. Other codes you can use include unna boot, the new ES for wounds code, and any "traditional" PT you do with them. Renee C, MSPT, MPH, CWS --- Hi, I work in a long term facility with PT/OT involvement. Our facility charges by visit and length of visit and the amount of intensity of therapy. It first bills through Medicare and its criteria then on the individual visits. Theresa
i have a friend who's mom has lupus, is being treated with cortisone and who now has a leg ulcer (appeared a few weeks after gallbladder surgery - related?). the doctors are considering surgery on the leg ulcer. is there a medical treatment that might help? Ellen	It all depends on what the underlying causes of the wound are. For example, venous or arterial insuffiency. The treatment will vary. The cortisone will slow down the progress of healing. Vitamin A supplements may help counter the effects of it. I suggest you find a wound specialist. Try www.aawm.org or www.wocn.org for one near you. Renee C, MSPT, MPH, CWS --- Go to www.diapulse.com to see if the Diapulse Wound Treatment System is available in your area. Non-thermal high peak power high frequency electromagnetic stimulation has worked wonders for all types of chronic leg ulcers. Thomas A. Sharon, R.N., M.P.H.
When I lived in Florida I visited a friend in a nursing home. I remember he use to have the aides use lanaseptic on him. Now I am up north and my aging parent could sure use some. Could you tell me how I can get a hold of some? Thank you Vik	Vik, Lanaseptic can normally be purchased at your local pharmacy or perhaps discount store. A prescription is not required. But as with any over the counter medication, you should consult your parents physician before using to ensure no contraindication or interaction with other medications in their regimen exists. Even topical ointments can be contraindicated in some patients. Pam Warmack RN,C CHCE --- You can locate Lantiseptic at- Summit Industries, POBOX 7329, Marietta, GA 30065 1800-241-6996. Amy Pastor RN, CWS
i am the new nursing supervisor in an extended care facility. I have been here one month. One of my responsibilities is wound care monitoring. we currently have two residents with long standing stage IV coccyx pressure wound. the wounds appear clean and without s/s of infection. my concern and question is re: to the edges of the wounds. The edges are hard and dry. Is there a recomended treatment for managing without surgical intervention. We have limited contact with any wound care M.D.'s. most are family phycians managing all aspects of pt care. Thank you, Nancy	The edges probably need debridement, based on your description. If you can't get a surgeon to do it (maybe same day surgery?), then silver nitrate application may be helpful. Until the edges are good, it can't close. Renee C., MSPT, MPH, CWS --- Try using silver nitrate sticks to edges to promote new granulation/growth. good luck --- I am a Treatment nurse at a long-term care facility. If the wound has no s/s of infection or necrotic tissue present and the edges are dry I have seen a product called Saf-Gel used on a stage 4 ulcer. Saf-Gel or Carrington Gel , they are basically the same product, just made by different companies. I would also recommend the pt. be placed on Vit. C, Vit. E, and Zinc to promote wound healing. We have also started using Arginaid powder, which contains Protein and Enzymes for wound healing. Kellie LPN/Treatment Nurse --- Nancy- You don't mention measurements, or other characteristics. Is the wound bed moist or dry? Yellow or other discoloration in the wound bed? Are the edges of the wound epibolized (healed)? If the wound bed needs debriding, you might try a papain-urea formula i.e Accuzyme or Gladase. If the wound is red & beefy and has no odor, you could try a hydrogel. Whichever method you need to use to prepare the wound bed for healing, lightly pack any depth with gauze. Be sure to fill in any undermining or tunneling with gauze to promote cell proper cell migration, then cover with a foam dressing to absorb exudate and prevent maceration. If the rim of the wounds look healed, you might try silver nitrate to reopen the areas. The tissue at the edge of the wounds may "think" healing is complete. Have these chronic wounds ever been closed completely? If so, how long ago? Your long term goal may be to minimize size of wound and keep free of signs/symptoms of infection/colonization. They may never heal completely. Is your dietician involved? Has resident had a pre-albumin done recently? You might want to add an MVI, zinc and/or Vit C to regimen. Also if you may want to consider a protein supplement if not contraindicated. Are alternating air matresses being used? Nancy arfe there any wound clinics in the area you could use as a resource? Good luck. Kim, LPN Wound Nurse --- Dear Nancy: Maintaining a moist environment with hydrogel is the most important thing that you can do. You will need to determine if the wound edges are necrotic. If there is necrosis then enzymatic debridement would help. as soon as you see sloughing, then the enzyme should be discontinued. If you have access to electromagnetic stimulation with Diapulse, the increased blood flow would bring about the natural sloughing of any necrotic tissue and likely negate the need for enzymatic ointments. You can get more information at www.diapulse.com Thomas A. Sharon, R.N., M.P.H.
When packing a deep pressure ulcer, it is a clean wound that has been surgically debrided, do you pack it very tightly or loosely? We use sterile NS and gause. Terre McGregor	There are differing opinions on wound packing. Many surgeons I know pack very tightly, as tight as they can. The going joke here is that Dr. X is the only one we know who can get 5 rolls of Kerlix into a pinkie finger wound. But whether to pack light or to pack tight depends on your goals. Surgeons usually pack tightly because their goal is usually hemostasis after a surgical debridement. If you are not having active bleeding in the wound, excessively tight packing can cause trouble. Remember, what is the goal of your packing? In most cases, it is to keep the opening from closing before the undermining/tunnels fill in, to prevent abscesses from forming. So you need to pack well enough that the opening doesn't close too soon. But cells are very sensitive to contact inhibition, and a cell that feels crowded, especially if it has a foreign substance jammed up hard against it, will often not feel like mitosing. So, think tight for hemostasis and light for mitosis. Bryan G., MSPT, CWS ---- I've always been told that when a wound is INITIALLY (surgically) debrided, tight packing is done to help stop bleeding for only 1-2 days. After that, the usual practice is a lose packing. Amy Pastor RN, CWS --- Pack loose, don’t create pressure inside the wound, just fill in the space and have contact with the walls of the wound. On my own wounds (ischial), overpacking created hard lumps that caused problems, underpacking caused tissue to move around and also caused problems. I’ve had success with gentle filling with gauze ribbon, and have also tried the PolyWic Cavity wound filler by PolyMem packing, it’s softer than gauze ribbon and still pulls moisture out. Only problem was if the wound opening is small, and the cavity is big, the PolyWic swells up inside the wound and gets constricted by the wound opening. Other than for that small group of wounds, it’s a neat product. Laurie R. PT, CWS --- Packing tightly will stop the normal wound healing process involving contracture of the wound and granulation of the base. If the wound bed is visible it is a simple matter of "laying in" of a wound care product that can expand to fill all dead space (Aquacell is good). If the wound bed is not visible, I find packing lightly with a product like Aquacell rope useful, as it will conform to the space without applying pressure to the walls of the wound which can cause necrosis and furthur tunneling. The key to packing any wound is to pack down to the wound bed and not leave any "dead space". KR. RNBN --- I hate the word packing, as it implies stuffing it tight. I like "gently fill." You want only one strip of gauze down in the tract. The function of the strip is to wick fluid up, and keep the hole open until the tunnel fills in. By packing tightly, you are inhibiting healing in two ways: separating the walls to prevent closure and causing new pressure necrosis on the walls. Renee C., MSPT, MPH, CWS -- Fluff, don't stuff! Debby RN/WCC candidate --- Hi, Pack lightly so you don't cause pressure from the inside out causing increased ulcer size. Loosely packing will maintain a warm, moist enviroment for healing. Theresa RN --- Dear Terre: Generally, packing a wound is a bad idea altogether because the pressure decreases blood flow, destroys granulation tissue and causes the wound to behave like a petri dish with the possibility of anaerobic bacterial growth. Therefore, if you must "pack" fluff the gauze and place it gently over the wound. Certainly you don't want the dressing to fall off, so secure it carefully without pressurizing the wound area. If you are using NS wet to dry, you will need to change the dressing at least twice per day to keep the wound from drying out. However, if the wound has little or no drainage it is best to use non-liquefying hydrogel under the fluff gauze. If there is moderate to heavy exudates then you need to cover the wound with a permeable plastic like Opsite and cover it with gauze to absorb the drainage. Above all do not irrigate or wipe. There are too many wounds that remain clean and never heal because the "wound cleaners" wash away the healing factors and actually prevent granulation. Thomas A. Sharon, R.N., M.P.H.

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