Thanks,

Alfred, MD

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The physicians in our center usually can tell by looking at legs.  Edema, locations of wound, hemo staining of legs, dermatitis-appearance
in general, with information provided through patient history..Since venous wounds require compression for healing we routinely do ABI's and T-Coms to assess arterial flow . The results of those non-invasive test help the physicians determine proper intervention.

My wound care book suggest the following Diagnostic Tests can be performed:
Doppler Ultrasonography (is subject to quality of operator interpretation)
Duplex scan
Impedance plethysmograph
Photoplethysmography
Radionuclide venography
Contrast venogram (invasive-carries risk inducing local thrombophlebitis & DVT)

Lynn, RN

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Hello- I recommend ordering Vascular studies- venous and arterial ultrasound as well as ABI= ankle brachial index- in the case you would like
to apply compression- which is the usual standard treatment for Venous
stasis.

Best Regards,

Jamie B. Pinnock, RN

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Most of the patients with stasis or venous ulcers have
superficial venous insufficiency. This can well be
seen using Duplex evauation. They either have Greater or lesser saphenous vein reflux. Sometimes they may have isolated peforator leak. For short term treatment they almost always heal with the serial application of unna boots. It has worked and it will work. Thanks to Dr. Unna. For long term control most of them need some type of ablation ( surgery, laser or Radiofrequency treatments)

Good luck KT KishanMD. Vein center of Indiana
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An ABI (ankle-brachial index) is the most reliable and universally accepted method in determining venous blood flow. This test is unreliable in diabetics, however. A vascular lab does a PVR study which is more accurate for diabetics as they do toe pressures. Hope this helps.
Pam E, RN, CWCN
Tenn.

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Hi-- I have heard that applying a calcium alginate dressing (a seaweed derived dressing ) to a post operative wound helps to control bleeding- In
some instances surgeons apply them standard. The calcium in the dressing is supposed to help the clotting process. Good old fashioned pressure dressings may not be such a bad idea.

Best Regards,

Jamie B. Pinnock, RN

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If the wound is superficial you might consider mepitel dressing by Molnlycke. I don't know if you have access to this or not. Is it bleeding a lot, is that why the pressure drsg? The mepitel is great for skin tear situations. It's silicone based and does not stick to the injured skin. It "attaches" to the healthy skin around the wound. It's nicknamed a peekaboo drsg as you can lift the corners up and assess the wound and put it back down. It only needs to be changed weekly. You will need to place a secondary drsg that can be changed daily such as 4x4's and a Kerlix. These will soak up the drainage from the wound. Due to the construction of this drsg you can apply an antibiotic cream right over it. It's appearance is similar to honeycomb and the ointment or cream will filter through the holes into the wound. We have had wonderful success with this drsg and have also found that the scars after healing are much less noticeable.

Shauna Dawes, LPN
Home Health

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I would stop the wet-to-dry, since that will probably worsen the skin tear, as it will stick to it. Something non-adherent would be better. Simple things could be vaseline gauze or adaptic, a hydrogel, or a non-adherent foam wrapped with gauze wrap if it is
draining moderately/heavily. Her skin is so fragile, any tape, adhesive dressing, or adherent gauze will tear it further.
Renee C., MSPT, MPH, CWS

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I would review the guidleines of the DNR. It means DO NOT RESUSITATE...Not do not treat!!! If her problem were respiratory or cardiac in nature that is something else. Depending on her appetite, I would try to supplement her diet to enhance skin healing. Check with her physician to be sure there are no internal issues
EJT RN, CLNC

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Have found that Panafil ointment is very good for healing. I believe it is costly, but effective for most problems. Michelle

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Once the wound has a good granulating base, I would use a Hydrogel topical with a gauze dressing to allow the wound to heal completely. HealthPoint makes a nice hydrogel topical.

Dan Klein, DPM, CWS

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Dottie,
Let's start from the top. A DNR relates to life sustaining situations and does not apply to prudent nursing care. If she has a family physician then I would recommend that you make an appointment for her to be seen. Stop the wet to dry dressing. This is a debridement type dressing and you will be defeating the purpose of stimulating new skin formation if you turn around and remove it with your dressing. If the wound is superficial, as you say with only the surface skin gone then your best approach would be to continue with your application of topical antibiotic ointment with a telfa cover and light wrap to secure. I would encourage an increase in her protein dietary needs and get her some Vitamin C and Vitamin E. Those will help her skin. If her wound has gone beyond the surface layer , again it is advised for her to see her family physican. Good Luck,
Janalene Eaton, LPN/ Wound Care Coordinator

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In my book, DNR means "do not resuscitate." That does not mean that a problem such a wound should not be treated in a healthcare facility if necessary. Moist wound healing is your best bet. Since I don't know what kind of wound your patient has, the general rule of thumb is--if it's wet, dry it; if it's dry, wet it; if it's deep, fill it. Dry dressings stick and damage healing tissue, so use an absorptive dressing that will keep the wound moist.

Nancy B. RN, CWCN

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Just because a person has a DNR does not mean she can not be taken to the hospital for treatment. DNR means do not rescusitate. It does not mean do not treat or do not make comfortable. T.O RN

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Hi:

I would suggest looking at the Bertek pharmaceuticals web site-- according to the info I read it is not indicated for dry eschar.

Best Regards,

Jamie B. Pinnock, RN

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I have used granulex several times in the situation you are explaining and it will eventually peal off the black eschar and leave new tissue under it.
We use it on Stage II and Above just as a preventative measure also, because it makes the skin tougher.
Jaime S. Burns, LPN

unsigned

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Hi--- Not usually. Pressure ulcers are staged using the 1-4 system. Arterial ulcers are usually classified in the leg ulcer category which most institutions class as partial or full thickness.

Best Regards,

Jamie B. Pinnock, RN

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No, Staging is for pressure ulcers only. When you are dealing with Arterial Ulcers the appropriate form of description would be Superficial, Partial thickness, Full Thickness or Full thickness with underlying structure exposure. Hope this helps.
Janalene Eaton, LPN
Wound Care Coordinator

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Hello, I am sorry you did not sign your name, I hope it is not because you were worried about posting your name with your question because it is a common question. The answer is no, you would not use the same staging system as your would for venous as they are completely different processes. What is critical in arterial ulcers is the ABI (ankle brachial index) this gives you an idea of the level of ischemia. The range is as follows:
1.0 normal
<1.0 - 0.8 claudicant (mild ischemia)
0.8 - 0.6 moderate ischemia
0.5 or less is critical ischemia and if there is tissue loss with that (ie an ulcer) you need immediate intervention.
One other important feature with the ABI is that if in attempting to compress the artery during the test you get up to 200 mmhg and still have audible doppler pulses you are dealing with a calcified artery and can not get an accurate reading. In this case only a toe pressure or an accurate TCPO2 will provide you with adequate info. Remember though all of these must be in conjunction with a CWSM (color warmth sensation and movement test).
Hope that helps.
Wendy Marr
Nurse Clinician
Vascular and General Surgery

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Have you considered Hyperbaric Oxygen Treatment? I just came home from an inservice on Hyperbarics yesterday and they are doing incredible things with this treatment. They also do wound care along with the treatments and the before and after pictures show an immense improvement. The one we visited is in Pocatello, ID and the tech who did the inservice reported on in Texas. He spoke generally on several back east. You might call the one closest to you and have a consult.

unsigned

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Gary,

It is correct that once you are MRSA positive that you will always be MRSA. And again it is correct that as long as your wound is asymptomatic you should avoid the over use of antibiotic therapy to prevent further resistance. One way that you can attack the MRSA from a topical stand point is with a Product called Acticoat 7. This is applied to the wound base and kept moist by sterile water saturated gauze that is changed daily with leaving the Acticoat in place for the full seven days. This will help prevent the wound from converting from a colonized MRSA to an active MRSA and also help in the healing process. Hope this helps........Janalene Eaton, LPN
Wound Care Coordinator

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The quickest, easiest fix would be to switch to the Davol Simpulse, which has the suction line coming from the disposable tip, and is designed for multiple, single-patient use. However, if you prefer another model, like I do (I prefer another model
(the Zimmer Varapulse), you have another option. I have a system I feel keeps it clean. I clamp off the tubing after use, cover the holes with tape or gloves. Then, when starting the next treatment, I spray the gun to clear the old fluid, as it's been stagnant. The suction keeps the germs in that line going away
from the patient. My infection control nurses have approved of it, and we've never noticed any infection problems with it.

Renee C, MSPT, MPH, CWS

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I would contact the company where you purchased the Pulse Lavage and have them send you a copy of their standards and recommendation. From an infection control stand point, it there is patient contact, body fluid contact, and it is plastic and comes in a package and not attached to the instrument itself that means it is disposable and for one time use only. Check with your infection Control Officer for your facility's policy for disposable equipment. ...
Janalen Eaton, LPN
Wound Care Coordinator