Steven

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First thing you need to have is what is referred to as the "purple" book. This is the standards of care that all wound care must be based on. You can get this book by contacting U.S. Department of Health and

Human Services
Public Health Service
Agency for Health Care Policy and Research
Executive Office Building, Suite 501
2101 East Jefferson Street
Rockville, MD 20852

This is a free publication. Next depending on whether or not you will be a free standing entity or attached to a hospital facility you will need to review your states hospital standards. The same principals apply in a Free standing clinic as does an hospital associated clinic when it comes to procedures, assessment, tracking, and documentation. Billing however is alittle different as there are codes for outpatient procedures and codes for inpatient care. So your work is cut out for you. Good Luck and if I can help in any way feel free to contact me at jeaton@dfqhugo.com
Jan, LPN Wound Care Coordinator

Thank you. Sincerely,

Sharon Snover, BSN, RN, & grad student

Alfred, M.D.

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Your question is not very clear. I think you're mixing up two devices. In planimetry, you take a sheet of acetate (or similar material), trace the wound, and put the tracing on a planimeter, where the area is then calculated. Then there are the photographic methods when you take a digital picture with designated marker in the frame to set the relative size. The photo is then downloaded, you trace the wound outline, and the software calculates the area. Both methods are accurate (lots of evidence support them), but, both are expensive and labor intensive, making them great for research, but not practical for the clinic.

Renee

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Just take series of pictures, you may use digital
camera, This gives more than the size of the ulcer.
nice way to track the healing process.

Good luck KT Kishan MD Vascular Surgeon Warsaw Indiana

Sharon,

Check out the Accu-Rulers at www.accu-ruler.com You can get a free sample to see if this is what would be best for your practice. They are disposable, cost-effective, and designed by nurses.

Gerry Martin

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Sharon,

In 1998, after having used hundreds of different methods, I got tired and created my own method to measure any type of wound. I conducted I one year study of this method and proved it to be just what, we as wound care specialists were looking for. this may sound as a plug for my work, but really is, but an innocent one. I am in Brazil now, and am the owner of a Home Care Agency that has within it's structure a wound care clinic ( the only model that seams to work in this country since, a study has shown that must of the wound care patient here are very low income people). I have not published the material as of yet, but would be glad to share with you, and let you try it yourself, it is very simple but its results will satisfy the clinician and the payer source as well. Send me your e-mail so that I can send this method to you, it will change the way you quantify and qualify your work.

E.O.Leme,RNC
Brazil

medika@onda.com.br

Vone

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There are several companies that you can contact but I have found that Medline Industries offera variety of dressings at a LOWER cost. Check it out at www.medline.com or call for a catalog 1800-633-5463. Amy Pastor RN MCP

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For the Surgical Dressing Policy by Medicare, refer to any of the Durable Medical Equipment Regional Carrier websites. For example, find this policy
at www. cignamedicare.com

Pamela McKeown
Health Economics Manager
 

Abigail

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Hi:
This process really depends on the wound care center. Most have a set protocol as to how they screen their patients. For example for venous ulcers they may order vascular studies-including ABI, wound culture, biopsy depending on the age of the wound. Usually, one good benefit of going to a wound center is that there may be multiple disciplines- such as vascular specialist, Infectious disease specialist etc. working under one roof. For Medicare patients the process is easy, but for managed care it is a bit more complicated because of the time lapse in services which depends on so many factors. I hope this answer helps. If you are looking for specific protocols as examples- well most are adapted from 'sound' wound care practice. You may have to form a committee of clinicians to develop a plan as to screening--and then again there are probable many floating around on the internet for the taking.

Best Regards,

Jamie B. Pinnock, RN
Tele-Medicine Wound Care Consultant

My question is...patient is receiving 3 different therapies and they are done often. Does this approach benefit the patient?

GC

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Hi:

It is not usually recommended that multiple topical therapies such as you described be used simultaneously- because it is difficult to understand or deliniate just exactly which product(s)is being effective. However, most clinicians through experience or research may employ a systematic approach to treating certain wounds. Is the patient a diabetic? More and more clinicians are taking a very aggressive approach to treating diabetic wounds especially foot wounds because diabetics are prone to multiple complications and the risk for amputation is high. The HBO therapy most likely is being utilized because the patient may have had a number of diagnosis- which may include diabetes, osteomyelitis-infection in the bone, risk for infection based of the patient's health status, arterial insufficiency. If I were you I would ask the treating clinician why they have chosen these therapies
together.

Best Regards,

Jamie B. Pinnock, RN
Tele-Medicine Wound Care Consultant

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The wound bed is being disturbed too much. You are not giving the new skin cells a chance to really get good and attached before you are disturbing them. It has been my experience that with the HBO treatment daily, that following treatment apply hydrogel to wound base and light pack with nugauze. We recently had a foot wound on a diabetic that went from the sole of the foot almost through to the other side. Diameter no larger than a pencil. We were able to have closure of this wound in 2 1/2 weeks using the above mentioned treatment. Consult with the physican caring for this patient and see if you can get treatment reduced to daily following HBO treatment. Good Luck..Jan,LPN Wound Care Coordinator

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Hi
I am a treatment nurse at a local rehab center. I have experienced the more you mess with a wound in an elderly pt the more damage you cause. I have had great results in using a product by Convatec "Aquacel Ag" it can be used to pack a wound or used to place on top of one.

Thanks for the time,
Deborah Summerlin Lvn

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My question would be does any residual silver from the SSD hang around and inactivate the Regranex. It might be worth a call to Johnson & Johnson to check. It's an expensive product to waste.

Renee C., MSPT, MPH, CWS

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Surgeons tend to order aggressive treatments with amputations since the risk of ischemia is high and the possibility of for amputation is still possible. I would question the fact that Silvadene should be used short-term only because of it impedes healing. BID woundcare is appropriate if there's alot of drainage, but that also can be controlled with an alginate. If there's not alot of drainage then the care should be daily instead. Amy PAstor RN, CWS

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GC,

In wound care I found that the practitioner has to have a mix of gut feelings and good clinical knowledge, old practitioners understand what I am talking about, it is as ,if you talk to the wound and the wound tells how it is doing. Each case is different each time. I graduated in USA, and now practice in Brazil, and I can tell you if using 3 or 6 different therapies is working for the patient, than so let it be. Off course that you always must use good clinical judgment, and work with goal that are well formulated and individualized.

E.O. Leme,RNC

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We've had a few patients that have used it for that reason. I'm not sure if there's proof of its effects on circulation but it seemed to have helped a couple of our patients. Amy PAstor RN CWS

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it is a true & real prescription.NTG as ointment mostly applied in patients suffering from the systemic sclerodermas.

Dr. Farid Taymouri ,Pediatric
Rheumatologist from Tehran.2

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Hi:

I have seen this used, but as far as effectiveness it depends on how compromised the patient is and whether or not the patient has other comorbidities that are contraindicated for the use of nitro ointment. As far as studies- I have not come across any--but this is a good one to research. I suggest looking for recent research on this via an internet medical search engine.

Best Regards,

Jamie B. Pinnock, RN
Tele-Medicine Wound Care Consultant

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We are a LTC facility that uses nitropaste all the time for wound healing. It works really well. We have had lower extremity ulcers that were nonhealing for up to 2 years that are now healed. I have the staff continue to rub nitropaste to the area to KEEP circulation to the area once they are healed. Keep in mind that nitro is to improve circulation and it works well in areas with poor circulation. Those areas are already compromised by poor circulation so you are just helping to keep circulation flowing. Because those areas have poor circulation, the nitro does not affect the heart or change the BP. I have found that on diabetics, the use of nitro improves the comfort to their lower extremities. I do use nitropatches (0.2mg) to each foot and the problems with neuropathy have resolved. I don't think you will be disappointed with the outcomes!!
Cindy Rice RN, WCC

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Claudette,
I have never read any recommendations for Nitro to be used specifically for this reason although it's an interesting concept. I would have to advise against it since Nitroglycerine decreases preload and to a certain degree afterload with changes in the coronary vessels, unless you can find/ or be provided with specific guidelines stating this as an approved treatment for arterial insuffiency.
Donna Cameron RN WCC

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Novel idea!!! It might work. May give the patient
headache. It has been tried for anal fissure to loosen the smooth muscle. Try it. Tell the patient about the side effects. Good luck Please let me know the results. vcindiana@yahoo.com

KT Kishan MD Vascular surgeon Warsaw Indiana

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Claudette,

I have heard of, but have never seen it done, it is like BIG FOOT story! I would never do it, as I would be afraid of the transdermal absorption of the nitroglycerine. I have more creative and safe ways of increasing the local and systemic circulation.


E.O.Leme,RNC.
Brazil

Julie

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Our Ohio state regulations now define any excoriation, shearing/friction as pressure and we must document and treat it as such.....you might want to check with your regulatory people.....always document extensively
about all the factors causing the problem and all the interventions you are using to correct it..........moliver, PT

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I don't believe I would classify these areas as pressure as they are not over a bony prominence. I would go with either denuded, non-pressure moisture related area or could also be coded possibly as a rash (if you look in your MDS book under section M) or just an abrasion. I really don't think I would go with traumatic I kind of thought a shear has more to do with bony prominences also. There have been some changes recently concerning coded skin issues. LPN wound nurse

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I am a wound care nurse in long term care in Alabama.What I have to do is stage the area but then I can explain the etiology of the wound in a narrative.Also important in avoiding state sanctions is to make sure you cover the cause in the patients care plan to prevent recurrence. My Name is Dee I am an LPN

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Determining the cause of the skin break down is the number one starting place for labeling wounds. If the cause is undetermined and the area is not located over a pressure point you can use the term "Lesion" in your description. This term is defineds as : (1) a wound: injury. (2) A well defined bodily area in which tissue has changed in a way that is characteristic of a disease. If the wound is not a pressure ulcer then a description of partial thickness or full thickness wound is also acceptable. Hope this helps..Jan,LPN Wound Care Coordinator

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MMM..This is such a simple but interesting question.

The wounds may be classified as stage 2 pressure ulcerations--because of the loss of the top layer of skin- if the patient is bed ridden, chair bound
etc. But, if pressure shear or friction is not a factor-then those areas may be the result of excoriation from urine feces etc. But always classify based
on the factor that is most prevalent. The patient may also have a fungal infection or other skin condition. The meaty part of the buttocks is usually
classified as the 'buttock'. It is best to have the patient evaluated by a wound specialist- because they are usually much more skilled at assessment
and documentation. If all else fails write exactly what you see. Example. There is a 0.5 x 0.5 cm x 0.1 cm area of break in skin located on R Buttock -present x 2 weeks. It drains a small amount of clear fluid. it is
painful to touch '5" on 1-10. Pt. also c/o itching to area. The surrounding skin is red and excoriated. The base of the wound is pink. There is no odor
or s/s of infection-etc etc. it is also good to use the Braden scale to assess the patient's risk for breakdown. There are many tools available for
wound assesment. There is just so much out there in wound care planning. I would encourage you to get a basic book on wound assessment and
documentation-- or suggest that your facility hire a Certified Wound Care Nurse-- if nothing else to offer eduational inservices on wound assessment
and documentation. If a Rep from a particular wound product company such as Coloplast, Convatec, Smith and Nephew Etc.. visits your facility ask him or her to host an inservice--many times they can arrange educational meeting
for you. Best of Luck.


Best Regards,

Jamie B. Pinnock, RN
Tele-Medicine Wound Care Consultant

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Dear Julie:

Wounds such as you describe are usually referred to as partial-thickness "erosions." People also sometimes use the term excoriation, which is not exactly correct because that means scratches or scratch-like wounds. You are correct that most often the cause is exposure to incontinence of urine and feces. These wounds are usually not on bony prominences, and are usually surrounded by a very large area of irritated red intact skin. Treatment that seems to help the most is the use of a non-lanolin zinc-oxide-based skin barrier ointment to the entire red area after every episode of incontinence. Prompt cleansing and drying after incontinent episodes and repositioning are important. There are many brands of Zinc Oxide ointment, and most are inexpensive (and non-prescription). Many have other things added, so read the ingredients to see if it has lanolin, fragrances, or other potential irritants or allergens. If the open area needs a dressing, you need to choose one based on the specific characteristics of the patient: size, texture of skin, quality of skin, location, severity of incontinence, etc., so it is hard to give a blanket statement that dressing X works best. Like any wound, if you remove the cause, they usually heal well regardless of dressing choice. Hope this helps.

Bryan Gibby, MSPT, CWS

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Julie,

You must not be permanently attached to any pre-fabricated description of a wound, I have always believed that a good clinician has to be prepared to go above set description protocols. Its is like you calling a UFO a UFO, instead of describing it. Besides, you have done a great job in describing this wound, that all you must do, describe with accuracy what you see. Don't be afraid of writing down exactly what you see, it is better than you writing what you think you see.

E.O.Leme,RNC
Brazil

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By the time you get this, the skin flap will be long dead. If you catch it immediately, you might be able to flatten it out. If it's still attached, you should be able to see if there's a twist in it, therefore if the right side is down. But, if it's in a ball, I would
probably debride it off, and do good wound care to the remaining wound.
Renee C., MSPT, MPH, CWS
 

In this case I would unfold the skin ; you can tell the proper side eventually looking for a hair follicle .It's not a matter of a 1/4 inch still being attached.The skin in this case behaves like a free skin flap . It is important no stitches are used. Just mold the
skin over the wound and have the courage not to renew the dressing for at least 21 days. Use a non adherent gauze over the flap . Some reabsorption may occur at the margins of the flap but usually
you get a perfectly healed wound.

I am an Orthopoedist who dwells mainly with trauma.

Best Regards
Bruno de Paola

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It is always a good idea to attempt to re-approximate the wound edges. It is easiest to do immediately following the injury however I have been able to do so a fairly short time following it by getting the tissue pretty moist with saline. The easiest way I can tell you to do this is by moistening the site well then using a cue-tip and gently getting under the skin flap and kind of rolling it onto the cue-tip away from the tear then rolling it over the open area. It may take a few try's but if you keep it moist and do this very gently it should work. After you have it re-approximated you do need to use steri-strips to hold it in place. It is pretty easy to tell if you have the right side up. These areas really do heel a lot better if you re-approximate the skin.

Miller

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Hi:

This sounds like a sizeable wound/ skin tear. 'Flapping' the skin over a 'new' wound depends on whether or not the skin is still viable- meaning
alive not dead and dry. Time is the key factor here. If it is dry and hard...more than likely it will have to be removed. It is best that the patient see a wound specialist, dermatologist, or even Primary care M.D. in this case to determine what structures are involved and what they best approach to treating it is.

Best Regards,

Jamie B. Pinnock, RN
Tele-Medicine Wound Care Consultant

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Dear Blesser,


If you are asking this question it is a good indication that you must find a health care professional to orient you in person. This type of wound must be analyzed, one must be able to identify the correct thickness of the detached part of the skin to determine if it has enough circulation to sustain healing or to promote tissue death, also there are many other considerations such as the possibility of infection etc. And if you look closely at your skin, you will be able to tell each side is up, but please look for help.

E.O.Leme,RNC
Brazil