Dear JB:

I cannot answer your question because you did not provide enough information. Are you talking about a Foley catheter? If so, male or female? Is it inserted in the genitalia or is it suprapubic. There are also other types of catheters such as nephrotomy, uretotomy, stomach feeding tubes and intravenous. Please specify.

Thomas A. Sharon, R.N., M.P.H.
nursetom@msn.com

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JB,
You have not said what catheter type and the sex of the patient. But I suppose you are talking about
urethral catheter. The problem you mentioned is a
common one especially in male patients requiring
catherization for a long time. The Pathophysiology is most likely as result of persistent wet environment
either as result of peri-catheteral leak or other
source of moisture that help in the growth of fungus,
then tineasis and ulceration of the region in Question
develops. This is similar to what is obtained in the
foot or the perineum where wetness aid the development of tinea pedis (athlete's foot) and tinea cruris respectively. The problem you mentioned is possibly further exacerbated by the movement activity as secondary traumatic event and not as a primary cause. The Solution to this problem either in the form of  treatment or prophylaxis may be to use saline solution (hypertonic) cautiously and regularly for open dressing alone or in combination with non-petroleum base antifungal agent as the case may be. This is in addition to restriction of movement of the catheter. Remember petro-base substances attack the latex material of the catheter.

Dr Sabo AM ,
MBBs, Msc
Physiology Dept.
University of jos.
Nigeria.

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Dear Ms. Bates:

12 hours.

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

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Hey Ann,

I've been doing home care for about twelve years. At the agency I work for now, we do bid wound care six hours apart. IF we teach the family to do it we recommend that they change it more like ten hours apart if possible. We have a "unwritten policy" at our agency now that am dressings are to be done before ten AM and PM dressings can not be done before 3PM but if the AM dressing was done at ten AM we have to wait until at least 4PM to do the evening dressing. I remember years ago when I had bid wound care patients at another agency.....bid meant q 12 hours so it was 8am and 8PM and that really was difficult to have a LIFE around those hours. Our goal, of course is to teach a caregiver or the patient to do the wound care and then they can separate the hours out a bit better...

Rachael N, RN, BSN

A lot of soaps are harsh, with a very high pH. If this is the protocol, make sure it's a milder soap, with pH as close to 7 as possible. Dial, commonly used, is especially harsh. I think Dove is mild, but check to be sure. Normal saline is usually quite sufficient.
Renee C., MSPT, MPH, CWS

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Dear Nurse Brickel:

Your ECF's policy is in violation of the universal standards of good and proper wound care whenever it is applied to an open wound of any etiology. The washing and dry dressings are preventing healing and are thereby rendering the patient more susceptible to infection and further catastrophic complications. The washing and irrigation obliterates the intrinsic healing factors that are necessary for granulation and the dry dressings rip off any existing healing tissue when they are removed. Consequently, your facility probably has the cleanest non-healing wounds on the planet. Thus your facility's policy or current practice is detrimental to the well being of its residents.

Additionally, your intuitive question seems to arise out a suspicion that something is wrong. Therefore, you need to be the catalyst for change. Here are a few suggestions:
-Do research on the generally accepted standards of wound care on the internet [there are hundreds of sights] and print some of those;
-Write a letter to the director of nursing, administrator and medical director and include the material you downloaded from the internet;
-Give the administration a reasonable time to respond to your letter;
-If there is no response contact the state health department to report the institutional breach of professional standards and violation of the state health department regulations [nursing care facilities are required to provide nursing within good and accepted standards of nursing practice].
Remember that there are laws that protect whistleblowers, but remember that being a patient advocate is the most important role of any nurse. Good luck.

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

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Hi:

I suggest that your facility get a wound care consultation soon to help set up protocols for skin and wound care. Soap and water is not generally good for compromised skin care because the alkaline nature of most soaps damage compromised skin- thus making it more prone to drying and breakdown.

Best Regards,

Jamie B. Pinnock, RN

FIlms, in my opinion, should be changed when the goal is met: wound closed, scar mature, or the moist environment is maintained and too
much fluid is contained. I like the idea of 7 days and PRN, provided the caregiver knows when PRN occurs. If the caregivers are not qualified to make those assessments, I would make it a shorter period
of time, as indicated by the patient condition.

Renee C., MSPT, MPH, CWS

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Dear Danette:

Always check the manufacturers recommendation [MR]. The clear site dressings are structurally engineered to prevent outside contamination while allowing exudates to drain off and providing wound visibility for visual inspection and maintaining natural moisture. The length of time that a dressing can safely remain depends on the permeability of the plastic film and condition of the wound.

Most brands that I know of recommend changing every three days. However, there may be more complex designs that call for changing every seven days plus PRN. Take a look at the package insert or go to the manufacturer's web site to see if 7 days plus PRN is the recommended protocol, or is the facility trying to stretch the three-day dressings to save money?

However, remember that the MR is merely a guideline. While the raging debate continues, every nurse should not lose focus on the overriding principle that the wound must be inspected for clinical progress every shift. The transparent property of the dressing makes that possible.

Here is a tip: Since the orders are for changing every 7 days plus PRN, changing the dressing more often is left to your discretion. Thus you can change it whenever you deem necessary and avoid arguing with the wound care consultant.

While I am on the subject, here is another tip that will foster the highest possible quality of care and cover you in any legal forum: When documenting your q shift observation of the wound never write "Dressing intact". Always note the size, color, quantity and quality of exudates, condition of surrounding skin etc. If you write "No change" make sure it is a "no change" from your last observation and not someone else's.

Thomas A. Sharon, R.N., M.P.H.
Author, Lecturer and Patient Safety Consultant

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LEAVING A TRANSPARENT/FILM DRESSING ON FOR 7 DAYS IS CONSIDERED APPROPRIATE UNLESS THERE IS ALOT OF DRAINAGE.
AMY PASTOR RN CWS

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Orders written q7 days & PRN allow you the flexibility to leave the transparent dressing on for a period of up to 7 days while also allowing you the option of changing the dressing as needed. If the wound is clean and the dressing is intact and clean, it may be better for the delicate periwound to leave the dressing on. Transparent dressings allow visualization of the wound bed, change it if needed. M. De Foster RN, CWOCN

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7 days is ok fas long as the drainage is not macerating the skin and there are no s/s of infection. Vicki, MSPT, CWS

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Hi Danette,
7 days is not too long at all. You would only use transparent drsgs on wounds with minimal d/c, and on skin tears with almost no d/c, I have left them on longer than 7 days. As long as the wound underneath looks clean with minimal serous d/c. The point with a transparent is that you leave it for as long as you can. If the amount of d/c from the wound is leaking past the edges of the drsg in only a day or two, you shouldn't be using a transparent.
KG RNBN

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Transparent films can usually be left intact up to 7 days depending upon the patient, the amount of drainage, the location etc. The wound treatment nurse did say q 7 days and prn- most likely this means that if there are no s/s of infection, if the dressing is not already coming of etc- it can ramian for 7 days. But if on day 3 you notice excess drainage etc then change it. Usually if after a day or 2 the film has to be changed consistently then the
treatment nurse has to be notified so that she/ he can choose a more appropriate treatment. To facilitate communication rather than creating a
divide- I suggest telling the treatment nurse exactly what is being observed- excess drainage, odor, pain etc.

Best Regards,
Jamie B. Pinnock, RN

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Dannette-
Most manufactures say that if there is NO drainage and you are protecting a scabbed area 7 days is fine for most transparent dressings. However, if there is drainage under the dressing it should be changed every 2-3 days but never more then 3 days. If you need some "fire power" to prove your point remind her that it takes 72 hrs to grow a culture, which means it takes 72 hrs for bacteria to grow (in a warm, moist enviroment) enough numbers to be deamed infection. Primary infection on skin or in wounds is staph, make sure you are montoring skin temp. around the dressing along with the color and odor of the drainage.

Tina (treatment nurse)

Rob,
I practice in a state where the practice acts of nursing and PT both allow for sharp debridement to wounds with an MD order. For nursing, the clinicians have to have a specialty certifications such as CWOCN or ET nurse to be able to debride. Each state my vary as to practice acts and rules. Check our New York's acts for more info.

As to wound education, the Wound Congress (meets this fall in New Orleans) and the Advances Symposium (meets this fall in Phoenix) are the best in my opinion. Lots of different presentations, for different levels of expertise.
Vicki, MSPT, CWS

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The technical difference is how they are trained. At our facility even though we have nurses certified in wound care we will often call upon our PT dept. for advice/assistance when we run into a difficult wound. The nurses in your clinic may have been certified by the WCON organization which only certifies RN. Wound Care Education Institute certifies PTs, RNs, and LPNs that meet their requirements. Excellent week long course. Well worth the time and money invested. For information on this see the top of this page.
Good Luck
Kate RN, WCC

---

There's a lot of overlap between nurses and PTs in wound care. We both do hand's on care and patient education. Nurses have the slant of their training, administer medications, and so forth. PTs have the slant of our training, and look at functional mobility issues, ROM, exercise, and orthotics/prosthetics, and do modalities.

Reimbursement for each discipline is very different.

For courses, look at: www.woundcaresymposium.com,
www.symposiumonwoundcare.com, educators2000plus.com.


Look also at www.aawm.org to learn about certification once you gain experience. I encourage you to also join the AAWC www.aawc1.org, the premiere wound care professional association.

Renee C, MSPT, MPH, CWS

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Dear Mr. Kaplan:

Wound care is one of the several areas of overlap between nursing and PT. However, when doctors order PT modalities as a wound care regimen, this falls more in your area (e.g. mechanical debridement and electrotherapy). When medications are ordered such as enzymatic debridement or antibiotic therapy, this falls within the nurses' purview.

My suggestion is to check with your professional associations for CE courses that will update your practice for wound care. Also, contact The Diapulse Corporation of America to inquire about their Diapulse Wound Care System. The web site is www.diapulse.com There you will find the most effective wound care program in history (I get no compensation for this recommendation).

Thomas A. Sharon, R.N., M.P.H.
Author, Lecturer and Patient Safety Consultant

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CONTACT THE AMERICAN ACADEMY OF WOUND MANAGEMENT. RN, LPN AND THERAPIST CAN OBTAIN THE SPECIALTY CERTIFICATION ( CERTIFIED WOUND SPECIALIST) THEY ARE ON LINE ALSO.
AMY PASTOR RN CWS

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Ron......there is no difference in the professions as far as being a wound care specialist......PTs, PTAs, RNs, LPNs,NPs and physicians can all sit for the certification exam.....get online with just "wound care" and you can find lots of references for courses and certification training....the PT journals and APTA will have courses listed and try your wound care products vendors...they all have training and specialists who will come out to the facility and help you(Smith & Nephew has a wonderful 3 day course that prepares you for the certification test) You definitely need a sharp debridement course.......but check your state practice act (in Ohio PTs are permitted to sharp debride) We bring a little different dimension to wound care because of our use of modalities (there are courses on modality use in wounds also)............the trick to harmony among disciplines is to co operate....everyone brings just a little different knowledge and experience to a wound....the Team approach works really well and it is a good way to demonstrate your knowledge and gain credibility with the docs and nurses......Good Luck, M.Oliver, PT

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Hi-

I suggest that you contact the New York PT board to find out what your scope of practice is as far as wound care. Some times PTs can do sharp debridement depending on training etc- but the board is the best place to find out what your qualified under your license to do. Did you know that wound care was originally a Physical therapy discipline? I wish you much success in your pursuit of this. Also, the hospital where you work may have protocols as to
who and how wound care is done--so check them too.
Best Regards,

Jamie B. Pinnock, RN

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I'm a CWCN currently working in LTC, but spent 2 years in an OP Wound Care Center. This is the way I see it--wound healing happens, no matter who does it, if the principles of wound healing are followed. It's like the difference between a DO and an MD; their philosophies may differ somewhat, but the outcome is the same. What I have observed is that PT's procedures are usually reimbursed by Medicare or insurance, whereas nurses' services are usually not procedurally charged for, with the exception of in-home dressing changes for those clients unable to leave the home or do their own dressings. PT's can charge for whirlpools, pulsed lavage, sharp debridements, etc. This brings in money for the nursing home, hospital, or home health organization. There are some nursing homes where the PT is responsible for the wound care and not the nurse, and I believe it is because of reimbursement. I know that the PT generally has a master's degree upon graduation, whereas the nurse may be an LPN or RN (AD or BS). What I don't know is what the PT curriculum includes. In nursing, we assess the entire patient, not just rehab potential. Our assessment includes physical, psychological, nutritional, social, educational, spiritual, as well as other elements. Unless the PT is really into wound care, I have not seen them assess the entire patient and identify those conditions which may impact wound healing, like malnutrition and other underlying medical conditions. That's not to say that PT's don't have a place on the wound care team; they do. But nurses and PT's have to learn to work together for the benefit of the patient. Carrie Sussman is a PT who has written a book about wound care, PT's and nurses. I haven't read it, but it sounds interesting. I have learned from experience that some PT's want no part of wound care and some are very into it. We had a PT come to our facility with the attitude that only PT's could do proper wound care. She had only worked in nursing homes with LPN's and had not worked with a CWCN before. We had our "encounters" and learned to work together. She left because our Medical Director wanted Nursing in charge of wounds and not PT. She also decided to pursue her CWS. I think she saw that certification in wound care is a plus. Hope everything works out. Nancy B., RN, CWCN
 

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Dear Andrea:

It would not be prudent or safe for me or any other writer to recommend a dressing. The person you are caring for must be seen by a wound care specialist at a wound care center for a medical evaluation. She might need debridement and/or antibiotics. Please take her to the nearest available facility without delay. At this point we don't know the underlying medical condition that caused the wound and is preventing it from healing

Thomas A. Sharon, R.N., M.P.H.
Author, Lecturer and Patient Safety Consultant

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#1 RULE IS TO OFF-LOAD THE PRESSURE. YOU NEED TO MAKE SURE PRESSURE IS ALLEVIATED (IE: APPROPRIATE MATTRESS/CUSHION FOR CHAIR) AND KEEP FEET/HEELS OFF OF FLOOR/BED.

REDDENED AREAS CAN BE TREATED WITH A HYDROCOLLOID DRESSING SUCH AS DUODERM OR COMFEEL, AND CHANGE 1-2X Q WEEK

STAGE3- NEED TO DEBRIDE SLOUGH THEREFORE TREAT WITH A DEBRIDING AGENT (IE: PANAFIL, ACCUZYME OR COLLAGENASE SANTYL) FOLLOWED BY NS WET TO MOIST DSG CHANGES, AND CHANGE DSG QDAY. THIS WAY YOU ARE PROVIDING ENZYMATIC AND MECHANICAL DEBRIDEMENT.

Amparo

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Hi,
Your best bet would be to find a home care agency or outpt clinic to take her that has wound specialist clinicians who will use moist wound healing protocols, minimal topicals (unless infected or needing to be debrided) and who will listen to you and answer your questions to your satisfaction. In my experience, if a clinician knows what he/she is doing, questions are not a bother for them to answer.
Vicki, MSPT, CWS

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HI.
From my experience I believe that you can use honey to treat that lady, and you can contact me for more details.

Dr. Almahdi Aljadi; PhD Biochemistry
aaljadi@yahoo.com

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I suggest you have her evaluated by a wound specialist. Make an appointment with her PCP and get a referral. One thing I would like to point out is that she may need a proper bed or surface to offload - without offloading the wounds probable won't heal and she runs the risk of developing new wounds all the time. Also, how is her nutritional status- is she getting enough protein- does she have any other underlying conditions that decrease her healing time or overall chances of healing? Is she incontinent? Is her
skin very moist? (more than normal moisture). The answers to these questions will help guide you what you need to do to help prevent breakdown.

Best Regards,

Jamie B. Pinnock, RN

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She is staying on her left side too long. Many different dressings would work as far as topical treatment--but they will not heal if there is not blood supply.  unsigned

Wanora

There is a big difference between Fibrocol and Promogran, and they are not interchangable. Fibrocol is a collagen alginate. Promogram is a
much more active dressing, working on the wound bed microenvironment, binding MMPs while protecting growth factors. Fibrocol is used to
absorb drainage and promote granulation with the collagen. A common effect is a temporary increase in exudate and size, and wound starts to
improve.

Promogran is used to help wounds heal, especially when they're been reticent to do so. There is no substitute for it at this time. I  recommend you contact your Johnson & Johnson rep, as both products are J&J.
Renee C, MSPT, MPH, CWS

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Dear Wanora:

Your question does not contain enough information for an appropriate answer. Please have a wound care specialist examine the wound and recommend the appropriate treatment. You need to establish a professionally prescribed regimen and follow it. The trial and error method is dangerous.

Thomas A. Sharon, R.N., M.P.H.
Author, Lecturer and Patient Safety Consultant

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Hi:
Fibracol is 90 % collagen and 10% alginate. Promogran is 45% ORC- Oxidized Regenerated Cellulose 55% collagen. Promogran is suppose to specifically bind to MMP's (new buzz word in wound care)matrix metalloproteases which is
a bad thing in the wound because it inhibits growth factors. I suggest you get a wound product guide such as Wound Care Clinical Guide 4th edition
Cathy Thomas Hess, Springhouse publisher.

Best Regards,

Jamie B. Pinnock, RN

Helping Dad

It is impossible to make solid recommendations without examining him. How is his circulation in the leg? I recommend you go to www.wocn.org
or www.aawm.org to find a certified specialist near you. Not every plastic surgeon / physician / nurse / podiatrist/etc. is a wound specialist.

Renee C, MSPT, MPH, CWS

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Dear "Helping Dad":

Take your father immediately for a second opinion to your local emergency room. I do not like the sound of what you described (marking the wound borders to see if gets any larger with no change in treatment). Given that you mentioned necrotic tissue and foul odor despite the consumption of antibiotics, there is a serious risk of gangrene and amputation and your father may need more aggressive treatment in a hospital. Certainly a culture a sensitivity of the wound is in order to because the current antibiotics don't seem to be working. Make certain that your Dad gets to see an infectious disease specialist for a consult in the emergency department before they attempt to discharge him. Do not accept anything less.

The history of cancer is significant, especially if your father has recently been on chemo or radiation therapy, as those modalities interfere with healing.

Remember, if you have doubts about the medical care you are receiving it is likely that your gut feeling is correct. I mentioned this in my book, "Protect Yourself in the Hospital" (McGraw-Hill $12.95). Good luck

Thomas A. Sharon, R.N., M.P.H.
Author, Lecturer and Patient Safety Consultant

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There are different options than surgery. Physical Therapy uses different modalities to treat non healing wounds. I would ask your doctor about getting Therapy involved. Your dad can also have a skin graft done if the conditions were right enough. I hope this will help you.

Debbie Bridgewater, Physical Therapist Assistant
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Without seeing the wound it is difficult to tell you what to do. In general, any wound that is infected or has necrosis must be cleaned up. If necrotic material is present then it needs surgical debridement by an MD ,or sharp debridement by therapists or nurses, or dressings that will help the wound clean up on it's own. Any cavities must be packed so that they heal from the inside to the outside and dont end up as an infection/abscess. If an infection is present, then the packing may need to be Dakin's-damp, silver-impregnated, or some other packing to help lower the bacterial load.

Try to find a wound specialist to go to who will talk to you and make sense.
Vicki, MSPT,CWS

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HI.
I recommend them to use honey, and they can contact me
for more details
Dr. Almahdi Aljadi; PhD Biochemistry
aaljadi@yahoo.com

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Hi
I realize you must be frustrated and troubled. I honestly suggest that you have your dad evaluated by a WOUND SPECIALIST- usually an M.D. who has experience in wound care - usually has a staff of certified wound nurses and other experienced specialist to help treat patients. Ask your dad's PCP for a referral. If he is sent to a wound center- usually house multiple disciplines under one roof- surgeons infectious disease specialist, vascular specialists etc.

Best Regards,

Jamie B. Pinnock, RN

If zinc is deficient, supplementation for a short period can help.  Long-term supplementation  must be looked at closely, as it competed with copper in absorption.  The Cochrane Abstract has 2 reviews on it:

link 1, link 2   
Renee C., MSPT, MPH, CWS

Jeff

The book Wound Care Essentials by Baranoski and Ayello have a chapter on sickle cell ulcers.

Nancy B. RN, CWCN

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Hi :

You are correct. I have a few articles. send me your contact info and I will attempt to get some info to you. Most literature recommend moist wound
healing, minimal debridement. If sickle cell ulcers drain more than a small amount most likely it is infected because these ulcers generally do not
drain.

Best Regards,

Jamie B. Pinnock, RN

jpinnock@podicare.com

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Jeff-
You can debride and treat at the same time if you have aloe vera... Use it the same way you would any hydrogel... but it contains natural plant steroids that reduce swelling and pain, natural enzymes to debride the wounds, something like 7 vitamins and minerals and protein. Not to mention antimicrobial and antifungal properties. get on the e-net type "aloe vera wound care" and search literally thousands of sites support it for ulcer care.

unsigned

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Dear Sandy:

You didn't mention what type of drainage you have, but you need to note amount, color, odor and consistency. You also didn't mention if the surgeon ordered a culture and sensitivity of the wound - that is a basic requirement for any signs of post operative infection.

In any case, I recommend that you go to a local wound care center and seek a second opinion. Betadyine has an irritating and drying effect. Wounds do not heal well under those conditions. Your wound may need an undisturbed moist environment. Plastic surgeons are generally good at reconstruction and altering appearances and but don't seem to do so well with wound care when there is a post operative infection. This is when the infectious disease consultant needs to step in.

Thomas A. Sharon, R.N., M.P.H.
(Author of Protect Yourself in the Hospital; McGraw-Hill; Nov 2003)

1-888-ask-4-kci for info on the VAC.
Renee C, MSPT, MPH, CWS
 

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YES SILVER DOES BUT I WOULD LOOK AT NOT USING SOAP/WATER-USE NORMAL SALINE INSTEAD.
ANTIBIOTIC OINTMENT BECOMES INEFFECTIVE AFTER A WHILE BUT SILVER CONTINUES TO BE EFFECTIVE, BUT USE ONLY IF WOUND INFECTIVE.

AMY PASTOR RN CWS

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Hi, I have had venous ulcers for 15 years off and on. What has worked for me is to use saline solution to clean it. I have had several doctors looked at them. Over the years I have tried creams and all kinds of medicine. My doctor that I have now prescribed silver sulfadiazine cream. It has work the best for me. She prescribed blood thinners and my wound went away in less than 2 week. It used to have my wound between 3 to 6 months. I am lucky to have this doctor, she knows what she is doing. Hope this helps. Renee

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Dear Karen:

You did not provide enough information for a definitive answer as to why your wound is not healing. However, for starters the washing with lots of soap and water actually prevents healing because you are washing away the cells and body chemicals that naturally occur in the wound for healing to take place. The question of silver being effective or not is not relevant

Other factors that determine the rate of healing are
age, weight, nutritional status, quality of blood circulation in the area of the wound, presence or absence of infection, underlying medical conditions such as diabetes, vascular disease, etc., prolonged mechanical pressure.

You did not mention whether this current regimen was prescribed by a physician or is this a self-management thing? In any event it is crucial that you immediately stop what you are doing and seek medical care from a wound care center.

Thomas A. Sharon, R.N., M.P.H.
(Author of Protect Yourself in the Hospital; McGraw-Hill; Nov 2003)