Clarification: Paper based is preferred right now and yes, pure documentation not outcome tracking. Thanks!!

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Documentation with every dressing change is imperative. The question remains is how detailed does your Administrator want? When I was a Nursing Administrator for a home care agency, my requirements were: each dressing to include type of dressing, location, describe the wound bed, i.e. pink with granulation around edges, the type and amount of drainage, i.e. saturated 2 4x4s with pink drainage, what the wound was cleansed and dressed with, and how did the patient tolerate dressing change (pain). What you instructed the patient/caregiver on and their response, i.e. demonstrated dressing change with aseptic technique. On a weekly basis the nurse documented length, width, depth, undermining and tunneling. Initially and monthly photos were done (with patient's permission) using a tape measure, date, patient's name and ID number in the photo. This society likes to hire lawyers and sue, it doesn't matter if they are Hospice patients. Complete, concise, accurate, and clear documentation is your only safety net. If you ever got pulled into court you would appreciate this type of documentation.

Sandra Nunally RN CHCE
Manager Case Management
PacifiCare Arizona and Colorado

 

Vicki,

I suggest you find a someone who specializes in wound healing. After this much time you may benefit from a biopsy to help figure out why it's taking so long. Also, based on the description, it might be a
venous ulcer, which requires compression to heal (after making sure your circulation into the leg is good). It's obviously time to try something else.

Renee C., MSPT, MPH, CWS
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Hi Vicki,

The wound needs to be assessed by a competent wound professional. It could be a venous insufficiency ulcer or an arterial insufficiency ulcer, or an ulcer that is complicated by both arterial and venous insufficiency, or something else entirely. To get the correct treatment, you need a correct diagnosis. For example, if the problem is venous insufficiency, you probably need some sort of compression on the leg. However, if there is significant arterial blockage, compression of the leg should be avoided. Find a wound specialist in your area who will explain things thoroughly and make sense.

Vicki, MSPT, CWS

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is the ulcer on the inner or outer side

what is the basic underlying cause of the ulcer, is it secondary to varicose veins, arterial disease, do you have raised BP, is there any history of a major injury to the limb, is there a diffuse swelling of the limb or is there pitting edema? Unless the underlying cause is addressed the ulcer will refuse to heal or will heal and then recur.

dr. kumkum khadalia (plastic surgeon)
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The first thing that you should do is find another doctor. Preferably one that is a specialist in wound care (look for a wound care center) or a nurse managed wound care clinic. For any wound of that duration, it should be biopsied to rule out any type of cancer. While they are doing a biopsy, they should also culture it (if it is not necrotic-- covered in dead tissue). Since it is on your leg, you also need vascular studies to see if you have enough blood flow to the area. You did not mention if you have swelling in your leg or if you have other types health problems. All of these relate to your wound so be sure to provide a complete health history. The type of dressing (saline moist dressing) does not sound appropriate based on the duration of the wound. You most likely have an underlying problem that must first be addressed before the wound will heal. For instance, if you don't have enough blood flow, you may need a medication to improve blood flow or surgery. If you have swelling, this must be taken care of. The number of years for the medication that you have been using is too long as well.

Good luck....April RN CWOCN
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Vicki,
First I would need to know exactly what kind of wound you have on your leg. It is probably one of two types, venous or arterial. If it is a venous wound it will be fairly easy to heal with the proper treatment. Arterial
wounds are harder to heal. I don't know anything about you personally but will tell you a little about the cause about the different wounds. Venous
Stasis Ulcers: usually appear form excessive edema in the lower extremities due to age, work history, and weight. They can be treated fairly easily with
compression therapy, and prevented by compression garments. With venous stasis you have good blood flow into the lower leg but have trouble getting
that fluid back to the heart. With Arterial wounds you usually have peripheral arterial damage, either hardening or blockages, and without blood
supply these wounds are hard to heal. A vascular surgeon might can help with this type. I would suggest seeing a MD and having an arterial test such as a Arteriogram to determine which type of problem you are having. Most wound specialist can look at your wound and determine which type of wound you
have. Also they can do a quick test by checking the blood pressure in your arm and your leg and determine if you are getting a good blood supply into
the lower extremity. Most clinics have a machine called a doppler that can detect a pedal pulse. All this said you need to know for sure which type of
wound you have because the treatment for a venous wound is contraindicated for an arterial wound. Once this is determined you can begin to treat the
wound. A lot of nurses and MD's generally treat wounds very conseratively and use the same treatment on a lot of different wounds. Find a clinic that specializes in wound care and they can probably help you, especially if it is a venous stasis wound.

Bryan Luster, PTA
lusterbryan@hotmail.com

I would not use Tegaderm on fragile skin. It can tear it further.
Something not adherent would be better. Someting as simple as Adaptic or Vaseline gauze, more expensive like a Mepitel, or even a non-adherent foam if it's draining a lot.

Try to find a wound specialist to help. www.aawm.org, www.wocn.org
Renee C., MSPT, MPH, CWS

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I have also seen a Tegerderm turn a simple skin tear into a Stage 4 wound.
BP

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Do the edges of the skin tear reapproximate (come close to touching each other and covering the wound)? If they do, usually the best results come from closing them with steristrips, which you would not remove until they fall off by themselves. Tegaderm can help to remoisten and revitalize if there is open, dried tissue, but if placed on a large skin tear as this, the fluid buildup can actually float the skin flap up off the wound base and slow down healing. Tegaderm also needs to be changed every few days, which, of course puts him at risk for further skin tears from peeling the Tegaderm off. If there is still exposed open wound after reapproximating the edges with steristrips, your best bet is to dress it with a non-stick foam such as PolyMem or Allevyn. This would only need to be changed every 3-7 days, depending on the amount of drainage. Secure the foam Kerlix or similar wrap, not with tape or adhesive, again because of the risk of further skin tears.

Bryan Gibby, MSPT, CWS

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I like to use a transparent film drsg on skin tears. Opsite is one brand. There is usually very little discharge with these tears and the opsite remains in place until the tear is healed. This eliminates the sticking and ripping cycle you mention. If there is too much discharge for a transparent drsg, I would suggest Mepitel instead of the non-stick pads you are using. Mepitel is designed to be left in place while you clean the wound "through" it and change only the outer drsg.
KR RNBN

It is a silver dressing. It comes as a contact layer and rope.  If you have another silver product on your formulary, you can likely substitute it.  http://www.silverlon.com/

Renee C, MSPT, MPH, CWS

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Hello,

The dressing you are seeking I believe is probably Silverlon. I have used it with some success in various wounds. It can be packed into wounds, which I like, and not all silver dressings can be packed. It can be found in some pharmacies in my area. A particular Rx note about it: it needs to be moistened with sterile water, not saline, to work.

Vicki, MSPT, CWS

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Actually it is called Silverlon, another brand is called Acticoat, and you can get an absorbent dressing called Aquacel Ag that is a silver impregnated dressing.

unsigned

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Sterling Medical Services stocks it. You can call 1-888-202-5700 for free shipping and no minimums

Michael Calogero RPh, PharmD, CWS
Senior Director of Clinical Services
STERLING MEDICAL SERVICES

Kazo

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Hello,

I have found that the product manufacturers are ususally very willing to help with problems such as yours.

Vicki, MSPT, CWS

If a Physical Therapist is available to you by all means include them on you committee. A PT can provide information regarding positioning devices, pressure relief devices and give an opinion on the appropriate treatment.

In the facility where I work, our PT is part of our skin care team. We make weekly rounds on all patients with pressure, stasis, venous ulcers as well as rounds on new admissions who are at high risk per the Braden Scale.
After rounds we meet and discuss the plan of care for each patient.

Our committee includes Nursing, dietary, physical therapy as well as a pharmicist who is involved if an area does not show improvement within 2 weeks, to review the patients medication profile.

Hope this helps you and good luck

Lynette,RN

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Good thinking on the part of your management to develop a wound care team. The best teams are multidisciplinary. I would include PT (especially someone who has advanced training in wheelchair seating), OT, a registered dietician, an MD, RNs, LPNs and CNAs and a PTA. Everyone needs to be involved since preventing and healing wounds require a holistic approach. A risk assessment should be done on every patient such as the Braden and then goals can be developed that are specific to each discipline. Don't forget to include the unlicensed personel since being involved in such a team can give them a since of ownership and make them more motivated to implement your strategies. You should also include whoever makes purchase decisions at your facility regarding wound care products and support surfaces so that this person gets a better idea of why you will ask for certain products, beds, wheelchair cushions, etc.

Good luck. April RN CWOCN

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Hello,
The members of your wound team should be people who are essential to the practice of wound care in your facility. Not all physical therapists know about wounds, just as not all nurses or other health professionals know about wounds. If your therapist knows about wounds and will be treating wounds, then he/she should be on the team.

Our wound team consists of PT, nurses (again, those that know about wounds), dietician, speech therapist as indicated, MD.
Vicki, MSPT, CWS

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Multiple disciplines should be involved. RN, Treatment nurse/LVN, CNAs, PT, OT, RD, infection control nurse, medical director, and so
forth. The role of the PT will depend on who you have on staff, what the state practice acts allow, and what reimbursement strategy you wish
to pursue. Some PTs love wound care and specialize in it, while other hate it. See who you have on staff. Also, for the part As, PT
involvement in direct wound care can raise the RUG to a rehab level, leading to increased reimbursement. For custodial patients, Medicaid
and Medicare B can pay for the services, while the nursing care is included. PT and OT can work on seating, positioning, and mobility also.

Renee C., MSPT, MPH, CWS