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Hi

Just read your post. I had a few thoughts - first, though he is hospice, he doesn't seem imminently terminal.

I imagine interventions have been trialed to improve nutritional state, etc, and so won't mention that.

From a course I went to recently, health professionals have to be very careful about trying home remedies such as honey, without substantial research that proves efficacy. Not following standard of care can get you into a legal situation with a resident of a nursing home, with all the lawyers out there looking to profit when someone with a wound dies from complications. Following evidence based standards is the best bet, and a doctor's order does not protect you from not rendering acceptable standards of care. Unless mechanical debridement is the goal, wet to dry is to be avoided, and traumatizes the wound. Wet to moist turns into wet to dry, which in turn turns into just plain dry unless it is changed 3-4 times a day, and it either doesn't control drainage or promotes a dry wound bed. An inexpensive dressing that takes a lot of nursing time isn't always most cost effective, especially in a nursing home that may have staffing shortages, and if you can get him down to 3 changes a week, it can end up that a more expensive dressing is actually the cheaper choice.

Maybe just keeping the wound from getting worse is the goal in a patient who isn't compliant with interventions. In that case, a dressing that adequately controls drainage and maintains a moist environment is the case. Consider the drainage, periwound skin and condition of the wound bed, and pick a dressing appropriate for the type of wound with as few changes as necessary which may improve his compliance for when dressings are necessary. I would stay away from honey unless you have some hard copy research proving that it works for the type of wound he is exhibiting.

Would make more suggestions but your post doesn't say much about the wound itself.

Good luck.

S.

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Research regarding the use of Manuka honey in wound care has been in progress at Waikato University, New Zealand for over a decade. You can locate their web site at http://bio.waikato.ac.nz/ or look up Google and enter "Waikato university Manuka honey" to obtain further information. A former district nurse, Julie Betts, has been closely involved in the project and has written a number of papers, some of which have been published in international nursing journals. Liz, registered nurse working as district nurse.

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Deedee-
There is a product on the market call Hyrofera Blue- it's a foam that you wet and leave for a few days (if the wound doesn't have adequate drainage to keep the dressing moist, it will require a quick spray to keep it moist).
Okay- honey dressings- I worked for a general practioner who was at least 10yrs older then most of our geriatric pt.
about 5 yrs ago, we had a similar type case... non-compliant diabetic, with bilat aka... this doctor ordered "clean with soap and water, apply a thin layer of HONEY to wound bed, and cover with transparent dressing Q3 days" It worked, maintained a warm, moist environment and gave the cells around and in the wound something to "feed" on when the blood sugar was low.
Tina (LVN Tx Nurse)

Grid film is one method. lay the film over the wound, trace it and then count the squares. To me, this is time consuming, inaccurate and inconsistent in different hands.

Centimeter rule for length & depth is another way. You just have to establish a consistent method, like Length is always done vertically, with the patient's head representing the starting point and the feet the ending point. Same type of thing with width. This method might be good for wounds that are perfect circles.

Depth is 'hard' when it comes to accuracy. Wounds are note conical in shape. So measuring the depth at one point is misleading, especially if you're trying to do volume calculations. But most people say take a sterile cotton tip applicator and insert it at the deepest point, then use the Cm ruler to measure it.

Finally, Smith & Nephew has a device called Visitrak. Trace the wound, place the tracing on this electronic pad, re-trace it and you'll get an accurate wound area.

Alfred, MD

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There are a number of methods, each with pros, cons, and levels of accuracy. Most texts will address this topic. The Sussman &
Bates-Jensen text has a great section on it.

Renee C, MSPT, MPH, CWS
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 Hello,

One way is to use Q-tips. Place one in the wound to what appears to be the deepest part and mark the q-tip to where the wound is level with the pts. skin fot the wound depth. You can do the same by measuring from the very tip of the length (head to toe) and the width, or you can use one of the many measuring devices for these measurments. Remember when documenting (always document) for consistancy's sake write the length, width, and depth in that order. Then you can describe the color, any distinguishing characteristics, odor, presence of exudate/slough, and whether there is any tunneling involved. Thank you for allowing me to review these techniques. I'm also sure there will be many additions to your post!!
Chuck Ditullio R.N.

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Michelle-
If you imagine a clock over the wound 12o'clock being at the top of the wound and at the head of the person then you measure:
Head to toe - 12o'clock to 6o'clock = length
Side to side - 3o'clock to 9o'clock = width
And finally depth- I use a Q-tip, index card and marker. Hold the Q-tip in the deepest area of the wound, slide the index card over so that it is flush with the skin and mark on the Q-tip where the index card touches. Remove Q-tip and measure from the end of the Q-tip to the mark.
*** If you already have your imaginary clock set up it will make life a lot easier when you get wounds with tunneling or undermining.
Tina (LVN Tx Nurse)

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Size is determined by measuring length, width, and depth (stage II, III, and IV), usually in centimeters. Length and width are measured from wound edge to wound edge. The key is consistent measurements. Using the "clock meathod", the top of the wound (12 o'clock) toward the patients head, the bottom of the wound (6 o'clock) toward the patients feet, is the LENGHT. Side to side (3 o'clock to 9 o'clock) is the WIDTH. The depth of the wound is described as the distance from visible surface to the deepest point in the wound. Every open wound has depth (stage I pressure ulcers should describe length and width only, because the epidermis is intact). Staging is determined by tissue involved NOT depth, (ie. epidermis, dermis, subcutaneous tissue, fascia, muscle, bone or supporting structures).

RD, Wound Consultant
illuminairs@yahoo.com

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Using the body as a clock, the head being 12 and the feet being 6, measure length from head to toe and width from side to side. The depth is measured at the deepest point of the wound. Tunneling can also be measured in the same manner. If tunneling is present at the top of the wound you would say: tunneling at 12 oclock and the depth of the tunneling. By always measuring in this manner measurements are more accurate reguardless of who does the measurements.
Hope this helps.

Bonnie, LPNWCC wound care manager
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http://www.medicaledu.com/document.htm

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Tricia....your question raises many questions in my mind....I would assume you are using the chlorazene to disinfect the whirlpool, not in the water with the wound (correct?), so if you rinse thoroughly, there should not be an issue....but, my other question is what kind of "leg ulcers" are you whirlpooling? Whirlpool is contraindicated for stasis........and is really only indicated for short term mechanical debriding of very dirty wounds until the debris is gone......if you are having delayed healing in these leg ulcers, I would stop the whirlpool. M.Oliver, PT

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Go to the source. Look at the package insert, and go with the manufacturer's recommendations. I believe it's daily, but check to be
sure.

Renee C, MSPT, MPH, CWS
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Description: Collagenase Santyl Ointment is a enzymatic debriding ointment. Manufacturer suggest that it be applied once daily or more frequently if dressing becomes soiled. Use of Santyl should be terminated when debridement of necrotic tissue is complete and granulation tissue is well established.
RD, Wound Consultant

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Karyn.......we use Santyl almost exclusively, and I would agree that if a dressing is not saturated with drainage, it is best to leave it.......however, we just had the rep from Ross Labs who distributes Santyl in our area and the literature she gave us says that it should be changed daily...my advice is to contact her directly with your question......her email is patricia.rozzotti@abbott.com M.Oliver,PT

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Hi

I'd read the product insert, and use that.

Sara
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Check out this URL, it has a list of those who have done studies at the bottom

Maureen S. Christopher
 

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My question is ... if you are for the most part healthy, how much are you on your feet everyday and in what kind of shoe?
A wound on the heel can be a horrid nightmare- every time you take a step, or even wiggle your toes you are applying pressure or friction to the wound. As long as you can keep up the treatment and not obtain an infection, it sounds like things are going as well as they can.
Tina (LVN Tx Nurse)

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 I would recommend that your surgeon consider using a VAC (check out http://www.kci1.com/) to help the wound "fill in". ( I am assuming that this surgical wound is not infected, has been debrided, and is at least partial thickness) Once that happens, and the wound is superficial and has a granular base, I like to apply an Apligraf to help with epitheliazation (sp?). Be prepared for this to take upwards of 3 to 4 months to heal completely. Don't waste your time and effort with steri-strips, attempts as re-suturing, etc, because they won't work. You should also use an off-loading boot for when you sleep to keep pressure off of the wound.

Sean Henning DPM
Elkhart, Indiana

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Try going to www.aawm.org or www.wocn.org to find a board certified
specialist in your area.
Renee C, MSPT, MPH, CWS

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Hi Dot,
First, I would consider taking a swab of the wound base to see if there is an infection present that is interfering with healing. Second, I would stop wet-to-dry dressings as when it bleeds, this is a disruption of the healing process. I would irrigate the wound with a 30 cc syringe with a 18 or 19 gauge needle to help to remove the exchar. You could cover it with either a transparent covering or a hydrocolloid. It is a slow process, but not harmful to the tissues.
Pat K-S RN,

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Dot-
Try this...

http://www.woundcareprotocols.com/

Tina (LVN Tx Nurse)

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Dot,

I would think the bleeding is from the trauma to newly revascularized tissue caused by dressing changes when the wound gets dry as when the saline-moist dresisng dries up. I would also be concerned with the eschar as unless this is debrided, you cannot get healing to proceed for the entire area of the wound. You might
try to autolytically debride with an Allevyn adhesive making sure also there is no infection first. The sealed in moisture will soften the eschar and once loose can be debrided by anyone experienced in debridement (otherwise get a surgeon to debride). Often, the eschar softens then a part can be removed, then you can switch to Gladase (an enzymatic debrider that will not harm good tissue like what "Elase" used to do). The Gladase can be used with an Allevyn adhesive which is combined foam (absorbs) and semiocclusive, retains moisture but breathable. When you use this, the wound will usually drain and you'd see yellowish/cheesy material from the softened and liquefied slough. This is okay as long as you do not smell a foul odor or there are no signs of infection. The dressing can stay for 2-3 days and changed as frequently as it needs to be (changed when the wound is getting saturated). Never wait till the dressing
is soaked as this can extravasate to the surrounding healthy skin and hurt these.

Once you get a clean wound bed, you should then expect beefy red granulation tissue, which will proceed to epithelialization.

Good luck!
Maria Carunungan, DPT, CWS

Dot,
Also, after the Gladase had cleaned the wound of slough, if infection is a worry, you can instead switch from Allevyn adhesive to
silver/foam dressing. Silver helps control infection.
Maria Carunungan, DPT, CWS

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Brian,
You can plug in "certified wound specialists" on your browser and this will take you to different sites where you can get directories for wound care specialists.
Good luck,
Maria Carunungan, DPT, CWS

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Candace,
I've seen what might be similar to what you have. It may be from friction, when the part of cannula platform rubs against skin when you move, especially, this is a highly mobile area close to the groin. I've also seen it when pressure might be too much and over a mobile area. I would temporarily discontinue the vac until the blisters have healed. If you resume the vac, I would recline and minimize movement as much as you can while the vac is on. You should not see
blisters any other place, if you do, you might need to get checked for allergic reaction to adhesive.
Good luck,
Maria Carunungan, DPT, CWS

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Hello,

There is much documentation that you will need for your paper. The one that you must have on there is that your pt. should bge able to successfully demonstrate a dressing change herself!!

Chuck DiTullio R.N.

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Renee,
I would always include:
- etiology of the wound (as understanding the etiology and relating
it to treatment plans help the pt or caregiver understand the importance
of adhering to the regimen you set)
- signs and symptoms of infection and other problems to watch out for,
like reporting also presence of odor, necrotic tissue, drainage, wound bed
color etc.)
- clean field technique and procedure
- dressing changes
- handwashing before and after wound care
- nutrition
- stress management
- medications
- management of other diseases/conditions such as diabetes, etc.
- properly discarding soiled dressings/wound care material
Good luck,
Maria Carunungan, DPT, CWS

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