K.

Excellent critical thinking. It is an absorbent dressing, so it should go on dry; otherwise it is not serving a purpose other than wetting the
wound, which a hydrogel can do cheaper. Because it gels, it rarely sticks to the wound, unlike alginates, which often stick.

Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS

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Hello,

I don’t usually wet Aquacel or any alginate before applying to a wound. If the alginate sticks to a wound, it can be removed easily by flushing it with n. saline and giving it a minute to let go. If a wound is dry enough for the aquacel to be problematic at sticking, the wound is probably too dry to need an alginate and a different dressing is appropriate at that time. You noticed I said I don’t USUALLY wet alginate. I have been known to dampen it slightly when applying to a wound that I have a question about the amt of drainage just so that I don’t dry out the wound bed. I did that recently because the thumb I/D I was dressing was cleaning up nicely, and the drainage was subsiding therefore, and I wasn’t going to see the wound for 2 days; I was dealing with an exposed tendon that I was determined to keep moist, and as you probably know Aquacel makes a nice gel with moisture that can continue to absorb some more drainage but will keep the wound bed moist. I would have rather used a hydrogel, but didn’t have one at the moment.

Vicki, MSPT, CWS
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Aquacel is a hydrofiber dressing, very absorptive and useful for highly draining wounds. The company will tell you that if the wound is not very moist, you may moisten the aquacel with saline, to keep the wound bed moist. You are correct that by moistening the aquacel, you limit the absorptive capacity of the dressing. I don't advise moistening the dressing, if the wound isn't moist enough for aquacel, you need to choose a dressing that will provide moisture to the wound.
Dawn, RN, CWOCN

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When you moisten an alginate prior to application you have basically turned it into a hydrogel that won't adhere to the wound. Some times alginates are used on wounds with a light exudates to prevent tissue damage with dressing removal and to keep from "drying out" the wound bed.
Tina (L.V.N./ wound care nurse)

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Hi K:

I have heard of this being done. Whilst I have never asked the Rep for Aquacel if this is appropriate, I would say moistening it first before applying to wound bed is inappropriate- because of just exactly what you said—further more if you have to make a decision to moisten the Aquacel before applying it to the wound—then one may need to consider another dressing choice. Often times clinicians try to be inventive with what they have instead of thinking of another choice. Being inventive does pay off in some situations. I too will be reading the answers to your question for learning.

Jamie B. Pinnock, RN CWCN

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hi:
i was sitting earlier with the convatec medical rep..talking about the aquacell.. if you wet it then why to use it...i alway concentrate on using
the right thing in there right place..and aquacell was made to apsorb and provide wet environment...in fact its written in the manufacturer that if the secondary dressing is wet then change the dressing at that time...so if you wet it ..then there is no use..
laila
RN. Wound care nurse

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Ideally, Aquacel is used for wounds with moderate to heavy exudate. It does however, help to reduce hypergranulated tissue. If the wound bed was not
heavily exuding, the nurse may have wanted to maintain moisture balance within the wound bed while controlling the hypergranulating tissue. This is supposition of course, as you do not mention the characteristics of the wound. If you are interested in wound care, you may want to hook up with a WOCN. Also, all manufacturers offer information on their products,as well as nurse consultants who can answer your questions about that company's product.

K. Papi, LPN
Wound Care Coordinator
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Always check with manufacturer for any questions.

unsigned
 

Cat

Hello,

Different clinics have varying protocols for measuring wounds. I have worked places where the greatest diameters are measured and documented via clock notation, such as 2.1 cm at 7 to 1 o’clock and 3 cm at 4 to 10 o’clock, usually using 2 separate measures as I just did but not describing them as width or length. I have also seen width always be measured as horizontal measure (across the body), and length vertical measure, despite where the wound is actually greatest in diameter. Volume can also be measured, but is more time consuming of course. Finally, some people use tracings, which I find is ok as long as you are very careful not to contaminate the wound with an unclean device (I know that sounds picky, but I have seen people who aren’t terribly careful about aseptic technique). I have two articles I like that discuss measuring wounds. More Than One Way to Measure a Wound: An Overview of Tools and Techniques by Richard Salcido and Robert Goldman, in Advances in Skin and Wound Care Sept/Oct 2002, volume 15, No 5, pages 236 thru 243, and Reliability of Wound Measuring Techniques in an Outpt Wound Center by Janet Bryant etal in Ostomy Wound Management, 2001, Volume 47, No 4, pages 44-51.

Hope this helps.

Vicki, MSPT, CWS
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You are right, typically wounds should be measured from 12-6 and 3-9 oclock, BUT, the longest measurement should be used. Therefore, if the longest measurement is from 1-7 oclock, this measurement should be used, but there should be a notation in the documentation that the measurement is taken from 1-7 oclock.
Regarding what to purchase for measuring wounds, you shouldn't have to purchase wound measuring guides. The companies that provide advanced wound care products will provide you with measuring guides for no cost. I get measuring guides from Hollister, ConvaTec, 3M, Smith/Nephew United and Healthpoint, among others. Check with your purchasing department to find out who you get most of your wound care products from, and ask that company to provide you with wound measuring guides.
Dawn, RN, CWOCN

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The clock method of charting wounds gives you reference points on the wound. If the longest point of the wound are at 1:00 and 4:00 the I would chart "length measured from 12:00 to 6:00 = X ,however length measured from 1:00 to 4:00 = Y" You can't be too descriptive when charting a complex wound.
Tina (L.V.N./wound care nurse)

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Hi Cat:

Measuring wounds is such a hot topic right now—I have to say—I have talked about this at least 4 x this past week. People are going crazy over this. Anyway, for consistency in documentation it is very important to standardize a method of measurement and require EVERYONE who works within your system to utilize that method. I was taught to always measure from head to toe--- head being 12 and 6 being toe. Many wound care companies have developed wound care measuring guides with grids on them to assist in measuring the wound more accurately. Looking at the wound from head to toe, regardless of shape-even a surgical incision------- mark the top most edge of the wound and bottom most edge of wound—draw a VERTICAL line between these points—this is the length. Do the same with the width--- only draw a HORIZONTAL line. There are even sophisticated computer applications and wound measuring devices to calculate WOUND VOLUME---which is really what is important in measuring numerical wound progress. One humerous analogy (only applies if you are a homo sapien): If you are 5’2” you wouldn’t want someone scaling you as 2’ 7”--- we are measured from head to toe. Measuring from head to toe (12-6) makes the most sense to me. Hope I didn’t confuse you. Email me if you like: j.b.pinnock@att.net.

Jamie Pinnock, RN, CWCN

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You are correct. 12:00 does indicate towards the head and 6:00 towards the toes. You would measure the wound at its widest parts indicating wound measurements from 1:00 to 7:00, and 4:00 to 11:00 = 3.0cm x 2.0cm for example. You can have as much documentation as you need to describe any and all characteristics of the wound. Any company dealing in medical forms can
provide you with "Skin Sheets" to use for documentation of wounds, skintears,
etc. Shop around for one which best suits your needs.

For resources you might want to start with Chronic Wound Care, Co-edited by
Dr. Diane Krasner, Dr. George Rodeheaver, and Dr. R. Gary Sibbald.
(1-800-237-7285) Also get online. You may want to start with
www.worldwidewounds.com or www.woundsource.com

Mesuring devices are a matter of preference. Most wound care companys offer some type of measuring device for free if you use their products. Puritan offers devices, check out www.puritanmedproducts.com. If using a measuring tape type device, use a cotten-tipped swab to measure undermining, tunneling, etc.

unsigned

I used to do home health wound care. The big problem I ran into was getting physicians to get on the moist wound care bandwagon, and stop ordering BID wet-dry dressings which just kill you under PPS. If you can develop a good relationship with your MDs and get them to let you use aggressive wound care to clean wounds up, then go to semiocclusives that can be changed less often, you will succeed. Also, be sure your admitting staff, whether PT or RN, fully understands how to document wounds in OASIS, because that can lose you literally thousands of dollars unnecessarily, as you probably know.

Vicki, MSPT, CWS
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Hi Jo:

I would say contact some of your wound product company Reps…they are an outstanding resource for protocol development. A great benefit also is cost containment—most of the time companies get lost in buying too many products, incur debt and never get beyond just breaking even… if you desire decreased cost, consider developing a uniform formulary and stick to it unless you have outlyers who require more advanced treatment—which in your case you will be referring out for. Also, having good relationships with local Wound Specialist can help—because you can have more expert opinion and a choice of individuals to send patients to for a second opinion if needed. Feel free to contact me if you need anymore assistance at j.b.pinnock@att.net

Jamie

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Jo Ann- Sounds like you have your hands full. Since you work in home helath, you are probably not able to have a contractual relationship with
any particular wound care companys or providers. You may want to start with a basic algorithm. What type of product(s) to use for each stage of a
wound and delineate further by dry, moist or heavily exuding wound bed. i.e. calcium alginate dressing for stage III wound with moderate to heavy exudate, cover with clean dry dressing daily. Each nurse can then deal with the appropriate insurance company and case manager to order this type of dressing. Pick a day of the week for home health nurses to measure wounds. If there is no significant healing they should be reporting to you or wound care physician. I would acquaint myself with any certified wound care surgeons, podiatrists, wound care clinics in your area. Should the need
arise for a home health patient to one of these skilled professionals, you will be familiar with who to send your patient to, also they usually do the
dressing change in clinic once a week, eliminating the needs for your or your staff to change daily. Hope I have been of some help.

K. Papi, LPN

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You would benefit from speaking to an agency like Paramed or CCAC here, we do that type of wound cost, issues, etc. here. WMarie RN
 

I'm sorry about your loss. Nec Fac really needs surgical excision. The area is so deep, and grows so rapidly, that maggots just wouldn't be fast enough.
Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS

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I am trully sorry for your loss. Maggots would not work fast enough. Time is of the essence with NF and the gold standard is to get the patient into surgery ASAP and do extensive debridement and then start IV antibiotics.
Chris Berke RN CWOCN

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Hi Ardyce-

I am sorry to hear about your loss. NF can be illusive to those who don’t know how to first approach it. I have not read anything on NF and maggot therapy, but that’s an interesting thought. As far as I am aware currently NF requires immediate intervention- radical surgical debridement is necessary. Once all of the necrotic tissue is removed- then basic wound care principle can be applied to healing the wound.

Jamie Pinnock, RN CWCN

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I use a foam around the PEG tube site, the foam acts as a mild sandpaper, apply the foam around the PEG, and change every 3 to 5 days.
Mary Ransbury RN CWCN, COCN
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If a tube isn't secured, hypergranulation tissue can result. While silver nitrate can treat hypergranulation tissue, the hypergranulation tissue can be minimized if the tube is well secured, so the tube doesn't dangle or flop around.
Dawn, RN, CWOCN

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Hi Debra:

Hypergranulation tissue is likely the result of excessive moisture in the area. Is the area too moist-wet? Consider using a foam dressing (Allevyn, Biatain etc.). Foams have been said effective in controlling hypergranulation. After the hypergranulation is controlled and epithelium has migrated across tissue-consider using a moisture barrier to area. Of course, choices are dependent on patient situation. Hope this helps.

Jamie Pinnock, RN, CWCN

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Debra - Try applying calcium alginate to the PEG site daily, cover with secondary dressing of your choice to maintain moisture balance at the wound
site.

K. Papi, LPN
Wound Care Coordinator
 

--

Hi Margaret:

Most wound care books have a body chart for location of wounds.
Jamie Pinnock, RN, CWCN
 

Stasis ulcers (AKA venous insufficiency ulcers) are on the lower leg, and occasionally the dorsal foot. This wound is likely arterial insufficiency and/or neuropathic. If the eschar is dry, stable, and intact, then preserve it. Paint with Betadine daily and let it be. Otherwise, it will open a wound that has little chance of fighting infection or healing. If, however, the eschar is loose, squishy,
draining significantly, or looks infected, then debride it. Sharp would be even better. It would take a long time for an enzyme to work on
that.
Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS

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Black eschar needs debridement when it is appropriate. Accuzyme can be used until it is appropriate for physical debridement with sharp instrument.
unsigned

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A wound will not heal if there is a black eschar cap. That cap needs to be debrided by a MD, PT trained in wound care, or a certified wound specialist. At that time, you will then decide what type of agent is needed depending on the type of tissue present in wound bed.


C.Walker LPTA, WCC
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It is hard to tell you whether or not you are doing the correct thing without knowing more. The biggest mistake I see usually with people coming into my clinic is the use of Accuzyme on a rock hard dry eschar with no method of softening the eschar. No enzymatic debrider (Accuzyme, Santyl, etc) will be terribly effective on dry leathery eschar. Also, if you have severe arterial insufficiency, using Accuzyme on the eschar may not be appropriate at all, because you may just open up a wound that will create an avenue for bacterial invasion. Find a wound specialist who will explain things to you and get you on the right track.

Vicki, MSPT, CWS
---

Accuzyme is appropriate for the debridement process, if the wound needs debridement. You need to consider the diagnosis that lead to the toe turning black, for example: gangrene? diabetic? PVD? thrombosis? is it infected?
Typically you don't remove dry eschar from a foot wound as long as it is dry and intact.
Tina (L.V.N./wound care nurse)

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Hi Parker:

You may want to first review the patient’s history for underlying cause. If the patient has inadequate circulation, then trying to debride this ulcer may not be the first choice unless the ulcer shows signs of infection. Accuzyme generally needs surface area to work on and I have been told that it is difficult for accuzyme to break through dry adherent eschar. Moistened saline gauze is often used with accuzyme to create more autolytic action. Cross hatching the eschar is a possibility to create surface area. I don’t know what your professional capacity is-so I am just going to suggest referral for evaluation by a wound specialist. The choice of treating this type of ulcer can vary depending on the underlying situation- diabetes, arterial disease, both etc.

Jamie Pinnock, RN, CWCN.

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Stasis ulcer on great toe? Sounds more like diabetic or arterial insufficiency, get another opinion. unsigned

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You must consider first, does this person have diabetes, a wet to dry, or intrasite jel, or if not that you could use an adaptic, or telfa over wet dressing, to aide in removing eschar... I hope this helps Parker

unsigned
 

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Saline is sterile (or at least very clean), unlike many tap waters. The mineral content is controlled, and is physiologically similar to
the body, resulting in minimal osmosis between the tissue and the fluid.
Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS

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I can't provide any literature citations regarding using tap water vs normal saline. I encourage patients to cleanse wounds with either, it's perfectly ok for a patient with a large abd. wound to go into the shower to remove the dressing and cleanse the wound before dressing re-application. I have never recommended use of tap water to be used for the moisture source for a moist gauze dressing however.
Dawn, RN, CWOCN

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The biggest difference is that tap water has minerals, chemical cleaners and bacteria... NS on the hand is packaged and sterile until you open it and contaminate it.
Tina (L.V.N./wound care nurse)

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Good Morning Jennifer, it is best to use Normal Saline, versus tap water, as more conducive to skins own flora... all the best Raechz RN

Go to www.bradenscale.com for info on that one. Also, the AHCPR
Pressure Ulcer Prevention Guidelines address both scales.
Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS

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Dear Kyri:

There is a chapter on pressure ulcer risk assessment in my book Protect Yourself in the Hospital Just key in the title on Google and you'll get thousands of links.

Regards,

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

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E-mail me directly I can give you resource r send you a copy of both. J.B.Pinnock@att.net.
Jamie Pinnock, R, CWCN

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look online under Braden Scale and Norton Scale

unsigned

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Your Medical Surgical Book should have the Braden Scale,  it is like going back to school, and it should be included in Chapter Wound Assessment.

 Raechz RN
 

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Hi Jean:

There is a wonderful wound care resource book—which also includes codes etc. I don’t know why more people don’t know more about this awesome resource—it is called the Kestrel Wound Product Source book. It used to be free to professionals but there is now a cost—it is amazing—hats off to them-- Contact info: 1866 804 3102---also www.kestrelhealthinfo.com. You will be pleasantly surprised what a resource this book is and well worth the cost for a busy wound care professional.

Jamie Pinnock RN, CWCN

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Good Morning Jean, yes there are listing, but you must also consider the supplier, what do your agencies or homecare permit in their compendium vs going to an other expensive type of dressing, and I have one by a supplier but in your Med/Surg text under "Wound Assessment" you will acquire the core at what you need to know, and suppliers can be helpful or if you have a wound care clinic close to you, or your peers, utilize them... all the best WMarie RN