We're having a discussion at our facility and I'd like to get as much input as I can.

Anne, RN

W.Wood RN Canada

Conservative sharp debridement is able to debulk the necrotic material, but not get me down to the level that I want.

Silvia F.
CWOCN

I personally like using a calcium alginate rope if it is just yellow fibrinous slough as it absorbs and debrides well as well as provides a moist wound environment when it turns to a gel. If you have not cultured yet, I would do that to make sure there is no underlying infection. Debbie, CWCS

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Providing the necrosis is not eschar, I have the best luck with enzymatic debridement. I have used Gladase-C and alginate with absorbant outer
dressing and changed every other day with no adverse effects. As long as the outer dressing can maintain it's integrity with moisture absorbancy.
Moisture barrier (A&D) to periwound tissue will prevent maceration to viable tissue.

Kim LPN
Wound Care Coordinator

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try Jetox* it's completely disposable and simple to use. Runs off oxygen (cylinder needed) and a bag of sterile saline. Just connect up the handpiece and tubing and debride the wound. Safer than surgical debriding, very little mess as it only uses micro droplets of saline. Virtually painless for patient but in some patients may need some anaesthetic. If you would like I will find out who sells Jetox in US.
Phil
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Please get a qualified surgeon to mechanically debride the wound frequently and do not rely too much on enzymatic debridment KT

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Have you considered using larva therapy? These are sterile larvae produced for wound healing. Although expensive to purchase they produce superb results in a short time and are therefore cost effective. Larvae can either be bought 'loose' or in bags like tea bags, they must be watered twice per day. I have used them on numerous occasions and have had good results every time. My most recent was on a foot ulcer of a non diabetic patient which was 80-90% necrotic with the remaining being slough. 2 tea bags containing 100 larvae each were left in situ for 4 days. When removed, there was an area of approx 5% necrotic tissue left. The remainder of the wound was beautiful and clean. You can get information from the Biosurgical Research Unit, Princess of Wales Hospital, Coity Road, Bridgent, Wales, UK. Tel +44 (0) 1656 752820. Fax +44 (0) 1656 752830. Web http://www.smtl.co.uk.

Happy healing!

Joyce

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Hi Sylvia:

I would suggest a consult with M.D. who can perform sharp debridement and evaluate wound further—always a good idea. Usually, if slough/necrotic tissue is resistant to debridement-autolytic, chemical, conservativesharp consistently; may indicate underlying problem with circulation, bioburden etc.

Jamie Pinnock, RN CWCN

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This is an old remedy I used on such mouth sores. We would burn alum on the element and once it was cold place it on the ulcer area. It stung but the area would seal off and heal. I do not believe it can do any harm. BEE

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For these types of lesions I have found that Xenaderm works wonderfully. It is prescription and you would need to get it from the pharmacy. Xenaderm not only acts a moisture barrier but you apply a thin layer in the morning and then only need to reapply after every fourth cleansing. Healing is rapid.(usually within 2-3 days depending on the depth of the lesion) but relief from the discomfort is immediate.

Janalene Eaton, LPN,WCC,HT

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Dear Sherri:

Cover it with a soft fluffy bandage. Puncture wounds are deep and there isn't much you can do with them as far as cleaning. It sounds like the E.R. staff did a lousy job with the patient teaching part. The most important thing for you to do is to watch carefully for symptoms of infection. The other important thing is that there should be no foreign material inside the wound from whatever it was that caused the puncture. Here is what you need to watch for:

increased redness
increased swelling
heat
increased tenderness (only be concerned if the pain gets worse than it is now)
a red line going upward from the puncture wound.
increased pain
Feel better soon.

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

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A pure puncture wound, without remaining fragment can be treated conservatively- i.e. without surgical debridgement, with antibiotics. Elevation will help reduce any swelling and be comforting. OTC ibuprophen, "Advil"/"Motrin" may be helpful. As far as cleaning is concerned-- yes it should be cleaned ASAP. Not having seen the wound, it's very hard to say what exactly need be done, however peroxide, or even soap and water are usually good ideas. Dressings- Bacitracin and a Band-aid are probably all you would need. Should you develop increased redness around the site, or any red streaking radiating from the area, for instance up the forearm from a finger puncture, return to your health care provider. You may need a different antibiotic, or something else. From James G. Roros, MD, Medical Director, Monmouth Medical Center, Wound Treatment Center. Good Luck

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You should protect your puncture wound, assess how much drainage your having to determine course, and it would be wise to call back to who treated you and get the advice they should have given you in the first place. W. Wood RN Canada

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Hi Sherri:

ER usually treats immediately, as they did, but for long term wound care it’s best to consult your M.D. who may treat you or refer to a wound specialist. You did not provide much info on your wound, so I am unable to make suggestions for dressing wound. — Questions : Is the puncture deep? the location? how long have you had the wound-at the point you wrote this message? Do you have any medical problems such as diabetes? Pain is subjective. Wound pain –specifically in a puncture type wound is not necessarily a bad thing because your body is doing it’s job by letting you know there is an injury present. If pain persists, is unreasonable to size of wound—then I would suggest immediate evaluation. Consult your M.D. in regards to pain and wound care.

Jamie Pinnock R.N. CWCN
 

Dear Mary Lou:

The hydrogen peroxide retards healing. It does not promote it. That is because you are destroying the healing factors and preventing granulation. Hydrogen peroxide must only be used to do one initial cleaning of a dirty wound. The best thing to do is stop using hydrogen peroxide apply a wet to dry dressing with hydrogel and gauze to keep the wound bed moist. Change the dressing as needed and do not disturb the wound bed. Apply the the Bacitracin around the edges to set up a barrier against infection and use sterile technique for dressing changes.

Feel better soon.

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

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Mary Lou Span,

The treatment you are using is fine for preventing infection, but will not help healing otherwise. The length of time to heal depends entirely on your physical condition and normal body healing. You might go to a health food store, obtain 2-3 ounces of powdered comfrey and sprinkle this on the wound every other day, then use your current procedure in between, flushing the area well. The comfrey is an anti-bacterial preventing infection but is also a stimulant for cell growth. I have used this several times in this type situation with good results. But you must watch carefully for abnormal cell growth in the healing process if it should occur.

I am anxious to hear your results. I do not have a medical degree, only experience.

S.Willis

sorry, no replies

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There are some problems with EZ-boot-type devices in that if the person has any degree of plantar flexion contracture or tone they can get
increased pressure on the met heads and the achilles area. Achilles wounds are somewhat common with these boots. However, any device
should be removed and the skin examined regularly (at least each shift), and the boot should be fit properly. Some are adjustible in the ankle angle to some extent. Alternatives include some of the foam boots (which some people like, some don't), and putting the calves on pillows. There's also the HeelZup, which is a cushion with side
bolsters to do what the pillows do with eliminating some of the problems with them. That can be effective if they don't move much. Lastly, with the Boots, even though they usually have a walking sole, they are not appropriate to walk in. Weight bearing puts a line of strong force across the middle of the plantar heel, which can create a
deep wound. Use them to transfer only.

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

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I generally dislike any molded plastic off-loading boot, especially for older people with poor circulation and no "padding" of their own. I generally use a Heelift boot by DM Systems. I have also used the Heelzup cushion by Intensive Therapeutics. Recently I had a rep from Think Medical show me a line of positioners that looks promising. Hope this helps.
unsigned

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There is a company that have waffle boots I think the web site is www.ehob.com to find a rep
Good Luck
Sue

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I have not had that info, the wound clinic here in Canada uses an unna boot,

W. Wood RN Canada

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Hi Barbara:

Would suggest Kestrel’s wound product guide—Wound Source—has all manner of dressings and offloading device information etc. Guide is in a comprehensive format that helps you to compare multiple products etc—Well worth the money—highly recommended for the Wound Care Professional. Should have lots of choices for heel lifters. www.kestrelwoundinfo.com.
Jamie Pinnock R.N. CWCN

yam

Heidi Knox

You're right to always look carefully at mixing products. Why would you even be mixing betadine into a product designed to support healing. That's contradictory, as Betadine will slow healing. There's always the risk of chemicals combining to form different ones or inactivating
each other.

Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS
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Do you have access to a Wound Care Clinic, Heidi...Your questions are excellent.


We use a petroleum base but on directly on wound care site Idosorb, betadine or providine used but not after a few days of trial Intrasite, jelonet, not used on diabetics Betadine or providine directly to site, for chronic, not much
ie: chronic wound for debilitated individual on nugauze strip one or two drops, do not get it on the skin cover with something like kaltostat and then 4x4..hope this helps some

WWood RN

In Canada it is the RN/RPNs, in correlation with the Wound Care Clinic, advising doctor of best course, and if not effective in 2 weeks to try another course of action, refer to the policy & protocol procedures, .get them thinking, ask more questions.

W Wood RN