Sincerely,
Ingrid Thrall

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My name is Angelique C. Carter. I am a corpsman in the US Navy. I checked with a couple of my nurses on shift and they said that it is a bad idea to use isopropyl alcohol as a cleaning agent. This is best used as a prep on unbroken skin. My nurses recommend that is the wound is not that big, then go ahead and use soap and water, being carefull not to scrub to hard. If the wound is large, but still mostly surface based, then irrigate with NS. If the wound has depth to it then do wet to dry dressings with NS.
Hope this is helpfull.
Sincerely,
HN Angelique Carter
US Naval Hospital
Naples, Italy

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I don't know if Isopropyl ETOH is cytotoxic.......but, I strongly urge you not to use it. Use NS or even soap and water to cleanse a wound.

Frankie (Frances J. Jessup, RN, BSN)

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Ingrid,
Alcohol is harmful to wound care, it dryes the wound thus hindering healing.
de rn bsn, wound mananger

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This is definitely cytotoxic while a good antibactericidal. Cleansing with sterile water is beneficial for wounds and if there are signs of infection, you can use antibiotics (topical or topical and also systemic if there are signs of infection) and bactericidal like silver-based dressings or gels.
Maria Carunungan, DPT

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Alcohol would BURN like crazy

Leah

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For pain, I also use topical lidocaine (4%). For some people, Tylenol or other pain pills might help.
Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS

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Theresa,
I never advocate soaking the Diabetic foot. It is not recommended due to maceration and opening pores to let infections in. Washing feet in a basin and getting out is ok. Diabetics should be taught to check their feet everyday. Teach your patients what infection looks like, making sure they know what the signs and symptoms are and to call for medical help. Antibiotic oint is a simple thing for them to do but make sure they know that an untreated or improperly treated diab wound can lead to osteomylitis and or amputations. The foot of a Diab is nothing to fool with.
DE RN BSN Wound Manager.

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Theresa,

I preach against foot soaks especially to open wounds, and especially to diabetics. There are additives you can mix in with the water to kill pathogens but they can be cytotoxic to the wounds. Then you have edema which you see often and soaking encourages more edema. I have a few suggestions:
1) I personally would refer patients with very thick toenails or ingrown for removal to podiatrists. All the nurses I know do a good job too except for liability purposes, even the nurses I know refer to podiatrists because they are supposed to be better at this by the intensity of their training and they most often are more equipped with better trimming equipment. Diabetics heal slower and more prone to infection. There is a potentially greater liability when infection develops with a diabetic whose toe got nicked during nail care and again by most standards "hard- to- do nails" belong to podiatrists or surgeons.
2) Use only sterile scissors to trim and for the nails
those equipment you can sterilize. If you think there is a high likelihood of nicking due to the condition of the nails, I would not proceed.
3) If they do get nicked, for reasons stated above, I would not do foot soaks. I would only irrigate with sterile water or NSS, then apply either the antibiotic ointment or use silver-based gel or dressings (these are anti-microbials).
4) If you do trim calluses, remember these formed due to friction on the bony prominences and do protect these areas. When they are trimmed, this leaves these areas more prone to injury by pressure or friction. It is okay to trim but maybe need to obtain an orthotic like an insert or even consider pressure/friction relieving orthotics like
diabetic shoes or if they have wounds- contact casting orthoses.
Maria Carunungan, DPT, CWS

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I'm quite concerned about what you do. Medicare wants diabetic nails trimmed by RNs or physicians. If those are hypertrophic nails, I don't know whether you should touch them. If those are ingrown nails, you are doing diagnosis and treatment. Also, I'm not sure whether your scope of practice includes debridement of hyperkeratotic lesions. I'd inform the diabetic patients about Medicare Diabetic Shoe program. Good shoes reduce a lot of callus and other problems. Regarding foot soaks, it's more important to make sure they dry their feet, especially between toes, than just soak the feet. I'd recommend that you work with a podiatrist.
JL, DPM, CWS

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Have you received foot care training by an accredited WOCN school? If not, you are practicing out of your scope and your license may be in danger.

Deborah Harris, BSN, JD, RN, CWCS
Louisville, KY
 

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While I was working in home health. I had a patient that we used an alginate under the unna boot and then increased the drsg change frequency to change with strike through is observed. This past year I have also had more Dr. prescribe for a silver nitrate (argales) powder applied to wound base before application of the alginate and unna boot. Shallie Witt RN wound care nurse

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When I use an alginate I usually go for a sheet product, like Smith/Nephew alginate. Its flat and conforms well to the ulcer and works well with an unna boot. If you use a foam type that may put added pressure to the periwound and this would not be good. Don't be afraid to use a silver pregnated alginate on these wounds. Many time these ulcers need a jump start for healing and may also have a Biofilm that needs treated.
DE RN BSN Wound Manager

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First I would be sure ulcers are venous only and not mixed with arterial disease. Have any studies i.e. doppler been done to determine this? You do
not mention wound characteristics other than large amounts of drainage. Does drainage have an odor, what color is it? What does the wound bed look
like? If there is any necrosis (dead tissue) it will need to be debrided. Also there are other types of wraps for legs which may be more beneficial
than Unna's boot. (Profore and Profore lite by Smith & Nephew) It sounds as though the patient should be seen by a certified wound specialist, perhaps a
podiatrist or plastic surgeon. Is there s/sx of infection? If there is a wound care clinic nearby I recommend an appointment. There is not enough
information to make any further recommendations, but there is much that needs to be looked at in the plan of care for this patient including nutritional status. Good Luck

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There are absorbents which wick away drainage from
the periwound areas because they travel in vertical direction only (hence periwound stays dry). Example is Aquacel. It can come with silver also like the Aquacel Ag for additional antibactericidal action.
Maria Carunungan, DPT

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I don't know why it has to heal before they remove the same area more widely. Talk to a plastic surgeon or an oncologic surgeon to do a thorough excision.
Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS
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My advice to all my patients is to be their own advacate. If you are not comfortable with your MD then change your MD. You have the right to choice your healthcare provider. You are concerned enough over your health status why would you want to be questioning your MD? Get someone you are comfortable and have total confidence in. Also remember to ask questions--they may not know you have concerns if you do not ask.Best of Luck
CB Homecare RN

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I would get an other opinion, get your primary care physician involved (to see if they can get you in to see someone else sooner). You need to stand up
for yourself and not wait around because that MD is booked..

Pamela A. Meadows, RN
Clinical Director of Nursing

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Have you cultured the wound? Infection will keep a wound from healing.Often times a wound that has a high bacterial count will not look infected, it just wont heal. Silvercel alginates are good if the wound has some depth and drainage. If the wound has at least a depth of at least 0.5 medicare should cover the woundcare products and treatment.

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Malu,
Have you tried Oasis? This product is expensive but it does work. You only change it monthy which would be very cost effective. You can then place unna boots on the legs and they should be changed weekly. The Oasis acts like a scafolding for new growing tissue.
DE RN BSN Wound Manger

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It can be frustrating to work within a tight budget. I would try the Acticoat again in conjunction with a systemic antibiotic. Review nutritional status. Protein intake, MVI, Zinc, Vit C, etc. If diabetic, are blood sugars well controlled? Does area require debridement? Reinforce proper positioning compliance. Aslo be sure before using a compression type dressing, that only PVD is present. If using compression dressing with any
arterial disease you can cause more damage, and delay healing process.

Kim
LPN
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HOW LONG DID YOU TRY THE PANAFIL? I LIKE TO USE WOUND CLEANSER FOLLOWED BY PANAFIL TO THE WOUND BASE, COVER THE WOUND BED WITH NONSHREDDING GAUZE THAT IS CUT TO FIT, THEN COVER WITH A 4X4 AND SECURE, CHANGE THIS DAILY...FOR SOME MILD COMPRESSION I LIKE PROFORE...ITS LIKE AN ACE WRAP BUT ITS MARKED WITH THE APPROPRIATE LEVEL OF STRECH SO YOU CANT GO WRONG. I HAVE RARELY SEEN PANAFIL NOT WORK AS LONG AS YOUR ALSO COMPRESSION IT WITH A PATIENT WITH VENOUS DISEASE. YOU CAN ALSO PUT SKIN PREP AROUND THE WOUND BED TO PREVENT MACERATION. KELLE ZIMMER RN BSN WOUND CARE NURSE

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Make sure it is Venous by differentiating with ABI must be .8 or Greater. then consider culture and sensitivity 2.systemic antibiotic 3. Iodosorb gel or Iodoflex pad directly on the wound bed. Then compress with a 4 layer compression that gives you gradient 40 at the ankle 30 at the calf and 20 right below the knee. Iodosorb is a 3 day dressing. It will clean the wound very nice. then you can stop the Iodosorb gel or pad and continue with promogran, Prisma, or better yet Oasis over the wound change the dressing weekly. This is following standards of care.
P.S. make sure you are cleaning wound with Commercial Wound Cleanser that delivers the right PSI.

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Have you considered underlying cause? For example, vascular problems, diabetes out of control, or some autoimmune disorder? I have seen wounds heal wonderfully when nothing else would work by adding prednisone as an example of treating autoimmune.

Deborah Harris, BSN, JD, RN, CWCS
Louisville, KY

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I suggest you look at other factors which may be
causing the delay. The hallmark for treatment of
stasis/venous ulcers is compression which if there
are no other serious limiting factors, should progress these wounds. Other factors can be infection, poor nutrition, maybe some meds? (some do delay healing), poor hydration, hypoxia, or even some arterial insufficiency combined with venous insuffiency, diabetes, hypertension. Most of the dressings you mentioned are good dressings.
Regranex is one I do not understand would have benefitted the wound. They work well with diabetic ulcers. So do begin looking not just at the wound, but the patient factors as well.
Maria Carunungan, DPT, CWS

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I have had good luck with Hydraferra Blue which is not as expensive as Aquacel-AG, or you may try Iodosorb, both can be changed q-3-five days, covered with transparent dressing for the Hydraferra Blue or regular 4x4 for the Iodosorb.
Cheryl LVN
Tx nurse

Leah

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Have you tried Hydrofera Blue? Bacteriostatic foam dressing. Works great, in addition offers pain relief.
More information available on the internet.

Sharon , RN, WCC
New York

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depending on the size of your stasis ulcer. But I have used Tenderwet or silvasorb sheets. which seem to help the deeper stasis ulcers. I use border gauze for primary dressing. If a lot of drainage maxisorb works well.

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 Hello,

Try Curasol soaked Kerlix BID if you think another shift will F/U with the TX.

Respectfully,
Chuck DiTullio R.N.

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Dear Malu, As I always tell everyone I am not a healthcare provider in anyway. BUT I am a former patient of Maggot Therapy. I had diabetic ulcers for over two years and tried "everything!!" Nothing worked and the doctors wanted to amputate. I tried maggots, which are raised, sterilized and sold just for this purpose. They cost under a $100.00. They are the most cost efficient means out there. They eat just the dead infected tissue, kill the bacteria and also excrete healing enzymes to promote healing. They worked on me and healed up my one ulcer which was a stage lV, the worst! Any doctor can order them with a prescription and they are FDA approved. please consider this, though it is "different" it does work. For more information here is our website about Bio-Therapeutics and we do offer free grants for patients without insurance or who's insurance does not cover. Good luck.

Pam Mitchell
Board of Directors
BTER Foundation bterfoundation.org

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Steri strips to a skin tear is not always a good idea. If the skin flap is approximated try putting an opsite over the skin tear. When removing you must lift and stretch while removing to prevent retearing the healed skin. You change them weekly and as needed if increased exudate. If the wound is very wet you can place a Smith/Nephew product that is a sheet of gel (can't remember the name) and it will absorb and is very cooling for the patient. If you must use steri strips you should skin prep the wound first and let it completely dry. This will help the strips stick. Gently pull and approximate the skin flap, slightly overlap the skin edges. With one side of the strip on the good skin, then place the other end of the strip on the pinched up skin. As you let go of the skin it should fall into normal alignment.
DE RN BSN Wound Manager.

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I would not personally use steri strips especially on elderly skin which are usually thinner and very easily torn, on the basis that different people apply these different ways and if applied with much tension pulls on the surrounding intact skin.
The general rule is you approximate the edges of the skin tear or incision without overlap and without using too much tension, then you apply the steri strips. As an added protection, I have used skin prep on the periwound areas prior to applying steri-strips.

Maria C. DPT