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Hello,
I would use the partial or full thickness classification system on anything that isn't a pressure sore.

Vicki, MSPT, CWS

You can usually make photos part of the general consent they sign at admission.

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

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Yes. Any part of the body is still an identifier for the
patient. Also, every patient has a right to privacy and every part of the body regardless of location is still covered by this universal rule on privacy protection.
Maria Carunungan, DPT, CWS

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Usually the agreement to be photographed is in the admission paperwork. If not yes they need to give written consent.

Michele Brantingham WCC in san diego

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Hello

I always have a consent to photograph signed by any patient that will have a photo taken, with the consent stating what area of the body is being photographed.

Vicki, MSPT, CWS
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Yes, you must always have a signed consent from the patient. unsigned

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yes

Dr. s.h.sultan
general surgeon

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yes - unsigned

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I dont know about the rules in your state or your company but in my state we do have to have prior permission for any photographs of patients. It would be better to go ahead and get the permission prior to taking the photos to protect yourself. Thanks, Sandi lpn

Regarding the refusal to admit, yes, they can select their patients by diagnosis (but not by race, etc.). Wounds can be costly, and they're probably afraid of losing money on those patients. Regarding opening the wound, sometimes yes, sometimes no. Has she seen a wound specialist? www.aawm.org and www.wocn.org will help you fine one.

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

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No I think this is illegal

still I believe that you should consult a plastic surgen

Dr s.h.sultan
general surgeon

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Unfortunately it is legal for a facility to turn people away, the justification being that a facility should not take a patient that they may not be able to provide adequate care for.
Your mom already having an ulcer with a depth that causes you to believe that it is a stage 3 - 4 means that the facility that does take her will have to have the resources to treat the wound. It may be easier to find placement for her if she is taken to a hospital and a plan of care for the wound is established prior to nursing home placement. Good luck.
Tina (L.V.N./ wound care nurse)

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I'm not sure that this is legal, especially if the facility accepts Medicare and Medicaid. Is this all the facilities that you have talked with, or just one in particular. I would call the state department of health and the ombudsman for your district to find out for sure if facilities can refuse a patient solely on the reason that the patient has a wound that is either a stage 3 or 4. Some facilities may not have a wound nurse that is familiar with these kinds of wounds and it would be to your advantage to find one that does. You can also call the wound specialist at your local hospital and she can help you with this as well. Sandi LPN

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Hi,

Nursing homes usually will shy away from stage 4 pressure ulcers because most likely there is osteomylitis which needs to be treated before the wounds heals. Has this been ruled out? Also, has the wound been cultured? As far as opening the wound more this is not necessary. The undermining is from her being pulled up in bed called friction and shearing so this needs to be stopped plus she needs to be off her pressure ulcer. She may need to be admitted to a long term acute care hospital that has good reputation for healing wounds OR have home health come and follow the patient. Maybe consider having a wound vac applied which seems to work well. Also what is her Albumin level. Is she eating? If not nothing will really heal on her until that gets up. We have used Oxandrin which is an oral medication that helps increase lean muscle in patients and helps with wound healing. It's a steroid but we have seen good results with this.

Take care

Michele Brantingham WCC in san diego

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Hello,

Is it legal, yes I believe so, but a lawyer would know more than me.

The wound should be packed with an appropriate dressing to help it heal. Negative pressure therapy such as the VAC or Blue Sky Versatile One might be helpful to get the wound filling in with granulation and healing.

Vicki, MSPT, CWS
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I'm not sure about the nursing home rules. But with this wound, I would request a bone scan to rule out any involvement of the bone. A nonhealing wound often is related to deep sinus infection or osteomylitis. What type of wound care has she received? What are the measurements?
Patti Schwartz, RN, WCC

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There are many reasons a facility can decline a referral which includes uncertainty on the facility's ability to provide the care needed.
In as far as opening up the wound, what is recommended by most wound care professionals is to have a surgeon look at the wound. Usually if the extent of undermining cannot be ascertained, one might recommend opening up the wound to determine extent of undermining. Opening
up a wound does not necessarily help healing. It is helpful to go over the factors which can delay healing such as infection, poor nutrition/hydration, immobility, comorbidities (such as diabetes, HTN, edema, heart and lung disease, etc); also medications, etc. to predict the healing rate of
the wound.
Maria Carunungan, DPT, CWS

thanks very much

deanne lee

In the Nursing Home I am Deputy Manager of in Dorset, England, we have an extremely good relationship with our area TVN, and she provides/ informs of free or cheap training that is available locally, and there is an associated TVN link nurse group which includes nursing homes. but we also have company reps that come and give free training sessions to a very high standard. They also provide free literature, which is not always company specific. Is this service available near you?.
Regards
Moira

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Deanne,
I have used the model clay recipe that is listed on
the WCEI site and made my own models of the wound stages putting each into their own glass case. I then added pictures of "real" pts wounds for each stage to reinforce the images. Everyone gets a good laugh at my artistic ability while learning.
Donna Cameron RN WCC

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www.healthedco.com

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I made some models with play dough. This would help only with he different shapes and the process of dressing or packing the wound. I wonder if you could do the cookie dough thing like they make ornaments?

Patti Schwartz, RN,WCC

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Try looking up your rep for companies such as
Smith and Nephew, Johnson and Johnson,
Convatec. They usually have cheat sheets
or cards they could give to you and your staff
for educational purposes.
Maria Carunungan, DPT, CWS

unsigned

Wounds need protein, vitamins, minerals, and other nutrients to heal. With malnutrition, the wound doesn't have the building blocks it needs to grow new tissue, as well as fight infection, remove dead tissue, and make the needed chemicals. Further, if a person is in a malnourished state, they are breaking down tissue from the body just to preserve vital functions, such as keeping your heart beating and your brain working. You can't make new tissue if you're breaking down tissue to survive.

I don't know about anxiety, per se, but stress does impair wound healing (and anxiety induces stress). Stress impairs your immune system, making it harder to fight infection. The chemical shifts that occur in stress alter the processes all over your body. Several studies have shown slower heaing rates in people under stress.

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

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Age by itself is a degenerative processes and can be a factor in delay of wound in the elderly with or without diabetes mellitus. Malnutrition worsens delay healing by depriving the body of protein for repairs of tissue and essential dietary source of Zinc, co-enzymes and co-factors for anabolic processes. Malnutrition involving vitamin C (Ascobic Acid) lead to failure of hydroxylation of Proline to hydroxyproline ( a much stronger amino acid) in tissue at the site of healing. Anxiety involve some form of stress that releases stress hormones(steroids) that can immunodepress an individual and increase the voraciousness of infection and this in turn impairs/dalay wound healing. An elderly person with anxiety is unlikely to have the wound immoblise and unwarranted movements provoking repeated trauma coupled with high sugar level in uncontrolled diabetes forming a good culture medium for infection, wound healing is delayed.

Ahmed Mohammed Sabo,
Human Physiology,
Unijos

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Adequate protein stores and good hydration, as well as a lack of vitamin deficiency, are all necessary for wound healing.

Anxiety, which is stress, has an adverse effect upon the immune system, and a functioning immune system is necessary for wound healing. Anxiety also can affect appetite.

Sara, PT, WCC

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1. malnutrition delay the wound healig process in all patints and specially in diabetics because tissue to heal need laying in of new fibers and cells in the wound and these need nutrients like protiens ,vitamines,minerals,...etc.

2. anxiety in diabetics may lead to increase thier blood suger (because it lead to increase in the adrenergic activity) and it can cause a lower immune defensive state

Dr s.h.sultan

general surgeon
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Just so that I have this right... the question is how does malnutrition and anxiety delay a diabetic elderly persons wound healing...
In order for a wound to heal you must keep it clean, keep blood floe to the area, and provide adequate nutrition. If all of these things can be met then in theory the wound will heal. But lets look at this wound one diagnosis at a time:
Malnutrition- meaning the body doesn't have enough energy to regenerate or grow new healthy tissue.
Anxiety- a persistent state of stress, causes constant challenges to the immune system, therefore making the effect of normal bacteria in a wound problematic and increases the risk of infection.
Elderly- someone who has lived long enough that organs (including skin) are compromised and the regeneration process takes longer.
Diabetic- because of the sugar imbalances related to the disease process cell nutrition and regeneration is comprised.
Taking all of the known diagnosis into consideration I will guess that the wound is on a leg or foot and the person also has peripheral vascular disease and should have some circulatory studies done to make sure the blood floe is adequate.
Tina (L.V.N./ wound care nurse)

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Hi,

Anxiety may in a sense make wound healing difficult if a patient is thrashing around or noncompliant with keeping off pressure off the area if that is the issue. As far as malnutrition, if the albumin is low (amount of protien in the blood) there is nothing for the body to use to be able to heal a wound. Elderly people who are malnourished need to have their nutitional status bumped up. I have been using Oxandrin and getting great results with it. It's a steroid but really helps with wound healing. the blood sugars may need to be monitored closer but I have seen remarkable results where I work.

Hope this helps

Michele Brantingham RN WCC in san diego

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hello unsigned,
The words elderly and diabetic together can be very challenging in and of themselves when dealing with patients. When you factor in malnutriton you have a lose-lose situation. Think about it. We all need nourishment to grow, to live, to just be. Wounds will absolutely not heal without nutrients and protein, and unless you are getting those things from an artificial source (tube feeding, TPN, etc.) you have to get them from food.
There are lots of good souces for information out there, the library, your advice nurse, your doctor, wound clinics, etc., that can offer you lots of information. Just remember that with the elderly wounds usually just do not heal spontaneously, Nutrition being just one aspect.
Cheryl Nichols
Treatment Nurse

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Hello,

Malnutrition can delay healing because the body needs nutrients, especially protein and certain vitamins, to close the wound. Anxiety can delay healing because stress has been shown to interfere with the immune system, and therefore interfere with proper healing of any open area of skin. For a more detailed discussion of nutrition and wound healing, I would refer you to a wound-healing or nutrition textbook.

Vicki, MSPT, CWS
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Malnutrition tells me that the patient is not getting enough minerals and protiens to form the building blocks needed for healing. This is true of any one with a wound, even a non-diabetic patient.
Anxiety can affect a patients appetite leading to malnutrition, it can also affect the amount of much needed oxygen available to the wound.

Patti Schwartz, RN, WCC

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Malnutrition and anxiety can delay healing
in "all wound types," not just on wounds
of diabetics. With malnutrition, the body
does not have the essential nutrients to progress
healing...either your body does not produce
enough proteins or you break down proteins
that the wound continuously breaks down as well.
Anxiety stimulates the production of toxic substances
which can delay healing, including cortisol.
Maria Carunungan, DPT, CWS