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

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Rita,
Your husbands occupation, and the fact he needed to have veins stripped, does indicate he has venous disease however I suspect that this is not the cause of his wounds as venous wounds are not typically painful. He should be offered medication to help deal with the pain. I also would suggest an opinion from a wound care specialist as to the true nature of these wounds.
Good luck to you both,
Michelle, PT, CWS

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Hello,

I am a Home Health nurse and I have found that neurontin is a very good medication for chroinc pain, plus it's a med for nerve pain as well. Also, does he wear ted hose during the day? And if it's possible can he get some walking in that helps with the circulation too.

Deborah Taft

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Ms. Smith,

There a re a few things which can cause pain to
wounds like dryness of the wound bed, circulation,
trauma from dressing changes (how gently are
the dressings pulled off, how often, etc), inappropriate dressings (some are "cytotoxic" meaning it is harmful to good tissue also). You need to describe the pain he's experiencing, in his own words to his physician as the type of pain can suggest different things...also where the pain is located, how often occuring, what triggers the pain (like what kind of activity?) and what relieves it. Having his legs in the dependent position
due to his work (on his feet big part of the day at work) can also contribute to delay in healing, even pain or discomfort as the legs/feet feel tight. Bottomline, ask him these questions and let him discuss these with his physician, especially one who specializes in wound care.

Maria Carunungan, DPT, CWS

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

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HI,

What a nightmare of a case! I used to be a home care nurse also and it can be so frustrating when MD's arent' open to other ideas.

I guess I would first be interested in what her prealbumin is. and also her H & H. Also has the wound been cultured? My guess that the blue sky is making the wound worsen maybe because the suction is too high??? Sounds like she may have some bacterial problems in the wound also. Would be interested to see if she has osteomyleytis from this wound. Has she had a SED rate or bone scan to rule that out?.

Let me know more and I would like to in touch with you on this one

Michele

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I don't think the problem is type of Negative pressure. THere are a lot of issues I don't understand completely, but I'll do my best to answer. The thing with Blue Sky is that if you are using silverlon, which is a good dressing, you MUST use sterile water to wet and the gauze packing should be dampened with sterile water also. The normal saline inactivates the silver
ions. Also I don't know what you are talking about when you say to put the silverlon into a tube. The other thing you have to remember with silverlon
is that if you get the old type, a solid gray cloth-like dressing, you must cut slits into it to help with the negative pressure and the drainage. The new silverlon has the holes already in it. Also remember they should not get an MRI or defribrillation with silver. You may want to try the Wooding-Scott
or irrigation drain tube for this wound as you can instill the sterile water daily without disturbing the dressing. With the silverlon you can keep it on
for a week, even if it becomes necessary to change the outer dressing. The cellulitis you are describing - I don't understand - I don't think what you
are describing is cellulitis. When you start wound care, are you probing for tunnels and then packing them? The channel drain would be perfect for
any tunnels (which KCI doesn't have). You could use the channel or Jade drain in the tunnel & the WOoding-Scott in the wound and put them to a
Y-connector and I don't see why it wouldn't heal up quite readily if this morbidly obese patient has her dietary needs met for healing. I also don't
know what an ischial fistula is. Maybe the fistula needs to be explored. Or maybe tunnels were never addressed right along and closed over and later
caused abcesses? I think the treatment is absolutely appropriate and the physician is correct, so there is something either not being done correctly or information not addressed here.

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

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Hi,
I am a home care nurse dealing with morbidly obese patient who has a wound measuring greater than 12 cm deep. She has had 2 surgeries on this wound to open it up, and both times has been sent home on a Blue Sky wound vac. Recently her wound doc added silverlon to the treatment and has instructed us to attach the silverlon to the drainage tube and insert it into the tunnel and leave it for up to 7 days before changing. My concern is this treatment is not working, she has been on the Blue sky wound vac since her latest surgery on October 31, 2005. Generally there is quite a bit of pink, yellow foul smelling drainage in the vac container, and several bouts of cellulitis. Initially the surgical diagnosis was excision of an ischial fistula. Anyone have any ideas? We've tried wet to dry and have gotten the depth down to under 11cm deep, but when the vac is reapplied the depth returns. The wound Doctor will not consider another treatment. I would like to try KCI wound vac. Any ideas would be greatly appreciated.
Thank you,

I am also a Wound care Tech. Trained through the VA. and I also have a patient with an abdominal wound that required a KCI wound VAC pump. My patient had a Lap exploratory surgery in may of last year, and the wound measuring 17 cm deep, 12 cm wide, and 16 cm long. My patient is a diabetic and has been having bouts with MRSA, but once or twice a week I gave a 1% Peroxide Irrigation, and wet to moist packing!
As of today my patients wound is at 8 cm deep, 5 cm wide, and 8 cm long.

Charles Roshe

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I am a spouse/caregiver, however, my husband has been on a KCI Freedom VAC due to infections causing ex-plant of 2 ICDs. As alay-perosn who has seen him through assorted surgeries since May, 2004, I can attest to the effectiveness of the KCI Freedom VAC. His chect wound healed much quicker and cleaner than before and there was very little problem. It was changed approx. every other day and for the first time, it we apparent that fluid was being extracted and the wound was in fact puling together. Just wanted to share some info. about KCI vacs from personal experience. God bless your patient and hope she moves towards recovery!

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A common mistake in the management of wounds
is we rely so much on the equipment forgetting
the essentials as "patient assessment"
and "wound assessment." There are many things
which can delay healing, not just the equipment and
a lot of times, these are inherent to the wound itself.
Check into his meds (anything that can delay healing like steroids, anti-cancer, anti-hypertensives?, etc), nutritional status (remembering that wounds which drain also drain protein...therefore are we trying to replace what is lost in the wound so the patient has something to build on to fill the wound...Have you looked at lab values or have taken these such as BMP, CBC? paying attention to TLC, calcium, glucose, potassium, magnesium, RBC, BUN, etc....also are you addressing increased nutritional needs like caloric intake, fluid intake, need for mineral supplements like vit C, A, zinc, etc.), degree of patient mobility to improve and maintain
good circulation, effectiveness of pressure relief systems, stress reduction (including pain management), etc. the use of silverlon is appropriate to have an anti-microbial effect as you use the VAC...however, silver nor vac are NOT "cure-all's." These factors need to be considered/checked on whenever a wound does not respond to any type of treatment for a period of two weeks...or the patient looks more ill. Consider a patient on vac who staff notice have lost weight, shows muscle wasting, signs of dehydration
including confusion...and as being confused moves
less...Do look into these, very important...
Good luck,
Maria Carunungan, DPT, CWS

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Hello,

I am a Home Health nurse and have been for 10 years. I have had great success with the KCI wound vac. If the wound had a odor may need an anitbiotic. Has it been cultured. If the wound has any eschar tissue it needs to be chemically debrieded with accuyzem. It's late and my spelling might be awful. I have seen wounds cleaned weekly and debrieded and they seem to stimulate the tissues, but first need to address the infection.

Deborah Taft, RN

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

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Okay, this is the scoop. If you are in a long term acute care setting all pressure ulcers that have eschar have to be staged at the worse one which would be a stage 4. If the patient is at home OR in a hospital acute short care then it would be an unstageable because we don't know for sure how deep it is. I think that way we are playing by the rules.

thanks for the inquiry\\\

Michele RN WCC

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Yes. Once an pressure ulcer has been staged a lll it will always be a Stagelll unless the wound deteriorates to a Stage lV. There is no such thing as back staging rather you would refer to the wound as either a healing Stage lll or Stage lll with presence of Escar over what ever percentage of the wound that is covered with necrotic tissue.
Janalene, LPN,WCC,HT

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This is a good question because I have had CMS address it and this is their response (in my words). If there is necrotic tissue in the wound bed, it
must be considered unstageable regardless of the previous staging - EVEN if it were staged at IV. This does not make coomplete sense to me, but we must follow the powers that be. I can see saying, for example if the wound had been a stage IV previously, a stage IV with necrotic tissue and describe the percentage and type. Also, once a wound is staged, it cannot be reverse staged. In other words it can't go from stage III to a stage II. It goes from a stage III to a closing or closed stage III.

Deborah Harris, BSN, JD, RN, CWCS
Louisville, KY
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Once a wound has been classified as a stage 3 it can change to a stage 4 but it should never be classified as a lesser stage. This is called reversed staging. It is misleading as the tissue will never be the same, even when closed. It is most accurate, for example, to describe the wound as a healing stage three. What you describe however is an unstageable wound (the wound bed is not clearly viable and the involved structures can not be fully identified). In some situations (LTC) paperwork required for reimbursement will not allow for this accurate documentation. In that situation stage 3 or stage 4 should be recorded (it is better to slightly overestimate the depth of tissue involvement then to underestimate).
Michelle PT, CWS

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Hello,

I thought as long as there is eschar you cannot stage the wound till you can observe the wound base.

Deborah Taft, RN

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When a wound has an eschar, this is unstageable and should be noted as such (eg. "unstageable due to presence of necrotic tissue) because you cannot
really ascertain how deep the damage is...You also
cannot downstage a wound according to the NPUAP. However, if you have to deal with MDS as in SNF's, where there is still no mechanism to consider downstaging and you cannot assign a value to "unstageable," this is staged "4." I may be mistaken as guidelines may have changed since I last worked in a SNF.
Maria Carunungan, DPT, CWS

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I would suspect the diagnosis first of all - I would take her to a good dermatologist. If it is gout, then I would first treat systemically with colchicine or allopurinol or whatever else is out there. I would also do a culture for bacteria as well as fungal, and treat accordingly. I would instruct on good foot care - check feet every night, keep clean and hydrated - apply cream, but DO NOT let cake between toes, do not wear ANY shoes that bind toes or rub in any way. Sometimes the best footware is a
supportive open-toed sandal. Then I might use a silver ointment like silvasorb and wrap loosely with a dressing or an antifungal if it ends up being fungal. Her diet has a lot to do with healing also. Make sure she has no sugar or significant amount of carbs & increase protein. When you say the
white tissue is obviously gouty, that does not sound gouty to me. Gout usually has edema with bright red taut skin and exquisite pain when touched.

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

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Has osteomylitis been ruled out?
Michelle PT, CWS

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Carol,

Has the patient been checked for "osteomyelitis?"
Also, how complaint is the patient in the management of gout (like adhering to diet restrictions), and how is the footwear? You may need to immobilize the part as a lot of movement can contribute to hypergranulation also...If infection come in check, can perhaps try silver-based dressing to keep off infection so the wound
can heal. The patient is also diabetic. How is the circulation to the part where the wound is, as poor circulation can predispose the patient to infections as well.

Maria Carunungan, DPT, CWS

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

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Pressure ulcers occur over bony prominences and therefore are the only type of wound that is staged. If you have an area that develops over a non bony prominence you need to determine if the wound is a ulcer, either diabetic, venous, or arterial. Until that determination is made you can use the term "Lesion" which is an accepted term to describe a wound that is superficial in nature. You can refer to the Wound Care Standards for wound identification and determination which will give you the guidelines you seek for documentation.
Janalene, LPN,WCC,HT

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Although blisters can be stage II pressure ulcers, if it is not over a bony prominence, it is doubtful that it is. However, if there is pressure at that particular area, it well can be a pressure ulcer even though it is not a pressure ulcer. I would be careful though, there are a lot of things that a blister can indicate systemically, but I won't get into that here.

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

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Pressure ulcers (of any stage) occur over boney prominences. A stage 2 pressure ulcer would be a partial thickness skin loss or a blister over a boney prominence.  All other wounds can be classified a partial thickness or full thickness but not pressure. Hope that helps! Michelle PT, CWS

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Pressure ulcers are called as such when the primary predisposing/causative factor is "pressure,"
and usually found over a bony prominence,
even on pressure lines that are soft such as
"brief or panty lines." If this does not meet
this first criteria, a blister can form also due to
"shear" and "friction" (eg. rubbing of heelcord
area against a new stiff shoe)

Maria Carunungan, DPT, CWS

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Prove your point...
Ask for a culture, if it is stool the culture should grow e.coli.
TIna (L.V.N./wound care nurse)

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I agree with you. It looks like, sounds like and probable smells like a fistula! I understand that negative pressure therapy (Blue Sky and KCI VAC) have been used with fistulas and may be just "what the doctor ordered" in this case. I think it would be in the patients best interest to have extra protection against the contamination. The Blue Sky unit packs the wound with Kerlix AMD (antimicrobial dressing) which should assist you in maintaining the infection free wound it sounds like you currently have. The KCI VAC has recently introduced a black foam that contains silver ions. If all is looking well currently and the wound continues to progress, you may be able to close this wound even without a second opinion to confirm your suspicions.
Michelle PT, CWS

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Suggest you send a specimen of the drainage for
lab study like C & S. Fistula is possible and
if lab studies reveal organisms found in fecal
matter, the likelihood of a fistula is high. You can
get brown drainage that is thick as fluid can be mixed with occult blood or even fresh haeme mixed with the fluid from wound which can cause brownish
discharge. What would be helpful too would be a scan.
Maria Carunungan, DPT, CWS

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Brownish drainage indicates enterocutaneous fistula. If your surgeon does not agree please get another
opinion. >>KT Kishan

The "bump" of hypergranulation tissue is in the skin/soft tissue of the surgical wound? Hypergranulation tissue is usually the result of a TOO moist wound bed or of colonization. You may need to try a different dressing to obtain an improved moisture balance but i suspect a culture would indicate the need for antibiotics to decrease the bioburden. How about a silver dressing like Aquacell AQ?
Michelle PT, CWS