Sometimes using a piece of hydrocolloid cut to fit the wound border will stick in difficult areas, and give the film something to stick to.

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

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You should never shave any area for any reason. It causes micro-openings in the skin and that invites more issues. I have had the same problem with a vac at this most difficult area. We even had the rep come and try to get us a good seal. Sometimes even through the vac is the appropriate treatment, it just isn't possible. You want to watch using the aquacel AG. I very well may dry your wound too much and then you will have little healing. why not try smith Nephew solosite comformable gel gauze. It provides a nice moist wound bed and that will encourage healing or Santyl until healed enough to possible try the vac again. Cov r site plus is a good cover dressing.
DE BSN RN

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Yes, I just had a patient yesterday with a perirectal wound. I have had good success with stomaadhesive paste (applying a bead) on to a 1" strip of hydrocolloid dressing and then applying it directly to the edge of the wound. I was able to get seal on the first try.
I also have had success using the putty strips by Coloplast.
Hope this helps.
Jesse Cantu, RN, BSN, CWS

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We have had success using a paste product such as Convatec stomahesive paste or Hollisters Adapt strips to fill in areas of creasing much like you use these products for peristomal creasing. In the instance of close proximity to the rectum, I place the paste in the tissue between the wound and the anal opening then use drape to cover the paste/adapt to enhance the seal. This has been very effective & has limited the need to consider a diverting colostomy for those patients where fecal contamination cannot be controlled. Sandy RN/BSN Wound/Ostomy Resource/ VAC certified

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Wish I was there when you placed it. There is a certain way to apply the drape, going in two separate ways from the rectum, works like a treat.

Julie Palmer RN
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I will be applying a VAC to a wound tomorrow for the first time that is located just 0.4 cm proximal to the anus. I don't know how it will work but I was advised a nurse at KCI to use spray adhesive and a thin strip of stoma paste to obtain a seal in this small and difficult area. Theoretically it sounds great, I will be finding out first hand tomorrow.
Michelle PT, CWS

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Hello,

I have used a hydrocolloid or self-adhesive thin foam on the skin, then the drape atop that before. It seems to work better on hard to seal areas than the drape alone.

Vicki, MSPT, CWS

This is not really my field, but it reminds me of going to the gym. When I do use the showers at the gym I always wear thongs on my feet, and never share them.
Just a thought.
Cheryl Nichols LVN
Treatment Nurse

It can be very hard, as there is not practical objective way to measure it except for when it's collected (eg: NPWT or pouching). Some advocate % of dressing saturation, but I don't like that as each dressing has a different capacity. My own personal scale, which I encourage others to use for consistency between people, is dry (obvious), minimal-wound is shiny and moist (all are done after cleaning), heavy/copious-I see drops forming while I watch, moderate-in between. It works for me, though it's not validated. I also look at the dressings I remove, find out how long it's been in place, and look to see what it's containing to help me decide, considering the capacity of each dressing.

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

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At our agency, we use the small, moderate, large. Small = dressing is < 25% saturated;
Moderate = dressing is 25-50% saturated; Large = > 75% saturated
Hope this helps

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Try documenting by comparing the drainage to something everyone would relate to For example a 4 x 4 foam has strike through drainage (drainage is seen on the outer side of the dressing) and it is the size of a quarter in a 24 hour period, if the drainage is the size of a dime or does not strike through the susequent days it is an improvement. If you have been changing the dressings 2 times a day because they dressing are completely soaked through some foam a kerlex wrap and before this you had noted less drainage this has to be documented The just as ambiguous words minimal moderate heavy and copious are the words of choice recently but wherever you work you need to define these on paper and get everyone to use them You need to establish what you consider defines these words For example no strike through on the dressing in 24 hours is mininal soaking a large dressing heavy etc. Dont forget that what the drainage is like is important too...serous seroanguinous ...odor bloody Thick green etc
Good luck Jeri RN wound care coordinator

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AT MY LAST WOUND CONFERENCE WE TOLD THAT WOUND EXCUDATE IS EACH PERSONS OWN OPINION IT MAY BE SMALL TO ME BUTIT MAY NOT BE TO YOU
RR

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Scant, small, moderate , large is the way to go.

Julie Palmer RN WCC

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 Hello,

How about measuring the space taken up on the dressing(4x4). The only thing is that everyone would need to be inserviced on whatever system that would finally be used to ensure the most accurate documentation.

Chuck DiTullio R.N.

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Hi,
I work in long term care and we document the exudate in color, oder, amount of drainage etc. The wound is measured weekly usually it is an LPN that does the measuring and the same one also on the measuring day the RN looks at the wounds also this way there are tow looking at it at the same time. Then the next day that RN and the ADON and DON meet. The RN report what each wound looks like if it has improved or is worse and together they discuss a plan of action.
Kathy From PA.

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I believe wounds should be assessed carefully at least weekly (photo, measurements etc.). If you have a nursing staff that you feel confident will report changes to you promptly it could be two weeks. But I would instruct them to document the same weekly assessment.
We have a policy that if the wound does not improve or if it declines over two weeks, we consider wound treatment change and re-assessing nutritional status, mobility and consider need for consult to appropriate physician (vascular).

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They must be evaluated at least weekly. Braden is reccommended q.week x 4 then with the MDS. The family, physician and dietician should be updated with any change in the wound.
DE BSN RN

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Every week, for documentation purposes and analysis of the wound. Is it getting better or worse??

Julie Palmer RN

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When I was employed in the nursing home, I followed wounds every week per guidelines; however, my experience was that the wounds of the frail elderly did not show significant progress like the wounds of younger people or even healthy elderly folks.
Nancy B. RN, CWCN

Actually, acetic acid shouldn't be used much. It can be effective against pseudomonas, but it's also cytotoxic to healthy cells. Most wound care guidelines recommend against using antiseptic cytotoxic agents when healing is the goal. www.guidelines.gov will help you find such guidelines.

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

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Any "wet to dry" procedure, including Acetic Acid, needs to be done TID because it dries. But other antimicrobials (that are not too harmful to tissues) are recommended instead. Examples of these products are Silver hydrogels or dressings.
Amy Pastor RN, CWS

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OH my, please leave the acetic acid alone.

Julie Palmer RN WCC

I don't know where you might find this information all in one place but try a google search on your internet and it might turn up some papers done by some of our recognized experts in wound care. FOr sure you need to use a dot (sticky dot from a place like Staples in the same size Place it next to the wound These dots are standard in size and give a referance for the wound size THere is soft ware out there that can actually determine the size of the wound from the picture after it is downloaded if the dot is placed properly You must always place a centimeter ruler next to the wound and phtograph form the same angle The biggest objection to digital photography (from the State regulatory people and the courts is that it can be enhanced or altered made to look better worse, less red. smaller etc after the photograph is downloaded. The insurance carrier for the facility I work in threatened to drop us if we took photos at all because of the field day attorneys can have with photos. Blowing them up making them look horrible for jurys that kind of thing. We have relatives taking photos with their phones wow those look awful..the redness is enhanced... Standardization is important Frequency size comparison devices like dots rulers and Documentation documentation documentation Jeri

PS  forgot Time date on the centimeter ruler and pt ID with a key NO names HIPPA problems there (in USA)

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HI Judy

Your need to consult with a certified wound care specialist.

Pat RN CWOCN

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Please try Aquacel Ag. Works like a dream

Julie Palmer RN WCC

We are looking for information regarding the clinical efficacy of heel protectors, sheepskin pads in the relief of pressure ulcers.  Would you please get back with me as to where I could find this information?  Thank you, Taryn

tbennett@wmhs.com

I don't like to use these in any instance. Heel protectors do nothing to protect the heel especially if the foot is placed on the bed or surface w/heel protector on it still causes pressure and sheepskin is not good either. The best thing to do to protect heels is to "float" them and get them completely off all direct pressure surfaces.

Theresa Keesee, LPN
Wound Nurse

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Sheepskin went out years ago. Please try foam bootees, or off –loadi.ng

Julie Palmer RN

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 Hello,

I can't refer to to proper written documentation but I can tell you that offloading the heels is the only real way to prevent or prevent further damage. There are alot of factors involvedie: pt's mobility, nutritional status, etc...but offloading is the best. Some like the boots but I've seen wounds occur from the boots as well.

C. DiTullio R.N.

Hi Holly,

I am presently seeing a patient with bilat. Venous stasis wounds that I am doing both the Vac and Profore compression wraps. He is having amazing results. Your ABI readings are on the high side of normal….is your patient a diabetic?

George Simmons, MSPT/RN CWOCN
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How many hyperbaric treatments did you receive and were you using Profore, VAC and HBO at the same time?

Kaye McClue, RRT,CHT

HyOx Medical Treatment Center
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 Hello,

I can't speak of the concurrent use of treatments with the vasc except duoderm to protect edges, and panifil on select necrotic areas. I can say that 4 weeks on a vac without any real positive progress is a long time. Also the presence of edema concerns me R/T his nutrients/electrolytes/h2o status. The vac can dehydrate one easily. I would also wonder about the young man's nutritional status as this is also an important consideration in vac therapy. Sorry I couldn't respond to your exact queastion.

Respectfully,

C. DiTullio R.N.
 

Hello,

E-stim is the only modality you mentioned that is currently billable under CMS guidelines. Of course, you can do ultrasound and phototherapy, but cannot get reimbursed for those modalities at present as far as I know. And, the reason ultrasound and phototherapy have not been approved for wound care is that they have not been demonstrated to be effective via well-constructed studies (evidence-based medicine). We need some good studies published showing the efficacy of these modalities for the CMS will pay for them. So, I guess my point is, why do you want to do all those modalities? Maybe start with the e-stim and see where you should go from there???

Vicki, MSPT, CWS
 

Once the surgical wound is closed the process of maturing the scar begins. In most individuals this process is about 2 years. during this time the composition of the scar tissue changes, the blood supply changes and thus the color of the wound changes. Silicone sheets can be found in most pharmacies that, when placed over the skin, help to keep the scar soft and moist. This will not speed up the process but give you the best cosmetic outcomes.

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I also went to a seminar on New Directions in Chronic Wound Care Management. Yes a wound should be cleanse with normal saline before a culture and then the specimen should be taken from the center of the wound or where the most drainage is and the swab shoud be pressed in that area and not brought across the wound. Here is a site that might have information you are looking for www.woundcarestrategies.com

RN in Long Term Care Facility

K, Pa

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You absolutely have to clean the wound first if it is going to be cultured. Otherwise you are getting surface contaminants. Sue, CWS
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You are 100% correct. You always clean off the wound before do a swab culture. Normal saline is a good choice for cleansing. Tell them they can go to the Wound Care Strategies.com or to the NPUAP position paper. Remember a swab culture is not the best choice for a culture, a punch biopsy is. All wounds are containated! If you don't clean off the wound before culturing, you are only culturing dead cells (exudate). It will not be a true culture.
DE BSN RN

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 I AM ALSO THE TX NURSE AT MY LTC. THE RN,DON I WORK FOR HAS ALWAYS TOLD ME THE CLEAN W/ N/S BEFORE DOING CULTURE. MAYBE YOUR RN WANTS TO HAVE A + INSTEAD -. IF U HAVE PT IN HOUSE, ASK THEM. GOOD LUCK. TS,LPN IN INDY

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Please tell the RN,s to go and take a wound care program. Of course the normal cleansing of a wound before wound culture should be done with normal saline, water or wound cleanser. Do not forget, to take the culture away from necrosis or slough. Julie Palmer RN WCC

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Hello,

You are right in cleaning the wound before culturing. You want to culture the tissue, not the drainage. Many journal articles address this. Gather some articles before your next meeting, and use them to demonstrate what experts in the field regard as best-practice guidelines.

Vicki, MSPT, CWS

Rather than making recommendations without seeing her, I suggest you find someone certified in wound care. You can go to www.aawm.org and www.wocn.org to find someone near you.
 

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

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Fibracol (Johnson & Johnson) is a collagen dressing and is also helpful with the absorption.
Amy Pastor RN, CWS

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hi have u tried acidic acid? i know it sounds harse. but this does work. try packing w/ it what do u have to lose? good luck

unsigned

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Hello,

Find a wound specialist if you haven’t already. You need to be on a good diet to heal. Dressing options might be silver alginate or silver gauzes to pack, as the resistant microbes might be a factor in this (likely are). KCI also has the VAC instill, which instills an antibiotic solution, and that might be an option. And, sometimes, cleaning a wound well with pulsed lavage several times a week will jump-start healing. I recently got a long-standing wound to heal using pulsed-lavage each time I changed the VAC dressing. Tunnels can be very difficult and tricky. You need a knowledgeable person handling your wound!!

Vicki, MSPT, CWS
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Hello,

Remember a wound that tunnelled but was healing great on the outside. Wound up using curasol soaked wound packing( packed lightly)after cleaning and before I left the facility the wound was almost closed.

Respectfully,
Chuck