It would depend on if the wound was closed (stapled) or if it was an open amputation. I suggest you ask for a wound specialist to consult on the case. It's too hard to give you the answers you want without an examination in person.

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

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As long as the cloth was clean it was okay to use. If the wound is closed up or at least scabbed over it's okay to use a non sterile cloth for cleansing.

Jenn, LPN and student nurse

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Ma’am,

Run, don’t walk, your mother away from this facility. Usually when you see wound management this poor, it is indicative of severe institutional deficits in many areas.

An open wound should be cleaned/irrigated with normal saline or a commercially prepared wound cleanser in a spray bottle.

Clean or individually wrapped sterile gauze is the norm to cleanse chronic wounds. That towel may leave fibers in the wound bed that impede healing.

Ellen BA, LPN, CWS

Wilma

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If you are wanting to charge for the material (the boot itself), you need to look in the HCPCS code book, not the CPT code book. I think it is the A section, anyway with the other dressings If you want to charge for the procedure look in the CPT code book.

Jeri

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cpt code for application of unna boot is 29580.
removal of unna boot is 29700.

Melody Walls, ACNP-BC, WCC

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una boots can be applied for up to 10 days depending on the amount of drainage. A calcium alginate can be applied to the wound if the drainage is too much to handle a 7-10 day change . I am a certified wound care nurse and I use Una Boots alot on cellutis and stasis ulcers. my email is bsn48623@netzero.com

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The CPT code for Unna Boot application is 29580. Reference: Pfenninger, J.L., Fowler, G.C. Procedures for Primary Care Physicians. St. Louis, MO: Mosby, 2003.

Diana, ARNP; Oklahoma

It is very easy for a blistered heel to turn into an ulcer in a short amount of time, especially if the heels are not being “off-loaded” with some type of pillow or cushion. Heels can have what is called deep tissue injury when they feel boggy to the touch and are slightly red. The heel in this state basically has already broken down inside and has yet to surface. At the nursing home that I am at we use skin prep 3X/day to toughen the heel and make it less prone to breaking down from the outside. We always encourage the elevation of people’s heels off the bed so that the heels are “floating” meaning that they are not in contact with anything. If a pillow is used it should be vertically placed to minimize placing pressure in another area of the body…when you off-load one area it increases pressure in another area…so you must look at all areas that may be now experiencing more pressure. PT should be consulted in a case of breakdown to obtain a positioning device but in the interim time a pillow should be used.

Good luck to you and your mom
Cyndy S. RN

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Dear Doris

Please check whether your mother is diabetic. I have come across a non healing foot ulcer and it was due to a constricted vessel in the leg due to diabetis. This can be determined by a dopler test( measuring blood pressure at different levels on the limb). If found so, a surgery has to be performed to remove cthe constriction and the wound will heal by conventional treatment.


B. G. Raghavan
Research Scientist
Schiwaz Health Care
Chennai, India

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If by waffle boot, you are saying that it is something covering the heel, that would cause even more pressure. If, however, the waffle boot has the heel cut out so it is 'floating', that is appropriate. Many companies make those type of products - EHOB & Posey to name two. If you have nothing until
that is obtained, use pillows under the calf until one can be obtained. You could probably get a prescription from the doctor and go to a local DME company and just get it to avoid any other complications. ALso, any dressing
that is appropriate to use, can be used with 3Ms heel dressing which is the best thing I've run across in a long time.

Deborah Harris, BSN, JD, RN, CWCS, WOCN
Louisville, KY
www.medastat.com
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A blister on a heel is considered a stage 2 because of the location unless you can determine it was not from pressure. You need to know that a pressure ulcer can occur in a matter of hours. It should be protocal at the nursing home that anyone who has limited self movement of an extremity especially a leg should have a heel lift boot at all times. A pillow heel boot is not adequate for pressure relief. Simple bed pillows under the legs can keep the heels off the bed and can be done by family members or nsg staff. Talk to the DON about their policies or the medical director concerning pressure relief issues. Make sure the dietician is involved because she should have vit supplements ordered. Call a care plan meeting ASAP to discuss care issues.
de RN BSN

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A PRAFO BOOT WOULD WORK QUITE WELL FOR THIS PATHOLOGY/WOUND
GOOD LUCK

unsigned

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do a search on the internet for MRSA patients at home It turns up some guidelines. Also

www.rcn.org/mrsa /patients/home

Jeri

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CDC has everything you will need.
de Rn BSN

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US DEPT OF HEALTH AND HUMAN SERVICES
(AHCPR) 1800-358-9295

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Daniel:

Washington state has great handouts and brochures on MRSA. This address gives all the information on that topic they have:
http://askgeorge.wa.gov/doh/query.html?st=15&charset=iso-8859-1&nh=7&style=sow&col=doh&origin=DOH&qs=-site%3Awww.sboh.wa.gov+-url%3Awww.doh.wa.gov/sboh&qt=MRSA

The brochure entitled: Living with MRSA at: prLivWithMRSA06 is excellant. Our College Health Center adopted the brochure in toto when I told them about the brochure. We hand it out to all students who have been diagnosed with MRSA. We also hand out a fact sheet on Staph and MRSA infections that we adopted from Washington State HD with their permisson.

Myra Badger, BSN, RN, BC, WCC
Schiffert Health Center
Virginia Tech
 

A wide variety of moist wound healing dressings and approaches could be possible, depending on the condition, location, and size of the wound. I suggest you find a wound specialist in your area to consult with on that wound. Www.aawm.org and www.wocn.org. Also, see www.AdvancingThePractice.org for a lot of resources.

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

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By open, I am hoping you don't mean open to air, but merely open without suturing or closing. Since a wound needs moisture to help the fibroblasts migrate to form granulation buds, any hydrogel will work if it is a 'dryer' wound. They also make hydrogel impregnated gauze that could be used. If there is a lot of drainage, you might try a calcium alginate rope fluffed out as it can absorb 20 times its weight and then turns into a gel. They make calcium alginates with silver too that can help with MRSA, VRE, pseudomonas, e-coli, etc. if that is necessary. Then cover the wound to maintain the moisture.

Deborah Harris, BSN, JD, RN, CWCS
Louisville, KY
www.medastat.com

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Open traumatic wounds respond well to the VAC. Check out www.kci1.com to read about using a wound VAC.
Kari , RN WCC

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Try negative pressure wound therapy…….KCI-VAC or the Blue Sky Versatile One

Have seen consistent positive outcomes with use of this modality in traumatic wounds

Ellen BA, LPN, CWS
 

Go to www.NPUAP.org Back-staging is still against the system, though forms like the MDS-2 require it.

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

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Reverse staging is not to be used except in the MDS. When maintaining records on the unit for skin you can list the pressure ulcer as a 4/3, meaning a stg 4, now a stg 3 but can’t reverse. The new tissue will always be referred to as a “healed stg 4” etc...because the skin is always more compromised and prone to re-opening than other areas.

Cyndy S. RN
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I just read that you cannot reverse stage a wound because the tissue underneath will never be back to normal. I believe it was on the wound care information network. Karen

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That is not true, however in the long term care arena, their paperwork does not conform to that, but CMS is aware of their incorrectness (if that's a word).

Deborah Harris, BSN, JD, RN, CWCS, WOCN
Louisville, KY
www.medastat.com

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I know there has been talk about allowing reverse stageing but haven't seen or heard of a go ahead with it. You must stage a wound as it appears, stage wise, for the MDS. That is the only place you may reverse stage. In you weekly wound rounds a stage 4,3,2, is always to going to be that way until resolved. The term healed is not to be used in documentation because you never get back 100% strength. The term to use is epithelized. In your documentation you need to describe the wound as it appears.
de Rn BSN

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there is no down staging anymore.

unsigned

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yes, stage 1 & 2 can be reversed, but not 3 and 4.

Judi Barton, RN
Regional West Home Care
 

Try this email address cthess@woundcarestrategies.com I went to one of her work shops and it was great.
K. Pa.

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Yes,

My company, Williams Consulting, Inc., provides fully accredited wound management programs to physical therapists and nurses.

Please call 405-740-5651 for details.

Ellen Williams BA, LPN, CWS
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You could look in the registry of the WOCN on their website that I belong to. (Wound, Ostomy, Continence Nurse Society)

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

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You might check out Medline's Educare programs -
http://www.medline.com/Education/advwoundcare.htm
They just did the one day "Educare: A Wound and Skin Care System" seminar in Tucson which covered a lot. While it's sponsored by Medline and their products are displayed, they weren't "pushed" during the seminar (ie, appropriate product type and application was presented.)
Patti, BS,RN

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Contact the Wound Ostomy and Continent Nurses Society - www.WOCN.org

and / or

The Association for the Advancement of Wound Care www.aawcone.org

Pat Devine RN CWOCN
pevine2@earthlink.net

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Contact Jeffrey Feedar, renowned wound care specialist from East coast. At feedar@woundcareresources.com
 

It's great to see such passion. Welcome to the world of wound care. First, collagenase is designed to be daily dressing, and Allevyn is designed for several days wear time. Plain gauze cover is fine for an enzyme. It's a lot of time, effort, and money to use a foam twice a day. If it's draining that much, it's probably infected and you should look at antimicrobials. If it's being changed for the sake of getting to it twice a day, it's not necessary. Since she's not eating and is disoriented, is she a candidate for a tube feed? Xenaderm would not be appropriate, as it is not designed for on necrotic tissue and full thickness wounds. Can she have oral pain medications? Most topical agents are short acting. Also, if she has only a daily dressing change that's going to be less irritating for her. She may even have some tape stripping from it. I don't know the family, but sometimes not wanting heroic measures is not for selfish reasons. Sometimes it is out of love and compassion to not want to prolong suffering and a poor quality of life. Check out www.AdvancingThePractice.org and www.aawcone.org for more resources.

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

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I think you have definitely chosen the right dressing - only I would only do it one time a day. Is it necessary due to the amount of drainage to change it twice a day?? If so you need to use a calcium alginate dressing to absorb the drainage then cover with guaze and foam to maintain the warmth.
Martha Reid BS RN WCC
Roxboro NC

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If the wound has a lot of necrotic tissue it can not be staged until the wound base is visible. Usually need surical debridment. Panafil is a debriding and deodorizing ointment or spray.
K. In Pa.

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Try irrigating wound with half strength peroxide/saline. You can use the collaganese on the stage 2 also. Make sure you are not packing the wound too much. This will cause a lot of pain.

Chris
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Never use a wet saline gauze treatment for debriding. Yes it is cheap but it is very painful to the resident on removal. Everytime you remove the dressing (should be removed dry), you are pulling good granulation buds off the wound bed. From the sound of this lady the wound may never heal. Santyl is a good debrider that will not cause pain and it works well. After all the necrotic tissue is removed, cover the wound bed with Smith/Nephew Solosite comformable gauze. It provides a cool, moist enviornment for wound healing. This is also excellant for pallative care which this lady may well be too. Get your dietician involved. She can provide additional supplement for healing. Xenaderm is an excellant treatment for many wounds. Contact a rep for instructions, pros and cons. Also, get out of the habit of documenting the word "pack" the wound. You fill the wound bed. Packing means just that and you do not want to pack the wound. If you pack the wound you will delay healing by damageing aready damaged tissue. You might want to consider an air mattrress and a special wheelchair cushion. Talk to the physician about pain meds prior to treatment change. The cavillon is a good thing to use too. You wet gauze is most likely the cause of maceration of the peri wound. Another reason not to use it, it is non-selective.
de RN BSN

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Call in a registered dietitian

Ellen LPN, CWS
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 Hello,

Sounds like your patient is in a stage of physical decline for sure. Don't think you'll like what I have to say but I believe that without proper nutrition, there won't be any healing. I don't know your patient but it sounds a little like some type of comfort measures may be what the family is looking for eh? Hospices are very good resources maybe a consult? Also, debridement may not be apprepriate as your patient's metabolism isn't in position to build up so any (even the smal;lest) amount of good tissue loss is bad and there will be some with debridement. I might recommend just a dressing change with an antimicrobial (TAO) would be the best choice. Som good to hear of a new nurse embracing the profession as you have.

Respectfully,

Chuck DiTullio R.N.
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I am not sure that the number one goal in this patients wound care is to obtain wound closure. I say this because, not knowing her complete medical situation, as a person begins to fail and the system" shut down" the skin is one of those many organs prone to organ failure. Healing requires not only for the organ to maintain itself but regenerate its self. Considering she does not eat and the family is looking at comfort measures only, the goals her seem to be: prevent infection, prevent worsening, decrease pain, decrease/prevent odor.
That being said, the cover dressing should be low tact (like mepilex) or removed in the gentlest way possible. if it is a hydrocolloid, roll it back. if it is a film, lift a corner and stretch it to break the adhesive. There are products you can apply to the wound base to numb it like 4% xylocaine. this needs to be applied and covered with gauze. you leave it on for 15-3 minutes before performing debridement. If you are not debrideing a wound, i don't know how practical this is for dressing changes since the most painful part of the dressing change is usually removing a dressing. More practical would be to schedule the dressing changes around the administration of her pain medication.

You did not provide much description of the wound base presentation. Does it have a significant amount of necrotic tissue to debride? trace amount? eschar or slough? Mechanical debridement (such as that performed by wet to dry dressings) is painful and destructive to the good tissue in the wound base. Enzymatic debasement (santly collagenase, accuzyme, or panifil) is most effective in combination with autolytic debridement but requires daily dressing changes which decreases healing time due to frequent dressing removal that decreases the wound bed temperature. I would only advocate this method if there is a large quantity of necrotic tissue. My top recommendation would be to promote autolytic debridment by providing a moisture retaining dressing that can remain in place for 2-3 days at a time. This could be a foam or alginate depending on the amount of drainage. Products to explore would be biatain foam with silver (contreet) or Aqucell AG or Acticoat 3. There are countless others but these 3 I am most familiar with. If the wound is very clean, look into Hydrofera Blue (a moisture retaining bacteriostatic dressing that remains in place 3 days).
I do hope this helps!
Michelle, PT, CWS
 

Mary

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There is a company called MoIlycke (not sure on spelling) it is a Dutch company I think. They make a line of products that I love. One that I think would work for you is called mepiform. You put it on and it sticks in place - no need for a secondary dressing. It is flesh colored. It can virtually stay on until it comes off on its own.

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

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I work in a nursing home and use vaseline gauze on skin tears. I cover it with some 2x2's and wrap it with kerlix. I have had very good luck with this dressing. I don't let them scab over. Vaseline gauze heals nicely with no scabbing. Karen

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On thin skin areas that tear easily i usually suggest vasoline daily. to those small areas that are prone to tear or that are exposed to friction i find that it creates a nice protectant barrier..it's also inexpensive!
maureen elliott lpn,wcc