Free or not, it doesn't matter.

Joe

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You can view the guidelines online – from the home page www.ahrq.gov, under “Clinical Information” click on “Clinical Practice Guidelines”, then “Clinical Practice Guidelines Online”.

You can order copies of the guidelines by calling 1-800-358-9295, or by mailing an order form (order form is posted on their website). They will provide up to 2 free copies to you if you are a health care professional. No shipping charge.

Lee Ann Beck RN, BSN, CWS, FCCWS

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I just ordered mine off of the AHCPR website and I believe they were free. (It was about a year ago, but I don't recall paying anything for them)

Margo Van Vorst, RN, WCC
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They will send you guidelinjes at no cost. Either call at 1-800-358-9295 or write to: AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.
Beth WOCN

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The books are free and you can contact them by going to the web and type in AHCPR guidelines. or writting to Office of the Forum for Quality and Effectiveness in Health Care, AHCPR, Willco Building, Suite 310, 6000 Executive Boulevard, Rockville, MD 20852.
de Rn BSN

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Ahcpr.gov

You can download free of charge

Ellen

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Hi. The AHCPR is now called the AHRQ (Agency for Healthcare Research and Quality). You can access their most current clinical guidelines at http://www.ahrq.gov/clinic/

Diana, ARNP, OK

What I have choosen to do in this case is document as follows:
For a pressure ulcer: '" a stage wo pressure wound of 15 cm x 10 cm containing a stage two pressure ulcer of 5 cm x 5 cm ."
For other wound catagories: A wound opening of 5 cm x 5 cm x3 cm with periwound maceration/inflamation/excoriations creating total affected area of 15 cm x 10 cm."
This is based on my decision to verbally paint the best picture possable, not a literature guidline.
Michelle, CWS

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The measurement should be descriptive. Note the wound measurements, and then describe the periwound area--whether it is macerated, flaking, erythemic, etc. I like to use the clock to describe where, and not how far out from the wound edge the abnormal tissue extends.
Beth WOCN

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Per the AHCPR guildlines, measure the actual open area then explain the peri-wound. You should have a PU flow sheet with things such as-measurement, drainage, amount, oder, color of wound, surrounding tissue, culture?, treatment, and notification of dietician, physician and family.
de Rn BSN

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Hi
When Staging pressure wounds is stage 1 through 4 and then unstageable.. Stage 1 is intact skin that are usually red and unblanchable so you measure the red area an open pressure wound you measure the open areas and describe the surrounding area.
They is a very good wound care book you can buy on line at www.lww.com the book is calle clinical guide wound care and is written by Cathy Thomas Hess, RN, BSN, CWOCN. She also gives seminars . You can get more information on this by going to www. wound care strategies.com
hope this helps
K. in PA.

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I would measure the open area, but photograph the entire wound surface including the abnormal areas.

Landry, PT

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You should measure length, width, depth, tunneling and undermining of the open area. Then you should measure and describe the abnormal peri-wound skin.

Gerry LPN

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link on worldwide wounds

R Czapiewski LPN Home Health Nurse

If the wound depth is not measurable, then yes, but describe why. For instance, is it a stage one with skin intact, or is it unstageable due to
eschar covering the floor? Or perhaps an abrasion that is so shallow that the depth is insignificant, then state so.

Vicki, PT, DPT, CWS
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you chart unstagable or uts (unable to stage
carolyn wound nurse

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I have avoided the terms non measurable as it does not indicated why. May I suggest using either "superficial" or "unable to determine due to eschar presence."

unsigned
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The correct way would be to say <o.1. The "no depth and non measurable" is unacceptable by standards. Superficial = <0.1
de Rn BSN

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Unstageable is the term we use for wounds without a clear depth or wound bed.

Linda PT

PS: I do remember that it was a Johnson & Johnson product.  It was the only thing that worked wonders.
 

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The collagen product is Fibracol by Johnson and Johnson. It is 90% collagen and 10% alginate so it has some absorbtion properties. It is meant to gell up down into the wound, healling from the bottom up and from the sides inward. It is a great product. Best of Luck.

Tonya H. - CCS Medical

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Was it perhaps Fibracol?. I personally don’t know of a gauze dressing as you describe, but Fibracol is collagen and looks a bit like a gauze because of its shape and texture.

Vicki, PT, DPT, CWS
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Oasis may be what you are looking for. It has a scaffolding effect for wound healing. They can be left on a wound for up to a month depending on the wound. The are very useful with stasis ulcers.
de Rn BSN

(NOTE from WCIN: OASIS is from Healthpoint, not JnJ)

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Hi Cindi,
Johnson & Johnson makes a Fibracol Plus Collagen wound dressing with Alginate it comes in a pad or rope.

unsigned
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HI Cindi, I am not sure but could it be Promogran? I know Johnson & Johnson makes it. It is the only product that totally closed up my diabetic ulcers after I used "Maggot Therapy" to clean up my stage lV ulcers on my feet. Hope all goes well with yoiur brother. If I can help further, feel free to email me thorugh our site at BTERFoundation.org

Thanks,
Pam Mitchell

I think seeing a wound specialist is a great idea. There are several reasons why this can be happening. Cellulities is the result of an infection in the skin that is often accompanied by swelling. Legs can also be red and swollen from venous swelling. This causes the legs to change color because the skin is being stretched to a point of unhealthy and often the skin becomes dry and cracks (leading to an increased risk of cellulities). So you can see they also go hand in hand. If your father has a history of varicose veins or congestive heart failure, if he worked in a "stand in one place all day" job or if he sat all day long he wound have a grater risk over time of developing this problem. Also, having pancreatic cancer may be increasing the edema (depending on medications and interventions) or even just pressure for the tumor or scar tissue from surgery/radiation. There is a "main drain" called the hepatic portal just between the pancreas and the liver that all the veins from the legs connect to. If there is pressure on this vein then the fluid is not drained from the legs fast as it goes in and, presto,you have newly occurring edema without having any other history. What this all means is, there is several reasons why his legs may be swollen. He has unhealthy skin and is vulnerable to developing large chronic ulcers and repeated cellulitits. That's not the quality of life we want to settle for . A wound specialist can help provide treatment to decrease the swelling and address and water blisters or ulcers that have formed. That may be manual lymph drainage, lymph pumps, bandages, stockings... depends on whats in there bag of tricks and what they see when they evaluated him.

I encourage you to go with this suggestion. They can offer advise and its up to your dad and the family if its advise that works for you.

In the meantime, here an important thing you can teach your dad. He should lie down and elevate his legs (above the heart) if the redness goes away that means he does not have cellulitis and does not need antibiotics. He just needs to elevate more. If the redness stays, he should call the doctor or go to the emergency room, he most likely has an infection and needs additional antibiotics.
Good luck.

unsigned

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Not knowing the rest of his condition it would be difficult to advise correctly, but I can give a few suggestions. First I would ask if any vascular studies have been done, venous and arterial dopplers to rule out deep vein thrombosis, venous hypertension, venous insufficiency (where leg pain is minimal), lymphedema, or arterial insufficiency. These tests can tell you what type of treatment he can receive. Have they ruled out venous insufficiency dermatitis or vasculitis? Compression therapy can be a form of treatment for a venous problem (once the cellulitis is resolved), but if he had an arterial problem he would not be a candidate for compression therapy. I hope this helps.
R DeLaney LPN,CWS

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Silver is a broad spectrum anti bacterial

For wound healing it must be "activated" -
comes in all forms of wound therapy

www.woundsource.com

Pat Devine RN CWOCN

Hello,

The best way to manage such severe LE edema is to compression wrap. However, there are contraindications to compression wrapping, and severe uncompensated CHF is one. A physical therapist, especially one certified as a wound specialist, could help you with the wraps if the compression is not contraindicated, and could train you easily since you are an RN.

Vicki, PT, DPT, CWS
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Understanding that etiology needs to be determined first, you have other options for managing the exudate in the meantime:

You can purchase specialty absorbent dressings – multi-layered non-adherent dressings that are highly absorbent and are available in many sizes and shapes, including a one piece leg dressing that wraps around the entire leg and fastens/adjusts to fit with ties or Velcro. This eliminates the “cutting and pasting” you are doing now and will give you a better result. These can be ordered through medical surgical dealers, home medical equipment dealers, or one of the online home care medical supply dealers. (These are commonly used in burn units to cover or wrap large areas of the body with burn wounds, and they manage heavy exudate well). Keep in mind, this will manage the exudate or moisture, but does not address the etiology.

Another option is a leg bandage system with absorbent layers that can be wrapped around the entire lower leg and changed as needed. Some of these kits come with an absorbent wrap and a Coban-type wrap to hold it in place. They may also contain layers for compression, which she may or may not need. A determination of etiology would have to be made by a health care professional before the compression layers could be used. If her physician determines that she needs compression to the lower leg, then choosing one of the compression bandage products with an absorbent layer would help manage her exudate. Additional absorbent wound dressings (foams, alginates, others) could be added underneath the compression bandage to provide extra absorption if needed. Good luck.

L. Beck RN, BSN, CWS, FCCWS

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Based on information provided it sounds like Venous Insufficiency. Poor blood flow back to heart from veins. With standing, blood pools
in lower extremities and due to congestion will move from veins to smaller vessels eventually seeping through legs. Lasix will not solve problem

Compression is usually treatment of choice with product covering the wound. The product depends on the etiology of wound. Kaltostat will absorb highly exudating wounds. It will not heal the wound. The wound is secondary to the initial diagnosis.

Before utilizing compression one must make sure there is no arterial involvement. If poor arterial flow you certainly don't want to use compression.

We utilize in our wound clinic several simple non-invasive test on all lower extremity wounds to determine the adequacy of utilizing compression.

She would also be wise to keep legs elevated when sitting. Walking is no problem. The calf pump in leg when walking will help push blood back up veins. Gravity pulls everything down and when sitting or just standing legs swell. What do her legs look like in early morning after she has
been in bed all night with legs up?

If you have in your area a clinic that specializes in wounds only, utilize it.
Remember chronic, non-healing wounds are usually secondary to another primary problem. Products don't heal wounds, they will assist.
Diagnosing primary problem will move you in proper direction for healing or at least preventing further deterioration.

Also Telfa will tend to hold drainage against the skin, causing maceration. I'm not sure I would use it. Granted it keeps from sticking but it really is
not the bandage of choice for heavily draining wounds.

Those are just some suggestions, not a dx.

Lynn Sherwood
RN
Wound Clinic Nurse
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Your intuition sounds like a great stepping stone to start from. But I have some ideas to help you. First, medicare does cover dressings if ordered by a doctor and accompanied by the proper documentation. ,Your local medical supply business should be able to help with that. Something to look into. Ultimately, the first course of action should be to apply compression to help alleviate the swelling. If there is thin skin, night resting pain, intermittent claudication or pallor on elevation, or absence of hair growth then be careful applying compression as she may already have some arterial compromise that could be increase with pressure. Secondly, if you do apply compression she should still elevate her legs and you should listen to her lungs. Fluid shift should occur with compression. But we want it to shift into the kidneys not the heart and lungs.
Alginates are meant for absorption but are costly. If there is no infection then I would open up an abd pad and apply a couple to the leg, secure with a conforming wrap. Exudry is another product that works well. if it is available. If there is any sign of infection and you want the added protection of an antimicrobial I would go to Aquacell aq. This is a slow silver ion release lasting 3 days. To get your moneys worth out of it, place the aqaucell ag next to the skin then apply a abd pad or an exudry over it, secure with gauze and leave in place for 3 days. When you have a final differential diagnosis or an ABI (ankle brachial index) that clears you for full therapeutic compression, she will want to be in an unnaboot. I have used all the above products under the unnaboot layers with good success. (unnboots are for ambulating patients, elastic multilayer compression wraps are for limited or non ambulating patients). oh yes, don't forget: elevate elevate, elevate!
Michelle, PT CWS

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A wound specialist (WOCN) not a wound clinic would be good but you are on the right track. Alginate products will help the drainage. Contact a Smith/Nephew in your area or Coloplast rep. You can find these on the web. Alginate does come in a role or single pieces. Wrapping the legs with unna boot may help the edema. You can change these every week. She may develop ulcers anyway from the sound of her condition. The treatment would be the same. Oasis works well with ulcers under the unna boot too. The boots will push some of the edema out of her legs. To apply the boots start just behind her toe base and wrap withing one-two inches from her knee. Work it like an old fashion cast, smoothing as you go, and overlaping about 1/2 inch all the way up. You can even wrap the unna boot with kling to keep the bed or her pants from getting too messed up. Shoes will be an issue with the boot. Put her in sandles or slippers for awhile. Hope this helps.
de RN BSN

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It's very important that your mom elevates her legs as much as possible ( above the level of her heart if she can tolerate it ) to decrease the edema. As for containing the weeping fluid, try wrapping baby diapers around her calves. They are cheaper than the dressings you're using, clean and very absorbent. Another choice you could consider is using peri pads / sanitary napkins. Again, they are cheap, clean, and can wick the drainage away. Hopes these suggestions help.

Kathy Ellison, RN, CWS
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Hi Kay,
you could try KERRABOOT byArk Therapeutics www.kerraboot.com it works by applying a kerraboot ----dressing boot literally like a boot and the wound fluid drains into an absorbent pad at base of boot---extremely easy to apply change prn usually 24-48hrs dependant on exudate levels. you will get all the relevant info from their site.
Terri RGN
England

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Kay is your mom on medicare? If she is her supplies will be covered if you have home health nurses come in to do the wound assessment and dsg changes. It dose sound like she is forming venous stasis ulcers. profore wraps can be used to get the fluid back in to circulation and out of her system, if this is not available you can use ABD dsg's and wrap her legs with ace wraps to stop the fluid from pooling, keep her legs elevated as much as possible. I would strongly recommend asking her PCP to write an order for home health nurses to do an evaluation for home health services.

R Czapiewski LPN Home Health Nurse

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You are on the right track. First would be dopplers to determine if there is an arterial involvement. If no arterial involvement, then discuss if compression therapy could be used (depending on how bad her CHF is). You can use calcium alginate pads with compression dressings. But until tests are completed, you can use a moisture barrier to prevent maceration (products with aloe work well, not a petroleum base if she is on oxygen), then large calcium alginate pads to absorb the weeping, because they will absorb 20 times their weight in fluid, then 4x4 gauze pads and lightly wrap with bulkee gauze. Calcium alginate is the best exudate absorber I have ever used. This will be quite an expense. Hope this helps.
R DeLaney LPN, CWS