Michelle,

Not sure, but it two possibilities come to mind:

1. Product cost. Silver dressings are more expensive than calcium alginates. If the patient is receiving daily radiation therapy, the dressing is being changed at least daily. Silver dressings are more cost effective when changed less frequently.

2. A silver product may not be necessary. Silver dressings are beneficial in helping control bacteria in the wound. If the wound isn't infected, is being cleansed and changed daily, and/or the patient is on antibiotics calcium alginate is an appropriate dressing choice.

Kim RN, CWS

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I know you can not use heavy metals when giving radiation therapy, although if a silver alginate is used on a wound then the dressing can b e removed and the wound washed before treatment. As for idodine and wounds, it is cytotoxix to human fibroblast and is not recommended to use on open wounds at all. Hope this helps.
R Delaney LPN,CWS

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It is only in the scope of the RN and specially trained LPNs. Look to your state board committee. Remember, LPNs cannot assess, only eval.
de RN

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I am a Registered Nurse and in our wound care clinic the RN or LPN can stage the wound. We also do all our own measuring, but legally I believe the nurse may choose to delegate the aide to measure but it is under her licence ( if the measurements are incorrect, the nurse would be responsible) I hope this helps.
Marie S RN

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I believe a professional license is what is required. Were one to be questioned, however, continuing education, credentials or at least significant work experience would come into play.

Sara. PT, WCC

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There is no "legal" concern regarding staging pressure ulcers. Any clinician can that understands the NPUAP definitions can figure out what stage an ulcer is, the concern arises as to who can do the assessment and document it.

Bill Richlen PT, WCC, CWS
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Hello. I am calling from the USA. Here in the USA only an RN can stage wounds. Do not want to sound up beat but that is the law. You have to have the ability to be a critical thinker, make an accurate assessment, and really know what you are talking about. Many attending Physicians depend on your ability to do this. Hope this will help you

Julie Palmer RN

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Any Nurse can stage a wound (LVN, LPN, RN) that includes ostomy nurses. However, they must stage only pressure ulcers (not diabetic, venous or arterial, or surgical wounds). CMS guidelines do not mandate one particular nurse (LVN, or RN) to stage. Nevertheless, experience is always good and most definately the nurse must have a good knowledge of the staging system. I do know (atleast in KY) nursing assistants cannot stage! Check your CMS guidelines.
Yolanda RN, WCC

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Hi,
It sounds like you need information on how to stage wounds and staff need taught to. There are wound site on here that can give you information on this or have a wound nurse come do an inservice. RN or LPN can stage wounds and yes an ostomy nurse also.
PA.

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Any professional performing a wound assessment can and should stage the wound as part of their evaluation. Unfortunately there is no coordination between specialties in most institutions and there are often conflicting stages on a chart. This becomes particularly sticky when the chart goes to court and a lawyer gets a hold of the conflicting data. Because the physician is ultimately on the block for the case I believe that they should decide on the staging and all other professionals should follow suit. Obviously if there is a disagreement there should be a conference or some form of communication to get consensus on the staging. I also believe that heel pressure ulcers should not be staged until the depth of the deep tissue injury is quantitatively assessed. Too many of these are under appreciated at first only to later turn out to be stage 3 or 4 wounds. Either an MRI or ultrasound assessment should be performed to determine the depth of tissue involvement before any staging is done. Until then they should be called deep tissue injuries of unknown depth or with depth to be determined. They could also be classified as “unable to stage” but I prefer “DTI-unable to stage”.

James McGuire DPM, PT, CPed, CWS, FAPWCA

 

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Lateral rotation is an excellent choice
I would recommend the Turn Q Plus because you can adjust the angle and degree of rotation
It would be fine for a Parkinsons patient
It sounds as if you need a more absorbent wound product in addition to more appropriate pain management
See if you can get a wound consult from a wound certified nurse
Best of Luck,

Sharon, RN
New York

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Liz,
First I would want to know what her pre-albumin is? Nutritionaly it sounds like she is lacking and nutrition is one important factor to wound healing. I am assuming that what you mean by right hip is the trochanter. One thing to keep in mind is that a patient, especially the elderly or those that are immobile should not be placed directly on the trochanter for positioning, a 30 degree angle turning/positioning is all that is needed. A pressure ulcer can develop in as little as two hours, yes, two hours. I would assess the time fram she is being repositioned and recommend that she be repositioned at least every 1 hour to prevent breakdown in other areas, just because she is on a special air mattress does not mean she should not be turned/repositioned. It sounds like she has many co-facotrs that make her very high risk for presure ulcer development. Have the hospice nurse evaluate her pain level and provide more comfort measures due to pain from her ulcer, also do not place her on the right trochanter ulcer. The "white" you are seeing sounds like the reticular layer of the skin. A wound bed requires 4-6 hours to warm up after each dressing change to a normal thermal environment to promote the healing, so I would not change the dressing more than QD, but would strongly suggest to change the dressing QD with no exceptions. As for the hard red area and tenderness around the wound, it could be the signs of infection, monitor for warmth, increased drainage, odor etc.. to determine if it really is signs of infection, it could be the ulcer is in the inflammatory state, where you will see induration (firmness to the area surrounding the ulcer) and the redness. It sounds like she may even have some denuded skin due to drainage as well. I would recommend Xenaderm by prescription (a product by Healthpoint) to the peri wound to prevent denuding and maceration, it also promotes healing as well as increasing blood flow to the area, which will help with her discomfort to the area. Then I would have the hospice reassess for proper wound bed preparation, and treatment protocol. Hope this helps.
R DeLaney LPN,CWS

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Hi, my advice would be to use Cavillon on the red skin around the wound. It sounds very much like maceration is trying to take palce from the exudate weeping from the wound onto the good skin. Akthough very down heartening the nurses are more than likely correct that the wound probably won't heal due to poor diet. I have nursed the elderly for years and found hip wounds a terrible problem. Try 2 hourly 30 degree tilting from side to side using a pillow for pressure relief and i personally prefer Lyofoam adhiesive to Allevyn as it seems more absorbant and if exudate is very excessive kaltostat deirectly onto the wound before the Lyofoam, Good luck keeping her comfortable.
Practice Nurse Jo Ashton

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Hospice may be correct that the wound will never heal, you may have to accept that. What you don't have to accept is incorrect care of the wound. The alternating mattress is a good choice, turn her side to side, using pillow to prop her. The sheepskin is only good for comfort. Don't worry about changeing the type of pressure on her wheelchair. Use a good gel cushion designed for a stage 2-3 pressure wound. You may have infection in the wound because of the firm red circle around the wound, an antibiotic may help with this issue. When doing your wound care, cleansing with normal saline is good. Always protect the peri wound with skin prep, 3M, or plain old vasoline to prevent maceration. If the wound is extremely wet using an Alginate for a while may control this, them to keep the wound bed moist by using something like Smith/Nephew solosite comformable gel gauze. Cover the wound bed with this. This product is very soothing to a resident and continue using the Allevyn (the sofe pillow-like) product. Check for undermining and tunneling. You can't do much with tunneling but with undermining can benifit from the solosite gauze because it can be placed under the skin. Don't forget a good pain management program. Many elderly will not ask for anything. If she is end stage parkinson, maybe your Hospice nurses can suggest a Duragesic patch.
de RN

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I am not sure about the matress but the following is a sugggestion for the wound.

I have found that using Panafil (or something comperable) in a nickle thick layer on the wound bed only and lightly packing the wound with calcium alginate, using a skin barrier on the skin surrounding the wound and then covering the wound wth an ABD pad and taping it in place works with these types of wounds. The Panafil is an autolytic debrider and the calcium alginate will also do some gentle debriding of the wound bed and also absorb the drainage and the skin prep works to protect the viable skin and tissue around the outside of the wound bed. The ABD pad is for absorbing and extra drainage as well as padding. I would also change to dressing daily to prevent maceration of the surrounding tissues. This may not "heal" the wound but I have experienced a similar situation and the wound did heal. Also please if she is not on a pain med ask the doctor for something.

Dianna
RN DON
Long Term Care

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Hi,
Even if the hip doesn't heal and you want her to be comfortable what are hospice doing for pain control??
Pa

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Have you contacted the surgeon's office and asked if Santyl Ointment wound damage/harm the mesh? Santyl will stimulate granular tissue over the mesh. Also, the wet-to-dry dressings sound like they could be damaging any new granular tissue that tries to form. A qd dressing might help the wound heal quicker, but not using wet-to-dry. You did not mention how mush drainage, did they drain the seroma?
Yolanda RN, WCC