In a patient who has both venous leg ulcers and arterial, ie both venous disease and arterial, should tubigrip compression be used?

When does one use iodisorb and when does one use acticoat 7, ie does it depend on whether wound is fully open or starting to heal.

Is mepiplex good for leg ulcers?

Any good medical resourses on these 3 questions would be appreciated.

Pablo

These questions are hard to give a definite answer to. Regarding the mixed vascular wounds-it depends on how bad the arterial insufficiency is. Sometimes, if the ABI isn't too low, mild compression can be used. See if they can be re-vascularized by a surgeon first.

Regarding Iodosorb vs silver first, rule out an iodine allergy. Otherwise, I pick a product based on the wound characteristics. One is easier to use in a cavity, one is better for a large flat area, etc.

Lastly, regarding Mepilex, it can be good like other foams when the wound is draining. Check out www.AdvancingThePractice.org for a clearinghouse of wound care resources and information.

Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS
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The standard of care is to obtain an ABI (ankle-brachial index) prior to start of compression. If it is below 1, you may still be able to use compression, just to a lesser degree. If below a certain number, say .5 depending on what your physician says, you would most likely not use compression at all.
Debbie Harris CWCN, Louisville, KY

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There is no hard and fast rule on any of these questions.

Tubigrip is a cotton stocking with bands of elastic in it. It does not provide a measurable amount of compression (ie: 15-20 mmHG) and comes in many different sizes. some apply one layer, some two. When lightly applied it seams to provide a light/ lymphatic stimulation, much like MLD would, and not venous or arterial compression. I myself have used it often on patients with mixed disease when i was concerned about using full compression. Most tolerate it well without signs or symptoms of impairment and excellent wound healing. I also have had patients with much more advanced arterial disease that could not tolerate it at all. Essentially, always worth considering but not always tolerated.

Iodosorb vs Acticoat: Both are antimicrobial. If someone has thyroid disease, Iodasorb is contraindicated.If someone has a silver sensitivity then Acticoat is contraindicated. Many say that Acticoat is newer therefore better and iodosorb has fallen out of favor. But it works well and still has its place. Both can be used in the initial and late stages of wound healing.

Mepilex and leg ulcers: You bet! i have used mepilex foam on ulcers under compression wraps, mepilex border on moderately draining wounds on severely atrophic skin. Which mepilex product depends on what the wound is doing and needs. These products can be used on any part of the body, on diabetic ulcers, on arterial and venous ulcers...

Michelle, PT, CWS

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You should not use any type of compression until venous and arterial studies are done to determine the severity of the blockage. You can do a lot of damage using compression if the blockage is severe. A lot of doctors will not even order Ted Hose, until they know the severity of the blockage. The doctor will have to order the amount of mmhg depending on the results of the studies. This will let you know how many layers to use.

Care will have to be taken with the heels and the area where the leg meets the foot, since these areas will have a much greater degree of mmhg applied than the rest of the leg/foot.

Sam McDew LPN

Treatment Nurse
 

Moist wound healing is the preferred approach in most cases. That means keeping it covered and preventing it from drying out. Leaving it open dries it, slows healing, and makes infection more likely.

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

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Okay leaving open to air or not that seems to be the question...Well, if the wound is dry like a scab...then leaving open is fine unless you want to protect the area for some reason then go for the cover (opsite works good to protect scabs) If the wound is draining than it should be covered to help absorb the drainage...so it depends on how much the wound is draining and then go from there...

Hope this helps

Michele in San Diego RN WCC

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A wound kept covered will heal faster than one open to the air. It will also be less painful to the patient, cleaner, and the dressing will aide in keeping the ointment where it is needed, in the wound.

Sam McDew LPN
Treatment Nurse

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Modern science says a wound needs a moist environment to heal, so if that means keeping it covered, fine, or if the ointment is occlusive enough that it doesn't dry out, that's fine too. Debbie Harris, BSN, JD, CWCN Louisville, KY

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Best to keep the wound moist – covered and protected. Do not allow to dry out.

L. Beck RN, BSN, CWS, FCCWS

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Hello,
I need more details. It will depend on what type of wound.
Thanks, Terri RN, WCC

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Hi Karen,

It depends upon the particular wound and what you are trying to do. Most of the time, you want to follow the modern idea of “moist wound healing” which would involve a dressing which is appropriate to keep the wound moist but not too wet. However, for some skin issues, such as excoriation from incontinence, I use Xenaderm (a Healthpoint product that I love) and don’t have to use a dressing. In general, you don’t want a wound to create eschar or scab, and most deep wounds will do so without a dressing. Some superficial wounds such as excoriation can be managed without a dressing at times.

Vicki, DPT, CWS

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Studies have confirmed that mosit wound healing techniques, heals wounds. Thus, it is essential that wounds be covered, maintaining a moist environment. Refer to Agency for Health Care Policy and Reasearch (AHCPR) FOR WOUND CARE QUESTIONS; FREE BOOK 800-358-9295 WWW.AHRQ.GOV
Amy Pastor RN, CWS

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Allowing a wound to stay open to air promotes dehydration of wounds, increases risk of infection, increases pain and decreases the rate of healing. It is very well documented that this is not good wound care. Regardless, some still advocate for this. Please understand this is solely a lack of knowledge and an opportunity to inservice and educate you peers in the current practice recommendations.

Michelle, PT, CWS

You didn't mention pressure reduction. I'd make sure he was on a pressure reducing mattress and turning often. And, people may "eat well" but be protein deficient. Has his pre-albumin been checked recently? Is there a chance he could have a high bioburden? Bacteria can delay healing even without causing an infection. Lastly, electrical stimulation may help stimulate re-epithelialization.
Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS
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Maybe consider doing a biospy on the area...may be something wierd..

Michele RN WCC

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If the patient has had the wound for awhile, there may be localized bacteria in the wound that is preventing epithelial cells to migrate across the wound.

I have had good results using a topical antibiotic. Usually good results after 1 week.

Sam McDew LPN
Treatment Nurse
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Hello,
1. What type of Mattress does she have at home? She needs a pressure relief or alternating pressure mattress.
2. Is she on a nutritional supplement?
3. Have you tryed Versiva adherentor Aquacel (Convatec product) this has a Hydrofiber. If no exudate then you may have to wet it slightly with NACL (Wound Wash). Go by manufacturers guidelines.
4. Does she take a MVI daily?
5. Preventative measures are the key, offloading the area, repositioning every 2-4 hours.
6. If up in a chair, a chair cushion.
7. How long did you leave the Hydrocolloids on for? The longer the wear time if no exudate is involved the less expensive and better healing time with less trauma.

Good luck,
Terri RN, WCC

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Hello,

Is the wound creating epiboly or rolled edges which may be impairing the ability of the epithelium to migrate and close the wound? Is the granulation piled up high (hypergranulation)? Sometimes, the wound perimeter needs to be reminded that there is an opening to cover, and silver nitrate to burn the edges will kick-start the inflammatory stage again and encourage migration of the epithelial cells to cover the defect. Also, I had a wound that had stalled once that responded to a few visits of pulsed lavage, perhaps to knock down some biofilm or colonization – whatever the reason, it worked and the wound closed.
Good luck,
Vicki, DPT, CWS

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We have initiated a regime of pineapple juice, glucosomine, multivit with minerals, ensure, arginaid, zinc and Vit. C. Wound healing time has improved and less wound infection has been identified.

TB RN DON
St. Louis, MO

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What kind of pressure relief is being provided; a group one overlay or group two alternating pressure mattress? Repositioning? Wound culture?
Michelle Pt, CWS

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As you know the steriod affects the ability to heal, so you need to improve all the other factors that affect healing. You say the patient eats well, what is his protein intake? Is he using a nutritional supplement like Ensure, Boost, or Prostat? You need to relieve pressure to the area by repositioning, he may need a specialty mattress. Would this patient benefit from a course of antibiotics due the prolonged time of having an open wound?
He may not have an active infection but may be overcolonized with bacteria.
How about trying a hydrofiber with hydrocolloid and change 3 times/week?
Zinc may be another supplement that could promote healing.
Relieving all pressure to the area is one of the most important factors.
Optimize nutrition.
Contain drainage.
use dressings that provide absorbancy or that provide moisture depending on the needs of the wound.
Laurie Ellefson, RN, BSN, CWOCN, CFCN
Prairie du Chien Memorial Hospital
Prairie du Chien, WI

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 Hi, first of all let me start off by saying I am not a medical professional but am a patient advocate for the BTER Foundation. Yes, I have a suggestion that may well help your patient out tremendously. "Maggot Debridement Therapy". It is non-invasive and works well. As long as your patient can keep pressure off the wound while the maggots are doing their job. This is a wonderful alternative to all the treatments already tried and failed. Maggots eat just the dead infected tissue(does not touch the good like surgery) They excrete enzymes to promote healing and they also kill all the bacteria. Maggot therapy is FDA approved but greatly under used. I am a former patient and maggots healed my feet up when all conventional methods were exhausted. I am a diabetic and was on steroids at the time. My ulcer was a stage IV. Please consider this therapy which is becoming more and more popular because it works. Extremely cost effective! To learn more and to order please contact the web sites I am including. Good luck with your patient.

Pam
 

Go to the WOCN site at www.wocn.org and they have a lot of that. Debbie Harris, BSN, JD, RN, CWCN, Louisville, KY

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I would interview some vendors such as Medline or Health Point, Smith Nephew, usually with their contracts you get books with protocols. THere are also companys who help set up clinics and get involved in the management. Alexian Brothers Medical Center wound clinic in Elk Grove VIllage IL uses one. Just do a Google search until you find the information

Jeri Wound Care Nurse

This is a complicated situation, and her wound could have any number of traits. I recommend you go to www.aawm.org and www.wocn.org to find someone who is certified in wound care near you.



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

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The basics of wound healing are that you cannot have a wound too wet or too dry....So not sure how much the wound is healing or what color it looks like or if it has been culctured....so cannot really say...most likely a wound should at packed with moistened saline....but if it;s draining alot the moisture form the wound will most likey give the wound the moisture it needs to heal.

Hope this helps

Michele RN WCC

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Without knowing more information, I say moist. Debbie Harris, BSN, JD, RN, CWCN, Louisville, KY

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A wound needs a warm moist environment to heal. You should follow the Doctors instructions. He is the professional.
Good luck.
Terri RN, WCC

The original article is in Decubitus 1988.

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

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Check out kennedyterminalulcer.com.

Debby RN, CWS

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Hello,
Look at their web site. Google Kennedy ulcer. I have seen them and some people are at end of life.
Terri RN, WCC

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I suggest that you try the Kennedy Terminal Ulcer website.

http://kennedyterminalulcer.com/

There’s a lot of information here which includes data and theoretical views.

Yvette

sorry, no replies

It all depends on what setting you are using. AHCPR guidelines state 4-15 PSI are safe and effective for wound cleansing. That was based on research (see the guidelines for the references). All commercial pulsed lavage units can be set within that range. Talk with your rep to see what PSI the settings correspond to.

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

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Currently, 4 to 15 psi is considered the safe range for wound irrigation. Most pulsed lavage units fall within this safe range or have adjustability to keep the psi within this range. There are several good textbooks on wound care that address this. One I would recommend is Wound Care by Carrie Sussman, PT and Barbara Bates-Jensen.

Bill Richlen PT, WCC, CWS

 

Try to find the Biologic 900, or wound-systems 900? it is a mattress and wheelchair pad combo, the guy who is renting to us called it a "dolphin pad". Something for the Navy. I have a patient at the VA who wouldn't stay on anything and he is happy now. It keeps patient in a 3D state and adjusts to movements every 10 to 15 seconds that patient doesn't feel. The wheelchair pad works the same way with the computer but you have to find a way to put on the chair(we used a backpack) Our patient has two decubs on heel and sacral and we are seeing dramatic decrease in the decubs. E-mail if not one in your area and I'll find their card at the office, don't have one with me.

Jordan BSN, RN, CWCN
Upstate SC

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Just saw your posting and I have a few suggestions.
one of the newest products that we have been using at my facility is the waffle mattress produced by EHOB.
These are inflatable air mattresses(overlays) that require handpumping, but take only a few pumps to fill to the suggested pressure. They are very
inexpensive(@$80) compared to some of the other products we use but do need to be replaced after @6 months of continuous use. The company also supplies chair cushions, boots and arm rests.
Some of the other things you may want to try are the
low- air-loss or alternating air mattresses. There are a ton of companies out there that produce these. They are much more expensive and do require a pump that sits at or hangs on the end of the bed. The best of these that I have seen so far is the DSF-3 mattress. I believe it is manufactured by Huntliegh Healthcare, It is expensive but is also a fantastic product, I have actually had two patients with very difficult wounds heal on this surface in the 4 months that I've been using it. If you want to stick with a simpler mattress the most basic is foam, which is not recommended but a good one is the Comfortline by Hill-Rom.
Hope this helps!

unsigned

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Sheepskin isn't very effective at preventing pressure ulcers. I would recommend get a good overlay for the geri-chair, and a cushion for his wheelchair. See a physical therapist for an equipment assessment.

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

sorry, no replies

It's hard to give specific recommendations without seeing him. I recommend you find a wound specialist near you to assess him. www.aawm.org or www.wocn.org.

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

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I don't know if you want to get him cleared thru a vascular surgeon or not, but that would be my first step. This is just a suggestion, I'm sure others would have similar suggestions. After bathing and bid, I would apply aquaphor ointment - it comes in a big jar to feet - and use a 4x4 elastogel on heel and wrap with kerlix and keep elevated off of it until it heals. The nice thing about the elastogel (by southwest technologies) is that you can check the heel and then reapply it. You need only replace it if it degrades. Medline has the exact same product and they call it dermagel. (they are a solid gel sheet) Debbie Harris, BSN, JD, RN, CWCN

Hi Heather ~
I think the "high-tech" treatments aren't going to stay in place long enough to be effective. What I would try if it were my mare is a good moisture barrier cream such as ProShield after a gentle wash with warm water or saline, plus a lot of desensitization training so it can be applied more often. If you use a good amount of cream so the application itself is soothing, she might become more amenable.
I'd be cautious about using antimicrobials, and would also get a culture for UTI and vaginal infection (especially would consider fungal infection if she's doing much rubbing). It could be vaginal fluid rather than urine.
I'd also have some thoughts on diet and exercise but some may feel an extensive discussion might not be appropriate for this list so feel free to pm me desertequinebalance@gmail.com .

Patti Kuvik, RN (and equine nutritionist)

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Hello,
I use a product called Xenaderm from Healthpoint for patients with incontinence who have skin breakdown. It works well, and no dressing required.

Good luck,
Vicki, DPT, CWS
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Xenaderm topical oint from HealthPoint should help. You can look into it at their web site.

Sam McDew LPN
Treatment Nurse
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I've never used this on a mare, but the VA is now using a product called Sensicare that is manufactured by Convatec. I have seen it at CVS also. The only thing about this product is that when you apply it do so thickly and do not wash it off! It is meant to be left on and to have only the top(soiled) layer wiped away gently. Then reapply to keep the layer thick.
Also do not apply to an open wound, just around the outer edge of the wound. The product is very thick and white almost like a Balmex. We use it for incontinent patients with skin irritations and urine burn. Susan

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There is a product named Xenaderm ointment, usually is twice a day, but will repel urine.

TB RN

Check your state's nursing practice act.

Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS
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My understanding is that any products that can be bought over the counter or through a supplier, not requiring a prescription, the CNA/CNT can apply it. All moisture barrier products. They must follow the facility's policy and procedures. A CNA/CNT can not do any wound care, such as, dressing application, that is outside their scope of practice.
R DeLaney LPN, CWS, FCCWS

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Depending on what state you are in, CNAs cannot apply treatments.. not even band aids! Otherwise some states will allow CNAs to apply only surface treatments (ie topical creams, simple dressings.) I don't think that there are any however, that will allow CNAs to do any kind of deep wound dressing or packing.

Susan

He will need on-going compression to reduce recurrence risk. The 2-layer stockings are easier to apply than one (2-20's rather than 1-40 mmHg stocking). And, there are donning aids to help apply them. For treatment, you can find a wound specialist to help him in your area at www.aawm.org and www.wocn.org



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

Possibly the dry, flaky areas are fungal. Try an antifungal and see if it responds. As far as compression therapy, there is a new product on the market called Coban 2 layer compression. It's got a foam contact layer so it doesn't irritate the skin. My patients are very comfortable in it and can get there shoes on. I would try it instead of the Unna boot.

good luck
Carly RN CWS

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It might be a condition called hemisiderin, which is another name for discoloration. Due to poor circulation there is an accumulation of hemoglobin and iron in the lower extremities. Not much you can do to dispell that except keep lower extremities clean and apply a good cream (not lotion) twice a day or an ointment like aquaphor. Keeping legs elevated and exercising of course would help. Debbie Harris, BSN, JD, RN, CWCN

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The brawny/pink discoloration on the lower leg could be scarring from cellulitis. If he needs compression, most likely he has a Hx of cellulitis in the lower leg r/t the edema. Over time and repeated bouts of edema, you will see this kind of discoloration.

If the dry flaky patches are where the wound was, this may be due to the normal sloughing off of dead skin cells. In areas with scar tissue the cells do not fall off as easily and tend to develop thick layers of dead skin, that in some cases, such as in a healed wound with a slight depression, needs to be manually removed periodically by lifting along the edges.

If this is the case, frequent hygiene using light friction with the wash clothe to aide in the removal of the dead skin cells, and application of a moisturizing lotion to avoid excessive drying should help.

Sam McDew LPN
Treatment nurse