Catherine

Typically any wound that has not responded to treatment in 2 weeks needs to be evaluated and treatments changed.
Katy Langness RN WCC

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In general, treatment should be changed if the wound hasn't changed in 2 weeks. I don't have a source, but know that it is published somewhere. I don't have a copy of the AHQR guidelines with me, but they might be one of the sources. The WOCN may also have it in their publications, visit www.wocn.org
Dawn, RN, CWOCN

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The Dept. of Health & Human Services Centers for Medicare & Medicaid Services state that if a pressure ulcer (the principle can apply to other ulcers also) fails to show evidence of progression toward healing within 2-4 weeks, the ulcer as well as the patient's overall clinical condition should be reassessed. Remember to look at all factors as to why the ulcer is not healing, especially the co-factors. Some questions to think about- could there be bacterial burden (a silver gel as an antimicrobial would benefit), does the dressing stay intact (a moist environment to facilitate healing), is there a necessity for debridement, is the exudate controlled, is the primary dressing conducive to increase healing rates (PDGF, Collagens, etc..), under-nutrition and/or hydration deficits, pressure, and many more thing to think about. The first thing to remember is "proper wound bed preparation". Hope this helps.
R DeLaney LPN,CWS,FCCWS
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Two weeks is the amount of time that you give a treatment before you change it. Susan R. Ervin wound nurse.

JD

Accuzyme is an enzymatic debrider, active ingredient is papain urea, this product works very well for adherent slough.
Xenaderm is not a debrider. Xenaderm contains trypsin, which some products have touted as a debrider. With xenaderm, the trypsin helps to keep the wound bed clean, but is not intended as a debrider. Recently, CMS has placed products with trypsin in a non-reimbursable category because of the trypsin.
Dawn, RN, CWOCN

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Accuzyme and xenaderm are not the same. First accuzyme is a chemical debrider and is very effective at debriding adherent slough. Xenaderm is NOT a debrider. It does contain some trypsin which gives it the ability to cleanse a wound bed but if used on adherent slough it would take a long time to work and really I would say that the wound debrided due to autolytic debridement. Patti CWOCN
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Accuzyme is, but xenaderm is a topical treatment to promote healing and the tripsin ingredient has come into some controversy with Medicare as of late.

Deborah Harris, BSN, JD, RN, CWCN, WOCN

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They are not the same. Accuzyme has papain/urea and Xenaderm has trypsin. I've recently heard from the Healthpoint rep and others (not Healthpoint) that the FDA has stated the trypsin in Xenaderm has not been shown to be an effective debrider and, therefore, Medicare/Medicaid will no longer pay for Xenaderm

Nancy B., RN, CWCN

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Xenaderm is not a debriding agent. It is used primarily to promote blood flow to stage 1 & 2 ulcerations & breakdown due to incontinence factors.
Beth WOCN

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Accuzyme has papain-urea in it which makes it useful for the debridement of necrotic tissue and liquefication of slough. Xenaderm is for wound healing (physiologically stimulates the capillary bed increasing circulation in the wound) and is not used for debridement. Hope this helps.
R DeLaney LPN,CWS,FCCWS
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Xenaderm is not a debriding agent, it is for healing. It also protects skin from urine, stool, or wound drainage.

Accuzyme will work on adherent slough, be sure your physician orders accuzyme. No generics, the generics are not a true copy of the original.

Laurie Ellefson RN, BSN, CWOCN, CFCN

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Xenaderm is a healing ointment and not used on necrotic tissue
Accuzyme is an enzymatic debrider
For more info go to Healthpoint website
SLC, NY

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No... Accuzyme is for debridement of slough and eschar, while Xenaderm is more for the use of Stage I and superficial Stage II's, also for skin tears.

K. Yergert LPN

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Accuzyme is an enzymatic debrider,Xenaderm is not. Susan RN BSN wound nurse.

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In my opinion, Accuzyme is terrific in debriding slough and worth the cost. I have tried 4 of the knock off brands and I fine they sting more and they are not as effective (however they may still get the job done over a longer period of time). In our hospital, I changed Accuzyme to formulary.

As for Xenaderm, it does not debride slough but rather is used for mostly partial thickness wounds and Stage II. I find Xenaderm worth the cost because it serves as a barrier for incontinent patients, you don't need a secondary dressing. Duoderm and foams at times tend to roll up and have to be re-applied if soiled, therefore you can create secondary problems for patients and increased nursing time. While I love the product Xenaderm, as an outpatient, Medicare and Medicaid no longer covers them b/c the FDA put out new guidelines and it does not seem to have enough evidence. Therefore, patients would have to pay out of pocket about $90 for the product. Clinically however, I think it is fantastic product.

Lisa MPT, CWS

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You didn't say what kind of surgeon your husband is seeing. The fact that he refuses to allow the wound care clinic to take over the care should be a red flag. A second opinion is ALWAYS a good idea, and only bad doctors are offended when a patient requests one.
If he were my husband, I would take him to a a plastic surgeon. So many people think plastic surgeons only specialize in cosmetic surgery, but they do wounds, among other things. Your husband must have a primary care physician (family doctor) who can give you a referral. By all means, have him seen by another doctor.

Anne, RN

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normally I would not reply to these but your husband needs help. The vascular surgeon should be his key man and I suggest you look up a diabetic specialist who will in turn know the right surgeon to see if he can be revascularized. There are new vascular procedures that get into the foot.Diabetic limb salvage is the way we like to go. I am in PA but I feel confident you should be able to get to the right person. There is a diabetic limb salvage at Georgetown University Hospital that may help in the referell. Good luck.610-357-7016

DeSales Foster MSN, CWOCN, CRNP

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If the ulcer to the right heel is stable (not draining, separating, red, inflamed, warm, foul odor etc...) it is safe to leave the eschar (black, dead tissue) intact and not facilitate removal. A person with diabetic wounds has more difficulty healing than those people that do not have diabetes. One thing I would strongly recommend would be no weight bearing or pressure on the heel (such as resting on the chair, bed etc..), keep the heel "floating" at all times, not touching anything (with pressure applied you block blood flow to the area). Many diabetics have a form neuropathy (a loss of feeling in the feet) and because they can not feel, they do not realize when there is pressure for too long a period of time, which would cause pain, as I would notice if my heel was in one place for too long because it would start stinging, then I would move or reposition it. As long as the ulcer is stable it is safe. I would recommend using Xenaderm ointment 2-3 times a day (it is a prescription), then either wrap or leave dressing off as long as the heel is floating. If there is a decline in the ulcer contact the MD immediately. A wonderful product for diabetic ulcers is Regranex, but you must have a red wound bed not yellow or black. Hope this helps.
R DeLaney LPN,CWS,FCCWS

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I'm very sorry to hear about your husband. Unfortunately, in my opinion it sounds as if the doctor is doing the appropriate thing. If the heel is a stable eschar (meaning no drainage and is black with no signs of infection) betadine with dry gauze is appropriate. By opening up the heel (debriding it) it sounds as if it would be very difficult to heal. Peripheral Vascular Disease complicated by Diabetes is a very serious and difficult disease. I would make sure that he uses an off-loading heel boot while in bed (we use the DM systems boot in our clinic). Essentially you need something to make sure when he is laying in bed that the heel is elevated. He also needs to make sure that he walks on the forefoot of that foot. If he walks on the heel, he is continuing microtrauma that will even more slow potential healing. Unfortuately though if your husband already had an amputation of one leg and has had a bypass with the other, including a black heel---his arterial flow is probably pretty bad and he may need an amputation in the near future of his leg. PVD is a progressive disease that gets worse with time, generally. There are some physical therapists in wound clinics and PT departments that do offer electrical stimulation 3-5x/ week in efforts to help increase blood flow to the leg. Some physicians and physical therapists think this is a phenomenal option, I think it may be worth a shot for your husband. Lastly, Hyperbaric oxygen might be a suitable treatment for your husband, but I am not an expert in that area. Best of luck.
Lisa, MPT, CWS

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I'm sorry to tell you this, but from what you've told me, your husbands may lose his other foot. The current, but not 100% agreed upon, method of treatment for heel wounds is to put betadine on them to keep them dry and hard and allow them to heal from the inside out. Of course if your husband doesn't have enough blood flow to the foot even after surgery, it will not heal. It does take a long time, as long as a year or more to heal. Also, he has to do his part in getting better. He needs to watch his diet and keep his blood sugers under control. Susan RN BSN Wound nurse. For referals to another Doctor in MI, google wound ostomy incontinence nursing society and look for a CWOCN nurse in your area. Susan RN BSN wound nurse

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Dear Joanne, Let me begin by saying I am not a medical professional BUT I am a patient advocate for maggot therapy., I know that it works being a diabetic who had severe diabetic ulcers, stage lV, with bone infections! My doctors wanted to amputate, also. Maggots are FDA approved.They are sterilized and sold just for medicinal purposes. They eat just the dead infected tissue, excrete enzymes to promote healing and kill all the bacteria. They work!! Please visit BTERFoundation.org for more info and contact me through there, for a list of doctors who have used MDT in your area. Time is of the essence in his care!

Good luck and God Bless!
Pam Mitchell

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Time to get a vascular surgeon second opinion. Though black areas that are intact eschar may be treated such as he has, the question is the perfusion of that leg and whether the circulation is adequate enough in general and specifically to heal the wound. It sounds as though there may be an issue there.

Deborah Harris, BSN, JD, RN, CWCN, WOCN

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This suggests that the blood supply is not adequate to sustain wound healing. If the area is showing as dry necrosis a wait-&-watch approach could be taken. Secondly long-term use of povidone iodine could be damaging to the process of wound healing.
Finally even if the wounds were to heal, is the local capillary pressure sufficient to allow the foot to bear the body weight without skin breakdown again?
A realistic approach is needed in the long-run.
Kumkum

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Have you considered the Vascular/Wound Care Center at Mayo? The waiting time for an appointment is long, but they always has someone on call for ER consultation. So sometimes I'd send urgent patients there through ER.

JL, DPM, CWS
 

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If you know the tissue layers involved, and all nurses learn skin anatomy in school, then you can stage a pressure ulcer. If you are not sure of the tissue layers involved, I would suggest getting someone more qualified. Many RN's as well as LPN's as well as FNP's as well as MD's do not know what tissue layers they are looking at when they look at a pressure ulcer. Description and staging is explained on npuap.org web site.
R DeLaney LPN,CWS,FCCWS
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Educational preparation is not what counts when it comes to staging pressure ulcers. The key factor is experience. I know many RN's who can't stage pressure ulcers. An LPN with extensive wound care experience can stage a pressure ulcer. I don't know what the law is in Ohio.
Currently, the WOCNCB does not certify LPN's in wound care, but they are exploring the feasibility of offering certification for LPN's. If you are interested in participating in this process, visit www.wocncb.org or send an email to info@wocncb.org
Dawn, RN, CWOCN

Karen Castle RN,CWOCN

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In February, the National Pressure Ulcer Advisory Panel modified the pressure ulcer stages. Basically stages I-IV remain the same, but the definitions are clearer. The stages now include deep tissue injury (DTI). They have also added 'unstagable' as a stage, for those wounds that have slough or eschar in the base preventing visualization of the base, and therefore preventing accurate staging. To see the new document describing the staging system, go to www.npuap.org, click on news room on the left column.
Dawn, RN, CWOCN

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The NPUAP (National Pressure Ulcer Advisory Panel) agrees with you and there are now 6 stages of pressure ulcer. Check out their website for more in depth information.

Deborah Harris, BSN, JD, RN, CWCN, WOCN

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 Have you seen the new NPUAP pressure ulcer staging guidelines? They were released in February and address suspected deep tissue injury, pressure ulcer stages, and the definition of a pressure ulcer. I wish they would also have looked at Kennedy Termiinal Ulcers.

Nancy B. RN, CWCN

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Hi Karen,
The NPUAP has recently put out new guidelines and separates pressure ulcers into 6 categories, Stages I - IV and then DTI and unstageable. I believe this is the best method but we are contstantly striving to improve, explain and identify pressure ulcers. I think one thing that is very important is to stage as appropriate and then put in comments related to your staging method. For example, can say left heel is stage II, but suspect proable DTI, evolving pressure ulcer at this time and expect that wound will worsen (based on the wound,state what leads you to this conclusion). Then explain what you are doing to prevent. Just some ideas. Hope this helps.
Lisa MPT, CWS

 

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I think serial instrumentation debridement means that one is using sharps such as scalpel, forceps, scissors, curette, etc. This does not mean excisional debridement for PT. Excisional debridement in the CPT code book means excising cutting out viable tissue, which PTs cannot do based on their practice act. MD's and PT's need to document the instruments used when debriding. I'm not sure if they put the word instrumentation in there b/c you cannot bill an excisional or selective debridement when you do not use sharp instruments (Q-tip, blunt probe, gauze, etc) Just my thoughts. CHeck the CPT code book and can check with your compliance department for specifics. Lisa, MPT, CWS
 

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I think bone should be debrided if there is bone infection or a significant change in the bone due to pressure. For example, the bone has become sharpened or changed causing more pressure. One question I would pose to you is that is the VAC not working b/c the VAC pressures are not high enough, using the wrong foam, infection present in the wound (need silver foam), patient not offloading enough. I would have a nurse clinical consultant come out and make sure the VAC is being maximized and used correctly. It should be maintaining a seal. So again there are many factors. Is there a specialty bed he is utilizing, is the wheelchair or other chair to narrow causing microtrauma? We have had plastic surgeons at Hopkins use tissue expanders and flaps to heal hip wounds. Also important to clear infection up first and make sure compliance with pressure relief and offloading. Also, how is nutrition. Just some suggestions. Best of luck. Lisa MPT, cWS

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Ann, Hi this is Pam Mitchell again! Please see my response to Joanne above. Or check out our web site at BTERFoundation.org. I really think MDT is the answer for your sister. It sounds like the perfect answer to me. You can contact me through there for any further information.

Thank you,
Pam Mitchell
Patient Advocate
BTERFoundation.org

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Negative pressure is tricky since you need a seal for it to work. It can actually make the wound worse if the seal is not maintained at all times.Bone may be removed if the physician feels that antibiotic therapy is not
working for osteomyelitis. Since it is a joint, that requires consideration, depending on how much bone would be removed, as a joint replacement could be another alternative depending on the situation and recommendations by the
physician.


Deborah Harris, BSN, JD, RN, CWCN, WOCN

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The protocol at the wound center where I worked several years ago suggested removal of the infected portion of the bone. We know that infected wounds do not heal and the source of the infection must be identified and treated. Bone infections are very difficult to treat with antibiotics alone. The theory behind excision is that once the infection is removed, the wound will heal. Some physicians will excise the infected bone and use antibiotics for a week or two afterward just to make sure the infection is gone.

Nancy B. CWCN

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I can think of two indications for bone removal in the bed of a pressure sore
1. in case of osteomyelitis
2. to eliminate the pressure point and make the weight-bearing area more diffuse
kumkum

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I would suggest a bone scan to determine if there is osteomyelitis (bone infection). Osteomyelitis could prevent the wound from healing. If osteo exists, removing the bone could be an option, another option would be long term (ie 6 weeks) of appropriate IV antibiotic therapy to eradicate the bone infection.
Dawn, RN, CWOCN
 

Try Hydrogel, Alevyn and Barrier film dressing (OPSITE or Tegaderm.
Change once daily and when the dressing becomes soiled.
Peggy RN

With the new NPUAP guidelines, it would be considered unstageable.

Deborah Harris, BSN, JD, RN, CWCN, WOCN

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When a wound has eschar in it , it can not be staged because you can not see the wound base. Therefore, in a long term care facility, they may stage it as a IV, in acute care they wound just say that it's nonstageable. Susan RN BSN wound nurse.

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You are correct in that the nsg home should not be calling a wound with eschar or necrosis covered a stage I or stage II. When this wound is potentially debrided it will be at least a stage III or IV and if on assessment it is called Stage I or II, the nsg home will own a nosocomial which correlates with an F-tag and would have to be reported to the state. You would not want to classify as stage IV b/c truly the wound after unroofing may be a stage III... So in the case you stated it would be considered unstageable. There are new guidelines put out by the NPUAP with 6 categories of pressure ulcers, stages I-IV and unstageable and Deep Tissue Injury.
Two excellent resources for you are the npuap.org with is the national pressure ulcer advisory panel as well as sorimltc.com, Courtney Lyder is an excellent resource and is an expert/consultant in LTC and pressure ulcers. Hope this helps and best of luck. Lisa MPT, CWS

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An ulcer with an eschar cannot be staged. To stage an ulcer you have to see the base of the ulcer. An ulcer would need to be debrided before it could be staged. More than likely an ulcer covered with an eschar will be a stage 3 or stage 4 but you don't know until it is unroofed. An ulcer with eschar can be measured for length and width and described as being unstagable due to the eschar. The NPUAP has descriptions of all stages of ulcers and the WOCN Society has a white paper describing how to classify wounds for OASIS.
Laurie Ellefson RN, BSN, CWOCN, CFCN

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First only "pressure ulcers" should be staged. There are other staging systems for diabetic and venous stasis ulcers, but not commonly used in the nursing field as we know it. A stage I pressure ulcer is "intact epidermis", no loss of skin. A stage II pressure ulcer can be a serous filled blister or a shallow crater (abrasion), which means a loss of epidermis (outer layer of skin). If the wound has slough or eschar (depending on the percentage of slough) it is either a stage III or IV. Pressure ulcers with the base of the ulcer covered with slough (yellow, tan, gray, green, brown) and/or eschar (tan, brown, or black) are UNSTAGEABLE - "NPUAP guidelines 2007", and MDS codes those ulcers as stage IV. Nursing should document unstageable pressure ulcers as "full thickness", because until the ulcer is debrided, it can not be accurately staged.
R DeLaney LPN,CWS,FCCWS

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If you are referring to a pressure ulcer, it cannot actually be staged until the wound is debrided. It should just be documented as a pressure ulcer unable to be staged secondary to eschar. This is b/c they are staged as to how deep the wound is, which is unknown as long as it is covered by eschar.
Here are the stages of pressure ulcers:

Stage I: Nonblanchable erythema (a red spot that doesn't turn white w/ pressure applied)

Stage II: Partial thickness; including the epidermis, dermis or both

Stage III: Full thickness; down to, but not through, the fascia

Stage IV: Full thickness; down to muscle, bone, ligaments or other underlying structures

Also, once a wound is staged, it stays at that stage. A stage IV will never become a stage III, II or I, it is just a healing/healed stage IV.

Justin

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Meg,

It is my understanding that a wound with eschar can not be staged at all. NOT a stage 4 not a stage 1 not a stage 2. Until the eschar is gone how do you know what is really underneath the eschar so how can you stage it at all? I have been taught (hopefully right) that until the eschar is off there is to be no staging and once the eschar is gone, either by surgically removing it, chemically removing it, or by mother nature, then the wound can be staged. A wound with eschar is a pressure wound (if over a bony prominence caused by pressure) but not able to be staged until eschar is gone. So it needs to be documented "unable to stage due to eschar" The documentation should include the wound characteristics, drainage color and amount, size, pain level it is causing the patient, estimated % of eschar covering the wound, treatment provided and how the patient tolerated the treatment. I hope this helps. PS it's important to make sure that the patient has enough protein to heal, checking a pre-albumin and instructing or providing a protein rich diet is also very important for wound healing, along with pressure relief, and diversion of any incontinence or moisture that may be getting into the wound.

Rachael Nottingham, RN, BSN

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Go to the National Pressure Ulcer Advisory Panel website for the definition of pressure ulcers. There you will find the new guidelines which define Stages 1-4, unstageable (covered with eschar or slough) and suspected deep tissue injury wounds.

Nancy B. RN, CWCN

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HI you cannot stage any wound that is covered by eschar as you cannot see the bottom of the wound. If you cannot see the bottom of the wound bed how do you know what stage it is?
Katy Langness RN WCC

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Meg,
The wound care nurses you are working with are not following the National Pressure Ulcer Advisory Panel's guidlelines for staging pressure ulcers.
Wounds with eschar cannot be staged. In order to stage a pressure ulcer you must be able to see the base of the wound to determine the depth. In Feb. the NPUAP came out with new definintions of the stages. Basically Stage I-IV are the same. They have added 2 stages. Deep tissue injury (DTI) is purple discolored tissue that is not blanchable. In this case, the spidermis is still intact, and has not progressed to the eschar stage. Previously this was included in the stage I description, now it is separated because Stage I pressure ulcers (area of non-blanchable erythema) can potentially be reversed with implementation of appropriate interventions to relieve the pressure. Stage I pressure ulcers may progress to stage II, or deeper stages if proper interventions aren't implemented. DTI is expected to progress, possibly to a full thickness breakdown. The other new 'stage' is 'unstagable'. This describes the wounds that are filled with slough or eschar, preventing visualization of the wound bed.
I hope this helps!
Dawn, RN, CWOCN
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Actually any time there is eschar by definition the wound becomes unstageable due to not being able to see how deep the wound is.

Donna Lynette Lewis RNC, WCC