Kathy

Don't forget to include your name and credentials if you are a healthcare professional.

Don't forget to include your name and credentials if you are a healthcare professional.

Don't forget to include your name and credentials if you are a healthcare professional.

Don't forget to include your name and credentials if you are a healthcare professional.

Don't forget to include your name and credentials if you are a healthcare professional.

I have been reading the discussion for several months, but this time I decided to write an e-mail as well.
I am a 56 yr old over weight female. This time last year, I developed small blisters on the outside of both of my calves. Thinking they it was some type of contact dermatitis I treated them with calamine lotion. They seemed to go away. I had never heard of venous insufficiency or venous statis [apparently within some medical circles the knowledge of both of these is well known. To you out there who don't know of it: venous insufficiency [I believe] cause the venous statis. The blood in your veins is not being pumped back to the heart as a sufficient volume and remains pooling in your lower legs and feet. Causing a back up where severe enough your legs swell, increase swelling forms the blisters. If not take care up shortly. The blisters start pushing inward instead of outward [like mine]. I didn't have insurance so did not see a doctor until the eleventh hour. I coded in the Emergency room when I was admitted, and had three surgeries. I was in a regular hospital for 6 wks, 3 in Intensive care. After that I was in a rehab facility 6 weeks learning to walk and climb stairs again. The would on my right legs were not as serious as those on my left. My right leg took about 8 months to heal, those on my left are still healing, some that have healed over break out again my smaller and more superficially. My wound care doctor put silver agate [or something like that] plain gauze, and compression dressing on my legs.
I not complianing or anything, I just think thst venous statis and vs ulcers ought to be more public known.

Don't forget to include your name and credentials if you are a healthcare professional.

Don't forget to include your name and credentials if you are a healthcare professional.

Don't forget to include your name and credentials if you are a healthcare professional.

Don't forget to include your name and credentials if you are a healthcare professional.

Don't forget to include your name and credentials if you are a healthcare professional.

Don't forget to include your name and credentials if you are a healthcare professional.

---

The foam I use is polymem max

unsigned

---

Yes, Hydrocolloids are a problem. Try 3M Hydrocolloid Thin. It's the only one I've found that doesn't "roll up". It stays in place nicely and comes off easily. As far as the bony prominences, the goal should be to position the patient off of the area. Dressings don't relieve pressure. Consult a PT or OT if you need help positioning patient. In addition, if you are concerned about a pressure point, you shouldn't be covering it with a dressing you can't see through. If the area is a concern, you're going to want to visualize it. You can't see through a "pad".

Carly RN CWS

---

Have you tried duoderm(hydrocolloid) dressing? It will protect the area. change patch every seven days.

margo momplaisir, RN, BSN, WOCN student
 

---

Hi there,
There are several products in the market that can be used, however, it will not resovle the issue if she still lies/sits on her coccyx most/all hours of the day. Be guided by the Rule of 30's - 30 degree angle on either side when lying on bed (not flat on back, nor 90 degrees on side as she'll develop ulcers on her iliac crest!), no more than 30 degrees when sitting up except when feeding as anything more than this encourages shearing leading to more pressure ulcers; as well, turning every two hours minimum is also a must. Don’t forget her nutrition/fluid intake too.

Estrella C. Mercurio, R.N. G.N.C.(c), E.T.
 

---

As far as I'm concerned, 3M No Sting Barrier Film should be the "gold standard" for protecting peri-wound skin. It's remarkable that clinicians are still using ointments and gels to protect peri-wounds from maceration. What do they think oinments and gels do??? They provide moisture and macerate!!

Carly RN CWS

---

Tosha,
The burning and tingling sensation you are feeling is normal with some patients with the use of Panifil. You may want to try Aquaphor to the perimeter of the wound prior to the application of the Panifil. This will protect the skin from any drainage from the wound. Good Luck!
Dee Potts, PTA, WCC

---

I would not use panafil, I would once again use polywic in the wound, and as far as a skin protectant Baza protect or Baza critic aid. Ileax is another excellent product I use around fistulas.

Unsigned

---

Recently I have found a product that work well and actually eliminates the pain and doesn't have to be changed as often as panafil dressing, you may want to try hydrofer blue. You can contact me for specifics and information if you like at your convenience. I beleive that they have a website as well
hydroferablue.com Let me know if I can be of further assistance or if you have results.

Connie Johnson, RN, WCC, DAPWCA
(908)-339-1690

---

try a zinc based ointment instead of A&D around the area. We have also had great response using Medline skin care products. they are excellent. email me and I will get you the necessary information when I get to work tomorrow. kate

---

If A and D irritates the area around the wound, try calmoseptine ointment. I had good success in using this product to protect the periwound from maceration. I t is a good product that contains calamine, zinc oxide, menthol and lanolin. It offers temporary relief of discomfort and itching and it is a good product to protect and heal skin irritations. By the way, prescription is not always needed to buy this product and they are available online as well.

Saturn B Dagwase, PT

---

You need to watch your skin for any redness, I have had a few patients that were sensitive to the copper in panafil and had no clue they were sensitive to copper. There are other debreiding ointments out there like accuzyme that work just as well to clean the wound bed. Panafil also is antimicrobial so unless you have an infection in the wound it probably isn't needed. As far as the A&D ointment on the healthy skin I wouldn't use it, it is petroleum based and can irritate the skin. I would use a moisture barrier such as calmoseptine or a zinc type product, both of these creams should be available at your pharmacy but I like calmosptine because if it gets in the wound it wont hurt it. Also it sounds like your are busy, are you eating enough protein so you can heal? I tell my patients that at each meal they should eat 2 sources of protein and a small snack of protein three times a day.
unsigned
 

---

Try Hill-Rom

---

do your have access to the braden scale. we use this to determine who has the potential for breakdowns and the use of low air-loss mattress for them . there is acopy of this one the internet. just type in braden scale. hope this helps. carolyn lpn wound care nurse

---

The 'Purple Book' by the Agency for Health Care Policy and Research is a very good source. It contains clinical practice guidelines in managing tissue loas while patient in bed and while patient is in wheelchair/sitting. It also offers guidelines in selecting appropriate surfaces and positioning techniques. The book contains evidence-based information for the prevention and management of pressure ulcer.

Hope this helps. By the way, I am a physical therapist who does wound care in a long term care facility too.

Saturn B. Dagwase, PT

---

Manufacturers of support surfaces have these guidelines and would be good resources for you: Hill Rom, KCI, National Wound Care etc… There are others. Contact them directly. You can get their contact info on the web.

L. Beck RN, BSN, CWS, FCCWS

---

Medicare will pay for preventive gel overlay mattresses to all medicare patients.
This goes on top of the existing mattress of a twin bed or hospital bed.
I have had very good results with this.
This is something that is considered "preventive action" and now that Medicare actually realized that prevention is much cheaper then healing it has been a blessing.
I get one for all of my home health care patients.
Mary Childs RN

Hi Angela,

It's always appropriate to keep the wound bed moist, but not too moist. Depending on drainage is how you would make that decision. More information is needed to help your husband. If the wound has rolled edges, then it has stopped healing. The doc needs to make the wound "acute" again by removing the edges. If it needs to be packed and there is a concern for infection, they should consider one of the Silver products on the market to pack with. The one I like for packing is Tegaderm AG Mesh. It feels like a gauze and doesn't break apart in the wound. Great for packing. If the wound is draining, then put it in dry. If there is not alot of drainage, I will put some Normal Saline on it or Hydrogel before packing.

good luck, Carly RN CWS

---

First of all the reason we have Super Staph is the misuse of antibiotics. Signs of infection include redness, purulant drainage, fever, swelling, increased pain and the wound bed will deteriorate.
Use polywic silver for 48 hours , then go to polywic regular for packing the wound. If it doesn't need packing then use polymem.
(polymem silver for the first 48 hours) Wounds need to be kept moist (like the body), warm (like the body) and undisturbed as much as possible. Once a wound is debrided, if proper wound care is performed. I have never had to have one of my wounds debrided after that! As far as activity level, can't give advise since I don't have enough information. Polymem was only made in Chicago and is patented so there are no subsitutions, it works like no other wound care product, I brought it from Chicago to Florida 10 years ago and still swear by it. I can't tell you how many feet I've saved, and wounds I've healed in less than a month and they had been open for months and months prior to me getting the case. e-mail me
directly at datt224@aol.com if you need help. Patricia

Hi Missy,

So sorry your Mom is getting such poor care. Something I did for protection in the Nursing Home was to use Viscopaste or Vaseline Gauze on my frequent skin tear patients. Viscopaste cut in strips (not around the arms or legs). Then I would wrap with cast padding and then put on the Geri-Sleeve or Stockinette. It would last about a week. It worked well for prevention. Of course the nurses need a lesson on proper transport or a patient.

For treatment of skin tears, have them contact a 3M rep and try a new product called Tegaderm Absorbent. It can be left in place until it falls off and works great on the skin tears.

good luck
Carly RN CWS

---

Hi

Look at the "Manual Handling" risk assessments for your Mum. If trauma is occurrring with regularity it suggests that procedures for moving your Mum are inappropriate. When you say lifting I would hope that a hoist is being used and they are not manually lifting her.

Bed rails should have bumpers attached to them so that if legs are inadvertently banged against them they will not cause trauma

Skin tears are best treated primarily with Meptital - or similar - a petroluem jelly coated open weave gauze. This is left in place for at least seven days - more if possible. A secondary dressing of non adhesive gauze is placed on top and this can be secured with a softban bandage followed by a crepe bandage. Use of any type of adhesive tape (including steristrips)should be discouraged on paper thin skin. If dressing becomes soiled with exudate only the top dressing is changed leaving Mepital in place.

Tubigrip, softban or anything that covers limbs could be used as further protection

I would ask to see evidence of training that staff receive in Manual Handling

I would make an appointment with the manager to voice and document your concerns

Hope this helps
Let me know

Helena Waller
Senior Nurse
---

 I have excerpted the following statements from your message:
the fluid began to puddle up like blisters on her legs and it looks horrible.
bang her legs will burst the blisters "or what appears as blisters".
wound and it drains onto the sheets and onto her clothes that she wears when she is up

Are your mothers legs edematous (swollen) all the time?
Are her legs really bruised? Could they be discolored?

It almost sounds like you are talking about someone who has venous insufficiency.
Poor blood flow back to the heart through the veins, causing pooling of fluid in lower
extremities. This fluid has to go someplace, so will move into the smaller vessels, then
tissue. Any slight bump will open up areas that allow the fluid to escape and can become
wounds. Sometimes skin changes in venous insufficiency will give purplish blue color, or
the color change caused by hemosiderin staining.


If she has venous problems the only thing that will help prevent and help heal her wounds
is keeping legs elevated and using compression. The purpose of that is to help the blood
move through the veins back to the heart. But before
compression can be utilized you also need to make sure her arterial flow is normal.
You don't want to use compression on someone who has poor arterial flow.

You need to get a proper diagnosis.

lynn
RN

---

You made a good point! Looks like the care for your mom requires a thorough asessment and intervention by a skilled professional. Remember that when the degree of complexity of the patient condition and the amount of care is complicated , consultation with skilled professional is waranted (per OBRA guidelines). You need to talk to the charge nurse to obtain an MD order for Physical Therapy Eval and Treat. The therapy people in the center are good resource and have the skill to identify the impairment (such as decreased ROM, improper body mechanics, etc.) which may be contributory to skin tear during transfers. Once they pick up the patient for skilled intervnetion, they will provide adequate training to the CNA's for safe transfers while addressing contributory impairments. If they therapy department is equipped with ultrasound machine, it is a wondeful modality for the resolution of hematoma or bruises.
Hope this helps.

Saturn B Dagwase, PT

---

First I would be meeting with the management to see if they are willing to monitor closely how your mother is being handled. It is always best to give management a chance to solve the problem. Then if the injuries continue then I would report this to adult protective services. When the caregiver slows down and moves your mother deliberately then possibly there will be less injury. In the mean time instruct the caregiver to make sure that the skin is conditioned with appropriate skin care, that the patient is hydrated and is eating well. There are a variety of dressings to place over an injury and a WOC nurse or CWS would need to see your mother first before recommending a dressing. Physical Therapist are good resources for moving instructions from bed to chair. May your mother’s Guardian Angel watch over her.

Karen Castle RN,BSN,CWOCN

---

Missy, the first thing you need to do is have a serious conversation with the facilities Interdisciplinary team, to discuss your fears. I am the wound/Restorative nurse at our facility and the wounds can be rehydrated by using hydrogel and a nonadherent dressing . I usually have very good results with the smith and nephew products. Allevyn adhesive. This is an extended time dressings, so that the wound will not be irritated by constant dressing changes. They are specifically manufactured for 5 to 7 day usage or a 75 % strike-through of drainage. They are most effective. You also need to impress upon the staff the need for gentle handling. Sorry, for you difficulties. I hope this will help you. Brenda LPN

---

I use nothing but polymem and conform wrap to all my skin tears, change every 5 days or 70% saturated. I just healed a nasty skin tear in just two dressing changes. nothing. I mean nothing works like polymem. Patricia Seemann RN BSN WCC

---

Missy,
First of all they need to be using a alpine lift or a hoyer lift with your mother if they are not. This will assist with prevention of trauma to the skin on the arms and legs. In addition, if they are using steri-strips for her skin tears that is fine if the skin is approximated properly before application. If she has drainage they may want to apply an AMD 2x2 or 4x4 gauze with a cling or kerlix dressing to secure it until the drainage has slowed down. The AMD product with help absorb the drainage in addition to assisting with the prevention of risk of infection. Long-term use of skin sleeves sounds like a good choice if your mother is that fragile and has a history of severe skin tears but the big thing is proper transfers to reduce the trauma to the patient and the patient's skin. Hope this helps.
Dee Potts, PTA, WCC

---

Hello.
I am very sorry about what is happening to your mother. It is unacceptable. I work in a skilled facility and do wound care.
If this were my mom, I would be having a fit and then i would call the Ombudsman.
Next, I would insist that the people doing the transfers are using enough people to operate the lift properly. We constantly use different types of lifts, and the only times I see this type of thing happening is when they are operating the lift incorrectly, not enough help, or they are in to much of a hurry.
Another idea is to use sheepskin on the bed rails, change them to half rails, or if she is indeed dead weight and does not move on her own, get rid of them altogether. You can also pad the lift. But someone really should be stabilizing her legs during the transfer so they don't "bang" around.
Cheryl Nichols LVN Treatment Nurse
 

unsigned

---

venous statis leg ulcers will basically heal if the conditions for healing are adequate

- regular cleaning with mild soap and water
- moisturize the surrounding skin or protect it from wound discharge [if significant discharge]
- pressure stocking or bandage
- elevation whenever possible
- heat therapy - the type that is used in the management of lymphedema cases may help by partially correcting the underlying venous pathology

kumkum

---

Compression (to counteract venous hypertension) is the “gold standard” treatment for venous stasis ulcers. Once the wounds are healed, you must immediately go into a compression hose/stocking to wear every day to prevent recurrence. The compression must be high enough to counteract the venous hypertension as well – if not, it will not be effective, or will be less than effective. There are compression bandages with varying levels of compression. They usually range from 20 – 40 mm at the ankle. Graduated compression from the ankle to knee is best and it should be sustained compression. The compression level and type of bandages that would be best for you depends on the severity of your condition, the presence (and severity) of arterial disease in the limb, ambulation status, size, exudate amount etc

Using ointments, dressings etc alone, without appropriate compression, will be less than effective. You didn’t mention if you had been treated with compression therapy. A wound specialist or vascular surgeon could make an assessment to determine what is the most appropriate treatment long term for you.

Lee Ann
RN, BSN, CWS, FCCWS

---
try polymem silver for the first 48-72 hours to make sure you don't have a heavy growth of bacteria, then switch to polymem, only change every 5 days or 70% saturated. If the skin around the ulcer looks too white (macerated), apply some zinc oxide to the intact skin before putting the polymem on. Nothing will heal it faster. You do however need to you compression stockings, not the white TED hose rather graduated compression stockings to not only help the healing process, but to prevent future ones. Patricia Seemann RN BSN WCC

---

You should try a pneumatic compression therapy pump. These pumps treat the underlying problem, poor cirulation. Medicare will reimburse if a patient has had a venous stasis ulcer continuously present for the past six months. And, most private insurance companies have allowables for reimbursement. Contact your physician to write a script for you. Search the web for the pumps, then call the manufacturer - they will be able to refer you to a supplier in your area.

---

I suggest consultation to a wound specialist. I am not a certified wound specialist yet but I do believe that having the right intervention is important in your case. Remember that compression therapy is still the treatment of choice in the presence of edema in venous ulceration. You may wanna consult with a wound professional for the selection of appropriate supportive devices or clothing to prevent the on and off recurence of the ulcer. Since venous ulcer is brought about by incompetent
valves in the lower leg veins, appropriate compression is necessary. Like what I said, wound care professional will help determine the amount of compression and will direct you if other tests are necessary prior to initation of care such as determining the ABI to r/o associated arterrial insufficiency.

Hope this helps,

Saturn B Dagwase, PT

---

If you can buy the WOCN CD on best practice then you will have nearly everything you will need. You will find it on the association web site.

Karen Castle RN,BSN,CWOCN

---

You may want to check with the your Ohio State Practice Act. Remember that having certification in wound does not give someone prescriptive authority unless the RN is an NP or CS.

Hope this helps,

Saturn B. Dagwase, PT

CMS is not paying for Xenaderm right now. There is an investigation of the ingredients at this time. I am having to look for something else for now.
Karen Castle RN,BSN,CWOCN