(silver nitrate sticks)

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I believe any discipline allowed to remove non-viable tissue on the wound may apply silver nitrate sticks because on clinical stand point epiboly or hypergranulation are considered as non-healthy tissue as they do not support wound closure or actually they are barriers for healing. Using the silver nitrate sticks to manage such is like removing a non-viable tissue in the wound. This is my clinical opinion but I encourage you to check with your state practice act.

Saturn, PT, CWS, FACCWS
 

Way to go! I have healed so many wounds that "Doctors" said couldn't be healed by using a little common sense. I applaud you

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Hi Linda
As a registered nurse I see many sloughy almost gangrenous wounds and bed sores that seem to be just to big to fix especially if the patient has had cancer treatments (chemo/Radio therapies). When I lived in NZ we trialled kiwifruit to pack sloughy ulcers and used combine dressing to absorb the exudate, and to my amazement it worked extremely well and was very cost effective. Kiwifruit conducts electricity or so I was informed which is part of the reason the wounds debride easier. But the results spoke for itself so i was quietly impressed with its success rate. So to watch people regain their mobility and dignity and to be pain free has become my motivation in wound care management. Thank you for you helpful tip I will certainly advocate to trial ichthammol if I have to in the future.
Michelle

Joe

It might, especially if it hasn't responded to antibiotics as expected. You can go to a wound clinic that has hyperbaric and they will evaluate you. Go to www.aawm.org and www.wocn.org for certified people near you.

Renee C, PT, PhD(c), MSPT, MPH, CWS
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Hyperbaric treatments will help with general wound healing, depending on the reason you have the wound. I don't know if it is especially helpful for MRSA. That requires specific antibiotics.
Patti, certified wound care RN

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MRSA - No

lynn
RN

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No

unsigned

JENNIFERM.Barnes@tenethealth.com

Jennifer,
You list your credentials to include WOCN, I take that to mean you have been to an accredited wound care course. I would ask your instructors or preceptors for help with these policies.
Dawn, RN CWOCN
Sioux Falls

Rose

I think Zimmer still makes the pulsavac.

Penny Walls, PTA

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Davol has a pulsed lavage tip and gun for tunneling wounds. However, since the irrigation fluid travels back through the gun toward the suction canister, the entire apparatus is discarded after each treatment (unlike while using the suction diverter tip, where the gun can be wiped clean and reused on the same patient at a subsequent session). It's an expensive treatment.

Sara, PT, WCC

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Canyon made a manual system. I don't know if it's still made or not. Also, there are several systems of pulsed lavage devices out there. (Davol, Zimmer, and Stryker are three brands.)

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

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I am a Wound care nurse and I use a syringe with a number 18 IV cather attached to irrigate tunneling areas. This works really well.

Phyllis Lucas RN

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One technique is to attach a catheter to a syringe and thread the catheter down into the wound. The size of the catherter and the syringe depends on the size of the wound opening.
Patti RN, CWOCN---

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A WOCN showed us how to use a 'Butterfly' for irrigating these type wounds and it works great!

Cut off the needle and wings part of a 'Butterfly' (used for venipuncture), attach a syringe filled with NS or cleaning solution, then just insert the tubing from the 'Butterfly' into the wound/tunnel and irrigate it that way.
Works great for very small wounds/punctures and tunnels.

No new ideas for splash guard other than goggles or a mask with eye shield attached.

ML DalSanto RN
Visiting Nurse Corporation of Colorado
Denver, CO
 

Patricia,
Peri-anal wounds are not pressure ulcers. Most likely the contributing factor in this case is moisture, and there may be a fungal component. Tests can be done to determine if it is fungal, but it's cheaper and easier to treat as if it is fungal, and if no positive response, then do lab studies to determine the source.
I have had good luck with criticaid AF, this is a moisture barrier ointment with an antifungal (2% miconazole).
Dawn, RN, CWOCN
Sioux Falls

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Patricia,

Just from the way you describe the periwound edges, it sounds like he has a hyperkeratotic callus that is macerated. Otherwise known as a callus that is getting to wet. We frequently see these in our clinic with paraplegic pts. My suggestion would be to find the closets wound center to you. They can help remove the callus and maybe identify where the pressure is still coming from. There are dressings out there that can help, but the ultimate issue is pressure.
Tami RN, BSN, WCC

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Perhaps a scraping or biopsy could be sent for microbiology and culture. Being on immuno-suppressants following the transplant, it is possible that there may be fungal growth. Surgical debridement combined with appropriate topical and systemic therapy based on the report would help towards achieving healing.
kumkum

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He need an evaluation at a wound care center. The white edge may be from maceration of the tissue rather than from fungus. Maceration occurs when the skin is exposed to too much moisture over and over again. Second, I would get your physician to refer you to a dietician to see if it is possible to reduce the loose stool frequency or assist with bulking up the stool. Best assessment can be done by a wound care center.

Karen Castle RN, BSN, CWOCN

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Wound care is a speciality unto itself. Just as you wouldn't ask a cardiologist about the kidney problems, you should find a wound specialist to evaluate his wound. It is not safe to make a diagnosis or treatment plan over an e-mail. Go to www.aawm.org and www.wocn.org to find someone near you who is a wound specialist so he can get the most appropriate care by someone who stays up to date and has advanced wound care knowledge.

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

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Dear Patricia:

Yes, a wound can be tested for fungus by culturing it. However, the wound that your brother has does not sound fungal. Usually fungus has a rash like appearance sometimes with itching. The thick white rim around it may be what is causing it not to heal. Usually when this thick rim develops, it tricks the body into thinking the wound has healed. Sometimes this requires surgical intervention to heal the wound. Sometimes it works to use a piece of gauze to lightly rub around the edges just enough to kick start the wound into knowing that it still needs to go thorough the healing process. This is the avenue that I would try first before requesting any type of surgical intervention.

Good luck,

TJ Frisk, RN

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Hi Patricia,
First of all and most important,
If the pressure is not removed from the area, it won't heal. Even with a Roho, depending how he sits, there may be too much pressure on the area. Evaluate how many hours he is on the area and shorten them. (Sitting in bed with the head elevated is a common cause of pressure sores in the area you describe too.)
The thick white "rim" is overgrown skin that for some reason can't move across the wound bed. It may need to be surgically removed before the wound can heal, but maybe not.
Is the surface of the wound at skin level? It should be pink or red with no yellow or white or black on it. How big is it?
If it is pink and healthy looking, bleeds fairly easily and doesn't have pussy drainage, but you have the white rim build up, that means there is something preventing the skin cells from moving over the wound bed, they are gathering at the edge making the rim.. It may be staying too wet or have a "biofilm" that is preventing the skin cells from moving across the wound bed.
Try scrubbing the sore with gauze and betadine or hydrogen peroxide until it bleeds, especially the edges of the wound. You can be kind of rough, but only do this once. These products are not good for healing but may cleanse the biofilm and "wake up" the wound. Then, apply antibiotic ointment like Neosporin or Bacitracin to the area 3-6 times a day. Actually any good sticky moisture barrier will work - you want to keep the air, poop and urine out of the sore, but especially the air. Calmoseptine Ointment, Ilex , even Desitin diaper rash ointment are some choices. Keep him off the area, on his side in bed if possible, only up in his wheelchair for 1/2 to 1 hour for meals 2 or 3 times a day if that is possible.
Good luck.
Patti RN, CWOCN

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Hello Patricia

My Elderly mother has pressure sores on her bottom as she is sitting too long after having a stroke about four years ago. The area is red and bruised so the nurses use Cavilon barrier cream or Cavilon No Sting Barrier Film. The spray on film is better instead of plasters but has to dry first or will stick to clothes.

A friend of mind who has worked in care homes and is now 60 told me to try Conotrane Antiseptic Soothing Cream (Yamanouchi Pharma Ltd, Surrey, KT14 6RA, UK. She also said the Cavilon Barrier Film was very good.

Do you have a 4 inch thich pressure mattress and pressure cussions but the nurses here say to keep lifting of the area every half hour and she has to try and put more fat on as she lost so much weight after a stroke.

I hope you can try the spray film made by 3M Health Care USA www.3M.com

Elizabeth Knutton

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Hi..sounds like you need to see a certified wound specialist in your area to assess the big picture of the problem. You may wanna also ask a referral for a physical therapist or occupational therapist to get consult on proper positioning while in bed and while in the wheelchair. Also, it is a good idea to get a culture and sensitivity test to know what is the real offending organism in this case.

Saturnino B. Dagwase, PT, CWS, FACCWS
 

Dear Wendy:

Smith and Nephew has developed a very handy pocket sized laminated card showing the different types of wounds as well as suspected deep tissue injury and unstageable wounds. There is also a really good picture of the skin structures and definitions of wounds "All the World's a Stage" which I think comes from Wound Care Made Easy. I'll have to check the source when I return to work tomorrow and will be happy to write again to suggest some other resources as well.

TJ Frisk, RN
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Check the Medline, Convatec and Coloplast web sites for free education. Kelle CWCN

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The only guide I can think of is knowledge of the local anatomy of underlying structures, the effects of injury to such structures in terms of bleeding, organ content leakage, function [movement at distal joint, sensation] and a high level of suspicion based on a detailed history of the nature of the accident. If there is no eye-witness and the individual is amnesic then the surface findings and probing after local anesthesia may give some idea of the direction of the injury and the depth. With the slightest doubt raised it would be advisable to explore.
Kumkum

I will agree with her. 12 hours is not enough time for her to see 40+ patients and document. I currently work for a 150 bed skilled nursing facility. I can have in excess of 45 wounds at any given time throughout the building. It may take 8 hrs just to see twelve to thirteen people. That includes the time you review the chart, measure, treat, make recommendations to the MD and document a very good note. There is too much liability when working in wound care. Not to mention the regulation requirements. It is just not the wound you have to evaluate but the whole patient and the environment including pressure relieving modalities. If you are planning to deliver the best care for the patient, you need to make your wound nurse a full-time employee.

Carmen Chill, RN, BC, WCC, MBA

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I would plan on 30 minutes per patient for wound rounds, including the time to assess the wound, document the status of the wound and recommended treatment.
Dawn, RN, CWOCN
Sioux Falls

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Hi, I am a Certified Wound Care Nurse in central PA. I have been doing wound care for more than 5 years now. A good rule of thumb, for the amount of work/assessment you are giving your wound nurse, would be 15-25 minutes per resident. Photographing is very time consuming and just replacing dressings takes up a great deal of this time. I would also give her an hour or so to do the separate tracking/reporting.

Kelle
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A wound care nurse will have to spend at least 1 hour a day in the office planning and documenting. At least 1 hour a day answering the pager and answering questions from the physicians, nursing, case managers and patient’s family. If there is a delay in seeing a patient then you may have to return to see that patient or wait right there until the delay is over. If photos are being taken, then the photo will need to be printed and placed in a chart. Then the product rep call on you. Don’t forget the product meetings, update with the nurse manager and the power point presentations to educate nursing. Oh yes, forgot about the wound vac exchanges. Even if nursing is trained to change the wound vac dressing then there are nurses who need help. Need leg compression wraps? Try to complete this wrap in a timely manner when the leg weighs 100lb. Did we talk about Bariatric size patient’s yet?

When you get home you are a mess. You have run out energy to give love to your husband.

Karen Castle RN, BSN, CWOCN

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I worked in a SNF as a wound care nurse. Initially hired to "fill in" only 16 hours/ week. I ended up working 10 to 11 hours/ DAY!! I had been told they had 10 patients with wounds; there were 33 patients with wounds. Some were extensive - stage 4 pressure ulcers, etc. Of course, I resigned from the facility.

I agree with your WOCN that it is impossible for her to see 40 patients at a time ! If that could be divided into four days, or so and the team would be available then it is a possibility. Assessing a wound, getting the orders, posting the orders, following the orders in wound care , assessing the dressings needed, and dressing the wound is definitely not effortless ! If you want to keep her - treat her right.

Frances J. Jessup, RN, BSN

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I am a wound care nurse and yes, in my opinion it is impossible to tx 40 patients a day effectively. Doing measurements, a head to toe assessment should be daily and then the time needed for wound vac therapy, would be impossible for one nurse to cover over 40 patients. No, you are doing a dis-service to your patients to expect one nurse to assess, tx, and keep evaluations current. Two wound care nurses can give the time needed and spot anything starting. Remember the new criteria for Medicare and if the decub ulceration is not shown to come into your facility, then your facility stands the cost of caring for that ulceration until it is healed. The importance to having a wound care team in place with it staffed properly, is financially sound and most beneficial to the patient.

Mary, LVN,WCC

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My wound care team consists of our medical director, the unit manager, myself, a dietician, and an administrative representative who can help with new policies and procedures being drafted. We are also adding someone from the therapy department. We start wound rounds at 6:00 a.m. as this finds most residents in bed, except for the dialysis patients, and does not interfere with breakfast. We have a 4 unit facility and do 2 units every other week. We have the unit manager make up a wound rounds sheet, listing all wounds on their floor. All of these residents are seen, including surgical wounds, every other week. Also on this sheet we can document findings and make suggestions for treatment changes. We do not have a wound nurse per se and do not measure the wounds at that time. We also put on a temporary dressing so that we can complete rounds in a timely manner. If your wound nurse sets up a schedule to see and measure and document on a certain number of wounds each day, she would probably be able to manage the dressings, measuring, and documentation. It would also depend on the acuity of the wound which needs to be factored into her time.

Hope this helps,

TJ Frisk, RN

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I have been a CWOCN for 12 years. I schedule outpatients for hour appointments and frequently run over if it is an initial assessment or they have complex wounds. Inpatients take at least 1/2 hour if I am going to do a good assessment, I have someone to assist me with positioning, and the supplies are already at the bedside.
You are asking her to see a new patient every 15-20 minutes. She could possibly do that if the patient is already positioned and she doesn't have to do any wound care. Don't forget she has to do documentation too. How long do the PTs spend with each patient?
Patti RN, CWOCN

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ideally your wound nurse needs to see your patients at least every three days to reevaluate wounds and treatments. also if you are using compression as a new treatment it should be reevaluated within 24 hours. your next best plan is major education for your regular staff. i have found since getting into wound care that nurses working on floors know absolutely nothing about advanced wound dressings. not that they are deficient, it's just that they have never been taught.

hope this helps!
Kelli, WCC

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What practice setting is this? In SNF- if your PT has a good experience in wound or is certified in wound care, I suggest utilizing him for all your stage III's and above. He will be a good person to monitor the efffect of debridement in the wound and a good resource for therapeutic positioning. If you therapy department has an active wound care program, you can utilize their data for your weekly notes as long as you are using the same tool to monitor healing. Therapists have deep foundation in anatomy and physiology plus if one of them is certified or trained in wound care that would be a great help to manage your big casel load. Also, remember that most practice act allows PT's to administer topical ointment or medication on the wound bed as long as they are prescribed by the physician thus depending on the practice setting and payor environment your therapy department may take a significant wieght off your load. Hope this make sense.

Saturn, PT, CWS, FACCWS
 

There is a lot of protein in wound fluid too. Make sure you're eating well with adequate protein, as you need it to build new tissue. You should find a wound specialist near you for expert care. www.wocn.org and www.aawm.org will help you find one near you.


Renee C, PT, PhD(c), MSPT, MPH, CWS
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You will lose protein from a heavily draining wound.
Albumin level will tell if protein stores are adequate for healing.
Also wound is on bottom which I hope you are staying off of.

lynn
RN

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First of all you need a swab on your pressure ulcer as a heavily draining wound is usually an infected one. Next you lose  a lot of protiens in a hichly exuding wound so you need to increase these.Also your wound will not heal whilst you sre severely anaemic as the tissues will not be getting enough blood supply.Once all this is sorted try the vac again and if that doesnt work try a foam dressing such as polymem
Janine Michaelides SRN ONC DIP HE(WOUND CARE)

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There are a lot of stuff lost from a draining wound. You can think of your essentila protein and growth factors necessary for granualation formation.

Saturn B , PT, CWS, FACCWS
 

Mary Rose

If you can document that these ulcers are truly, soley pressure they would be stage II pressure ulcers. I would argue that the primary source of these wounds is friction and shear. I would encourage limited use of attends, don't tape them together when patient in bed, and use a moisture barrier ointment such as aloe vesta, or if skin is irritated, use sensicare.
Dawn, RN, CWOCN
Sioux Falls

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Hi. I am a Certified Wound Care Nurse and yes these are stage II pressure ulcers that must be treated as such. The key to not getting a deficiency related to these is to provide education to the staff and to INTERVENE when they happen, ie adding a preventative powder or cream. Thanks Kelle

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It is you job to determine whether it is
tape burns, skin reaction to tape or
actually result of pressure.

If it is pressure stage 2 is a blister (intact or not)

Lynn, RN

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A serum filled blister that is due to tapes should not be considered a pressure ulcer. Granted, the wound may be on a boney prominence, but tape is the culprit. The definition of a pressure ulcer is localized injury to the skin and/or underlying tissue usually over a boney prominence, as a result of pressure , or pressure in combination with shear and/or friction. The injury suffered on the inner thighs from diapers being pulled against the skin, or tapes stuck to the skin is different from stage II pressure ulcers. Under Stage II pressure ulcer definition is partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open.ruptured serum-filled blister. Further description goes on to explain that a Stage II presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. I would label those wounds caused by diaper/tapes as partial thickness skin loss/injury due to tape injury/diaper injury.
A way to help combat these injuries is to make sure the diaper or brief is not too small and that the fastenings are Velcro. The new generation of diapers which are composed of a breathable material instead of the plastic covering are great and the cost is comparable.

Dixie Lombardo RN CWS
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Dear Mary Rose:

When a blistered area forms at a pressure point - and also when it opens, I understand that to be termed Stage II pressure Ulcer.

Are you certain that these blisters are Stage II pressure ulcers? You didn't mention pressure points except mentioning the hips.

Could they possibly be a reaction to the attends? allergic reaction to the adhesive? Are there other patients with this?

Frances J. Jessup, RN, BSN

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We only stage pressure ulcers - blisters weren't caused by pressure, rather friction

unsigned

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Dear Mary Rose:

I don't know what state you are in, however in our reporting system, these wounds are classified as stage II's. Although some of your wounds sound like tape burns, because they form a blister they meet our criteria. Check with your state's regulations and any resource people that you can utilize.

TJ Frisk, RN

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I think I would chart them as "partial thickness" wounds, not pressure ulcers. They are not really caused by pressure. Although shearing could play a part in their development and that might nudge them into a pressure ulcer definition. Try a thin layer of vaseline, or other "grease" around the area when the diapers are put on to see if it helps prevent their development.
Patti RN, CWOCN