Best practice for sacral ulcers?

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    Hi, I have been a nurse for two years now and I work on med-surg. We don't have a ton of patients with pressure ulcers, and the ones we do see we usually put a tegaderm on and they get discharged and we don't ever see the results of our treatment. Recently though I have had a couple of patients for a longer than normal stay (over a week) that have had stage III ulcers on the sacral area, and it was not until now that I have realized the debate/controversy over wound care/treatment. It does not help that there is no policy or wound care specialist at my hospital. It seems that every nurse has a different opinion and is very sure of themself. I have done research on this, and even went to a wound-care conference on this, and I still don't feel like I know what to put on these stage III sacral ulcers.
    For one thing, we don't have any cool treatments, all we have are thin and thick hydrocolloids and opsites. Many nurses I work with think open to air is the best policy, besides obviously turn Q2 and nutrition, but I lean towards the moist wound healing offered by opsite and the tegaderm. The only problem is the wrinkles that form when these are placed on the sacral area. I have tried every trick to get them on smooth and perfect but they always end up wrinkled.
    Also, how do you keep the intact skin around the wound from being macerated, and how do you know when the exudate that is supposed to be healthy for the wound bed is not so healthy any more?
    Any insight or tips at all wound be helpful. I even asked the doctor this morning and she didn't know- she said she is used to having a wound care nurse to ask...
    so it is in my hands at this point.

    Thanks a lot!
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    I don't have a ton of experience...but I'm just going to respond based upon what I've seen. I work in sub-acute rehab and we see a LOT of wounds.

    Personally I hate hydrocolloid type dressings, especially for sacral areas---for two reasons. 1. It doesn't sit well with me to cover something up for days and not see it. 2. I've seen hydrocolloids do a lot more harm than good---they roll up, pull on surrounding skin, fall off or get soiled way more frequently than they are due to be changed, and as a result I have seen them make smaller areas much bigger. I think hydrocolloids are better served as preventive dressings---for example on your kyphotic LOL who has no skin breakdown but might if she's in bed laying on that spine all day. I've seen them prevent things when used in that manner. If using them in that manner, I feel the placement needs to be checked frequently, so that the hydrocolloids don't do anything I described above.

    I've never used opsites to cover a open area, so I can't really speak to that.

    I think best practice for sacral ulcers depends a ton on what the ulcer looks like. I'm currently taking care of someone with a rather sizeable sacral area full of thick yellow slough. It has been debrided a bit, but we are currently tx'ing with Santyl and packing it BID pending further debridement. Once the area is fully debrided the pt will be going on a wound vac. This may be a more serious example than what you are describing.

    On reddened/excoriated Stg 1 type areas, I've seen zinc oxide do a great job healing things up. Once slough is involved, we tend to use Santyl. What do the areas you're talking about look like?
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    Everything depends on the size/depth of the ulcer. It's can be very difficult to heal these - keeping the pressure off is a main priority. Opsite and hydrocolloid are not the way to go here.
    There must be someone that can be consulted for this. To avoid soiling, you will probably need to 'windowframe' the dressing so nothing gets under the edges of the dressing. And you can vac a wound with a lot of exudate - that is part of why a vac is good.
    Best Wishes!!!
    Simba&NalasMom likes this.
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    Hmmm. I'm not a wound expert by any means, but I found a really good article that addresses the maceration issue:

    http://www.nursingtimes.net/nursing-...200016.article

    The article does mention that there is no evidence that suggests that a moist dressing necessarily contributes to maceration. Another important thing to consider is if the wound is clean or infected; if infection is present, there are several products, such as alginate and silvasorb, that can be used.

    You also mention that other nurses prefer to leave wounds open to air. I would NEVER choose to do that on a stage III; when a decub gets to that point, there is serious risk for infection and it can easily spread outside the wound.

    It's SO challenging to get a sacral dressing to stay put once you put it on; like you mention, they really do like to wrinkle no matter how careful you are...it's just the way things "shape up" down there. On top of that there are body fluid issues to contend with if your patient is incontinent. Have you tried cutting your tegaderm to fit the shape of your individual "bootie?" Some nurses will cut a semi-circle to fit over where the cheeks separate and that often helps keep the dressing clean and intact.

    I have also discovered that skin prep and Hypafix tape are my best friends as far as getting dressings to stay better. Apply skin prep in about a 2 inch radius outward from where your dressing edges will be; allow to dry so that it's slightly tacky, and apply your dressing. I'm not sure if you've seen Hypafix or Mefix tape, but it's kind of this stretchy tape that sticks amazingly to skin but peels off very nicely when it's time to change your dressing. Those two things will help your dressing stay put by 100%.

    I'm happy to see your interest in wound care; as an LPN I've worked in many a nursing home and treated many a stage III/IV, and I cannot stress enough the importance of early intervention. Thanks, AmyAnn!
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    Quote from mamamerlee
    Everything depends on the size/depth of the ulcer. It's can be very difficult to heal these - keeping the pressure off is a main priority. Opsite and hydrocolloid are not the way to go here.
    There must be someone that can be consulted for this. To avoid soiling, you will probably need to 'windowframe' the dressing so nothing gets under the edges of the dressing. And you can vac a wound with a lot of exudate - that is part of why a vac is good.
    Best Wishes!!!
    Yeah, wound vacs are amazing. However, it's imperative that nurses get the proper training from the woundvac reps; if they're done wrong, it could do more harm than good. My best experience has been with KCI. Their nurse consultants will spend as much time as it takes with you and your patient to make sure it's done properly, and they are available via phone 24/7.
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    Have you checked out the wound care forum on allnurses.com? There should be something there.

    The care of Stage III ulcers is difficult at best and requires a multidisciplinary approach. In terms of the wound bed itself, it depends on the percentage of eschar, exudate, infection, etc. For less exudating wounds, foam dressings work well (if you can get it to adhere appropriately) and agressive incontinence management needs to be addressed, especially in light of the proximity of wounds like this.

    For highly exudating or infected? WOUND VAC. If your hospital uses KCI vacs, they should be willing to inservice and are always available by telephone.

    Recently in our hospital, we formed a wound care team. They sent us to training and we now have a few certified as WCCs. We developed a policy and procedure specific to wound care so everyone is using the same modality for wound care, and there is a resource if nurses like you have questions like this. Sounds like you need a wound care team.
    Simba&NalasMom likes this.


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