Holy Wound Batman!!

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    Lady admitted to facility with a stage 4 pressure ulcer on coccyx. Bone is noted in wound bed. Drainage is now a problem (heavy serous). I think it something like 5cm x 6 cm x 3.5 cm with undermining from 6 to 3, undermining measures between 5 to 7 cm. I swear she is 90 pounds soaking wet. Poor nutritional intake. I am thinking it really is a failure to thrive and in a catabolic state. Doing the normal turn and reposition, specialty mattress, barrier cream, RD involved, however with not really eating, this wound is not going to heal. I just am kinda at a loss as to how to manage it.

    Tried aqaucel CE, skin prep, cover with abd pad, but that was when drainage was minimal. Until I can figure out something else, I decided to have nurses unroll and gently pack kerlix, skin prep, cover with abd and change daily. I was really trying to avoid daily d/t comfort reasons but I don't believe this is possible. No matter what I throw at this wound, if she isn't going to eat and continues to lose weight, it will continue to worsen. Has foley placed. Request trial of arginaid, but again, she really isn't drinking anything either, including fluids such as water, med pass, juice, soda. She really should be placed on hospice which I think she will ultimately go, but I still need to figure out what to do with this wound.

    The goal isn't for it to heal, but really that the resident will allow wound care to be performed and that she is comfortable. Unavoidability statement requested. She is also refusing to get out of bed...more of a passive refusal. She really is not awake that much.

    Thoughts??
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  3. 7 Comments so far...

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    For her comfort and to decrease time spent on dressing changes you can't go wrong with the wound vac. Drainage won't be an issue as it goes into a throw-away canister. Typically dressing changes are Monday, Weds., Friday, but in this case you can go the full 72 hours between changes. The only problem I see is reimbursement. Typically the insurance company wants to see improvement in measurements.
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    Quote from 3PRN
    For her comfort and to decrease time spent on dressing changes you can't go wrong with the wound vac. Drainage won't be an issue as it goes into a throw-away canister. Typically dressing changes are Monday, Weds., Friday, but in this case you can go the full 72 hours between changes. The only problem I see is reimbursement. Typically the insurance company wants to see improvement in measurements.
    Yeah... I thought of a wound vac. If she was a healthy person who is eating and able to take supplements I would definitely go with a wound vac (if I could get it approved), but I don't think it would do any good. You can do the best wound care out there, but if the person is not taking in nutrition. There is nothing for the body to rebuild the tissues and structures. Wound vac rentals START at over $2000 a month by me and that does not include the supplies.
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    Hi PsychNurseWannaBe,
    How is your patient doing? Can NG or parenteral nutrition be considered part of a necessary wound treatment? Or would the patient not allow that either? I'm a student, so forgive me if this is a dumb question...
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    Don't see too many of these anymore(thankfully!) I'd try to manage exudate first-alginate rope for packing-loosely!-foam as secondary. This will help odor as well. Karaya paste as perimeter to secure dressings to helps in difficult spots. Skin prep to periwound to protect from maceration. Shoot for manageable and realistic outcomes first-try to keep from getting larger,esp. tunnelling. Fortunate pt. preferring to remain in bed,keeps area offloaded. If drainage copious and becomes unmanageable,considering pouching? Also remember pain management prior to dressing change,sounds like you're trying to take this into account. She may already be determining her outcome- Good luck to her and you!
    michelle126 likes this.
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    I have one almost the same in my facility. I am using kerlix soaked in a dilute mix of hibiclens to pack and a foam cover drsg. This is only being changed M-W-F. Have you tried Pro-Stat AWC?
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    I wouldn't want to live if I was in a nursing home with a huge hole in my arse down to the bone. I think not eating and staying in bed are pretty reasonable actions. I hope she is a no code with adequate pain medication prescribed.

    I have no clue about dressings, but i hope you just use whatever will provide the least discomfort. I bet my bottom dollar even if she ate she wouldn't heal.

    Poor woman.

    I dealt with one like this 19 years ago on a TCU. Had to do wet to dry dressings and she got a tylenol 3. It was horrific. So awful for her. I think that was a major factor in my chossing to go other directions.

    It is awesome that you are doing all in your power to help her.
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    WOW... I just saw all of these response. Thanks everyone for your suggestions and support

    The doctors are thinking she might last 2 weeks if that. The goal is pain control and comfort. She stopped eating and barely takes a drink.


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