NON HEALING stage IV pressure ulcer HELP????

[NC29mom]

i really need help!! i am a nurse in a ltc facility that is responsible for measuring, documentating and caring for all of the wounds in the facility. i have this patient that was admitted about 3y ago. when he was admitted he had x 2 stage iv pu, one to l ischium and one to r ischium. he is approx 50 y/o, and has no use of his ble. well, we eventually were able to heal the pu to the l ischium by using a combo of e-stim (by pt) and hydrogel moistened guaze packing. it took awhile to heal, but it eventually did about 7 months ago. however; the pu to the r ischium remains. currently the trmt is to pack tunneling depth with hydrogel moistened guaze and cover with dry guaze qday. when comparing the measurements from jan 2009 to measurements from jan 2010, there was very little improvement. the wound measures 1.5 x 0.5 x 2.0cm. the tunneling depth measures 2.0cm and is to the lateral aspect of the wound. the wound base that is visible is a pale pink color. no exudate, no odor, no slough noted. 100% pink. i am at a standstill with this wound. i approached my don about possibly performing a wound culture and her response was, "oh they don't even recommend doing that anymore. all wounds will have bacteria". i also requested that the patient be sent to the wound clinic (about 45 min away, and we have used them before for other non-healing wounds. this pt has never been). but her response was, "oh his insurance won't pay for him to go (or transport)" - and the facility is unwilling to pick up the costs. the patient has the very best mattress & cushion for his scooter, is on a strick turning schedule, only gets up oob three times a week for 4h at the time, has a foley catheter, has had pt work with the wound on 2 separate occasions, takes supplements, labs drawn and all wnl r/t wound healing. i just don't know what else to do for this wound!!! other trmts we have tried are: wet to dry and silvercel. neither were successful. to all the wound professionals, your opinion/knowledge would be greatly appreciated!!! please help me with some ideas as to why this wound won't heal (and keep in mind, my don won't let me culture wound) and what other kinds of interventions or trmts could be successful. all knowledge is greatly appreciated!:confused::confused:

post questions if you need to and i will answer if you need more information. i will check back often.

[NC29mom, ASN, LPN, RN]

If only I could get my DON to agree to a wound vac.........................

[thehipcrip]

This patient should not be getting up AT ALL. The most critical factor in healing a pressure ulcer is staying off of the wound until it is healed. Allowing him to sit up on it for four hours at a time three times a week is likely adding months to the amount of time he'll need to be in bed, off of the area, in order for it to heal.

[Jaguar Boy]

Hi NC29,

I'm a nursing student and came across your thread because I had a pt in my care today who, after surgical debridement of an unstageable coccygeal ulcer yesterday, has a Stage IV PU. I've been researching the literature and have come across an interesting study published in 2007 on the use of honey vs. conventional dressings. Their results showed that the honey dressings facilitated healing significantly. Now, I think that the participants in the study had stage II and III ulcers. But, anyways, it's interesting information.

Cheers

[SuesquatchRN, BSN, RN]

There is an utterly awesome product out there called Promogran by Johnson and Johnson. We had a guy with his cartilage showing, had been treated for at least 6 months - within ONE WEEK of starting this he had beautimous granulation tissue there. It's expensive, though - collagen matrix. But well worth it, and far cheaper in the long run that a non-healing wound.

[knorahs65]

It has been more than a month since you first asked advice on this wound what is the current assessment of the wound now?

[wound specialist]

There is a product called polymem. I have used it on stage II, III and IV Pressure ulcers and always had excellent results. I'm not a big fan of wound vac's. Polymem is the only product that you do not have to use Normal Saline and you change it every 5-7 days. It is also less expensive then a wound vac and it will save a lot of your time. Have a rep come out and talk to you and your DON. Remember your the avocate for your patient and if your DON is only worrying about cost, I recommend you talk with your administrator.

wound specialist

[sorlando]

I think the wound vac is probably a good idea. You shouldn't have to get you DON to agree to a wound vac. All you need is a Dr. to order one and the insurance to approve it. If your pt. is on Medicade he would most likely be approved. Since you don't have experience with wound vacs a KCI rep could come to your facility to show you how to change the dressings.

[sonjamontg]

I have been in wound care for about a year and we use a lot of prisma and silverlon with these types of wounds. The prisma has the collagen and silver in it. I have plenty of experience with KCI and Egenex wound vacs. Have applied them both in the gluteal fold, groins, testicals. Adapt may be needed to get a good seal but if you use the barrier wipe prior to draping and after draping the seal is usually no problem. Can also use Prisma and silverlon with these vacs. Had great results. Good luck.

[kcicc]

Must agree with a couple of the other posters, even tho my screen name is a dead give away. Need to R/O an osteo, trim off those wound edges and no R ischial weight bearing allowed. Until then, it will not matter what dsg you choose, so keep it inexpensive

[SarasLPN]

I would just send a request/communication to the MD and then the DON really has no say in what is done. I work in LTC and the DON really doesn't say what we can and cannot do as far as making appts and treatments for people. We just ask the doctor and whatever he/she says goes. Maybe you can just check with them and then let her know it's "doctors orders"

[Jspoon0926]

Try Medihoney. It is a product by dermasciences. They make it in rope form with calcium alginate, or calcium alginate 2x2 or 4x4 pads. Research it. It works wonderfully! It is all natural, helps with pain, helps reduce bacteria load in the wound.