Advice with severe vascular leg wounds

[garnetgirl29, BSN, RN]

I have a patient who's vascularity is so poor, he's been denied for amputation because the surgeon feels that he will not heal.

So, I am left to treating his numerous wounds that start just below his knees and continue to his heels. Bandage changes are VERY painful for this man (even with PRN and scheduled pain medication) and his severe pain is keeping him bed bound. Right now we're using anasept cleanser (blotting with gauze because he says spraying directly is more painful) and covering with adaptic, calcium alginate, ABD's and wrapping with kerlix. It's very difficult to get all the dressings in the correct place and to stay there until the kerlix is wrapped around . I really wish I had adaptic on a roll rather than little squares! We're changing daily because of the drainage and the dressings sticking to the wounds.

So, I'm looking for advice on anything I can do (or suggest to the MD) to make his wound care more comfortable? I wondered if unna boot would help, but I've never used them on such large wounds with so much drainage.

[KatieMI, BSN, MSN, RN]

This is what is done in my place, and we have tons of patients like this:

1) optimize what still can be optimized. Perfusion (meds), diabetes control, etc.

2). If patient has diabetes, consider specific meds targeting neuropathic pain such as Lyrica.

3) ask patient what body/leg position is more comfortable. For some of them, keeping legs up/down makes difference.

4) equianalgetic dose of meds split as 2/3 to 1/3, approximately. 2/3 is longer-acting, better combined (like tylenol containing combination) and given so that it is at max about 30 min before dressing change. This 30 min before, patient is given 1/3 of quick acting medication. You may need a pain specialist consult for this.

5) he might like just distilled water/sterile saline, warm or cold, better than anasept. Soak sterile gauze and apply while almost dripping wet directly over old dressing for a few minutes. We do local baths sometimes if patient likes them.

6). To make things easier when you only have two hands: do wounds one by one. Soak, clean, cover, apply alginate or whatever. Soak next one while you do this. Do only one or two rounds of Kerlix over the first one, then just leave Kerlix near, repeat.

Hope it helps. I really feel for this poor soul (who, BTW, really needs second surgical opinion)

[Candogal]

Hi, I presently work at 2 outpatient wound centers- check a local hospital to see if they have a center. I would highly suggest the patient go to a wound center, which the staff will then instruct you on dressing treatments along with weekly visits to the wound center for debridments, follow-up care etc. Compression and Elevation are going to make the biggest improvements, your patient has to do their part by elevating to heart level as much as possible- they don't like to comply but it makes a huge difference!!! For more than light compression the patient will need to get ABIs (arterial-brachial index) done to make sure that compression will not cut off circulation. Unna boots are for patient's that are ambulatory because they're meant to work with the calf muscles, since you said your patient isn't right now than it's not an option. Stronger compression devices that most commonly used are Coban 2 lite, Coban 2 regular, Profore 3 layer and Profore 4 layers- but again ABIs are a must and it's a doctors order. Drawtex is more super absorbent than alginates. Silver dressings would probably be very beneficial for this patient such as Acticoat 3 or 7. Cauterization to help decrease wound drainage with silver nitrate applicators by the wound doctor might also be something they'd consider, it's used for heavy bleeding wounds after debridements but a podiatrist became a fan of it on a foot amputation patient who had excessive drainage. Once the wounds are healed and the edema has been controlled then they are an ideal candidate for specialty compression stockings or farrow wraps. But really, recommend the patient go to a wound center or at the very least a podiatrist, most of the staff at both places I work at are podiatrists because they deal with wounds from the knees down.