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Wound   (22,352 Views 57 Comments)
by adrienurse adrienurse, LPN (Member)

15,007 Profile Views; 1,275 Posts

Say, hypothetically you have all the money in the world at your disposal.:chuckle

Patient is 90 yr old NIDDM patient with dementia and constant oozing of stool. Her status is palliative, and decision has been made to do no aggressive forms of treatment. Diet is tollerated very well, but is limited because of NIDDM status, swallowing difficulties and various other feeding complications. Has indwelling cathether and is bedbound with multiple contractures of the legs. Stage IV ulcer to coccyx has been present since 1999 (!). Multiple products have been used over the years, multiple clinical nurse speciallists and infection control specialist have been consulted. Pt had been on VAC therapy for 6 mo, but this lead to a deepening of the wound bed, and was d/c'd in 2001.

How do you propose to treat this client?:)

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1,244 Posts; 8,837 Profile Views

OK, I'm not a wound care nurse, but I find wound care a challenge, so I'll go for it.

Of course, care is dependent on some further questions:

What kind of bed is she on? (Facilities here usually rent an airbed, but I have issues with airbeds, but I'd put her on a RIC mattress, http://www.kci1.com/rik_mattress.html )

Is the wound bed clean or necrotic?

Does it have a lot of exudate, or a little?

and if the wound bed was clean, wash with wound cleanser and use a collagen gel filler. Cover with hydrogel and tack the edges down using skin prep.

If it was not clean, I'd use an enzyme debrider for the base; pack with impregnated gauze and cover with hydrogel.

Our wound care nurses have used products similar to this with good results--i.e., the wound did not get worse.

http://www.bardmedical.com/skinwound/woundmgmt/stage4ulcers.html

Of course, if the purpose is only palliative, I would still treat it for pt comfort.

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279 Posts; 6,423 Profile Views

After using the vac the patients wound deepened? Did you get an order for panafil to the wound before the clean sponge is placed? Try that. We used to think that you couldn't use any other tx. while wound vac was being used. Now a represenative from KCI showed us different.

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1,275 Posts; 15,007 Profile Views

Wound has moderate amound of serous drainage. Because of proximity to anus (6 o'clock is 4 cm from it) impossible to keep stool away from wound bed. No infection present at this time, wound is clean, but definately not sterile.

Wound bed is pink and surprisingly healthy. Some bone is present at 3 o'clock as well as fascia. There is no evidence of osteomyelitis. No eschar is present. Was all removed prior to VAC therapy using Eusol recommended by infection control physician. Wound demensions are 10 X 6 cm with a depth of 4 cm at some places. There is tunnelling of 4cm at 3 o'clock and 3 cm at 9 o'clock. Wound is round in shape and edges are healthy with occasional splitting at 12 o'clock and occasional slough formation at 3 o'clock.

Appreciate your imput. Sorry about metric measurements.

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1,275 Posts; 15,007 Profile Views

Gilda, I'm not sure what panafil is. Can you explain?

I've been only working in the facility for a year, so Vac therapy was d/c'd before my time there. Charting is unfortunately very sketchy at that point, so I don't know exactly why it was d/c'd except that although the wound bordes shrunk considerably, the base deepened and exposed more bone.

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1,275 Posts; 15,007 Profile Views

Thanks Gilda, I've only used Santyl as an enzymatic debrider, and only once or twice. It seems to only be used by the staff who believe in it. There are two camps here: Those who believe in enzymatic debriders and those who like to use a lot of Eusol. From my own experience, Santyl does not always work, and is +++expensive. Some decide to get around the cost by getting pharmacy to mix it with petrolium jelly -- probably decreases effectiveness, though.

Some other details:

- Client has a low air loss mattress. I don't think any other mattress has been tried ($$$)

- Is currently taking a multivite with increased zinc. Was recently put on a high protein supplement to be mixed with her food.

- Have tried hydrogel (S & N) with packing in wound bed. Wound edges are ++ prone to maceration. Have not tried skin-prep ($$$). Were painting wound edges with calmoseptine for a while, but ct. develloped sensitivity and develloped pustules all over edges.

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839 Posts; 11,985 Profile Views

HHmmm....rectal pounch for stool containment...how 'bout alginate for primary dressing? if so monitor for dessication of wound bed...but if it doesn't dessicate, it can be left in place for a length of time...

How AQUACEL works

AQUACEL interacts with wound exudate to form a soft gel in the wound. It utilizes a unique gelling fiber technology derived from hydrocolloid fibers that delivers highly effective exudate management and supports an optimal moist wound healing environment.

AQUACEL absorbs and retains more exudate than gauze. Its vertical and controlled lateral wicking holds excess fluid away from the wound and surrounding skin, reducing the risk of maceration

http://www.aquacel.com/en_US/products/information/woundcare/woundCareRepository/aquacel.html

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1,275 Posts; 15,007 Profile Views

I think that aquacel has been tried. Apparently, it dried out the wound base too much. It was abandoned, and now Allevyn square is being used to cover packing. Resident hav sensitivity to adhesive allevyn, so now we cu a 20x20 square into quarters and use that.

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