Need experienced nurses help with new Stage 2 wound

[hakunamatata, BSN, RN]

Hi there - I'm a hospice nurse/case manager and haven't had much bedside experience with pressure ulcers in years, and would love an opinion. I have a patient in ALF who has had issues with incontinence dermatitis on his buttocks/sacrum for awhile, and while assessing today I discovered that he now has the beginnings of a Stage 2 pressure ulcer at the very top of his sacrum. It is about the size of a pencil eraser and is showing a little bit of slough (from what I remember...that's what we call it ...). He is going to have to move to skilled if we don't get it healed in 2-3 weeks and there are numerous reasons I don't want that to happen.

My MD gave orders but she seemed a bit unsure of herself, so I just want to double check that this treatment sounds appropriate for the patient's sake: pack with calcium alginate rope and cover with Tegaderm. My other RNCM told me to apply some gauze in between those for it to drain. Three to four times a week. Does this sound good? I know I sound like a nimrod, but I've been doing HIV research and then bartending for years now, and have been a bit removed. Appreciate anyone's input!

[annabanana2]

You might get a real live WOCN responding, which would be ideal, but in the meantime, I see many many wounds, so I have opinions. What's the drainage like? A calcium alginate + Tegaderm seems a bit weird to me, typically I'd use a calcium alginate product for LOTS of drainage, and Tegaderm for minimal drainage. How deep is the wound? Does it truly require packing? By definition a stage 2 ulcer is shallow (partial thickness) and does not have slough, so based on your description you're looking at at least a stage 3. Can you consult with a wound clinician? I haven't seen the wound so I can't recommend specific treatments, but I can recommend consulting with somebody who definitely knows what they're doing.

Even more than product use, the MORE important issue is offloading the pressure. Truly, I think in a lot of cases you could stick a Band-Aid on a wound and it would still heal if you can optimize pressure relief. I hope this client is on a pressure-relieving surface, and/or is being turned very frequently. Can they get out of bed and be up in a chair for a bit? No matter what you stick on the wound, it absolutely will not heal if you don't remove the pressure. Also, ensure he's getting adequate protein for wound healing.

[adgn, LPN]

I am treatment nurse at a ltc. Implementing a turning schedule and off loading pressure as much as possible. Left to right only every two hours. Depending on drainage, duoderm will do the trick every 3 days or a foam dressing daily. Also, calmospetine cream to protect skin from incontinence.

[chopwood carrywater]

Has anyone had any experience using a wipe on skin protectant such as cavalon onto stage I through III pressure wounds? A wound care nurse, who was also a 3M rep, said it was effective in reducing exposure to urine and stool and therefore helped protect the site. She said it was suitable even for fairly open stage III wounds. Depending on circumstances, she said it would last 1 to 3 days. It was also ok to apply barrier pastes such as Calmoseptine over it. I used it often when I worked in a hospice IPU, and I have continued to use it on pts I see in the field as a CM.

I have also applied it to excoriated areas on the skin that are, or might, be exposed to body fluids such as a leaky feeding tube.

A fellow RN said she would never use it on excoriated or broken skin bc it would sting upon application.

A SNF I worked at years ago, used protectant wipes on PUs to heels. I guess it might help in reducing friction, but as mentioned earlier, if you don't relieve the pressure, the skin remains at risk of getting worse.

There is also a point at which many pts who are at or near the end of their life, no longer are able to nourish and repair their skin, and PUs can become harder to avoid and heal. A type of PU known as a Kennedy PU can occur quite quickly and increase in size or depth over a very short time and is a sign that the pt is at or near the stage of actively dying.

[Nurse1113]

Hi :) so a few things... If there's slough, it is a stage 3. All wounds heal best within a moist environment, so a hydrogel and a foam dressing would be ideal. Hydrogel will also facilitator automatic debridement of the slough. Foam will be absorbent and provide cushion. Turning and repositioning and protein/water intake are vital!

[Nurse1113]

I only use skin protectant wipes to peri wound skin! NEVER heard of using it over an actual wound. And the alcohol-based kind will burn like crazy. No-sting ones are best esp for denuded peri wound areas

[Candogal]

See If you can get her treated at an out-patient wound center where the wound can be assessed by a doctor to determine if it needs debridement, wound vac, packing such as iodoform etc. If not Santyl (for the slough),dry gauze, plus a foam on top for padding to prevent further breakdown. I agree if it has slough than it's at least a stage 3. Definitely no skin prep to the wound bed, only to the peri-wound if needed. Make sure the patient has an adequate protein intake and vitamins. And off-loading, off-loading, off-loading. Sacral wounds take a long time because of location, that's for sure but it doesn't automatically mean going to a sub-acute as long as you can find a local wound center which are becoming more popular. We have many that come to our center who live at assisted living centers, they get assessed, treated and instructions on how to care for the wounds are provided until the next visit.