NON HEALING stage IV pressure ulcer HELP????

[NC29mom, ASN, LPN, RN]

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.

[annaedRN, RN]

sounds like the wound has become chronic and healing has stalled. changing treatments most definitely is indicated. have you considered VAC therapy? In a nutshell, the wound needs to be made acute again in order for it to heal...sometimes a trip to the surgeon is necessary as well.

[knorahs65]

What kind of supplements? Protein? What is the albumin level?

[NC29mom, ASN, LPN, RN]

supplements included: zn, vitamin c and protonix (short term), albumin level was wnl. appetite is good, eats well. i thought about the wound vac, but thought that this wound was too small & didn't have enough drainage to constitue a wound vac (location may be an issue also, since it's right in the gluteal fold), but i'm also not an expert with wound vacs, have never really worked with them honestly. and i agree, a trip to the surgeon would probably be a good idea. there would be signs if osteomylitis had set in, right? i mean, obvious signs?? the hard part is getting my don to agree to anything. this patient is a bit aggrevating, and i think she has long lost her patience with him. i feel like his attitude shouldn't affect his treatment regimen and care.

thanks so much for the ideas!! what kind of drsg would you use??

[groovy jeff, RN]

i am a brand new nurse and know nothing about ltc; but, doesn't a local dr see this pt occasionally where a referral could be made? does this guy have family that can advocate for him? i am probably totally ignorant on the policies and politics that surround ltc so i apologize in advance.

[wound warrier]

The wound VAC sounds like a good idea. You can bridge the foam of the VAC from the wound to his hip so that he is not sitting on the trac pad. Maybe the KCI rep in your area could help you. May also want to consider using aquacel ag (ConvaTec) and a foam dressing, such as Allevyn(Smith&Nephew). This can stay on the wound up to 7 days, altho I usually change the dressings after 4 days. Wounds need to be at a certain warm temp, and it takes a wound 4 hours to get to the correct degree after a dressing change. Hence, leaving a dressing on for a few days can be bebeficial

[NC29mom, ASN, LPN, RN]

don't you think the wound is too small for a wound vac? i just don't see my don agreeing to the cost and trouble of getting a wound vac for such a small wound. i have never tried the aquacel ag, i will definitely try to find out more information about it. thanks so much for you input! and, it would be nice to be able to leave the drsg in place for more than 24h. this particular patient goes to the shower three-four times a week. are these drsg's pretty stable with patients that shower (lying on a shower bed)?

[wound warrier]

You do make a point that the area may be too small. I would try the aquacel ag and allevyn. Use the aquacel ag ribbon that is reinforced - it will then come out of the wound easily. When he wants to take a shower, try putting Glad press and seal over the dressing. It is like a plastic wrap, found in the aisle where plastic wrap is found in the grocery store. Just apply the press and seal over the dressing i it is gentle to the skin and will keep the dressing fairly dry. This also works well over ostomy appliances too!!

[annaedRN, RN]

If the wound doesnt have exudate, I'm not sure I would use Aquacel AG though. If it is moist, maybe. Maybe Prisma and Allevyn? I still think if it has stagnated and stalled out for that length of time that a trip to doc/surgeon or local wound clinic would be most beneficial

I agree with wound warrier - I love using Glad Press N Seal - wonderful stuff :)

[OncallRN]

if you have no drainage could it be epithilaized? I think it's pretty rare but I have heard deep wound epithializing.

also call the wound vac company, I believe that there is NOT any size limits big or small

[wound warrier]

I f the wound is deep, it heals by granulation - filling in from the bottom and contracting in from the sides. Sometimes the periphery of the wound becomes slightly rolled under and has epithelialized over these edges - called epibole. When this happens, the wound will not close together, as skin does not heal to skin.

[Chaya, ASN, RN]

I'm not a wound specialist but have seen many, many wounds of all varieties. I would definiately look into a wound vac dressing; I have seen them work miracles with wounds that had had no progression in monthes.