KimT08

In my experience I have seen patients with similar wounds and situations that you are describing heal and I have seen others who have not. This persons chances of healing depend on the control of his diabetes, his nutrition, the level of his infection, ect. I would suggest that they consider using hyperbaric oxygen therapy. It makes a huge difference in the healing process. It will help eliminate anaerobic infections, helps increase angiogenisis, accelerates and enhances osteoclast and osteoblast activity, increases blood flow because it hyperoxygenates the plasma which can get oxygen around diseased blood vessels(which most diabetics have), ect. The use of Hyperbarics, a wound vac, IV antibiotics, ect will give this person the absolute best opportunity for healing. Using these things I have seen people with wounds similar to this heal without skin grafts. I hope this helps!

I do know that KCI has studies comparing the two therapies. I have personally used both and do not like the S&N version. I had a patient who had a wound that got worse after the LTC facility refused to get the KCI version and the surgeon I worked with had to take the patient to surgery for open debridement. One point I can make to discuss with your DON is the fact that they are changing the S&N dressings more often which does not make it more cost effective than the KCI version. I have wonderful KCI reps. If your rep is not helpful you can go to the account exec in your area. I hope this helps.

My first question is why would this resident need a muscle flap if the wounds are progressing well with a wound vac? There are several factors you must consider prior to deciding if it is time for the flap. First of all this is never a nurses call however I will give you a few things that the surgeon might ask being that I have worked closely with several different surgeons. The first thing is the resident's nutritional status good. You would need prealbumin, albumin, and total protein levels. If these labs are within normal limits then the resident is probably well nourished. If these labs are low then it would be a red flag for the flap. Secondly are there any signs or symptoms of infection or colonization of the wound i.e. malodorous drainage, heavy drainage, unhealthy wound bed, etc. If there are any signs or symptoms then it would be another red flag. What type of bed does this person have? Typically all patients/residents who undergo a muscle flap procedure require at least 6 weeks on a Clinitron bed post op. Is that possible for this resident? If not the surgeon considering the flap needs to be informed of that because it may influence his decision. Next thing to consider is the resident's general medical condition. These are just a few very important things that should be considered and relayed to the surgeon considering the flap before he makes the decision to proceed. Any surgeon that I have worked with would not proceed with a flap if the resident/patient was making progress with a less aggressive treatment. I hope this helps.

There are several resources out there. The best place to start is with your sales reps. Healthpoint, KCI, Smith and Nephew all have online free educational tools. All sales reps usually have educational programs that they can offer you if your facility uses their products. An important thing to remember however is the goal behind offering these programs for free is to get you to use their products. I would get all the information that I could find whether it meant reading lots of books, asking many questions, looking up things you don't know or understand, and even asking your facility to send you to educational courses. Ultimately you are responsible for the residents with wounds and you will be held accountible to ensure that the residents are getting the appropriate treatment and interventions. It is important that you understand that wound care is not just about what to put on the wound. You must also look at nutrition including lab values, the type of bed and chair the resident has, foot wear, vascular and arterial status, etc. I hope this helps!

Hello all, I have been out of a job for a while and even though I had applied at a lot of facilities the only place I was interviewed and offered a job was a local nursing home. I had to take the position because I needed the job. The position is an ADON. I do not have any LTC experience. The DON and administrator are both RNs as well and they both have many years LTC experience. I am very nervous about starting this position due to my lack of LTC experience. The DON and administrator both assure me that everything will be fine and they would rather train me that hire someone with a lot of experience who is set in their ways. I would appreciate any advice anyone could give me. I don't even know what my duties are. I am also concerned about what my legal liability will be as I have seen some care that is not up to my standards. The other thing is I was in a meeting and overheard someone saying that there was always an RN on call. Is the ADON typically oncall? I don't feel I know enough to be oncall. Also the reason I left my previous job was I was required to provide oncall and it got WAY out of controll. I guess I am just nervous and scared and would appreciate any advice! Thanks!

As a wound care nurse I can tell you that you definately need support hose as we are more prone to venous stasis disease. A good support hose can help prevent that. If you are starting to experience swelling and discomfort you should go with a hose with at least 15-20mmHg compression. I am 30 and wear 18-20mmHg compression for prevention. My patients with venous stasis disease are prescribed 30-40mmHg. I will tell you that the hose needs to be snug to work. You should get a new pair at least every 6 months as they wear out quickly. I wear a brand called Medi as they are affordable and stay up. I wear knee highs and they do not cut into your legs like TEDs. The Medi brand also has some with a silicon band at the top to keep them in place and for comfort.

As a wound care nurse I can tell you that yes your grandpa should be seen by a wound care nurse. While the burn nurses are experienced with wounds resulting from burns they are probably not very experienced with other types of wounds. It sounds as if your grandpa's wounds are probably caused by friction and/or sheer from him moving about in the bed a lot. They could however be associated with something else also such as shingles (as his body has been through a lot of stress), a reaction from a medication, a reaction from heat, moisture, and/or incontinence. There are several factors that need to be evaluated and ruled out including his nutrional status. Simply putting a cream on it will probably not fix the problem. You must find the cause of the wounds, eliminate that cause, and treat the wound. The air mattress is probably a good start. I would make sure it is an alternating air mattress as their are many mattress. The alternating air mattress provides pressure relief. One thing that you and your family can do if your grandpa is stable enough is change the position of the head of the bed. Most hospital beds are set about 30-45 degree angles which is not good for people who slide down in bed because that makes friction and sheer. If your grandpa like to have his head elevated alternate between 20-25 degrees, then 30-45 degrees, then up to 90 degrees, etc. which will help to displace the pressure to different points. This will help if the wounds are caused from pressure. You could also try to get your grandpa to lay on his side if his condition allows it. These are just a few simple things that will get you started. If the burn nurses are offended when you ask for a wound care nurse just ask the doctor to write the consult or if you miss the doctor I would just explain to the burn nurses that while you have no doubt about their ability to care for wounds you would prefer to have a wound care nurse consult to ensure your grandpa can get the best possible wound care evaluation and treatment to prevent his hospital acquired pressure ulcers from getting worse. I hope this helps!

There are only 2 associate degree programs that I know of in the area. One is at Northeast State www.northeaststate.edu and the other is at Walters State Community College which is about 45 minutes away from Johnson City.

Being in a hospital is helpful in that you usually have better access to things. Just let me know if you need any more help.

I know here in TN you would make more money being an EMT than a CNA. I guess the path you take depends on what your goals for the future are. If there is a VA hospital near you I would check there for a job as they give Veterans first priority and have great benefits and pay. There are some options other than CNA and EMT. Some hospitals hire EMTs and Paramedics to help out in the ERs. Something you might also be interested in is becoming a hyperbaric tech. All you have to do is find a hospital that has HBO and if you get hired you would get OJT and in most facilities a 40 hour course on HBO. After one year of experience you could sit for the certified hyperbaric tech exam. It is a very interesting field but depending on where you live there may be limited facilities offering HBO. If it sounds like something you are interested in you could find a facility close to you and ask if you could shadow someone for the day. It is a very rewarding job. Also some physicians offices hire EMTs as well.

Nutrition is important to consider. Could this be a kennedy terminal ulcer? They typically occur when a patient is getting near the end of life. If the wound is infected you could try using 1/4 strength Dakin's solution. I have tried this before when I had a wound that has traveled the same path you are describing with very good success. I would definately help the wife to understand if this patient does not have a good prognosis the wound may never heal.

Silvadene is an antimicrobial but it is somewhat unique in that it will penetrate necrotic tissue. It is not a debrider but can be used when there is necrotic tissue present in an infected wound. I personally do not use Silvadene a lot. I mostly use it for burns. If I had a LTC patient I would typically use something else for a couple of reasons. One reason is that using Silvadene on an infected wound usually results in a swamp because an infected wound usually has a lot of drainage and if you put a wet dressing on top of something that is draining a lot you will usually end up with a macerated wound (good skin around the wound gets white) which can cause the original wound to get larger. A cheap alternative to Silvadene for an infected wound is 1/4 strength Dakin's solution. It is a bleach solution and is very effective. All you would do is pour the Dakin's solution on a Kerlix or 4x4 and pack into the wound then I would usually cover with an ABD pad. Also Silvadene must be changed BID. The Dakin's solution should be changed BID initially until the drainage slows and then can be taken down to daily until the infection resolves. You do not need to apply a saline gauze to the collagenase. The collagenase will break down the necrotic tissue sort of liquifying it so a wound that is not draining much before applying the collagenase will start draining more after applying the collagenase. The drainage will keep the wound moist. The hard part is keeping the wound moist but not too wet. If you see the surrounding skin start to get white (maceration) or red and irritated trying using a more absorptive cover dressing. You can also use a skin prep on the surrounding skin if you have that available. Skin prep essentially creates a barrier over the good skin to protect it. Just think of when you get clear fingernail polish on your skin and you get a clear film covering your skin. The same thing happens when you apply skin prep to good skin. I am glad that I am able to help you! I enjoy being able to help! Just let me know if there is anything more I can do to help!

Yes you should include all work experience. Even though it might seem unimportant to you it is valuable information. For example I worked at a day care when I was going through college the first time and then worked as a secretary/patient care assistant while going through nursing school. All those things are important as the day care work helps with taking care of children and working with the public and the secretary/assistant work helps with all the insurance, answering the phone, dealing with patients etc. Sometimes those things make a difference between you and someone else getting the job.

First things first. Wound care is not like any other part of nursing in that there is not a set treatment for each type of wound. Most wounds will require a treatment plan to be adjusted multiple times before the wound heals. The are several steps in deciding what product to use on a wound. The first step is to look at the color and amount of drainage on the previous dressing. The next step is to determine if the wound appears to be infected. Next you need to cleanse the wound with saline and gauze. Now you need to look at the wound base. You need to determine what type of tissue is present. Granulation tissue is healthy tissue and it looks like the inside of a watermellon, red and bumpy. Slough is yellow or brown in color and is not healthy tissue. Eschar is dark brown or black and is like a scab. It is also important to determine if there is any bone or tendon exposed. If you see something that could possibly be bone you can simply tap it with a q-tip and if it is hard it is most likely bone. Tendons and tendon sheaths usually appear white if they are still healthy and yellow or brown if they are dying. To determine if a tendon is present you can usually move the body part and if a tendon is present you should see it move. Next step would be to measure the wound length, width, and depth. You also need to explore the wound base to determine if there are any tunnels or tracks. Now that you have all that information it is time to chose a product. To try to make it a little less confusing I will just go down your list and try to give you a general idea of what each of the products you mentioned are used for. The hydrogel is used for wounds that do not have a lot of drainage and have 100% healthy granulation tissue. The hydrogel will require a daily dressing change. I am not that familiar with the Caraclenz but after researching it I would not recommend it be used on open wounds. It appears to be simply a skin cleanser and I would see that it could be used to clean skin after an incontinent episode. Duoderm is a hydrocolloid product and should be used on minimally draining wounds. The dressing does not require a cover dressing and should only be changed every 3-7 days. If you are in LTC I would not see a big use for Duoderm. I would typically use this on a Stage II wound that is caused by friction or sheer. It is very important to remember to only use this on minimally draining wounds. Also important to make sure if it is used on the sacrum, cocyx, etc to make sure it is checked once per shift to ensure that it has not rolled up as this will cause pressure. Tegaderm should only be used for slightly draining wounds. I typically only use Tegaderm for skin tears. Tegaderm is usually changed every 7 days. Collagenase (Santyl) and Accuzyme are enzymatic debriders. Basically that means they will disolve the slough in the wound and get the wound back to all healthy tissue. Accuzyme should not be used as it has been taken off the market. Santyl is the only enzymatic debrider left on the market. It should be used in wounds that have slough. It is applied once daily and will also require a cover dressing. Bactroban is simply an antibiotic ointment. It should be used in wounds that are not draining a lot. It is effective against MRSA. The dressing should be changed once daily and it will require a cover dressing. Calium alginate is the one and only product that you have on your list that is for moderate to heavy draining wounds. It comes in a ribbon or 4x4 sheet. It should be packed into the wound and covered with a cover dressing. In heavily draining wounds it should be changed once per day but as the drainage slows down it can be changed less frequently. It also requires a cover dressing. Now as far as cover dressings go there are many options. The most cost effective and easiest to get are probably simple gauze, Kerlix, and Abd pads. The gauze will work for minimally draining wounds. Kerlix will work for arms or legs and also should be used to pack deep wounds so that there is no chance any gauze will be left behind. ABD pads are great as they are very cheap and very absorptive. The important thing to remember is that no mater what dressing is used the dressing must be changed if it becomes soiled. Wound care is a lot of trial and error. Something that works on one wound might not work on another wound. I know this is a lot of information and I tried to make it as simple as possible. I hope this helps! Feel free to contact me if I can be of further help!

The reason I do not recommend diapers are that most hold moisture and stool against the skin causing a multitude of problems from yeast, to excoriation, and ultimately ulcers. Most staff members do not take the time to find the appropriate size diaper either which results in one of two things, either the diaper is too tight causing the diaper to cut into the skin and cause a wound or the diaper is too big and will bunch up creating a pressure point which will result in a wound. Chucks and pads can be bad also because a lot of staff members will use more than one and they will bunch up and create a pressure point. Bottom line is that no matter what method is used the patient must be cleaned up promptly, have the proper fitting diaper if used, and ensure that there are not wrinkles or wads underneath the patient. If these things are not ensured then the patient will most likely end up with wounds. I hope this helps!