E. Chester, LPN

Sharp debridement?!? No way. Order or not. I know it requires an RN with wound care cert and sharp debridement training in FL. (The entire reason for the bags under my eyes...)

Alphabet, I completely agree with you. Remove the cause of the wound, and it "may" heal. In the case of pressure ulcers, pressure is the key. Offloading is one manner of "prevention"; the key word in F-314. You can heal all the wounds you want; however, if your resident heals and redevelops or develops in-house, guess who gets the tag if the wound is determined to be avoidable. The larger number of proper interventions you have in place, the better off for all involved.

comment by [color=#0e614d]laurie swezey rn, bsn, cws,cwocn on april 1, 2011 at 1:19pm in reference to skin prep and heel protection - "skin prep is great to protect from friction/maceration, but will not prevent the damage caused by pressure." (swezey, 2011) bibliography swezey, b. (2011, april 1). wound educators. retrieved april 9, 2011, from woundeducators.com: http://www.woundeducators.net/profiles/blogs/preventing-heel-pressure-1

WCS or CWCA? You are entitled to your opinion. Your argument concerning finding a treatment recommendation on the Braden scale is unfounded and illogical; Braden scale does not offer recommendations. Do you see on the Braden scale where it tells you to utilize NPWT (KCI) on a unstageable with less than 50% slough? Braden makes no recommendations for particular treatments. We will have to agree to disagree on this one. Granulex as evidenced by the link provided, is most assuredly utilized as a skin barrier against friction in the case of almost every admission to LTC. Maybe at Suwannee they don't do this, but this is the case in my area, but south of you we have to get this order discontinued upon admission. I completely agree with you on the subjective nature of wound care, especially when most MDs do not know how to heal a wound. Therefore, evidence-based practice is what we have to fall back on. I have offered my rationales for my decision to utilize skin prep as a barrier to friction, not as a prevention for decubiti. The state, my MDs, medical directors, a RN-CWOC, a RN-CWS as well as a corporate wound care consultant all concur and support the use of skin prep as utilized above. As far as pressure ulcers starting at the hypodermis; you are absolutely correct and my mentor was one of the first to utilize ultrasound to prove the same, as well as the existence of what we now call suspected deep tissue injuries (sDTI). In the acute care setting, what do you utilize? As a side note and in all seriousness, why do all my admissions come to me with red mushy heels? Serious question.

With all due respect to the WCS, I think we are missing the rationale for the use of skin prep. It is NOT utilized for the prevention of decubiti, it is utilized to address one of the risk factors for the development of decubiti; friction. Feel free to check the link to Dr. Braden's link on protocols associated with Braden Scales. If you do not address the risk factor, you will get tagged (F-314 at a level greater than "Isolated") (quote from a state survey team leader this year, 2011). This is also the rationale for Granulex; it prevents fricton. http://www.webmd.com/drugs/drug-3729-Granulex+Top.aspx?drugid=3729&drugname=Granulex+Top&source=0&pagenumber=4

Full-Time Wound care nurse for two years. Here is the way to justify "Skin prep to bilateral heels q.s." (Yes, my nurses hate it.) F-314 states, " Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing." According to Smith-Klein as seen here, http://www.americandiabeteswholesale.com/product/smith-nephew-no-sting-skin-prep-wipes_17.htm , Skin preps reduce friction. When utilizing the all-too-familiar Braden Scalen, most nurses believe their job is complete. In LTC however, this is only the beginning. Dr. Barbara Braden also has protocols that go along with your outcomes on the Braden Scale that MUST be implemented in a partial effort to avoid an F-314 tag. If you fail to initiate these protocols, you WILL get F-314 and probably at "widespread" level. As we can see, even at the lowest level of risk, "At Risk - 15-18", the protocol clearly states to "manage friction and sheer". As seen above in the visible link, Skin Preps reduce friction. Skin preps to bilateral heels Q.S. with supporting documentation of the same being done accomplishes all of the above. Two years, five surveys, and ZERO F-314 tags. You still must manage the other co-morbidities for residents; however, this has proven to demonstrate an effort being made on the part of your facility to AVOID heel wounds, DTIs, etc. As a side note, we utilize skin prep on DTI (without open areas), blisters (not open), and yes scabbed areas (eschar) in addition to stable eschar, and they all do exceedingly well on preps. Again, NO F-314 TAGS or any tag with regard to wounds in five surveys.

I have personally graduated from Rasmussen's LPN program, and I am a fully licensed LPN in the state of Florida. I have the luxury of choice when it comes to my bridge to RN, and I am waiting for Rasmussen's Bridge as I am completely satisfied with the education I have received from Rasmussen.