profore question

[sphinx, BSN, RN]

We have a patient who has profore wraps......she has venous stasis, but her legs are like none I have ever seen or come accross. She struggles with edema, but is also simply overweight. Her knee and just below her knees are very dry and bumpy. Below the legs go from weepy to dry, depending on whatever. She used to have comprilans wraps, tried ace, they all roll down very quickly after putting them on (mostly due to the way her leg balloons out just below her knees). We have tried several dressings below the wraps and are currently using aquacel and lyofoam to the wet areas. If an area is ok, we leave it. We were doing her profores twice weekly, but her hygeine was horrid and we needed to shower her more, plus one of her legs developed cellulitis. So now she is changed Mon, Wed, Fri....showering on the Monday and Friday. So basically what we have is aquacel, lyofoam, light layer of kling to hold it on, then the 4 layers of the profore.

Some times you take off her dressings and they are saturated and smelly. Other times, the aquacel has dried out so much that you have to be careful not to rip it off along with her skin. Either way, my coworkers blame the profore. I almost wonder if it is instead, the dressings we are using. The profore has really helped the edema...they only slide a little bit, hardly at all, compared to the ace or comprilans which practically fell right off.

She can't wear Una Boots, as she is allergic to one of the ingredients.

Anybody have any thoughts?

[RN1989]

I've had several pts like this. Actually, drier is better because it is not holding in the bacteria like the wet areas do. I found several pts that became infected after one of the nurses started lotioning their legs under the profores.

Basically with these pts, the doc's and my tactic was to get everything dry. The profores were changed 3 times per week. We used the Aquacel AG to get the drying effect. Then the pt's had their profores cut off at home and they showered or at least used the kitchen sprayer to help clean their legs up. We encouraged the pts to pick off all the dry, dead skin that was peeling off. When they got to the wnd ctr, I would scrub their legs with wnd cleanser trying to get off more junk. After several weeks of this, our pt's legs were looking much better. They were sometimes still weepy but the dry skin wasn't holding in any infection because we had gotten it all off. Then we concentrated on getting things dried up with the aquacel and other absorbant dressings underneath the profores. If the profores are wet with exudate every time the pt comes in - the pt needs to get dried out before having the profores put on or they will likely continue to have infections. Sometimes you also need to look at having the pt put on manual lymph drainage to help with this while you are leaving off the profores until you get the legs drier.

[sphinx, BSN, RN]

Well, she comes in Mon, Wed, Fri.......Monday and Friday are her shower days and she showers and they sprays her legs with a hand sprayer. Afterwards they dry with a towel (pat dry) and loosely put an adult brief on her leg just for the trip down to the clinic (it's aides doing the shower and they can't do any type of dressing). On Wednesdays she just comes to us and we just cut her dressings and go from there. Even when she showers I usually use would cleanser to clean her up. I don't put any lotion on her calves or anywhere the wraps cover. I mentioned to my coworkers giving her more time to dry out between the shower and coming to us. But they pointed out (rightly) that she is pretty dry after the shower, but starts to weep between then and when we start her dressing (we often do other stuff with her before hand, as she gets nebs, BG check, bloodwork, etc). You mentioned manual lymph drainage. I don't mean to sound stupid, but what is that?

We were using Aquacel AG at one time but our NP changed to plain Aquacel. I'm not quite sure why. We also put lyofoam over the aquacel. Is that helpful?

[sphinx, BSN, RN]

I am still experiencing problems with this poor woman. PLEASE BEAR WITH ME, this is long, but I have a story.....I am so frustrated. She was actually doing quite well for a while. We stopped any kind of dressing such as aquacel, lyofoam, etc. We started using only the mesh that comes with the profore, then doing the wraps. Previously, we'd just been tossing it, because "oh we never use that". It's like no one even really knew what it was. I'd looked up on the profores website and read a bit and suggested we try it and was totally worried it would backfire.....but she comes in for the next dressing change with dry legs! This did well for a long, long time.

Then she started having problems with her left leg bumping against the side of her wheelchair, and this eventually happened after a shower while her wraps were off. That area became infected, so we went to the aquacel ag again...it made her legs sooooo much worse! Then we tried just lyofoam. Even worse! She began having large macerated areas again. So finally I said we need to go back to the mesh and profore alone, which we did, and again the legs dried out. We then discovered that the woman seemed to have very sensitive skin, and using any kind of lotion on the dry skin ended up with weepy, macerated areas, and wound cleaner made her skin slough off, and soap was a problem too! We went to just plain water in the shower for her legs, and saline on the non shower days. She dried up again.

Then.....the mesh started sticking to the dry areas, as if her skin was a little moist, dried up, then adhered and were hard to take off. No matter how careful we were, even just spraying the mesh off with water, the areas became irritated. So boom, we put xeroform on those areas, as well as the mesh. Soon we were using large amounts of xeroform. Then she was unable to come to the clinic on a Monday and dressings were not changed for 5 days...when we took them off her legs were terribly macerated..again! So back to the aquacel ag under the mesh, then the profores. Legs got worse. So again I talk to our NP and say please, lets try just the mesh again, it has dried her up before.....so we do, and her legs are still macerated. It's awful. No matter how much you try to get her legs dry before applying the mesh and wraps, it's impossible...she drips fluid onto the barrier pad we put on the floor! I am at my wits end. For whatever reason, she has become my "special project". Another co-worker and I have always taken extra interest in her, but she was let go with 'downsizing' and while my other co-workers are caring and competent, they certainly don't worry about her wound care on their days off, lol!

Please, if anyone has any suggestions, I would love to know!

[RN1989]

As long as you have been having these issues, it may be time to consider more palliative treatment as a more cost-effective measure for someone that is unlikely to achieve the level of decrease in edema that Profores were meant for.

It may be time to look at simply getting her legs dry and using stockings to help discourage more edema and not have the goal of getting rid of the edema. This would decrease her pain and risk of infection as well as treatment costs.

[sphinx, BSN, RN]

As long as you have been having these issues, it may be time to consider more palliative treatment as a more cost-effective measure for someone that is unlikely to achieve the level of decrease in edema that Profores were meant for.

It may be time to look at simply getting her legs dry and using stockings to help discourage more edema and not have the goal of getting rid of the edema. This would decrease her pain and risk of infection as well as treatment costs.

The question is, *how* to get them dry? We tried several other things before this, and they all left her legs a sopping mess. The profores really have helped her with her edema, it's just the moisture is such a problem.....yesterday they looked a little better, but not enough. Her legs are so big and oddly shaped I can't imagine any stocking fitting her, and in the past we've tried comprilans and ace wraps and they both start to fall down very quickly.

If you have any ideas how to dry her out, I would appreciate some tips.....

[AnnemRN]

You may want to try adding ABD pads before wrapping with the kling and the profore. I have tried this when the patient has so much drainage that it overwhelms the dressing. It helps to wick away the wetness and seems to work well.

[RN1989]

It probably needs changing multiple times a day using alginates, 4x4s, and abd pads wrapped with kerlix. Using the wound cover layer that comes in profores or "wound veil" on the sites that keep pulling open can help with that problem as well.

One of the problems that I have seen is that a pt gets "dry legs" after you get them dried up and the first reaction is to put a moisturizer on. Every time someone did this to my patients, it just caused more problems - particularly when they were in the profores. Moisturizers under those profores should be banned. Those suckers are hot and people sweat under them. Add some moisturizer to that mix and you are just asking for maceration and infection.

This woman needs thigh hi teds with a garter belt to keep them up. You can use the hose over the bandages or wait until you get her dried up. Have her wear the hose which will help some with the edema as well as protect her legs. It would also be a good idea if she always had pants on over those thigh hi hose as a double layer of protection against banging on the chair.

[AnnemRN]

Another suggestion would be to pad the areas of the wheelchair ( with foam and taping in place) to decrease the possibility of injury. I know from experience that there are times ( like just after showering) where the patient does not have anything on their legs and that's when they injure themselves during transfer.