questions on wound care

[fiffy]

My patient suffered from a wound tunnel of more than 6.5cm in length.

I have been treating him using mesalt for more than a month and there is no sign of the tunnel healing. In fact the condtion is much worst, it was less than 5cm one month ago.

The hospital have issued my patient with antibiotics but the medication does not seem to do anything. The doctor simply told him to wait for the flesh to granulate, but unfortunately it does not.

1. what other products should I use?

2. what other better treatment option is there?

3. should I advise my patient to go for MRI scan?

4. what are the chance that he would have to go to another operation, I have been seeing this patient almost twice a week for more than 4 month, and everytime he is in pain, cant really bear the pain if he have to go to another ops.

5. is there anything that can help speed recovery, I already recommend he get zinc + vitamin C tablets and he is also drinking at least 2 glass of milk a day.

[RNBearColumbus, BSN]

Might you be able to suggest a wound vac as treatment here? I've seen it used with tunneling wounds with positive effect.

[alabamaparamedic]

Would a referral to a would care clinic be appropriate? Sometimes, they can perform hyperbaric treatments for hard-to-heal wounds....

[CoffeeRTC, BSN, RN]

Where do you see this pt? In the home?

What are the labs? What's the other medical history? What about pressure relief? Incontinance?

Have they seen a wound specialist? Normally we try to bump up the protien intake, use silver products and wound vacs.

[shiccy]

We sometimes use alginate for wounds, but all suggestions and opinions are typically from wound specialists. If it's not granulated after this long, is a debridement needed?

[jkaee]

Agree with above posters...definitely feel a Wound consult is in order esp since there hasn't been much improvement in several months. Also, depending on your practice setting, a dietician needs to see this pt to make sure his labs are normal. You will not heal any wound if nutritional needs aren't met. Instead of milk, try Ensure or something along those lines to increase protien intake.

Also, how often are you doing dressing changes? Maybe you need to cut down on the number of times you are exposing the wound to air. Every time you change a dressing, the cool air causes vasoconstriction, which decreases the O2 and nutrients to the wound, and can delay healing by as much as 4 hours. On that note, make sure the cleaning agent you are using is warmed to bath water temp, for the same reasons. But what's most concerning is that the wound depth has increased with this current treatment, you need to change the treatment ASAP.

And please, please manage this poor man's pain. Before you do anything else, get his pain level to an acceptable level.

Good luck.

[loriangel14, RN]

Why would they continue using Mesalt when it is not working? They should be using a silver product instead like Aqucel AG.

[nursenow]

Considering it is not infected, it is safe to assume the antibiotics are doing what they are supposed to do. I would remind the MD, dietary and anyone else you can of the situation and document that.(cya) It is interesting Dietary did not order vit-c and zinc from the start. What is the actual depth of the wound?(not the tunneling) I have noticed in the past that for some reason tunneling can heal alot slower than depth even with a wound vac. I dont know why. I have used wound vacs and they are absolutely incredible for healing. I currently have a stage 4 in the coccyx area with ALOT of tunneling. We flush with 120 mL of NS and pack it with wet to dry tid (clean not sterile), give vit c and zinc and do nothing else. (lots of prn pain meds of course) Even though the tunneling has not decreased the wound has become very clean and healthy looking. that is typical of what we do for most wounds of that nature.

I came back to edit this and add we also give Prostat and Ensure bid. One last thing. Did you do the original measuring of the wound a month ago or did someone else? I regularly measure a wound and find that the other person/people doing it is not accurate with their observations. The first person gets it wrong and everyone seems to stick with that until someone comes along and corrects it. The first time you measured it was there a big difference between yours and the original nurses measurment or has it been gradual by YOUR measurements?

[fiffy]

hi thanks for all the reply.

Here are a few clarification

I work in local clinic with very limited facilites and wound products, we only have mepilex, kaltostat, mesalt, my clinic (government own), do not carry silver products.

Yes the patient seen both the doctor and the wound care center in the hospital that done sugury on him. He was given a swab test and blood test but they did not detect anything. The hospital wound care ask us to continue to use mesalt. I also know mesalt is quite useless but I have no idea any good silver products for tunneling wounds. Btw I am in Singapore.

His wound when out of suguery was 2.5x 4.5 x 1.5 cm (L x b x h) using the furthest distance.

Now his wound is 0.5 x 0.5 x 1 cm, but on around 6 o clock direction there is a 6cm or longer tunnel

Wound is at right buttock.

I was a bit surprise when the doctor did not advise him to go MRI or Negative pressure therapy treatment. The thing is NPT is not cheap (yes the hospital have it), if the hospital doctor do not write a recommended letter to him, he would have to pay for the cost in full. He is already out for job for few months so I dont wish him incurred higher cost. I did ask him to call the hospital doctor about the negative pressure therapy but the hospital told him the treatment is not really needed unless he suffer from some illness that impaired healing such as diabietics.

About the measurement. It was done with a measuring stick. It was inserted slowly until a resistance is meet. All the measurement I stated are base on my own measurements. Other nurses treat him too, but overall is still there is not much improvement in his tunnel.

He was issued pain killers, but he insist he wants to bear the pain. Guess that is a typical behavior of a young male man.

by the way. He keep asking me if he need to go for another suguery? I did not reply him because I have yet to heard anyone going to surguery to remove wound tunnel, but then I not sure so i kept dump.

[fiffy]

To be honest i talk to him about food, he ate fish, pork, chicken, lots of veges and fruits, he claim he ate at least 4 servings of fruits and 4 serving vege per day. One whole kiwi is one serving for example. He also have 2 glass of milk, drinks lots of fruit juice (various types), he also have bottle of essense of chicken daily, and a glass of milo daily. I dont think protein is a problem.

He also take Shen yu, I dont know the name of the fish in english (not raw fish), chinese typically take it when recovering from injuries and yes it is known to speed up recovery by more than 25% most of my relatives and friends swear by it. To be honest all other nutricient supplement effectiveness depends on person to person, but Shen yu effectiveness is like work for everyone except if u allegic to seafood. Ask any chinese what to eat when injured they would tell u 3 things chicken essense, shen yu and yunan baiyao, although some would say tian qi. I note sure about chiense medication but I heard from ppl yunan baiyao can work wonder but I dont trust china products so I never recommend to my patients. But some of my patient told me they use the product with good effect. There are 2 kind one for internal and for external, I advise against the external one as it may impaired our wound treatment process.

Zinc maybe a problem, since he is chinese and all chinese seem to avoid beans, nuts, and all seafood except fishes , when having open wounds.

The reason is these food contain either poison (not the poison that can kill) or is more likely to be infected or cause infection. As for why we are not sure. Some even go to extend to ban managoes.

This is why I recommend him get zinc pill, but then again even blood test (done b4 he took the pill) show no sign of zinc defincientcy but never the less I ask him to take. But then seem like zinc does nothing much, he only claim he sneeze less.

[fiffy]

an update. The patient now has tunnel length of 8.5 cm to 8cm.

His antibiotics has run out and the doctor has reuse to give more supply citting it is unnessary as there is no infection detected.

He visited us every 2 days where we would clean his wound including flushing. And packed his tunnel (previously we use mesalt but now the doctor at the hospital told us to use inadine)

He has added to his food intake by drinking zinc and vitim c pills, milk and essense of fish (shen yu is call snakehead fish is asia, it is know for its healing properties. He is also on tien chi, which is know by studies to improve blood flow, regulated blood pressure, improve chi, as well as improve immune system. It does help in recovery but not directly.

To be honest both the clinic and hospital doctor confirm that nutrients is not why his tunnel have not recovered. The thing is every part of the wound has recovered except for the tunnel.

The question now is since he has good nutrients and his wound is clean and packed. He has refraint from excessiive movement and also reduce his time on the chair. But how come he has still not recovered. Even the doctors cannot provide a reasoning. All they say is wait. They already rule out MRI since it does not affect any organ or bones for now. They also ruled out Negative pressure therarpy by saying the condition is still not critical yet to warratn Negative pressure wound therapy, I have no idea when would it be critcal.

My question now is beside improving nutrients, packing wound, and negative wound treatment which is vac i think, what else can the patient do.

And is surgery needed , if so can some one explain to be how would the surgery be. The wound is in the right buttock, in the middle, 7 o clock tunnel, 0.5 x 0.5 cm wide, 8 to 8.6 cm in length. From the middle of the right buttock towards the right leg.

[LexPhD]

A wound care clinic in the hospital here recommended colloidal silver and medihoney. Hasn't healed yet though. Does anyone know about either of these treatments?