skin graft

[NC29mom, ASN, LPN, RN]

Need help please ..........

Pt had skin graft to L hip >40 y ago. r/t deep, non-healing abscess. Area healed nicely s/p graft originally. Left area measuring approx 12 x 9 x 2cm scar tissue/graft site. Never had any issues till now. Appears skin has separated (wound bed/wound edge) in an area and measures approx 1.6 x 0.4 (appears to be almost tunneling depth/sinus track?) but couldn't measure bc so painful to pt). The wound edge thats involved also has induration extending approx 3cm each way along wound border (to left and to right). However, pt reports area has always been "hard to touch" Exudate is purulent/foul smelling and moderate in amt. Wound bed 100% yellow slough (that I could visualize) . On day 5/7 of levaquin for URI. Diabetic. Complains of severe pain to area, unable to lie or sit with pressure to area. Ambulatory, continent.

Its difficult for me to really describe. Imagine a 2-3cm crater...100% healed...then someone takes a scapel and basically cuts a linear area at where base of wound meets edge (bottom of wound). Kind of like undermining. ..but not really....

What trmt would be appropriate? I put silver alginate rope along wound edge separation, and used mepitel bordered foam drsg. And of course skin prep periwound bc i love skin prep. And, how would I categorize this wound? I dont want to use "old skin graft site"....

Thanks in advance for any and all suggestions. .....and.....I guess I should add....this is a HOSPICE patient. ...palliative care...though this is an ES Cardiac pt, so wound not r/t terminal dx....but our wound formulary is very limited

[mlbluvr]

Your patient is terminal (hospice), but is in pain with a maybe infected wound, and you're wanting to use expensive, curative-aimed (and possibly uncomfortable) rather than palliative-aimed treatments on the wound, (not to mention pain control in general) because your hospice has a limited formulary? Might wanna run this case by your DON.

[NC29mom, ASN, LPN, RN]

Wow. I would love to know why you feel my choice of dressing would be inappropriate, or "curative". Im trying to cure infection. ..absolutely. we still use abt in hospice...and as I said this wound is NOT RELATED TO HER TERMINAL DX. She needs an abt to help reduce pain.

I used silver alginate for antimicrobial aspect....and bc of amt of exudate. I used foam in hopes of sparing pt frequent dressing changes (along with alginate) . The supplies I used were also my own personal wound supplies, as our formulary is very limited. We would only provide ca alginate and guaze. I gave her enough to do several weeks worth of the silver. I also asked her dr for an antibiotic (and provided description of wound, s/s of infection). He wouldn't order an abt bc pt currently taking levaquin. I also obtained an order for pain medication. so, please ....tell me why you feel what I did was not appropriate? Yes this is a hospice pt....who is still rather functional.

I think this would be a different scenario if the pt was actively dying....then I likely would cover area with a basic dressing.

[rabbitbowchou]

I am not sure the story about hospice, insurance reimbursement or formulary.

However, based on your description of the wound, despite that it was a skin graft site, I would certainly start the treatment with topical antibiotics ointment (ex, bactroban, for infection reason) and alginate (for drainage issue), adding on it, change daily for sure. Once the infection is under controlled, and we can deal with slough.

however, I do think this patient needs to see wound care doctor. Maybe an IV antibiotic with wound culture would help from inside out as well.

[NC29mom, ASN, LPN, RN]

I am not sure the story about hospice, insurance reimbursement or formulary.

However, based on your description of the wound, despite that it was a skin graft site, I would certainly start the treatment with topical antibiotics ointment (ex, bactroban, for infection reason) and alginate (for drainage issue), adding on it, change daily for sure. Once the infection is under controlled, and we can deal with slough.

however, I do think this patient needs to see wound care doctor. Maybe an IV antibiotic with wound culture would help from inside out as well.

So, just apply the bactroban, then alginate and cover daily? Should i just use a hydrofiber, if Im just trying to manage drainage? Or...should I use a ca or silver alginate?

Unfortunately, going to a wound dr is not an option. I have asked the dr for an oral abt.

Actually, it looks much better after only a week....the exudate is not as as purulent or thick as it originally was. Due to the location/ degree of wound its difficult to visualization depth bc its really like a cut....rather than an actual tunnel/or obvious wound bed....

Thanks!!!!!!!!!!!!!!!!!!!!!!

[mommy.19, MSN, RN, APRN]

I think using a silver alginate would be very appropriate, and the secondary dressing you chose is a great comfort dressing (the mepilex border). I would not apply antibiotics topically, as this is not evidence based practice and can promote antibiotic resistance. Your initial plan seems very appropriate and I would recommend a would culture for targeted abt therapy instead of impiric or topical.

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[NC29mom, ASN, LPN, RN]

I think using a silver alginate would be very appropriate, and the secondary dressing you chose is a great comfort dressing (the mepilex border). I would not apply antibiotics topically, as this is not evidence based practice and can promote antibiotic resistance. Your initial plan seems very appropriate and I would recommend a would culture for targeted abt therapy instead of impiric or topical.

Sent from my iPhone using allnurses.com

Thank you....I actually left the original order (silver alginate/foam bordered drsg). Our drs are a little more willing to do wound cultures here lately. ...great idea. I will definitely ask for one...