someone please clarify stage and tx

KimT08 · Jan 3, 2009

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!

overwurkd · Jan 5, 2009

You're my hero right now!! I was getting nervous that I wouldn't get a reply as I posted this so long ago, Accuzyme was still on the market. Wound care is definitely an art of nursing all it's own. You broke it down very nicely and actually made it very clear. 2 more questions, if you have the time:

1. Silvadene? Is it a debrider or antibacterial?

2. Since a moist wound enviroment is best, after applying collagenese on slough or eschar the gauze used to cover should be dampened with saline? or dry?

overwurkd · Jan 5, 2009

I just read that silvadene is only an antimicrobial, so that answers that question.

KimT08 · Jan 5, 2009

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!

overwurkd · Jan 6, 2009

Thanks so much:) I'm actually on a med surge floor in an acute care hospital but we get alot of pts. from the nursing homes around us. Most of the time, more than half of my floor is total care pts.

KimT08 · Jan 6, 2009

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.