Stage III and growing...Please help!!!

[bluegeegoo2, LPN]

I have a pt in my LTC that has a now stage III, (likely IV) on her right buttock. It is getting worse by the day, and we are at a loss as how to at least stop the progression of damage. A little hx: 77 y/o female c dementia, ambulatory x1 asst, L shoulder fx, (d/t the fx, we can only roll her from back/right/back) appetite fair, fluid intake adequate, HTN well controlled, NOT diabetic. She is currently on an air mattress, gel pad for chair, Zinc and Ca+ supplements, protein supplements, MVI. The area was discovered as a stage II on 5/19, and was approx 0.25 cm round. It is now approx 4cm x 2cm x 1.5cm deep. The skin around it is dk red/purple and non-blanching. The wound bed is eschar-like. However, we have been applying Normlgel TID c wet to dry drsg to debride it, and the wound bed has turned to a greenish/gray gelatinous material. When I changed the drsg today, some of that material pulled away and it was evident that the wound has tunneled, as I could not guage the depth.(I couldn't see the bottom!) A culture was done, and came back today as moderate growth for e. coli. I should mention that she is incont of bowel/bladder. She has also run a low-grade temp x 2 days. I called the Dr. for a order, but the "on-call" wouldn't touch it c a 10 foot stick and told me to call her "primary" tomorrow. (I really don't blame him). I'm just looking for ANYTHING I/we can do to help this woman. Her husband is distraught as he expected her to heal from the fx and come home. Tx started c allanderm BID/dry drsg. Everything we've done has only seemed to make it worse. Our facility doesn't (read: won't) afford such luxuries as wound-vacs or the like. Any suggestions will be GREATLY appreciated.

[annaedRN, RN]

Cannot really tell you what to do but in my patients when I see "green" I ask the doc for something antimicrobial to help decrease the bioburden - often something with silver in it. I have seem some wounds that were progressively worsening start to heal once the bioburden decreases. Also, if the patient is otherwise stable and the husband can help care for the wound - get a referral for VNA if available in your area. They can teach husband wound care as well as monitor the healing process while letting the patient stay at home. Just my

[diveRN]

See if your medical director will approve a wound vac. VNA will manage.

[VivaLasViejas, ASN, RN]

In addition to topicals, I'd ask for a wound culture and an appropriate systemic antibiotic, plus Vitamin C BID and a high-potency zinc tablet, 220 mg QD X 4-6 weeks only (it's apt to cause a copper deficiency if not discontinued after six weeks). The wound won't heal unless the underlying problem is corrected; it will also probably need some surgical debridement as well. Good luck to you and your patient........and thank you for advocating for her!

[oldiebutgoodie, RN]

She should probably get a surgical debridement, and then application of a wound vac. Otherwise, the wound will just tunnel more and get bigger.

I see that your facility won't approve wound vacs. A less effective option would be to "rig up" a vacuum suction of the wound post surgical debridement. Place saline gauze on wound, a channel drain into wound, cover with Tegaderm, and hook up to wall suction. It might work. (or not).

Oldibutgoodie

[bluegeegoo2, LPN]

Update: We have changed the tx to Dankin's solution, wet to dry, and have started the ATB. The wound is looking cleaner with less exudate, and doesn't smell as bad. She is going to be going out to a wound clinic. Also, we found out that she has had a pressure area there before, that was healed from the outside in, more or less. I feel about 1% better about it, but still...

[EHRN]

1/2 strength Dakins is an excellent choice. Are you able to probe to bone? If so, you will need to get a bone biopsy for pathology to rule out osteo, if osteo +, they will need a 6-10 week course of IV Vancomycin. You don't want to do Dakins for too long. You can paint 1/4 inch or 1/2 inch plain packing with Iodasorb, and place it to depth of wound (do not pack), and then apply Iodasorb to remainder of wound bed. (This works better than using the Iodaform packing strips, it absorbs better). Place a piece of Aquacel over the wound, then skin prep the periwound and place a combiderm over the site. Iodasorb can stay in a wound for up to 3 days, depending on the drainage. The most important thing will be to offload the wound at all times. Hope this helps...

[AnnemRN]

I have had good results irrigating the wound/s with normal saline then packing lightly with a silver impregnated alginate. I then fill the dead space with ca alginate - cover with a foam dressing and secure with tape. The orders would be to change the dressing daily and prn x 14 days, re-eval once a week.

The silver product has antimicrobial properties to help decrease the wounds bioburden.

[FranNHRN]

A wound vac would be perfect for this wound. Hopefully the wound clinic will recommend it. How can your facility refuse? It should be covered by Medicare and continue when she goes home.

[BRWRN]

Cover wound with Hydrocolloid drsg for 5 days straight let it debride itself. It might need more debridement after and if so go another 5 days. At this point if its stringy green etc. Go wet to dry with gentamycin for 3days or so and let it clean out wound bed for you. At this point you need to eval drainage. D/C wet to dry and if wound is minimal drainage go with cleanse with wound cleaner,dry,apply hydrogel cover with foam drsg change Q 3-5 days,PRN. It is important to not change daily as this will disrupt the temp of wound bed and delay. Now on the flip side if drainage is moderate to heavy go with cleanse with wound cleanser, dry, and apply some Alginate Ag secure with mefix. Change 3-5, prn. Other suggestions Vit C, foam pad in w/c instead of gel pad (gel pad messes with temp of wound bed more if in direct contact, foam pad seemed to work better for me.) I had similar situation and this is a repetitive process but it resolved. Good luck hope I helped.:nuke: