Stage 3 sacral ulcer, what dressing and how to keep clean?

[hakunamatata, BSN, RN]

I could use some serious help and appreciate any responses. I am a visiting hospice nurse and have a patient at an ALF that has a now Stage III clean pressure ulcer. Multiple issues - no one seems to know the best treatment, and I cannot for the life of me get a dressing to stay on. He is incontinent of B/B. The wound is 2x3cm, showing some white slough but clean. Depth about 1cm. We have been packing with calcium alginate, but my instincts are against this, as there's really no drainage or moist areas. I've tried bordered gauze dressings, cutting Tegaderms, securing with retention tape, nothing is working and I have no idea what I'm doing. I can only get there 3-4x a week at the most, I'm wondering if I should just recommend that he go to skilled? I am the only person that can dress the wound, and he is very non-compliant about turning himself in bed and eating the right diet, and the ALF is not much help, as they're not staffed to take care of things like this. I feel like an awful nurse because I know with these circumstances, he's just likely going to get worse. My other nurse recommended medical grade honey and a duoderm. Still confused on how to get these to stay on.

I deeply appreciate any responses!

[adgn, LPN]

I am a treatment nurse at a ltc. I have a similar pt. We've tried many types of packing and dressings. We've finally found a tx that has been helping. Cleanse with normal saline and pat dry. Packing the wound with wet to dry technique. Pack only the wound with soaked gauze with Dakins solution. Apply prep skin around borders. Cover with Allevyn foam dressing 5x5 in a diamond fashion. So far this pt has been responding well to this tx.

[Candogal]

I hope I can help, I have worked at 2 wound centers and very rarely do either place use tegaderm anymore-only for example when the patient is going to the beach and we don't want sand and water to get into the wound. The wound really needs to be assessed by a specialist- Santyl ointment will help loosen the slough but that needs to be put on everyday. Medipore tape is the strongest wound dressing tape that I'm aware of and the prior comment about the Allevyn Foam dressing cut into a diamond shape and then apply medipore tape would be a good option to try, just make sure to apply skin prep barrier wipe on the peri-wound to prevent irritation and breakdown.

[woundnurse4u]

The patient isn't turning himself? The ALF isn't going to provide that level of care so you just answered your own question about the level of care that is needed. CAN the patient turn himself? Is the patient on a surface to redistribute pressure? Does the patient need a low air loss surface? What is the goal for the patient? Is he hospice and he needs palliative care or is the goal to heal the patient? If the patient is incontinent of B&B, what kind of care is the ALF going to provide for that? Getting help with the bathroom is one thing, having an aide provide continual incontinence care is another thing.

As far as the dressing, calcium alginate is a horrible idea if the wound isn't exudative. You could try Santyl, Mesalt, and a dry dressing to cover. Or Santyl, saline dampened gauze, and a dressing to cover. Just remember that Santyl is a daily change, is not cheap, and needs moisture to "do it's thing". Which takes me back to your goal. Heal or palliative if patient is hospice.

If you want a palliative dressing, you will need something that will keep the wound clean and stay intact. The goal would be to protect the ulcer fro stool and urine, prevent infection, and keep the patient comfortable (hopefully that means not having to repeatedly change the dressing every day).