Stalled wound

[tktjRN]

I have a patient with a stage IV pressure ulcer to her coccyx. The patient has had this for over a year and I've been the primary nurse. When I first saw the patient it measured 6.0cm x 6.8cm x 1.3 cm. Now, a year later it's 0.5 x 0.3 x 0.2. It's been this size for months. Pt is bed bound, but gets up in chair throughout the day, has a specialty mattress and a roho cushion for the w/c. Transfers with hoyer lift. Spouse is the primary caregiver. Initially, pt was on a wound vac but wound showed no evidence of healing, did acidic acid wet to dry daily for months and the wound made significant progress. Wound became to small to continue treatment.. In the past 3-4 months I've used: Aquacel AG, honey, and now I'm using prisma dressing. I change it 3x weekly. I've cultured the wound approx 1 month ago and it was + for MRSA. Pt is on juven and ensure bid, appetite is poor. I did a pre-albumin level and it was 19( range is 18-46) Pt is not able to go to a wound clinic, transportation is an issue. Wound bed 100% red, sm-mod serous drainage, no odor, surrounding skin is macerated, but has improved since using an eakin seal.. Any ideas?

[elfie2013]

Couple of things. You've done a great job getting the wound healed to this point! This area of the wound probably continues to receive more pressure than realized. Has roho cushion been replaced recently? Is this patient's position changed frequently throughout the day even while on the roho? Have you thought about getting an order to use a silver nitrate stick? If the infection has been treated and now cultures are negative, using the silver nitrate could "wake up" the healing cascade. Just a thought.

[tktjRN]

Would I put the silver nitrate just on the wound edges or on the wound bed as well? Pt only stays up in the chair for a 1-2 hour period and then lays down. Spouse does not reposition Pt at noc, which I could write a book about.. Pt had the roho cushion for about 6 months...also has a Foley catheter.. Thanks

[silverbat]

unless the MRSA is colonized, that needs treated in order to heal the wound. The silver nitrate cauterizes, so it needs to only go in the wound, would make wounds of the edges.. Does she have a pressure relieving/air mattress? that might help even if not repositioned at night. Some beds actually turn the resident. Would think the roho needs replaced, too. Need to dry up the edges, so maybe prisma not best choice(?). We've used skin prep on the edges of wounds to kind toughen them up..... just some ideas!! Its hard sometimes to heal that last little bit.. but I truly think addressing the MRSA will help!

[mommy.19, MSN, RN, APRN]

The patient should be evaluated for an underlying bone infection, or osteomyelitis. This can generally be a situation where a large wound heals to a very small size but will not ever close. I would consult a plastic surgeon in this case. Silver nitrate does not need to be applied unless there is non viable tissue, a simple sharp wound debridement performed by a physician at bedside would begin this healing cascade. I don't believe it is within a nurse's scope to cause harm to viable, bleeding tissue within a wound anyhow. Would it really be that difficult to get the pt to a wound clinic one time for an eval? You know this person much better than I