What dressing to use?

[LPNfurever]

I have a pt with skin cancer who picked off one of the lesions on her hand. It started out as a scabbed over sore about 2 cm in diameter. It keeps getting worse despite PRN dressing changes. It is now approx 5 cm in diameter, and .5 cm deep, has a foul odor to it and when I change the dressing its completely saturated with serosanguinous drainage. The wound care I was instructed to do was cleanse the area with NS wipes, then to use a skin prep pad over any area that would have adhesive on it, then to cut a piece of COPA foam to the size of the wound, place that in the wound, then use a COPA foam island dressing on top of that. The I am to wrap the whole dressing with coban( resident picks constantly) to secure it in place. Is this appropriate wc? I also began to skip the island dressing as the adhesive seems to irritate her skin and just double the COPA foam, wrap with kerlex and then use coban. I think the kerlex helps the coban not get too tight and adds an extra absorbant layer. Any help would be appreciated.

Thanks!

[KateRN1]

How often is the dressing changed? Best practice is generally not to disturb the wound bed more often than every 3-5 days if at all possible. If there is too much drainage to allow this, I would look at a different product for packing the wound and keep the COPA for a cover dressing. Since your description indicates a degree of infection, I would consider using a silver-based antimicrobial dressing. I like Aquacel Ag, it absorbs a ton and does a really great job of keeping bioburnden down. Skin prep may be irritating the peri-wound skin, in addition to the Island dressing. Consider using a cover dressing that does not have an adhesive backing since you're having to cover with kerlix and coban anyway. Good luck!

[Emergency RN]

The only other thing that I would add to respondent KateRN1's suggestion is to ensure that the wound had been recently cultured. The presence of a foul odor is the classic sign of an anaerobic infection that may need antibiotic coverage. Silver sulfadiazine does have broad spectrum impact, but in this case the effect is only local. The patient may need something systemic if the infection is severe.

*** Sidebar *** I would also investigate the use of protective mittens for a patient that cannot seem to stop picking at a wound.

[LPNfurever]

Does the skin cancer progressively cause the wound to get worse? The dressing is scheduled to be changed Q 3 days and PRN; although it needs changing usually every other day due to the drainage. Would a wound culture be appropriate in this instance?

[LPNfurever]

One other thing is that I am a new grad LPN, and at this LTC facility we do not have an official Tx or wound care nurse. Also the manager for my hall is also a new grad. Its very frustrating. Do I need a doctors order for dressings and wound care? I am being told what to do by an RN, however, I dont remember seeing anything in the chart from the physicians.

[mamamerlee, LPN]

Yes, you need orders. Write what you want on a fax to the MD if s/he won't come in to see the wound. Wound cleanser, 4x4s to pat dry, and the rest. Silvadene is a prescription item.

Maybe ask for a wound care consult.

[ghillbert, MSN, NP]

I like medihoney for infected wounds and have used it with great effect. Put into wound, then secondary dressing to absorb drainage, then wrap.

[KateRN1]

Holy moly! No orders from the physician? Yikes! Yes, you need orders for wound care of any kind. That doesn't necesssarily mean that the physician will magically appear, know what to do, and write appropriate orders for the wound. Ha! As mentioned above, generally the nurse just writes the wound care orders on a telephone order slip and the MD co-signs when s/he is in the facility. Best practice would be to call the doc and tell him/her what you want and ask if they're agreeable, but I've worked LTC and know that rarely happens for wound care.

Even if you're getting direction from an RN, it's still your responsbility to make sure there is an order for this wound care that *you* are performing. If there's no order, you're both acting outside your scope of practice. Get the order ASAP.

[erroridiot]

Dr. needs to examine the wound for infection and possibly biopsy for spreading cancer. Cancerous wounds can also have a foul odor.

Polymem is has antibacterial properties and so does Silvadene, but they will not have any effect on a malignancy.