Wound care opinions (apologize for length!)

[CaringGerinurse525]

I currently have a resident that was admitted to our facility with the understanding he would be hospice care soon. The first few days he was rarely out of bed. The POA had a change of heart and asked for resident to begin therapy. :/

Resident began getting out of bed and attending three hours of therapy a day. Developed large water blisters on legs. Wound doctor was consulted and came in and removed water blisters leaving open areas that cover most of the one leg and foot. Order is to cleanse, cover with non-adherent foam, abds, and wrap with kerlix.

The problem is resident is soaking through the dressings every 1-2 hours. Being LTC resident is frequently out of bed and out of room esp with therapy. Skin is white and macerated despite frequent dressing changes, and barrier cream to intact skin. We have a differing opinions right now on proper treatment.

I and the previous wound nurse (still employed at facility but they did away with Tx nurse to save money) believe that resident should be in bed with exception of meals and therapy until some of edema resolves as more areas are developing. We also believe leg should be open to air with exception of adaptic placed on open areas to preserve the intact skin and keep area from being saturated. I did this my last night on and notified house dr and area looked so much better by morning. We also think the open areas should have adaptic placed on before the foam when being dressed.

ADON who took over wound rounding with doctor believes we should follow dr order as is and refuses to discuss changes as tx is not working. House doctor refuses to be involved and we are unable to contact wound doctor. He comes in day shift weekly and adon will not contact him. ADON said area will not stay dry if open to air? I tried to explain area isn't staying dry with current tx and instead is becoming macerated.

Sorry so long! I would love to hear what others think of the current treatment and who is right in this situation. Also open to other suggestions! Thanks!

[CaringGerinurse525]

Bump would really like some input!

[CryssyD]

I would recommend consultation with a wound/enterostomal nurse if possible. Otherwise, maybe an alginate dressing--they are highly absorbent-would be helpful. A wound-vac system is probably your best bet. However, my knowledge is probably outdated-ask a specialist!The right treatment depends on the etiology of the drainage--if it's clear fluid from edema, you will never get anywhere until the edema itself is treated successfully; remind your ADON that you should treat the cause, if you can, and not just the symptoms. I'm with you--if the patient can't be up and around without puffing up like the Pillsbury doughboy, the PT is not being tolerated at this time and the patient should remain in bed or in a chair with legs elevated until the edema resolves. With all that moisture, infection is bound to set in eventually, and then you'll have a worse problem.

[calivianya, BSN, RN]

I don't think you're going to be able to do anything to fix the blisters, either.

What does the patient have to say about this? If he's well enough to get up and walk, is he cognitively intact enough to know what's going on? Could you have a real heart to heart with him about how PT is only exacerbating the swelling in his legs and it might be appropriate for him to refuse PT at this time?

[melsman1904]

If the drainage is r/t edema, you would need to control the edema. What is causing the edema? Venous insufficiency? Do you have a current ABI? From what I read, my next step would be to discuss with the Wound MD the possibility of utilizing something along the lines of the Coban 2 layer wraps if this is venous insufficiency. If Wound MD agrees to order, you need to get an ABI so you can select the proper pressure.

Further reading that you may find informative:

3M Coban 2 Layer Compression Therapy: Intelligent Compression Dynamics to Suit Different Patient Needs

Cobanâ„¢ - Wound Care: *: Critical & Chronic Care : 3M United States

[CaringGerinurse525]

I would recommend consultation with a wound/enterostomal nurse if possible. Otherwise, maybe an alginate dressing--they are highly absorbent-would be helpful. A wound-vac system is probably your best bet. However, my knowledge is probably outdated-ask a specialist!The right treatment depends on the etiology of the drainage--if it's clear fluid from edema, you will never get anywhere until the edema itself is treated successfully; remind your ADON that you should treat the cause, if you can, and not just the symptoms. I'm with you--if the patient can't be up and around without puffing up like the Pillsbury doughboy, the PT is not being tolerated at this time and the patient should remain in bed or in a chair with legs elevated until the edema resolves. With all that moisture, infection is bound to set in eventually, and then you'll have a worse problem.

The previous tx nurse is the other fulltime nurse on my hall on days off. She's a certified wound nurse and has been for 20 some years so usually we go by what she says. For some reason the new ADON thinks we have to follow the wound Drs order without asking for something else when it isn't working.

The resident was just diagnosed with CHF but is also being tested for Pemphigoid (waiting on biopsy result). Resident is on lasix and NAS diet. Open area on legs are ptw only through the dermis. They just aren't healing due to excess weeping. Therapy is actually on board with keeping resident in bed (when they don't have him) but we aren't being allowed to care plan this so we can only control when we are working. We did get Adon to order exudry so hoping that helps!

To

[CaringGerinurse525]

I don't think you're going to be able to do anything to fix the blisters, either.

What does the patient have to say about this? If he's well enough to get up and walk, is he cognitively intact enough to know what's going on? Could you have a real heart to heart with him about how PT is only exacerbating the swelling in his legs and it might be appropriate for him to refuse PT at this time?

Unfortunately resident is only alert and oriented to self. Very pleasant but also wants to be done and says he's ready to go. Family has all the say and are controlling the therapy.

[CaringGerinurse525]

If the drainage is r/t edema, you would need to control the edema. What is causing the edema? Venous insufficiency? Do you have a current ABI? From what I read, my next step would be to discuss with the Wound MD the possibility of utilizing something along the lines of the Coban 2 layer wraps if this is venous insufficiency. If Wound MD agrees to order, you need to get an ABI so you can select the proper pressure.

Further reading that you may find informative:

3M Coban 2 Layer Compression Therapy: Intelligent Compression Dynamics to Suit Different Patient Needs

Cobanâ„¢ - Wound Care: *: Critical & Chronic Care : 3M United States

Thanks for this info! I will pass it along! Unfortunately the wound dr the facility has hired is very particular and will only speak to Adon about treatments. We are not even allowed to call him. That is why I tried to speak with Adon about suggestions. I have brought DON into the situation so hoping we can get better care to resident! Thanks for everyone's help!