Wound care puzzle

curiousauntie · Jan 28, 2012

Wounds like this may be best treated with a wound vac. Although it will be expensive and I am sure the facility will expect hospice to pay for it, it may be more cost effective in a way in that you shouldn't have to make multiple visits to do wound care, and you would use less supplies. (Most of the LTC facilities in my area expect the hospice nurse to do any or all of the wound care, and to provide the supplies). It would contain the exudate and the smell the wound may be having.

I agree with not using the Dakins solution. It may be a very mild solution, but it is still bleach and the wound sounds large...maybe not the best combo?

SuesquatchRN, BSN, RN · Jan 28, 2012

The incision is not related to his terminal diagnosis. The facility is required, under CMS regulations, to perform and pay for its care.

313RN, BSN, RN · Jan 28, 2012

You could create a wick in the area that's tunneled with something like iodosorb or a thin slice of hydrofera blue or an acticoat flex 7.

Pack the rest of the wound with the Aquacel Ag and cover with fluffs and a heavy drainage pack if you have it. Otherwise try and double or triple an ABD pad and then tape it with hypafix or paper tape. You could leave the drain in place and the change the Aquacel when it turns into mush while just changing the outer pads.

I think you need the Aquacel for its cytotoxic properties so I'd suggest you keep it if possible. If you've got Acticoat flex it will drop some sliver too but is non-absorbent. There is an Acticoat absorbent but it's quite a bit more expensive than Aquacel.

A wound vac may be appropriate, but you'd have to be able to get the sponge into the area that tunnels.

As a very, very last resort which I don't really recommend you can put a OET suciton catheter into the wound wrapped with an acitcoat flex or gauze and on low continuous suction. Dress the wound as normal and cover with tegaderm. Cut a small hole in the tegaderm, lay the cannual over it and cover with another tegaderm. If you have a good seal it will suck up most of the drainage. We call it a "weep no more".

Good luck.

ErinS, BSN, RN · Jan 29, 2012

The incision is not related to his terminal diagnosis. The facility is required, under CMS regulations, to perform and pay for its care.

I am feeling like the best bet may be to just turn over the wound care to the facility, and help with dressing changes to relieve their burden and so I can do my wound assessment. In my experience, this kind of wound does not respond well to wound vacs because it is nearly impossible to debride the slough that is likely in the many tunnels of the wound, and the vacs do not work well for wounds with slough. I will let you guys know how this week goes. Thanks for your suggestion.

Vtachy1 · Jan 30, 2012

The incision is not related to his terminal diagnosis. The facility is required, under CMS regulations, to perform and pay for its care.

I'm just learning this. Had a patient last week that I learned it was not related to his terminal diagnosis.

What are some examples that it would be related to terminal diagnosis? Thanks bunches!

ErinS, BSN, RN · Jan 31, 2012

Wounds related to terminal diagnosis:

1. Any wound related to cancer

2. Pressure sores in a debility pt

3. Surgical wounds related to primary diagnosis (so a wound from paracentesis in a liver failure pt)

Hope this helps!

CoffeeRTC, BSN, RN · Feb 4, 2012

Hospice never does the wound dressings for us in LTC we do our own. (unless they are in to assess the wound itself)

As fas as the facility not using a product because it isn't policy...does this still apply with hospice coverage?

We all know that Dakins isn't a great thing to use, but when the wounds aren't going to get better and the pt is terminal..does it really matter what you are using as long as it is providing comfort, cost effective etc?

BTW...I'm all for the newer wound supplies and treatments, but I've seen dakins wtd do wonderful things for a wound when used short term. Some of you may remember the honey/ betadine dressings used years ago...honey has made a comeback in some areas in some wound supplies.

SuesquatchRN, BSN, RN · Feb 4, 2012

As fas as the facility not using a product because it isn't policy...does this still apply with hospice coverage?

It depends on the facility, but if TPTB have determined that they don't permit a certain method they're not usually likely to make eceptions. Who is responsible gets murkey, and possession is 9/10s of the law.

NC29mom, ASN, LPN, RN · Feb 10, 2012

It doesn't matter if the wound is related to the diagnosis or not. Once a Pt elects hospice, we are responsible for providing ANY and ALL needed supplies. That would incude this particular patient, and his wound. I can promise you, the facility is going to send YOU the bill for any wound care.

For example......you have a Pt with a diagnois of CVA. They have a colostomy. Hospice would be responsible for providing any and all colostomy supplies. A wound vac is not considered "hospice appropriate". Way too expensive.

Do you not have a wound specialist you could refer to? There are some good suggestions listed above. Good luck to you. You could also ask your DON/manager, someone higher up in your company, to ensure you are making the right decision, for the Pt and for the company.

Ruffles 1 · Feb 10, 2012

Hello everyone! I love wound care, but am in the midst of a puzzle. I admitted a 50-something year old man with liver failure. Hx of etoh and Hep C. So he has a dehiscence post I&D of his right hip. On the surface the wound looks good, maybe 3cmx2cm. But upon cleaning with sterile q-tip I find the wound tunnels and is more like 13cmx 8 cm. It is having copious amounts of yellow drainage, starting to smell infected. We are restarting an ABX that was stopped before he came to us. He is in a facility, and in the past I have treated non-healing wound with lots of drainage with Dakin's solution, but the facility says that is against their policy.
The problem is that this wound is having to be change 2-6 times a day to manage the drainage, and it is cost prohibitive with dressing changes that frequent to use any of our more standard wound care products (facility recommended aquacel AG or Maxorb AG).
I am hoping someone out there will have some cost-effective recommendations on how to manage this wound. Thanks!

I wonder if you could try normal saline wet to dry dressings for this wound. You could pack it with the wet saline gauze and cover with a dry dressing. This also would help with debridement and be cost effective. It would help the wound heal from the inside out. The ABX should also help with the infection. What percent of Dakin's solution are you using?

SuesquatchRN, BSN, RN · Feb 10, 2012

It doesn't matter if the wound is related to the diagnosis or not. Once a Pt elects hospice, we are responsible for providing ANY and ALL needed supplies.

That is simply incorrect. We are not required to pay for any number of things unrelated to the terminal diagnosis.