wound care question!

Specialties Wound

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patient was multiple small sore near perineal area. posterior thighs, but below the buttocks pt has a foley cath and morbidly obese. non ambulatory.

MD classified them as pressure ulcers. But my interpretation is perineal dermatitis secondary to macerated skin d/t her cath leaking for 3 days. sores are there bc she lays on the catheter and it forms breaks in skin. so i guess by that it can be classified as stage 2 pressure sore.

MD order is to cover the area w duoderm... In my opinion, it is not very effective bc the area stays moist due to sweating, etc. and it rolls on the edges due to friction of pt moving her legs up and down etc. pt complains that it is very painful and tender.

what other treatment should i suggest to the MD? silvadene cream?

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First of all I'd like to say this is often an area of confusion, and I myself sometimes have to set things straight in my mind before proceeding with a POC---you're correct in feeling that this is incontinence associated dermatitis (IAD) rather than multiple decubitus ulcers. However, if a sore is caused directly by the catheter having placed pressure on the tissue, this specific area is, by definition of etiology, a pressure sore. Does the pt have a low air loss mattress in place and is she turned regularly? Generally for this condition a good skin barrier cream is in order and the use of especially soft bedsheets is particularly important. I find that with IAD there is no real "Dressing" that will stay in place functionally, rather, using a skin barrier cream over the area daily or each time after the pt is soiled is the key. Reducing pressure will also help the IAD because it becomes complicated by pressure, as will reducing the shear with good quality sheets. But there definitely needs to be a low air loss mattress in place--hope this helps!

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she is a medicare patient... the only thing that medicare covers for bariatric hospital bed are the alternating pressure matress. According to our supplier. We often provide low air loss mattress to our patients, but the maximum weight for those is 300lbs. For the alternating pressure, I was told that I have to provide measurement updates for the wound progress and as soon as it is healed they have to take it back! I was a bit appalled!!! I will call them again on monday to make sure.

I have been encouraging pt to always reposition herself, but she is so heavy that no other position is comfortable for her besides a semi- fowlers!!! mostly because that is the only way she can still see the television. which is the worst position since that is the place where we are trying to avoid pressure!

thank you for your advice. would aloe vesta be sufficient as a barrier cream?

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Oh wonderful medicare. Yes, theyre reactive, not proactive so I see the bed situatuion. I know a hard subject to approach is can she lose weight? Many dont ask because it seems to be an 'off limits' subject but it is very important. Aloe vesta is great.. We use it a lot. Is she incontinent of bowel as well? I'd make sure that each time she goes, she is cleaned and the skin protectant reapplied.

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She is bowel continent. She has a caregiver that is able to help her to stay clean.

I saw her this morning, and the area is just so raw... and moist. I took off the duoderm (which by now has rolled up and traveled to a completely different spot in her back side!) I cleansed the area, and generously applied some A & D cream on all that is red. She now has a little bleeding. I just have no clue how we are going to keep the area dry... it gets very moist underneath all that body mass. poor thing...

I've discussed diet with her... I imagine that it would be very difficult since he is bedridden. She has a lot of pain to her knees d/t arthritis and possible patella baja. So I don't even know how she will manage with PT. She needs to get an MRI, but MRI machines cannot accomodate her size...

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That sounds like a definite situation. I do think the duoderm is not doing any favors for her at this juncture. The bleeding is likely due to the shearing on already denuded skin. Have you tried anything like InteraDry AG in her skin folds and over her buttocks? It is a moisture wicking layer with silver that is meant to be placed in between skin folds. It is rather pricey but just a suggestion.

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Specializes in LTC, Wound Care.

3M No Sting Skin Prep. You will not believe the change in one day!

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3M No Sting Skin Prep. You will not believe the change in one day!

:idea: is that safe to put on open areas?

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Specializes in Wound care & basically everything else.
:idea: is that safe to put on open areas?

Yes - it's safe. You could also powder with stoma powder after the skin prep. Same effect as a hydrocolloid.

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Specializes in LTC, Nursing Management, WCC.

I have got good results from Desitin MAX, which is 40% zinc oxide vs the typical barrier cream that has 13 or so %. I have used stoma powder. Works nicely. I would chuck the hydrocolloid if she is so sweaty that it isn't going to stick. If anything it might trap moisture underneath it. Flander Buttocks Ointment is good for IAD. Try to get her to wear loose undergarments to help circulate air. I wouldn't use commercial cleaning products for bathing if it is severe. Patting with cool damp wash cloth and then patting dry will help not to irritate. Also if you are using barrier creams, make sure staff knows not to rub it off. But to just take off the top layer and reapply.:twocents:

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I have got good results from Desitin MAX, which is 40% zinc oxide vs the typical barrier cream that has 13 or so %. I have used stoma powder. Works nicely. I would chuck the hydrocolloid if she is so sweaty that it isn't going to stick. If anything it might trap moisture underneath it. Flander Buttocks Ointment is good for IAD. Try to get her to wear loose undergarments to help circulate air. I wouldn't use commercial cleaning products for bathing if it is severe. Patting with cool damp wash cloth and then patting dry will help not to irritate. Also if you are using barrier creams, make sure staff knows not to rub it off. But to just take off the top layer and reapply.:twocents:

THANKS!

I am going to show up at her house with a bunch of products to try. What makes it hard is she is so obesed and the air cannot really get to the area to keep it dry. right now I switched her from A&D to the sensicare protective barrier since that is a bit thicker. I'm going to try the skin prep also... we don't have the 3m in stock, but i have the kind from cloroplast. SOMEONE PLS TELL ME IF THAT's okay. there is mild bleeding due to irritating and shearing. pt has been putting neosporin on the areas.... Is it time to ask for a prescription for silvadene?

this is the one time when I really wish the md just told me exactly what to do. but, he has no clue either. :eek:

she has nystatin ointment and powder that we use on her skin folds... would that help at all with her IAD?

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