wound that won't heal!

Willow Moonsidhe · Mar 22, 2010

Has a air bed or air mattress been tried? Are the care givers keeping the pressure off it? Silverdene might help.

Blessings

~Willow

txredheadnurse, BSN, RN · Mar 22, 2010

How is his nutritional status? Is he getting adequate protein intake? Adequate amounts of zinc and vitamin C? Has he been evaluated for diabetes? It has been my experience that in addition to providing appropriate dressing materials and relieving pressure or friction sources to the decub site that without good nutritional support these sites tend to not heal or stay healed plus an undiagnosed case of diabetes that isn't addressed will certainly hinder healing.

javanurse2000, BSN, RN · Mar 22, 2010

If you are ever able to get it to heal over, I've seen granulex do wonders to promote circulation to the area and help strengthen the tissue. The suppliments and protein are a must - they make special drinks - high in protein and vitamins for wound healing as well.

As a last resort, if they are willing to try surgery again and can get a dr to agree, a few layers of healthy tissue from the thigh graphed on might be the "leg up" he needs. Good luck!

RhiaRN75, RN · Mar 22, 2010

You could always try posting on a paraplegic/quadripelgic support forum. (Just keep in mind your pt may be a member so don't be too specific!) Depending on your pt's ability maybe you can see if you can get him to research it as well. Young as he is, it may help with his compliance. He'll be an adult soon so if he's not participating in his care he needs to start, IMO.

I agree wth the other posters who asked about nutrition. A wound won't heal if nutrition status is poor- I think anyone who won't heal needs a nutritionist. If he can't tolerate mighty shakes or ensure (yuck!), maybe he'll like carnation instant breakfast. It's cheaper and tastes a whole lot better. I've been told by a mom w/ a child with DD who won't eat enough that scandishakes taste good. Then there's the possibility that he's already getting a lot of milk-based supplements and is lactose intolerant and doesn't know it. If he has a protein losing enteropathy he's not getting much nutrition from anything he eats.

I have seen some difficult chronic wounds heal after using a clinitron bed. I don't know if it's something that can be used at home though. HBO seemed to help as well. Does he have a trapeze on his bed?

If his compliance is the root of the problem maybe a child/teen therapist will help. I'm sure bedrest for so long for anyone would be difficult.

ChristinP · Mar 22, 2010

Recently I have had quite a few patients with wounds that were not healing, some +MRSA. I do see some improvement with Aquacel Ag. Wound vacs work great for some. The one thing that I didn't believe would work is, I have seen huge improvements in the healing time from hyperbaric O2 therapy. It's time consuming and requires Mon-Fri QD visits. If I didn't watch the these wounds heal at an amazing rate with my own eyes I probably wouldn't believe it. Of course I'm sure it isn't 100%

libbyjo5 · Mar 22, 2010

Thanks everyone! yes, he has been on an air mattress, he has a G-button and gets supplemental feedings over night of Isosource 1.5 cal. He has no diabetes. Tried the silver. And as far as keeping pressure off it, that something that the family could do just a little better with. I'd say that they are 90% compliant with that. They get to feeling sorry for him and let him up in his wheel chair sometimes and then when he has a Dr apt. he has to be up. I don't think they've tried Granulex, unless it was before I came. I will check! And I will do some research about the skin graft thing! When it does start to heal, it wants to heal on the outside first and meanwhile the wound tunnels inward! That is why the Dr keeps opening it up. I know this does happen to paraplegics especially, but it is frustrating!!!

libbyjo5 · Mar 22, 2010

Hmmm..hyperbaric O2 therapy..would insurance cover this? and Is the Aquacel Ag a silver drsg? they have tried the silver I know.

As far as himself researching, he is dev. delayed and that is not in his realm of capabilities, but his parents could.

thanks everyone for giving me more to look into!!

filipina in Australi · Mar 22, 2010

why not to take swabs to determine what type of antibiotic to give. If not allergic to seafoods and iodine,try to apply iodosorb dressing packing

txredheadnurse, BSN, RN · Mar 22, 2010

It is possible to add protein powder and other nutrients to tube feeding formulas. I agree he needs a nutritional consult to help from that end in assisting healing. Also he probably would benefit from a referral to a wound clinic. Most of them in my area also have hyperbaric chambers available. I had a paraplegic with developmental delays with a recurrent pressure wound (self induced from sitting with his legs crossed over each other constantly) and the wound clinic, hyperbaric chamber and nutritional consults were the only way I was able to heal his recurrent and resistant decub. His PCP should be able to give the family a referral to a wound clinic and, at least in my state, a referral from the PCP is covered by Medicaid.

Super_RN, BSN, RN · Mar 22, 2010

Have you tried the wound vac WITH the silver dsg in the wound? I've had some really good results with that!

kaliRN · Mar 22, 2010

OP: I think you have gotten some great advice here, especially about Granulex and hyperbaric. A note of Granulex, you do not have to wait for the skin to be intact. However since it is oil-based, it would be a phenomenal breeding ground for bacteria. Instead, the wound can be packed, then Granulex applied and massaged into the intact skin. The Granulex does not need to be removed from the intact skin (it is designed to be left in place) Just ensure the wound edges are cleaned again with wound cleanser or NS (whatever protocol is being used). If the packing has become saturated or still has contact with the Granulex - repack. When massaging pay special attention to where the tracking and tunneling is present.

As nutritional consults and pressure reductions surfaces have all been implemented. Sinus tracts are the most difficult part of any wound to heal, the granulation tissue covering the surface often will close a decubitis before any has formed ... which is what you have seen. The only suggestion I can offer which has not already been made is from your post, it seems difficulties in compliance are primarily wheelchair-based. There is a product called a ROHO cushion, it is a air pressure-reduction surface (a cushion) designed specifically for wheelchairs, they come in different sizes. Depending on the insurance, it may be covered, perhaps the family could request an order from the MD.

Hope this helps. My experience with this is personal, not professional, so I know first-hand how difficult this issue can be.