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Specialties Wound

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Say, hypothetically you have all the money in the world at your disposal.:chuckle

Patient is 90 yr old NIDDM patient with dementia and constant oozing of stool. Her status is palliative, and decision has been made to do no aggressive forms of treatment. Diet is tollerated very well, but is limited because of NIDDM status, swallowing difficulties and various other feeding complications. Has indwelling cathether and is bedbound with multiple contractures of the legs. Stage IV ulcer to coccyx has been present since 1999 (!). Multiple products have been used over the years, multiple clinical nurse speciallists and infection control specialist have been consulted. Pt had been on VAC therapy for 6 mo, but this lead to a deepening of the wound bed, and was d/c'd in 2001.

How do you propose to treat this client?:)

Oh, I forgot to ask. We don't use rectal pouches here. Can you please explain what they are and how they are used?

also called fecal containment device...similar to colostomy bag, but around orifice instead of stoma...there are devices special for this, but for the life of me i cannot come up with a lijnk for you....

Specializes in Home Health.

OK, my two cents...How about a hydrogel, like carrington, covered by a large duoderm. The duoderm keeps it water proof, protects from stool, and keeps moisture in the woundbed. It can also stay on for about 3 days, or removed prn for stool problems.

Agree with the air matress for the bed, or maybe a clinitron is probably best for this pt.

Also nutrition must be addressed. If nutrition is not adequate the wound will never heal. Are her sugars under control? I think add ing the vitamins as suggested by sleepyeyes is an excellent idea!!!

You have to attack decubs from the big three nutrition, pressure, and hygeine, at least that's what I see working the best. When all three factors are being aggressively addressed and managed, the wound will begin to heal.

if i remember right,

medicare doesn't feel these would be necessary together...

Sugars are under control. Despite everything, it's amazing what this lady does have going for her. She has been on a multivite for some time.

Duoderms are good for stages I-III, but not really advisable for stage IV. Can't remember exactly why but they can increase levels of bacteria at the wound site (I think).

Specializes in Home Health.

Well, then the only thing I have ever seen work for a stage 4 decub is clinitron bed. We had one pt w such a huge decub and he had such diarrhea, and we were not allowed to use chux, b/c the wound is supposed to make contact w the bed. It was gross, the bed was all stained from the poop, and the pt had to lay in the stained area, which to me seemed so gross and unsanitary, but it did heal the decub. I believe Medicare does cover a clinitron for a stage 4 decub.

I know duoderm isn't indicated for stage 4, just thought maybe it would keep the wound clean from the stool.

Has the pt been seen by a plastic surgeon?

Let us know how it turns out!! Good luck to you, this pt is lucky to have you as her nurse, your concern for her speaks volumes about the kind of nurse you are. :kiss

Specializes in LTC, ER, ICU,.
originally posted by shygirl

panafil is an enzymatic debridement product. go to: http://www.medicaledu.com/enzymati.htm

panafil would have been my suggestion but since the wound does not need to be debrided, it defeats the purpose and panafil, for what i have seen, heals near the surface and keeps the wound from healing completly. cleansing with ns and applying santyl bid should do the "trick".
Specializes in LTC, ER, ICU,.
originally posted by adrienurse

sugars are under control. despite everything, it's amazing what this lady does have going for her. she has been on a multivite for some time.

duoderms are good for stages i-iii, but not really advisable for stage iv. can't remember exactly why but they can increase levels of bacteria at the wound site (i think).

duoderms keeps the wound moist, or it can depending on the wound, and some wounds needs to be clean more than a couple times a week. duorderms products are designed to stay in play for a specific amount of time and usually without other products to help aid in its healing effect. therefore, a wound such has you have describe needs more attention than the duorderm protcol.
Specializes in LTC, ER, ICU,.

another thought, have you tried a wet to dry for a couple of weeks then moving to santyl? as i am sure you are aware, it takes at least a week or so to determine some out- come from what ever product is being use to rule it out or not.

Originally posted by hoolahan

Well, then the only thing I have ever seen work for a stage 4 decub is clinitron bed. We had one pt w such a huge decub and he had such diarrhea, and we were not allowed to use chux, b/c the wound is supposed to make contact w the bed. It was gross, the bed was all stained from the poop, and the pt had to lay in the stained area, which to me seemed so gross and unsanitary, but it did heal the decub. I believe Medicare does cover a clinitron for a stage 4 decub.

I know duoderm isn't indicated for stage 4, just thought maybe it would keep the wound clean from the stool.

Has the pt been seen by a plastic surgeon?

Let us know how it turns out!! Good luck to you, this pt is lucky to have you as her nurse, your concern for her speaks volumes about the kind of nurse you are. :kiss

Gee, hoolahan, I'm shocked! Our facility used to rent Clinitron beds, and they came with paper "breathable" chux and an extra, washable "sheet" (which resembled the material they use for tents). Even so, we would have pts. with poo in their wounds, and the bed made it hard to position and stabilize them to change the dressings. Plus, I noticed, the folks tend to "run hot" on those beds too. Don't know if that's good or bad, but the air seems to have a warming effect.

Anyhow, those are just a few reasons why I came to prefer a RIK mattress. It's expensive. But I was so hooked after having a couple of pts who should've had decubs and just never broke down, I had my mom buy one for my dad who has MS and though he's been immobile for years, he's also free of decubs. Of course, they say the clinical indication for that mattress is a stg II or greater, but what are they gonna do now that they're moving away from staging decubs?

Am totally enjoying this thread, too, BTW. Thanks!

Stephany, I don't think that Santyl is indicated in this situation, because there is no eschar. It can be a little hard on new granulation tissue.

Does anyone use Cavalon spray? I just noticed yesterday when I was at the librairy that it comes in single use packages, in cream form (has anyone used this)?

Does anyone use Allevyn products?

P.S. No, we have never consulted a plastic surgeon for this patient. She is palliative, and gets comfort care only -- so therefore no aggressive treatments are to be done.

I think the reason fo any improvements is our excellent CNS who makes a point to come to see her at lease once a week. He has given a wonderful new perspective to this woman's treatment.

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