Necrotic toes wound care

Specialties Wound

Published

Hello,

I am a (new) home health nurse. I do not have a lot of experience with wounds and am trying to research and learn the best I can as I encounter new things. When I'm not sure what to do - I ask my boss / charge nurse who is a very experienced nurse.

That being said, I recently encountered something I'm not at all sure what to do about:

I have a pt who is in his 60s, diabetic, ESRD on hemodialysis x3/wk. He was in the hospital for cellulitis of the foot and has now been sent home with IV antibiotics.

His 2nd and 4th toes on in R foot are necrotic. in the 2nd toe, it's not the whole toe rather just the base of the toe (most of the circumference but not all) is black and drying, and the tip is normal pink color with ~2-3sec cap refill. The 4th toe is also necrotic but it's the whole toe, and that one does not appear to be drying out. I am also worried about infection / gangrene there as yesterday when I took off the dressing, that toe's skin on the tip looked kind of "sunken".

My boss told me to paint necrotic tissue with provodine solution (makes sense) and apply Xeroform in between the toes (this is the part I'm not sure about). The orders he got sent home with are "paint with provodine and cover with gauze daily x14". Usually the doctors want us, the home nurses, to tell them how we would like to treat the wounds, not the other way around. I don't want to make a recommendation for something I don't even understand. Should I be cleaning the area and drying before applying the provodine? I've read forum rationales for both doing and not doing this. What about deriding the dead skin / slough in between the toes? (also read pros and cons, not sure what the best course is).

What is the rationale for the Xeroform?? Am I to apply it to good toes or the bad? I tried asking, and got a "just do what I told you" :-/

I've tried researching this on my own, but am still confused. The skin in between the toes is macerated and he has skin loss and some redness on the neighboring toes where they come in contact with the bad ones. He does have very poor circulation in both hands and feet (usually cool to the touch, weak pulses - if I can find them at all), no pain. I want to help this pt as much as I can, but am not sure I'm not making things worse. Any wound care nurses with advice?

What are my goals here? I mean, the best I can figure out, the goal is for the necrotic toes to dry out. But how do I best do that, while protecting the surrounding good tissue?

Any advice is highly appreciated! I realize this is a novice thing not to know, but really feel like I was just thrown into the water with no life jacket and just a written pamphlet called "how to swim". I don't want my pt to suffer consequences because of my inexperience.

Thanks in advance for your advice.

Any necrotic toes should be kept dry. We always paint with skin prep or povidone iodine and leave open to air. The xeroform gauze I am familiar with is soaked in petroleum and would not be appropriate.

1 Votes

Xeroform provides a bacteriostactic moist wound environment, bismuth is impregnated into the gauze, similar to silver in its ionic ability... Don't think you want to keep those toes moist...providence should be enough, unless there is a small amount of epidermis that would benefit...I would clarify the orders with physician...

2 Votes

Sorry, spell check, povidone should be enough

Thank you TammyG and mrosette for your advice. I did more research and ultimately what you advised is pretty much what I ended up doing. It seemed to work best, given the situation.

2 Votes
Specializes in CWON - Certified Wound and Ostomy Nurse.

Dry gangrene should stay dry. If a person has gangrenous toes we should look at the big picture. Why does he have gangrene? Likely, poor perfusion. Painting the toe with betadine is the most appropriate tx....what often happens is xeroform is thrown on everything. Yes, it has antimicrobial properties but it can cause a dry wound to become moist = wet gangrene which can spread infection rapidly. I've always been taught with folks in this situation (and with diabetics which often goes hand in hand) keep the toe web spaces dry.

1 Votes
Specializes in WCC.

Everyone is right. Stick to drying only. What you're going to want to watch more is where the necrosis stops. Sometimes it continues to grow up the toes and to the foot, seemingly to the point of adequate perfusion. If you identify that with this patient's risk factor and appearance that this area may just continue up the foot and into the lateral medial leg, it may be leading to amputation.

All I'm getting at, I've seen toes dry up and fall off, leaving a perfectly nice foot left over (with proper drying)

If you see the areas as stable, be hesitant when the surgeon offers up amputation.

I bought a pair of the orthofeet to wear on a tour of Italy that included walking 8-10 miles a day. I had been experiencing foot pain and plantar fasciitis. I was desperate to find a shoe that could get me through a day of walking without pain. Well I found it, the Chicane not only gives me the foot support and pain relief I needed; they are also a good looking shoe that can be paired with many different outfits. The Chicanes took me about three weeks to wear in so that they were comfortable enough to wear on a 4-8 mile walk.

+ Add a Comment