Wound tx's

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Specializes in LTC.

I have a pt who has a stage 3 on her butt. Yesterday pm...as I was starting my med pass I got a whiff of something...TERRIBLE...it wasnt bm, or pee, it smelled like....a rotting dead body or something. Sooo....I followed my nose to what I thought was the source....the wound. I go in this room and pull back the dressing which was only 24 hrs old to look at this wound and ohhhhhhhhhh myyyyyyy goddddddd.....I almost got sick. this wound is about the size of a quarter and down to the meat....with a big piece of loose flesh just hanging on it....the tx is for calcium alginate packing ...the alginate was covered in a thick, green slimy puss like substance with an odor that would knock you down! I have a stomach of steel but that wound....was just ....the worst smelling Ive ever dealt with in the past 9 yrs that I have worked there! soo....I go and get the stuff to clean this wound out...along with a betadine swab just to make sure it was really clean. I repacked it and covered it....but that smell was just lingering......I finally got some cleaning stuff and cleaned that entire room esp around her bed and trash cans and tables and the floor with a towel....by hand. That did the trick...but....aside from that....there is no doubt this wound is infected. the tx is only supposed to be done every 3 days. she is on hospice so I doubt that they would even attempt more aggressive tx for it..but debridement sure wouldnt hurt it. Anyhow...my ? is this.....for your pts who have had wounds like this ....what kind of tx's did you have and did they work? How long did it take to heal it up? What are some of the most unusual wound tx's you have heard of or used? Ive heard of tx using betadine and honey soaked packing before but ...something has got to give on this one! she either needs some antibiotics, a different tx. or a daily drsg change..or all of the above.

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Specializes in LTC, short term rehab, hospice, MDS.

I work for a hospice, and my organization does debridement (sp?) when needed. With out seeing the wound its difficult, but sounds like Santyl, a mild enzymatic debrider, may be appropriate. I would also ask the MD to consider a PO ATB if the family is not opposed. Using a charcoal pad can help with the smell. Cleansing with dakins may be appropriate for a period of time as well. Sounds like the wound should be changed to a daily dressing too. These are all things the hospice I belong to have done for wound care. Some things to consider with a Hospice patient, however, are that despite best efforts, the wound may still not heal due to the patients poor nutritional status. just some ideas, hope it helps

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Specializes in LTC.

Unfortunately ....our hospice doesnt want to pursue any further tx with it....Im not sure why? shes not actively dying...she has declined alot in the past year though. as for this charcoal pad....does it have a specific name? Ive never heard of it before or seen it used....I have used dakins and santyl on patients before. The dakins....stunk...smelled like clorox which burns my nose and gives me a headache. However.....Im still not understanding why they wont change it to a daily drsg. THe DON says that since she is on hospice (palliative at that!) then hospice basically has the say so in what to do with it......however...I dont agree with that. We have a doctor there..plus a wound doctor that comes weekly....if the wound doctor could get in with her...he would have already ordered santyl ...thats normally what he orders on those kinds of wounds. I had a pt with a stage 4 plus osteomyelitis whose wound didnt look like this or smell like this............its awful! I think Ill try again and just put her on our facility doctors book and see what he says. If nothing else....some antibiotics would probably help out.

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Specializes in LTC, short term rehab, hospice, MDS.

Very sad that the Hospice wont pursue treatment... The goal for this pt's wound should be to maintain and/or improve the wound WNL for the patient's disease process, and while I can understand treating in a non invasive manner for a hospice patient, (i.e. no sharps debriedment or painful enzymatic debrieders) to just let the wound go seems uncaring on their part to me. Have you talked to the RNCM or routine Hospice nurse that comes to visit the patient? Have they seen the wound lately? Its apparent that the current tx is ineffective and needs to be changed. As far as the charcoal pad, its sometimes called an odor absorbing dressing. I will go to central tomorrow so I can find out the manufacturer

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Only every three days????? I never heard of calcium alginate dressings being changed so infrequently! Ca alginate is for draining wounds, so why would this be ordered q3days? That's neglectful! If this pt is on hospice, they are at the end of life. The body is breaking down, a wound could " take off" in no time. Poor nutrition, poor hydration.

poor thing, does she have adequate pain control?

I think ca alginate is not a poor choice, just needs to be changed more frequently!

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Specializes in LTC.

The hospice md came in and changed the ca alginate to some kind of a cream....miconazole? mixed with something else ......but yea....that dsg order was for q 3 days....I was changing it daily when i was on duty b/c I couldnt take the smell. When I changed it that one day....and cleaned the room and everything...the smell wasnt there for 2 days. Then i was off....and it was back..full blown...this is so gross..but Ive noticed that more and more flies are flying around her...I think they are attracted to the smell of that wound. Might be wrong though...as for talking to the hospice nurse..they only come in on day shift to do their weekly checks or whatever it is that they do...I have seen them one time at shift change and they just went in...did some vs, charted it on their computer and asked when she had a BM last..and left. Didnt see her do anything else. The day nurse said she asked them about getting it debrided...and they refused to do that....we are giving her protein and wound healing supplements....that arent seeming to help out....a good round of antibiotics would be so nice..just to see if it would help it at all. She eats about 50 to 75 % of her meals....which is normal for her. She loves her liquids. She'll drink more than she will eat. I flavor her water for her so that she'll drink it...its thickened and has a lemon flavor to it that nobody likes. After some flavor...its gone in no time flat. I give her tylenol on my shift...daily....its all she has ordered...she doesnt talk or anything but I do it out of comfort on her part. She sleeps alot...she takes bp meds....one is lopressor 4 x day...and Imdur 4 x day...but her bp's are always good...so I dont know why she would need so many doses...Ive tried to get it cut back but that fell through. ...the doc wouldnt decrease it. I think thats why she sleeps so much....says right on the card that it will cause drowsiness. We got her an air mattress to help her out but...its like my hands are tied ......when I mention doing other things ..the DON starts in about " that costs money you know ! ".....or "hospice wont pay for that"....I told her she needed to go in and change that drsg and she'd see why something else needs to be done. ....which naturally....she wouldnt do. i honestly dont even think she knows how to do a drsg since shes been in mgmt so long.....she wouldnt be able to find her way around in the tx cart.

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First get a culture and find out what kind of bacteria you are dealing with. Most hospice I have worked with allow antibiotic and wound treatment care. But before you can determine treatment it's important to get that culture. The smell you describe sounds like MRSA. And vancomycin is atb of choice for that. Vanco now comes in an oral form so if hospice says no to IV therapy, vanco can still be given. As far as topical treatment... normal saline flush, santyl, and moist saline gauze packing, cover with abd. I would also suggest wound vitamins Vit C 500 mg qd, zinc sulfate 250 mg qd, MVI qd, and protein powder supplement BID. Arginade drink mix also effective.

In situations not involving hospice, wound vacs are great for healing wounds that don't respond to other treatments. But this can be quite expensive. I have seen duoderm used but I am not impressed with it.

The weirdest treatment I have seen was maggots placed into the wound to debride the necrotic tissue. That was several years ago but I believe it is still done in some places.

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Specializes in LTC.

OHHHH thank you!!!!!!!! I am going to put this info down on the MD book and give it a whirl! UGh....the smell....is one Ill never forget. And hallelujah....when did vanc become PO? this is the first Ive heard of it but its about time it was made PO. Ive only seen it IV and in eye gtts. Her family will not allow blood to be drawn on her or IVs to be put in. I wouldnt think that they would mind a culture since the wound is already opened up like that. I talk to her daughter daily so that wouldnt be an issue to get that ok'd with her. I dont see how she hasnt noticed that smell...shes never mentioned it to me but anybody with a functioning nose can smell it. We currently have her on vit c 500 bid, she is on a protein wound supplement qd and another supplement 4 oz tid. Again....thank you so much.

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Yeah Ca alginate could be left for 3 to 5days depending on how much drainage you have and or if the pt is on hospice as you mentioned... you should probably use calcium alginate with silver... just make sure you secure well the dsg so that it wont leak and/or give you a bad odor...

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Specializes in LTC.

Good news! Its HEALED! YAYYYYYY...and no more odors. Ya cant beat that with a stick!

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I Just got TX nurse job......And i m on 3 weeks training...........tomorrow is my 8th day of training....usually i follow nurse,,but sometimes there is only gt dressing change or suctioning,,and nurse let me do it..

So far i havent seen any pt that u are talking abt,,,,,,but yes i have done some wound vac,,,and some of pt smell is like,,i cant tolerate.........so this is just my beginning.. Will see this types of wound later in my life....

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Sasha2lady,

I just want to thank you for taking such good care of that pt. Asking questions to try and help heal her wound, flavoring her water to get her to drink more, questioning the orders for lopressor, etc. It's nurses like you that really make a difference. I bet you played a big part in helping to heal that wound as well. Kudos to you!

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