wound care (Full Version)

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joshua5 -> wound care (March 11, 2006 4:04:00 PM)

i spend some time as a PT in a SNF. i have a resident with a venous ulcer on the medial aspect of her lower leg. she was receiving estim at the local wound care center 3x/wk for an hour prior to coming to me. i've done some stim on pressure ulcers but not venous legs. the wound is approx 6 cm x 2 cm and very very shallow. mostly a nice red bed. had it for about a year. i'm signed up for a wound care course for the spring and i looked through my electro book but more info would help. i have discussed the case with the wound care clinic she was going to but i feel like this is an area i'd like to learn more about for my residents. does anyone have any websites or info that might lead me in a good direction towards various treatments? not willing to go through my statistics book to decipher heavy journal articles (i'm a new dad and would rather spend my time in those endeavors!) thanks for any replys, i really appreciate it.



FLAOrthoPT -> Re: wound care (March 11, 2006 4:39:00 PM)

it has been a long time since I did wound care, but let's not make it that complicated. If I remember right, medial ankle is usually venous ulcers. So, do not have this person dependant in a whirlpool. The trick here is compression compression compression. Now you can waste time with microcurrents and high volt and anodyne, but let's treat the real problem. Keep the wound moist but not wet, and not dry. So depending on the amount of drainage or dryness select the appropriate dressing, non adhering preferably. but even if it is not venouos from PVD, but more from a cut or something, treat it by providing a healthy non infected wound bed, debride any necrotic junk, keep it moist but not macerated, give it some wetness via gels etc if it is dry, if you can afford some granulux etc do it, and make sure they are keeping it clean and elevting and compressing if necessary. Wound care was rewarding and VERY cookbookish, not so hard, just neat the stomach for it, have fun, screw the E stim
Ben



tucker -> Re: wound care (March 11, 2006 6:06:00 PM)

Great job Ben! E-stim is indicated for chronic wounds that show no progress in several weeks. You have a clean granulating wound so you are on the right track. As Ben just stated, the main treatment will be increasing venous return with compression dressing, preferrably a multi-layer dressing (ex. Profore, which has 4 layers). An Ace bandage is not as effective. leg elevation, frequent ankle pumps, NO whirlpool, no smoking, adequate nutrition, avoid crossing legs and static standing, etc..and promote a favorable wound healing environement as Ben stated..Keep the wound moist and cleanse with saline moistened gauze (jet lavage is also an option for larger areas, if tolerable).

I doubt this is a problem if the wound bed is beefy red, but anytime you begin compression dressings, circulation must be addressed with a pulse exam. If there is a palpable pulse at the DP, blood flow is adequate..proceed. If it is not palpable, an ABI (ankle brachial index; normal is 1) is indicated to rule out arterial insufficiency and predicts the ability to heal. ABIs above 0.8 will heal. ABIs of 0.5 to 0.8 means high risk for non healing and should not be debrided or compressed. A referral to a vascular specialist is indicated as well. Finally, ABIs greater than 1.0 may be a falsely elevated for patients with diabetes with calcified vessels.

A great wound care reference:
Wound Care by Carrie Sussman and Barbara Bates-Jensen

Hope this helps and congrats with the new baby. I have a 3 year old and a 3 month old.

Darin Trees, PT, DPT, CWS



tucker -> Re: wound care (March 11, 2006 6:18:00 PM)

More information on venous insufficiency from emedicine. Pictures are included at the end showing the hallmark signs of stocking discoloration and varicose veins.

http://www.emedicine.com/DERM/topic474.htm

Darin



joshua5 -> Re: wound care (March 12, 2006 10:21:00 AM)

thanks guys, this is just what i was looking for. not so sure the profore is indicated as there isn't much drainage and swelling is negligable which went against my preconceived notions.

another quesiton...
what estim parameters have you had the best luck with for this type of wound? i know the ones i'm using are ok but i'd like to heal this thing up asap! yes, i understand that one patient/resident's parameters may not be ideal for another but i want to give her the best chance possible of healing. thanks for any replys.



FLAOrthoPT -> Re: wound care (March 12, 2006 11:43:00 AM)

don't waste the time of cleaning or setting up the e-stim I think is what we are saying. I fyou are insistant upon using it: here is a good site:
http://www.medicaledu.com/estim.htm
good luck,
Ben



tucker -> Re: wound care (March 12, 2006 2:20:00 PM)

I agree with Ben.

What compression dressing are you currently using for this patient? What has she used in the past for compression?

Darin



ehanso -> Re: wound care (March 13, 2006 4:22:00 AM)

Let's not forget the basics. Nutrition and perfusion. Is the patient getting a good nutrition and what are the O2 sats. Without these basics taken care of the treatment selection is not that important.



Jeffre -> Re: wound care (March 13, 2006 7:12:00 AM)

Tucker,

How does the Profore compare to an Unna boot in terms of effectiveness? Is it a cheaper alternative?



tucker -> Re: wound care (March 13, 2006 1:45:00 PM)

Good question Jeffre. There have been a few studies on the topic and multi-layer compression bandages are believed to be superior because they do not lose elasticity as quickly as an Unna and keep a constant pressure even when supine. Unna boots rely on walking and the muscle pump action it generates. Unna boots would have little use for a bedbound patient.

As far as 'clinically effective'..I am not aware of any studies that show it is more effective. The studies that I have seen are with several pressure sensors on the legs to look at compression over time and with activity. Cheaper alternative? Definately better than no compression at all, but I would prefer the multi-layer if available.

Here are a few studies:
Hafner J, Botonakis I, Burg G. A comparison of multilayer bandage systems during rest, exercise, and over 2 days of wear time.
Arch Dermatol. 2000 Jul;136(7):857-63.

Bergan JJ, Sparks SR. Non-elastic compression: an alternative in management of chronic venous insufficiency.
J Wound Ostomy Continence Nurs. 2000 Mar;27(2):83-9. Review.

Darin



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