Dry wound

• Intrasite gel (15 g tube); cover with Telfa, for example

• Duoderm: if no infection

• these products promote debridement

Wet wound

• Foam

  • Allevyn-pink side up

  • Biatain

  • Mepilex-good if painful wound

• Calcium alginate (Kaltostat)-no lateral wicking; has hemostatic qualities

• Hydrofibre (Aquacel)-when wet, becomes a gel that peels off easily; can be layered

Edema

• Edema predisposes to skin breakdown

• Elevate legs above level of heart 1.5 h tid (even 1 h bid might help)

• Elevating legs to below level of heart may stabilize edema, but would not likely reduce it

• Can use elastic or inelastic systems to decrease edema

• After edema is decreased and any wound healing is complete, can start compression stockings

Elastic systems

• Profore elastic bandages (better if pt is not very mobile); Surepress is another brand

• used to decrease edema, perhaps 1-2 wks

• Check ABI first

  • ABI 0.6-0.8 : can use 3 layer (approx 25-30 mm Hg)

  • Normal ABI: can use 4 layer (approx 40 mm Hg)

• Apply padding to shin, malleoli before applying these systems

• If elastic system causes pain, remove

• Change daily x 3 d, then 2-3 x /wk until wound healed (or, if no wound, until edema controlled)

• Apply from base of toes to base of knee

• CCAC can apply these

• Just before nurse arrives, pt could take off bandages and wash with hand-held shower

Inelastic systems

• Short stretch Comprilon (about 40 mm Hg)

• Check for normal ABI first

• Patient should be ambulatory

• CCAC can apply these

• wrap limb x 1-2 wks to decrease edema

• when edema decreased, can fit for stockings

Compression Stockings

• Use stockings AFTER edema has decreased and any ulcer has healed

• Check ABI first (in interim, could use tensors)

  • If ABI >0.8, can use high compression stockings

  • if ABI 0.5-0.8, can use low compression stockings

  • If ABI <0.5, don’t use stockings; also, spontaneous wound closure may not be possible

• Strengths

  • Class 1: 15-20 mm Hg; over-the-counter; example: maternal support stockings (for pregnancy)

  • Class 2 : 25-30: the minimum suggested for someone with edema

  • Class 3: 45-50 mm Hg

• Below-knee stockings are sufficient; tighter at foot, lessening pressure up to knee

• Go for fitting first thing in the morning when edema will be less

• seek pharmacy where someone is qualified to fit stockings

• Cost: about $40-100 per pair (Dell East Mountain $55, for example)

• Stockings should be worn all day; they last 4-6 months

• Wash stockings out each night, then hang to dry (prescribe 2 pairs at once)

Infection

a) Subclinical infection:

• Poor quality granulation tissue

• Friable/grey-violet dusky colour

• Increased pain

• Increased discharge

For subclinical infection, could start topical abx; if improves over 2-3 wk, then continue until better

If not improving, switch to po abx

Topical antibiotics (for subclinical infection, not for infection prophylaxis)

• Flamazine: perhaps less resistance; at least daily dressing change (apply bid, for example); not ideal if wet wound; not if sulfa allergy; using a silver-based dressing may be less expensive

• Bactroban—better spectrum of coverage than polysporin; useful for impetigo

• Polysporin

• Fucidin: potential sensitizer/contact reaction, esp in those with venous insufficiency ulcers

• Iodosorb

• Betadine for non-healable wounds (ABI < 0.5)

• Metronidazole gel: covers anaerobes; useful if odour

b) Frank infection/cellulitis

• Non-diabetic ulcer: Cephalexin (Keflex) 250 qid

• Sacral ulcer: cipro 500 bid

• DM foot ulcer

  • cipro 500 bid + Clinda 300 tid x 2 wk (this combo also covers pseudomonas) or

  • Septra + clinda or

  • Metro + (keflex or Septra) or

  • clavulin

Taking a wound swab:

Try to sample from a clean base; use zigzag motion with swab

Other wound care notes

• Mechanical debridement of necrotic tissue is important (intrasite or duoderm allow some debridement as an alternative)

• Infected or very wet wound: mesalt

• Avoid wet-to-dry dressings

• usually sufficient to change dressings q 2-3 d unless excessive drainage

• Every pt with DM + neuropathy should see podiatrist or chiropodist for foot care

Arterial disease ulcer: distal, painful

• Mgt: tensor okay; NOT compression stockings

Acute stasis dermatitis: bilateral, crusting, can be red, warm

• mgt: elevate, topical steroid