SuperHawk Asked May 2020
Any practical advice for a total novice on wound care for unstageable pressure sore management?
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The doctor was willing to discharge my dad back home and without any nurse support nor instructions which was shocking to me. He simply said "He is an old guy"....meaning ? Let his wounds become infected?
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I would call him back and ask for a script for home care, for a nurse to assess and provide in home wound care. Start researching and contacting home care agencies to decide on one to choose, as it is your choice, not the doctor's.
If he won't do that, try to find a wound care specialist or wound care clinic. In my area, large hospitals sometimes have special wound care clinics.
To infer that he's old and not provide care is to me irresponsible. Even if he's old, wound care would make his life safer.
Discharged from a US hospital? Call the patient advocate tomorrow and report this.
AFTER you get the doc to prescribe home care services, of course.
I would write a report stating specifically what happened and send it to the hospital, the AMA and the states governing body for doctors, this doctor needs to go mop floors.
You say I ought to call the hospital but for me the hospital belongs to this medical group. I don't think there is a hospital manager.
Make sure your dad gets extra protein.. Ensure, lots of protein, for some reason someone told me that it helps because the body needs protein to heal...??
If dad got it in hospital,,the doctor knew it and knew you didn't know how fast and bad these things get..
rotate every 3 hours. keep him off that spot.. clean bandages.
If you can find it, there is a protein drink called Juven. It is supposed to help with healing after surgery; my sister drank it while recovering from her most recent pressure wound.
Diagnosing this would mean they’ve done some sort of evaluation.
Is it unstageable because it is not an open wound? Usually unstageable pressure ulcers are open wounds or can’t be measured for depth/width/length. Stage 1 is redness around an area With no open areas (yet). In order to be classified as unstageable the wound needs to be evaluated by a MD as they measure depth/length/width. When I was a HC RN we measured the wound weekly to assess for healing.
Did a wound specialist see the pressure ulcer while dad was in the hospital?
If it’s unstageable and no one has seen it, how could someone write woundcare orders?
Now dad will have to see a woundcare specialist to determine treatment. Then homecare will get ordered for woundcare if needed.
A physician needs to write homecare orders & specify woundcare to be completed and homecare orders the supplies designated by the doctor. Nurses can assess the wound but not write woundcare orders (unless they are PA’s or NP’s).
I can’t believe that doctor just discharged him with no instructions. Usually a nurse will come and explain discharge orders to a patient, not the doctor. Did anyone discuss this with nursing on dad’s discharge?
Change his position every two hours. Get an order for an alternating air mattress for his bed while he is sleeping.
Make sure he gets protein in him to promote tissue healing.
What does his wound look like now? As a nurse I am curious.
I'm shocked that there are 9 areas of concern, not to mention the size of the sacral wound. Could you provide some background how these occurred? Is your father primarily sedentary, limited in mobility, and spent a lot of time sitting or laying down?
What was the cause that prompted hospitalization?
I am definitely not criticizing, just inquiring. His conditions at home could provide insight into how the ulcers developed and contribute to an appropriate curative plan. I'm also wondering if he's diabetic?
You are aware I hope that you can ask for a different doctor? I did that when a hospitalist and two young things with little people experience outstepped their bounds. I don't recall if I approached the Charge Nurse, or called the hospital Administrator, but I got rid of the insensitive ones and got a doctor who focused on elderly care.
He was much more sensitive; although he was also frank, he was professional in addressing the issues, unlike the "baby doctor" who still needed to learn how to deal with older people.
Shane is very insightful and I anticipate will have more questions and advice.
It has been 3 weeks since admission and yesterday nurse informed there are now 9 pressure points plus sacral is 10-15 cms.
Is it normal to be in hospital with 3 nurse shifts and have that many and sacral expanding? I read wound care is very expensive. Is that why they are expecting me to accept there is nothing more to do?
Not even rotating him??
The size of the largest ulcer is to me indicative of need for medical treatment in a hospital, or perhaps even a rehab center. I think this doctor may be thinking of his "quick discharge" score in wanting to send your father home.
I think the Hospital doesn't want to admit its their fault. It can be considered abuse. Get someone to order an in home wound care nurse.
When my father makes it back home I need to make sure someone VERY specific oversees his decubiti. Or are all rn's knowledgeable and trained enough?
I shiver thinking of dad's actual wound state. No one can answer anything. Almost as if they were under a gag order. I am so afraid for him.
What turned the corner for her was Procellera. It is gauze with tiny metal dots on it that, when exposed to moisture (like sterile water or saline), creates a small electrical charge. This stimulates the blood supply and promotes healing. My sister was the first patient in our city to use it, with the approval of her wound care doctor. We bought it directly from the company because it was a new product that had recently been approved by the FDA. I believe it is more readily available now and may be covered by insurance. (I don't work for them, but the product worked for my sister and I have told many people about her success using it.)
Sounds incredible. A charged dressing.
I hope your sister will continue well. Were these private consults or through insurance? Access to consult with 2 different doctors sounds luxurious.
With an HMO once you select medical group you can only have doctors under that umbrella for coverage. Asking for second opinion among them will certainly have conflict of interests. Second guessing colleagues is something not covered so it is never brought up I suppose.
You wrote the magic words: HMO, rotating doctors assigned by the HMO.
It might be costly to get Medicare now, but please do consider it.
And even though the HMO assigns the doctors, you still have a right to criticize, or call an Ombudsperson. And I would do that.
I am looking into getting an ombdusperson if they try to discharge him to an unsafe skilled nursing facility without consulting me. I hope the SNF know better and tell them not until his sacral sore is not addressed medically. I do not think dad is getting antibiotic therapy to avoid sepsis. They are with the wait and see approach. Very mean system.
Go to a health oriented store, ie Trader Joe's, Natural Grocers, even a farmer's market and buy RAW honey. It will be a bit cloudy because it is not processed and it is expensive, but a little bit goes a long way. Be prepared to pay around 10.00 a cup.
I discovered that not everything labeled as honey really is when treating a skin rash on holiday. I ran out and picked some up, needless to say that all healing came to a screeching halt, that is how I discovered the fraud.
He needs proper wound care Doctor, treatment nurse, and nursing assistants. He needs a team.
Take pictures, take pictures.
As a Medicare patient your dad has rights. As a patient he has rights. Complain to Medicare.
Then within 1 hour a case manager called and said they had found a placement in a SNF. So they could discharge him tomorrow. I said I was already in conversation to have him back home on Monday. She said once there's a placement available and discharge in place patient needs to go. Or you could be hit with some fees for the extra days. So I had to rush decision and move dad's return home for tomorrow!
No time for mattress negotiating....I was assured by social worker he would get what he needed. Rest assured. So now I just realized that I will be 99% responsible for all his care. When I asked if nurse could also help with dad's stoma bag I was told if that day needed change. But that nurse was mostly wound support. Now I just realized that if mattress is not alternating pressure.....I will need even more to be on top of repositioning.
24 hours a day. Just not physically possible. Yet that is what they are leaving me with. So I will have wound, stoma and condom Cath care verification all day and night.
When will I sleep? May have to get a relative to caregive moonlight shift for some compensation.
I was so fixated on dad's wound care I had forgotten the package was much larger. This was a savvy entrapment. Feels very coordinated ....impossible to out maneuver the system. This will be my last good night sleep until I get plan B set in motion. Rotational mattress and/or shout out to a cousin to help during night time repositioning. Somehow they still manage to slide in the word team (working with me).
My mom never has pressure sores except when in the hospital or rehab. At home we use Desodine to prevent them.
Getting up moving around and changing positions is also key.
He is 90 so that number alerts hospice in preparation for the end. Currently he is bedridden. I almost lose hope upon looking at his wound for the first time today. Almost but I have a little left.
How could you muster courage to undertake stage 4 curettage? I will start on peanut butter breads tomorrow. And smile with my slice of hope left.
Thanks much for your success story. You did everything right.
Answering your question here.
I have worked with RNs (as their secretary) and my daughter is one. They all know what a pressure sore is and how to treat it. Just some, like my daughter, are better trained. She runs a Woundcare unit and was a wound care nurse at a facility she worked for.
Someone mentioned they had been shown by a Nurse how to dress the wound. Thats OK but a nurse should be checking it regularly.
it also sounds like you need a different doctor.
Healthy skin needs all these components:
good oxygenation = good circulatory and good respiratory system functions
good nutrition = balanced diet and if there are wounds, a little more protein and probably vitamin pill
good hygiene = mild soap and water and mild rubbing on healthy skin to remove bacterial load
good mobility = moving self or help repositioning every 2 hours , if there are wounds, keep bodyweight off that area
good hydration = enough water so person urinates every 3-4 hours and pee is clear to straw in color
As for wound care. The adage is, "If it is dry, make it wet. If it is wet, make it dry."
Wet/Oozing wounds - clean with liquid soap like Hibiclens in water, rinse with clear water, place non-stick pads over all of wound, pad with gauze to absorb fluids, and wrap with rolled gauze or elastic bandage(ACE) and secure in place.
Dry wounds - clean with liquid soap like Hibiclens in water, rinse with clear water, allow to air dry, coat with triple antibiotic ointment, place nonstick pad over wound, wrap in rolled gauze or elastic bandage (ACE), and secure in place.
Change dressings daily and keep a record of the size, depth (use a Qtip), drainage, colors. Let doctor know if wound is getting bigger, deeper, or changing colors or drainage. Doctors can prescribe antibiotic ointments or oral medications. Doctors can also prescribe visits from a wound care specialist.
In some older folks, wounds do not heal well or easily since they usually have problems with circulation, nutrition, mobility and/or oxygenation. So, do not get discouraged if your efforts do not yield speedy results.
Dressing it only hid it from view. This hospital has an outpatient wound care clinic and they boast they are among the best. Their specialty is non healing wounds.
So....if money could buy you better dressings....why doesn't anyone put that on the table? Then one decides what or how to gather the money.
I am wondering WHY they allowed dad's pressure injury to go "day by day" denying it was actually getting worse !
Re: gel mattresses -- in addition to turning the patient, don't forget to turn the mattress (or rotate, whichever the instructions recommend). My sister had one that Medicare provided and after a couple of years, it developed a sunken place right where my sister needed the most support. (She has since purchased a Purple mattress, with her wound care doc's approval. Not cheap or covered by insurance, but it is holding up well.)