Wounds1 Discussion with Susan Mendez-Eastman, RN

August 13, 2003

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Wounds1 : Welcome to today's Wounds1 discussion with Susan Mendez-Eastman, RN.

Wounds1 : Susan Mendez-Eastman is certified in both wound care and plastic surgical nursing. She has served four years as a Surgical First Assistant at Omaha's Plastic Surgical Center, and is a research nurse for the University of Nebraska Medical Center College of Nursing.

Wounds1 : She maintains independent practice privileges at several Omaha systems and is also a wound care nurse for the Nebraska Health System Center for Wound Healing. She received her ASN degree in nursing from Metropolitan Community College of Omaha, Nebraska.

Wounds1 : Susan Eastman-Mendez also serves as continuing education coordinator for the American Society of Plastic and Reconstructive Nurses in addition to performing legal case reviews in the area of wound care. She has delivered some thirty conference presentations and is the author of over a dozen medical articles on wound therapy.

Wounds1 : We are pleased to have Ms. Eastman-Mendez as our guest and we welcome questions from our users!

Sandy Smith : I have been dealing with a fractured heel for a year and walking with a compression stocking on and a cam walker, sweating caused a blister on the outer edge of my foot. 2 weeks later and careful watching, the blister turned into an ulcer in 24 hours. After reading articles in here it's at a stage 3. Dr. has me with deoderm changed 3x week, and on augmentin 875 mg BID. I've had to discontinue PT and the stocking. Swelling and stiffness are at it's worse. Walking 50% with 2 crutches. Return to the Dr. in 4 days. Would whirlpool therapy at PT with chlozipine added help heal an ulcer at this stage? How long do I treat with deoderm until debridement is needed?

Sue Mendez-Eastman, RN : Because every wound is different, and treatment varies dependent upon not only the wound, but the host, this is difficult to answer without a complete physical and assessment. At the Center for Wound Healing (CWH) at Nebraska Medical Center, we take an interdisciplinary approach where several disciplines are involved in the treatment. We don't use a lot of whirlpool treatments due to cross contamination problems. A wound must be debrided in order to heal or consider skin grafting or flaps.

carol vassar : About three months ago I had a skin graft applied to my lower left leg. This wound area I've had since 1981, as a result of surgery, from being bitten by something, while working in my garden. I wonder if you could tell me what the average recovery period might be. Also how long it takes for the stitches to dissolve. The wound measured 2 inches by 2 inches.

Sue Mendez-Eastman, RN : In a healthy host, complete healing will always take at least 6 months to a year - this is when the wound is considered to be completely healed and achieved it's maximum healing capability. As far as the stitches, it depends on the type the surgeon used. Usually they will dissolve anywhere from several weeks to several months. We usually keep our skin graft patients, who have grafts to the lower extremities, in compression stockings for approximately three months, but the graft itself would not be considered completely "healed" or matured for 6 months to a year.

amanda catton : What are the signs and symptoms of venous and arterial leg ulcers and how do you make a differential diagnosis?

Sue Mendez-Eastman, RN : venous ulcers are caused by decreased or absent venous return. Arterial ulcers are caused by decreased or absent arterial flow to an area. Many times the ulcer is caused by both venous and arterial insufficiency. The signs of a venous ulcer. The best diagnosis is made by doppler studies. Venous ulcers are usually superficial in depth - although full thickness, drain quite a bit and the leg has signs of venous insufficiency (woody appearance, dark coloration). Arterial ulcers are usually deep and appear "punched out". They are almost always very painful as they are caused by lack of oxygenated blood to the area. They are usually dry, if not infected, and are often accompanied by venous ulcers as well.

[email protected] : I have a patient with pressure ulcer on ear. She is bed-bound and total care. We have tried several different treatments and dressings and nothing seems to be working. Any ideas?

Sue Mendez-Eastman, RN : All pressure ulcers must first and foremost have the pressure relieved. This can be done with foam or a gel pad in some instances and alternating the head from the opposite side to the back of the head until the wound is healed. Whenever a wound is not responding to treatment, infection or other co-factors should be considered. Keeping the wound clean and moist (not wet) with a hydrogel, for example, may be beneficial - once infection has been considered, treated, or ruled out.

BC : What are causes for persistent bloody drainage from pressure sores? If a pressure sore is classified as non-healing and complicated by chronic bi-lateral osteomyelitis is there any documented instructions for the caregiver? My son is only 29 yrs. old and is paraplegic from a fall from a tree 7 year ago and has been plagued with decubitis sores since then.

Sue Mendez-Eastman, RN : Blood is usually considered a good sign - in moderation. A wound must have adequate blood supply to heal. With that said, if osteomyelitis has been diagnosed, this must be treated before healing can be expected. Treatment for osteo can include IV antibiotics, Hyperbaric oxygen, and debridement. Debridement would be a surgical procedure where the infected bone is removed to the point that healthy, bleeding bone is exposed. Depending upon the size of the wound at that point, a muscle flap may be considered. Also, as noted in the previous question, if this ulcer is due to pressure, the pressure must be relieved. This can be accomplished with frequent repositioning and pressure relieving support surfaces (bed and chair/wheelchair cushions).

Jonathan Harris : What is Vacuum Assisted Closure of wounds, how does it work and when is it used?

Sue Mendez-Eastman, RN : To BC - I suggest that you contact a social worker to assist you in finding all of the available resources for support. Your son is likely eligible for many things, like a specialty bed, special wheelchair cushion, etc. A social worker can help you acquire the help you need. Your son's doctor should be able to get you in touch with a social worker.

Sue Mendez-Eastman, RN : Vacuum Assisted Closure (VAC) therapy is controlled negative pressure that is used for a variety of wounds. VAC therapy works by stimulating circulation to the wound bed, decreasing edema around the wound, decreasing bacterial load, and drawing the wound closed in a moist, protected environment. VAC therapy is used on both chronic and acute wounds. The VAC does not take the place of antibiotic therapy in an infected wound, but can assist with the treatment of the infection by increasing blood flow to the wound and removing stagnant wound fluid. There are many web sites and articles about VAC therapy in the media today - I think it works great and encourage you to go to the KCI web site to learn more specifics or call your local rep to come and explain it to you in more detail.

Valerie Martin : My son had a skin graft to cover his open transmetatarsal amputation of his left foot on March 24, 2003. The graft on the foot is healing nicely, but the donor site on his thigh has problems. It also was healing nicely up until two weeks ago. Then, large blisters started developing all over the site. These blisters opened up and were quite painful. We had gotten to the point where the site was uncovered and open to the air. Our plastic surgeon has now advised to keep the area covered with Silvadine ointment and change the dressings twice daily. We have been doing this for one week. The site was looking much better for three or four days, now blisters are starting to form again. We're not sure how we should treat this now.

Sue Mendez-Eastman, RN : When a wound is not responding to a treatment, the reason for the non-response should be investigated. If the surgeon has not cultured the area for possible infection, I would suggest that this be done to rule out or diagnose infection so that appropriate antibiotics can be ordered. Silvadene is a antimicrobial ointment, but is only topical. If the wound is infected, oral or IV antibiotics will need to be ordered.

Missy P : I have a 2nd degree burn scar on my right leg. It is about the size of my hand. I am dark skinned (hispanic) and although it has been a short while the majority of the area is pink with a dime size white patch. Will this ever turn brown again or is there a cosmetic surgery to replace the pigmentation. Any references will help!

Sue Mendez-Eastman, RN : If the burn was truly second degree (It is sometimes hard to be sure when the wound is still new) then the pigmentation should return. If, after 6 months to a year, the pigmentation does not return, there is no current surgical treatment. A scar revision may be considered after the scar has fully matured. This revision would try and minimize the scar size.

[email protected] : I have recently burned myself while parking my motorcycle (dumb). The burn is located on the back portion of my right calf. This happened 5 days ago, I have been very careful to keep it very clean and apply Silver Sulfadiazine. The burn area now has blistered and peeled and has red raised areas along with what looks like new skin in the center. It also seems to look wet or leaking in some areas now since it peeled. Is this OK? Is this the normal progression of this type of burn? Is there anything else I can do to keep it healing correctly. Thanks so much for your time and

Sue Mendez-Eastman, RN : It sounds as though this is normal. The leaking is lymph fluid - this is the fluid that your body sends to respond to injury. This is also why the area seems "wet". From your description, it seems to be following a normal course. Keeping it clean and covered with the silvadene is what we would probably do. I would suggest that you continue checking in with the doctor that ordered the silvadene to make sure the wound is progressing as it should, but it sounds like you are doing all the right things.

[email protected] : Hi . I just recently had breast reduction surgery about 4 weeks ago and I have been having a problem with some wounds not healing . every time my surgeon stitches them back up, the skin pulls apart from the stitches. the surgeon said he believes that it is due to a slightly higher than normal platelet count. I don't have any infection, did have some necrotic tissue and the surgeon has removed all of that. Help. please. I don't know what else can be done to close the wounds. thanks!

Sue Mendez-Eastman, RN : At the plastic surgical center in Omaha, Nebraska, if a wound opens (the skin pulls apart), we don't re-suture. We allow the wound to heal in from the bottom up (secondary healing) by supporting a moist wound bed with an ointment or saline gauze or other topical dressings. When a wound heals this way, it is likely to have unsightly scars - but these can be revised in several months. I have always learned that if a wound opens after being sutured, you are more apt to get an infection if you try to resuture it. During the time that the wound is healing in, the doctor can investigate the reason why your platelet count is high. Also, minimizing stress to the area (bending, stretching, lifting), NEVER SMOKE, and eat a high protein, well balanced diet will assist with wound healing.

Julia : About 6 weeks ago, I got 8 stitches on my upper arm. The stitches were taken out 10 days later, however they have left a very unattractive, raised, bumpy, pink scar. It seems that the stitches were in for too long and therefore got infected. The scar does not hurt. What do you suggest to diminish the scar?

Sue Mendez-Eastman, RN : During the maturation period of a scar many things are occuring under the skin. During the healing process the body first wants to heal for strength. In doing so, a raised, bumpy, usually pink scar forms. During the next several months the scar will reform beneath the skin. During this time, the collagen and fibrin that are holding your skin together will break down and build up several times until a nice, even layer of scar tissue is formed. I know this seems like a long time to wait, but it really does take this long. In the meantime, we suggest that you keep the area moist with lotion - nothing fancy - just a lotion, to keep the area moist since scars don't have oil glands. If the surgeon used disolving stitches beneath the skin, the bumps will be more pronounced. These sutures take several weeks to months to disolve. When we do any suturing, we explain to the patient that we must wait at the very minimum, six months before scar revision can be considered. In most cases, the scar will mature on it's own and leave a fine line, flat, smooth scar.

roger st amand : I have had venous leg ulcers going on 6 months. Visit Doctor every two weeks. Was looking good finally a few weeks ago. Spent one week without una boot wore compression sock. Next visit started with ulcers again. Should I consider Hyperbaric Therapy? Is there other things to consider? Presently have una boot and compression sock over same.This seems to be long time for healing to occur.

Sue Mendez-Eastman, RN : Venous ulcers are caused by a lack of venous return in the legs. When venous blood pools, it breaks down within the skin and causes wounds. When you have venous deficiency, it is a chronic problem and lifelong treatment with compression is usually needed - usually with elastic wraps or compression stockings. Hyperbaric oxygen therapy works well with some wounds and there are non-invasive tests that look at your oxygen level at the skin surrounding the wound that would indicate whether it may be beneficial to you. A skin graft can usually be done to close the wound, but compression therapy will be a lifelong fact in order to minimize the chance of reoccurrence. The good news is, is that many companies offer attractive prescriptive compression stockings that are easier to apply than before.

Paul Peterson : My mother has been diagnosed with peripheral Vascular Disease and has some open wounds on her legs. Do you have a recommendation for what type of chairs are available to assist in keeping her legs elevated?

Sue Mendez-Eastman, RN : In order to improve venous return, the legs must be elevated above the level of the heart - not many chairs can accomplish this. What we suggest to patients is that along with compression therapy with ace wraps or compression stockings, that they lay in bed with legs elevated on a pillow several times per day for at least an hour. Another way to elevate the leg comfortably is to lay on the couch with a couch cushion under the leg. A recliner is not going to allow the leg to be elevated high enough for adequate return. Prolonged sitting, of any type actually reduces blood flow as the bend at the waist slows the blood from returning to the heart.

Wounds1 : Users, we are out of time. We thank Susan Mendez-Eastman for joining us today and appreciate all of this insight into wound care.

Wounds1 : Stay tuned for future Wounds1 and Body1 discussions!

Wounds1 : Thanks everyone for joining us.

Sue Mendez-Eastman, RN : Thank you