[LTC LPN 2006]

Looking for help answering some questions or opinions/suggestions. TIA!!!


1. If a wound is unstagable due to slough or eschar but say the eschar is on a heel, dries up then peels off to be very superficial appearing as a Stage II, can it be a Stage II or must it be Stage III even if it isn't deep because you cannot have slough or eschar in a Stage II.

2. For SDTI that was purple and blister-like where the top layer of the blister opened up but the underlying tissue was still purple in color how would you stage it? Can it be staged? It no longer qualifies as SDTI because it is open (or can SDTI be open??) I thought it would be unstagable because I cannot visualize how deep the tissue damage goes, however there is no apparent slough or eschar. Depth wise it was very superficial like a Stage II, but with the purple color I assume it will progress deeper.

3. With the addition of SDTI I am confused on using the Push Tool as to a value for "Tissue Type" It is closed, but that seems misleading as it probably will open up and it doesn't really fit any of the other tissue types either. Along these lines, if a wound such as the one described in Question 2 were to be evaluated, what tissue type would that be? It isn't closed, the wound bed is purple, not deep granular, not slough, not eschar, but not pink shiny epithelial tissue either.

[cougarnurse]

#1 will be an unstageable, as you couldn't see underneath.

As for the others.....I'd have to ask my Consultant; she'd be able to answer those. I would hazard a guess that #2 would be a Stage 2; as for the PUSH tool...never used it. Sorry!

[LTC LPN 2006]

For question # 1 - once it becomes stagable and the eschar or slough is gone, can it ever be a Stage II or must an unstagable wound either be Stage III or IV because at one point slough or eschar was present?

[cougarnurse]

I was told at the seminars that you can't 'downstage' a wound. If it is unstageable, it is unstageable. When the eschar is gone, it is a healed unstageable.

[LTC LPN 2006]

I originally thought that as well, but when I asked corporate she said you cannot leave something unstagable. Once you can visualize the wound bed you must stage it... and from there it cannot be downstaged. The staging can only get worse and once you can see bone even if you cannot completely visualize the wound bed it is a Stage IV because it is at least to the bone.

[cougarnurse]

Example I am thinking of: heel, 3 by 3 hard eschar; unable to see underneath. Used Betadine for antimicrobial/keep area 'dry'. Eschar flaked off, revealing pink, healed area. Will never know what stage it was. Could have been 2, could have been 3. Tough call, really.

[LTC LPN 2006]

True, in that instance I would go from unstagable to resolved without ever giving it a stage I suppose.

So do you guys use Betadine for those types of heels? I like that myself, but Betadine is not part of our protocols and I got the impression corporate didn't care for the stuff.

Ever have a pt with osteomyelitis? I've got an unstagable heel with possible osteomyelitis... he went to an infection control specialist this week... I wasn't really sure how to handle that. I didn't know if debridement would open a can of worms or if we should try to dry it up... doc chose Santyl so we'll see how that goes

[cougarnurse]

Betadine worked wonders on the two heels I've had. Consultant had no problem with it. Not really on the books, but my judgement call.

Never used Santyl. Accuzyme....yes! That stuff is great.

Don't recall any osteo., but did have a case of gangrene . Wasn't our fault, though.

[LTC LPN 2006]

Since Xenaderm started having problems being covered by insurance I guess the next ones to have problems according to their rep is Panafil & Accuzyme... so our corporate decided to start using only Santyl before problems with reimbursement begin. Santyl is a collagen based debrider that works on the connections below the eschar to break it loose as opposed to Accuzyme that debrides from the top down.

[cougarnurse]

Panafil is the best, but need pre-approval with that stuff. Would pick that over anything. Keeps the *smell* down.