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I have a resident in a SNF that had a Stage 3 pressure ulcer on his hip- had been improving for months with the use of collagen and then began to deteriorate recently. Started noticing increased bleeding at the site,hypergranulated, friable, initiated Vashe cleanser to see if this would help reduce biofilm and did improve for a couple weeks and today was bleeding more consistently and seems to have become deeper /cratered again in the last week. He is a complicated individual that refuses care much of the time, is on a low air loss mattress. Looking for recommendations for the next step in dressing options.
Nov 24, 2020 by Cristin Craft,
4 replies
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Nov 24, 2020
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Nov 24, 2020
Cathy Milne
APRN, MSN, CWOCN-AP
Hi Christin,
When wounds deteriorate after doing well, I always step back and wonder 2 things- Is this an environmental issue or a physiological issue. Environment is pretty easy to look at - is the patient's bed functioning correctly? (Sometimes the CNAs change the settings from LAL to static or I've found them not plugged in - so ask the CNAs if something funny happened...also - what kind of wheelchair seating does he have? Is is properly inflated?
Either way - if you have access to pressure mapping (ask your Therapy Dept.) it's always a good idea to have the w/c and bed mapped if possible....Also -was there a new CNA taking care of the patient? Does the patient report being a "little off" when positioned in the w/c?
Let's move on to the patient - Has the patient been ill recently? Sometimes that will stall a wound out? Nutrition status OK? Blood sugars controlled? Vit D levels adequate? Thyroid OK?? Taking supplements (preferably with arginine/glutamine)? Does this patient have spasticity that needs to be addressed? Sounds as if you've done well at bioburden control...have you done an osteomyeltis work-up? Given what you've told me, I wonder if this is indeed the problem....I typically find that is the ESR is over 60, I may have osteo and I begin the deeper dive.If the patient does not have osteomyelitis - talk with the Therapy Department regarding the use of an adjunctive - such as diathermy or e-stim...
The hypergranulation may be related to bacterial load and I find application of silver nitrate a few times a week for 2-3 weeks can be helpful...but I suspect there is something deeper going on here...
Hope this helps!
Cathy
Nov 24, 2020
Elaine Horibe Song
MD, PhD, MBA
Agree with Cathy's insightful thought process. The fact that the wound is deteriorating would prompt me to reassess the entire patient and the treatment plan, to see if the underlying conditions/co-factors/comorbidities that cause the PU/PI or impede healing have been adequately addressed. The suggestions Cathy mentioned above are a great checklist specific to cases like the one you shared; and here is another checklist for reassessment of treatment plan that might be helpful. https://woundreference.com/app/topic?id=pressure_ulcer_injury_treatment#plan-reassessment

From your description, it seems the predominant tissue of the wound bed is hypergranulation (can't see the pic well though). Along the same vein, resolving the cause is the first step in treating hypergranulation tissue. Some typical causes of hypergranulation include infection (osteo? local infection?), repeated trauma to the area (is the patient being adequately repositioned/offloaded? any environmental changes, as Cathy mentioned?), excessive bleeding/exudate, low oxygen levels. Patients with diabetes are more susceptible to infection and also may develop hypergranulation tissue more easily, so if the patient is diabetic, it'd be important to see if it's adequately controlled. 

Since you also asked about next step in dressing options for hypergranulation: assuming the causes of wound deterioration/hypergranulation are adequately addressed (including infection/osteo work-up) as described by Cathy, in addition to removal of hypergranulation with silver nitrate (or conservative sharp debridement if available), another option that has been reported is hypertonic NaCl dressing (e.g. Mesalt® or Curasalt®) as primary dressing and a non-occlusive dressing such as foam (e.g. Mepilex Border, Allevyn), as secondary dressing. Other options include medical honey-based dressings or silver-based foam dressings (hydrocolloids and hydrogels may increase hypergranulation though)

Here is more info on osteo work-up for PU/PI: https://woundreference.com/app/topic?id=pressure-ulcersinjuries-introduction-and-assessment#infection-associated-with-pu/pi29
And here is a related CSC post: https://woundreference.com/app/post?id=489
Nov 24, 2020
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