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Wound Care: Part IV Jassin M. Jouria, MDDr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various

teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.

AbstractAlthough many types of wounds are easily treated, some require specialized expertise in order to resolve or treat the primary cause and to prevent additional wounds. Registered nurses and advanced RNs who opt to specialize in wound care provide an important skillset to patients suffering from chronic or acute injury, disease, or medical treatment. Most of these nurses adopt a holistic approach, coordinating efforts from the medical team to ensure that all aspects of a patient's health are considered in the treatment plan. These nurses provide both initial and ongoing wound care and serve as a resource to prepare the patient to continue care at home. As wound care is a rapidly advancing field, continuing education is necessary to ensure that nurses stay on top of the latest techniques and strategies. Nurses also have several options for certification in the field of wound care.

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Continuing Nursing Education Course Director & PlannersWilliam A. Cook, PhD, Director, Douglas Lawrence, MS, Webmaster,

Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner

Accreditation Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses.

Credit DesignationThis educational activity is credited for 3.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

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Statement of NeedNurses need to understand causes of skin breakdown, and, importantly, of wound prevention, types of wounds, and the treatments of acute and chronic wounds to allow healing.

Course Purpose To provide nursing professionals with knowledge of wound risk, phases of

development and healing.

Learning Objectives


1. Identify the importance of medication management in wound healing.2. Describe how a holistic approach can encourage wound healing.3. List strategies for preparing patients for wound care at home.4. Explain the role of continuing education for wound care nurses.5. List wound care certification organizations.

Target AudienceAdvanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses, and Associates

Course Author & Director Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence,

Susan DePasquale, CGRN, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC

Release Date: 1/21/2015 Termination Date: 1/21/2018

1. The wound patient should be provided with information about the nutrients that are important for wound healing. In this regard, the following is/are true:

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Please take time to complete the self-assessment Knowledge Questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the

course.

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a. less protein is needed when a patient has a significant wound, such as a burn wound.

b. the patient who is considered relatively healthy does not need nutritional guidance.

c. the patient needs an average energy intake each day to promote wound healing and should strive for 35 to 40 kcal/kg each day.

d. a person who is obese does not suffer from malnutrition.2. True or False: As part of the comprehensive and holistic wound

care assessment of a patient, lupus is one of the medical conditions that must be considered.

a. True. b. False. 3. A diabetic patient with a foot ulcer on the ball of the foot should a. walk and put pressure on the affected foot while the wound is healing to promote circulation. b. rest the area and elevate it on a pillow or blanket when a wound is in an extremity. c. rest, and be informed that elevation hurts with venous return of blood to the heart and encourages venous stasis d. a., and c., above. 4. Compression stockings are often used in management of venous ulcers but

a. the nurse, not the patient, must apply the stockings because applying them correctly is important for healing.

b. when stockings are applied while the patient is in bed, the nurse should lower the level of the feet to promote venous blood return.

c. a nurse should be aware that compression stockings can worsen wounds and ulcers that have developed from arterial insufficiency.

d. none of the above.5. Other principles that should be included as part of foot care for diabetic ulcer prevention include: a. Checking the feet at least daily for signs of injury or infection b. Avoiding walking around barefoot, which could cause injuries to the feet

c. Avoiding trimming or cutting calluses or ingrown toenails and having these conditions treated by a healthcare provider.

d. All of the above.

Introduction


In some situations, wounds are slow to heal, stalled, or are considered “hard to heal” when they take months or years to be fully restored. Alternatively, some wounds respond to standard treatments and heal without complications. Regardless of the situation in which a wound has developed, the factors surrounding the cause, course of treatment, and potential complications of the wound must all be weighed closely as part of wound management. While practitioners who care for patients with wounds typically address the physical factors required for wound care: the appropriate dressings and medical treatments to use, as well as the patient’s medical background, a holistic approach should be incorporated instead that comprehensively addresses factors that contribute to the delayed healing.

Holistic Approaches

There are several factors that must be considered as part of holistic healing of wound care. Patient-related factors, aspects of the wound, and the skills and knowledge of the clinician all impact not only how the wound will heal, but should also be included as a regular part of assessment and management of the wound. For instance, a patient who has altered coping mechanisms for managing anxiety related to his wound treatments may have a difficult time undergoing treatments. The patient’s ability to endure wound treatments and his or her ability to cope with anxiety about the treatments should be assessed at each encounter when the nurse provides wound care.

A position document developed by the European Wound Management Association discussed the factors to include as part of the comprehensive and holistic wound care assessment that are related to the patient’s background and these include physical diseases and medical conditions, such as diabetes, obesity, or lupus; additionally, psychosocial factors, including gender, economic status, and a history of mental illness and other patient-related aspects that may affect management of the situation,


including the patient’s spiritual background, beliefs, cultural practices, and coping mechanisms were included.52

Factors associated with the wound that must be considered have been discussed throughout prior courses in this series, and include such elements as the size, depth, or stage of the wound, the presence of infection, the development of granulation tissue and the condition of the wound bed, whether inflammation is present, the location of the wound on the body, and how well the wound is responding to treatment. Finally, the characteristics of the healthcare provider who manages the wound must be considered in terms of skill sets and a firm knowledge base on which to support practice parameters. The clinician factors to consider with wound management include knowledge of current and appropriate wound treatment techniques, continuing education practices, certification in certain areas related to skin and wound care, and the background knowledge of the process of wound healing.52 All of these factors form a base of assessment that includes a holistic approach to wound healing. When these factors continue to be assessed and addressed during treatment sessions and encounters with the patient, the clinician is working toward a comprehensive approach to wound care.

Because a wound may take a significant amount of time to heal, the wound patient may be in a state where he or she is able to provide self-care at home, or resides in a long-term care environment. Either location may not provide the continuous nursing support needed for managing health while the body heals from a wound. Therefore, it is important to provide education and guidance about various factors that will impact wound healing that the patient will need to perform on his or her own and to check in with the healthcare provider on an ongoing basis.

Medication Management and Patient Education


Management of the medications administered to the wound patient, as discussed in Wound Care Part III, involves not only an understanding of the indications, dose, and routes of administration of the drug, but it also means educating the wound care patient about the specific information needed to know about the medication. The patient who takes medication or who uses such items as dressings that are infused with medications must have a thorough understanding of the reasons for and potential outcomes of the medication. A better understanding of the purposes of medication on the part of the patient may more likely increase compliance with wound care.

Some patients want to pursue their own measures for healing or controlling the health of their wounds. They may take medications or apply topical ointments to the wound as a method of treating the wound, which may or may not work in conjunction with the medical care the nurse is trying to provide. For example, a patient may believe that even though he or she has regular dressing changes on an ankle wound that applying hydrogen peroxide to the wound every day will help to prevent infection. When discussing medications used for wound healing, the nurse may also need to discuss what measures the patient should avoid, as certain agents can cause more damage to the wound and surrounding tissue.

A patient who is at home with a wound should be educated about the medications needed for wound care and treatment, which may include topical ointments and/or systemic antimicrobial drugs. Education about medications in this case is similar to teaching a patient about taking any type of medication; to follow the orders of the prescription and take the medication as prescribed. If the patient will be responsible for applying a topical ointment to the wound, the nurse may have the patient demonstrate the proper method for applying the medicine before he is expected to do it on his or her own.


Finally, as with other forms of medication teaching, education about the medications associated with wound care measures must cover what side effects or interactions require further contact with the healthcare provider. The nurse may need to review the patient’s current medications to ensure that they do not interact with the medication the patient will need to treat a wound. The patient should also be taught about common side effects associated with the medication and when to call the healthcare provider.

Nutritional Guidance

The process of wound healing, including formation of proteins in skin structure and skin cell proliferation require extra energy that typically must be taken in through nutrients in food and dietary supplements. The malnourished patient, in particular, needs extra energy in the form of calories, protein, and vitamins, to facilitate the wound healing process when he or she cannot pull nutrients from energy sources in the body. Alternatively, even the patient who is considered relatively healthy and was not malnourished prior to wound development should still have ample energy intake to support wound healing and prevent delays.

The nurse must provide education to the wound care patient about the importance of nutrition; teaching provides information about how wounds can be more likely to develop in the absence of adequate vitamins and nutrients. Teaching should also focus on what nutrients the patient should take in on a daily basis and how much of each the patient should strive for, with examples provided of types of foods and preparation methods available. It may be helpful to have the patient speak with a registered dietitian or nutritionist for further ideas about how best to gain enough nutrients for wound healing.


The Joint Commission has emphasized the requirements of screening and assessment for patients who are at high risk of malnutrition and to follow up on these assessments with routine evaluations to determine effectiveness of interventions.20 This practice is particularly important for patients who are malnourished and who have developed wounds; however, even high-risk patients who have background factors that could lead to malnutrition should be routinely assessed for their nutritional intake and its effects on wound healing.

The clinician may need to measure the patient’s height and weight and calculate the body mass index (BMI). As stated, even a person who is obese can suffer from malnutrition, so the outcome of the BMI does not necessarily reflect specific nutrient intake or lack thereof. However, the BMI results do provide a starting point for the nurse to discuss the importance of nutrition and of maintaining a healthy weight, as well as what should be considered if the patient needs to gain or lose weight. Discussion of the BMI also provides a setting in which the nurse can talk about intake of certain foods and learn more about the patient’s overall caloric intake as well as intake of other important nutrients, such as protein.

According to Wild, et al., in the journal Nutrition, the average intake of a healthy person is between 30 and 35 kcal/kg body weight per day, which is dependent on the amount of activity the person engages in. When other health factors are present that contribute to wound development, such as advancing age, a history of chronic illness, or malnutrition, the patient needs more energy intake each day to promote wound healing and should strive for 35 to 40 kcal/kg each day.53

The patient should be provided with information about the nutrients that are important for wound healing, why they are needed, and how they can get them into the diet. Protein is a macronutrient that is essential to wound


healing because of its role in building collagen, which provides a structural framework of the healing skin tissue. Proteins also make up the backbones of many cells of the immune system, including macrophages, lymphocytes, monocytes, and leukocytes.

Normal protein requirements are approximately 1.5 g/kg of body weight per day; more protein may be necessary if the patient is malnourished or has a significant wound, such as a burn wound.20 In some cases, supplementation with formula preparations is beneficial and can add calories and protein to the diet of a patient who has difficulty taking in enough nutrients on a daily basis. Protein supplements, such as liquid nutritional shakes, can be purchased over the counter or may be available by prescription. The healthcare provider should first determine the amount of protein and other nutrients needed in the patient’s diet before advising the patient to go and purchase protein shakes. However, with proper guidance, some brands of nutritional supplements can be very helpful in supporting nutrition for the wound care patient.

While lipids and carbohydrates are important components of the diet because they provide energy for the patient, their intake should be monitored carefully and the patient should be given instructions about how much to take in of each of these elements to avoid overfeeding. Chronically elevated glucose levels in the bloodstream can lead to changes in the cardiovascular system and can alter the body’s immune defenses. Further, excess intake of fatty foods can cause hypertriglyceridemia and can impact liver function.20 These elements should be carefully reviewed with the wound care patient, and the clinician should determine the patient’s normal intake while also preparing guidelines for how much the patient should be consuming of these nutrients. The amount needed and the amount the patient normally eats may not be the same. This is the time that the clinician can discuss the effects of excess carbohydrates and lipids in the body, as


well as their effects on wound healing, and how to take in proper amounts of these nutrients to support good health.

As stated, vitamin C is important to protect the immune system and to support collagen synthesis in the wound bed. The patient should be encouraged to increase his or her intake of vitamin C in the diet. This is done by consuming more fruits and vegetables, including citrus fruits, such as oranges and grapefruit, as well as other fruits and vegetables, including strawberries, tomatoes, broccoli, and cantaloupe.

Vitamin A may be added to the diet to increase wound strength as the wound is healing. The patient can be taught about the benefits of vitamin A, as well as how best to get this fat-soluble vitamin into the daily diet. Vitamin A may be taken in through supplements or the patient can consume foods such as sweet potatoes, carrots, and dark green, leafy vegetables.

Vitamin E deficiency causes negative effects in the body because vitamin E has anti-inflammatory properties that can control inflammation in and around the wound. Vitamin E is also an antioxidant and has been used in topical preparations for skin care. A true vitamin E deficiency is uncommon, partly because it can be easily supplemented into the diet through vitamin preparations or foods.20 Vitamin E can be found in foods such as almonds and peanuts, green, leafy vegetables, including broccoli and spinach, and vegetable oils, such as corn, sunflower, and soybean oils.

McCullogh and Kloth, in the book Wound Healing: Evidence-Based Management, state that two other micronutrients, zinc and iron, are important for maintaining health when a patient is healing from a chronic wound. Deficiencies of zinc in the diet can cause decreased fibroblast production in the wound bed, decreased epithelialization during healing, and an increased risk of infection. Iron is needed for heme molecules in the red


blood cells to support oxygenation of the tissues and it is necessary for collagen production.20,53 Deficiencies in both of these trace elements can lead to serious deficits in wound healing and may more likely be seen in patients who suffer from chronic illnesses such as alcoholism, iron-deficiency anemia, and gastrointestinal disorders. Patients can increase intake of zinc by increasing intake of lean beef and turkey; or, seeds, such as sunflower seeds or pumpkin seeds, or by eating beans and lentils. Iron is also found in red meat, poultry, and beans, as well as eggs, dried fruits, and iron-fortified cereals.

A patient who is already malnourished will need an assessment of his or her overall health and ability to get enough nutrients through the diet. Such factors for assessment include any situation that prevents the patient from taking in, digesting, and absorbing nutrients. If there are physical abnormalities that are causing malnutrition, these items must be addressed as part of wound care treatment, or the provider can expect delays in wound healing.

Alternatively, a patient may have a wound that is being managed but may not be malnourished. In this case, the patient must still be taught about the importance of nutrition and diet, but supplementation may not be necessary. The provider may order enteral nutrition or supplementation for a patient who is malnourished, but for someone who does not have difficulties with getting enough nutrients, diet and fluid intake should provide adequate nourishment. If the healthcare provider decides to order supplements of specific vitamins or nutrients to support certain aspects of wound healing, this may be based on the client’s condition, the progress of wound healing, and other individual health factors.

Emotional Support


Much of the wound care provided by the clinician will focus on the physical aspects of wound treatment; the size of the wound and how well it is healing, the use of the right kind of dressing or debridement practices, and whether or not other factors, such as infection or malnutrition are present. Although all of these measures are very important components of wound care and treatment, the emotional health and wellbeing of the patient must also be considered as a primary factor in the promotion of wound healing and prevention of complications.

While a clinician or healthcare provider may be very focused on treatment regimens and techniques required for wound healing, the patient is often more focused on how the wound impacts his or her life. For example, although a nurse may decide to utilize a new type of dressing to promote wound healing, the patient may be more concerned with the appearance of the dressing or its bulk that appears underneath clothing. Although the physical aspects of wound healing may be important, the nurse must address psychosocial factors in order to provide holistic care to the patient and to better ensure that the patient will be a willing partner in working toward wound healing.

Wounds International developed an expert working group that discussed wound care health and well-being of patients. The group defined well-being as:

“a dynamic mix of factors, including physical, social, psychological, and spiritual….The ultimate goals [of wound healing] are to optimize well being, improve or heal the wound, alleviate/manage symptoms and ensure all parties are fully engaged in the process.”54

The process of supporting the patient’s well-being involves considering all aspects of patient care, to include the patient’s physical needs for wound


care, pain control, and management of chronic diseases, as well as supporting the patient’s emotional, spiritual, and psychosocial health, as these components are tied into holistic wound care.

A patient with a wound may suffer from a multitude of emotions related to the cause of the wound or injury, the appearance and healing process of the wound, or how the wound affects the body. A person who has suffered an extensive wound may have disfigurement in addition to the pain and discomfort associated with wound care practices. He or she may struggle with grief in accepting how the body has changed as a result of the wound. A wound may cause psychological stress for a patient in other ways as well; having a wound may also make a person feel sad or ashamed because of the condition, and the patient may feel like a burden to others who are responsible for caring for them.

The physical discomforts of a wound also cause psychological stress for the affected patient. A patient with a wound may struggle with feelings of loneliness and isolation, particularly when the wound affects the patient’s mobility. The patient may be embarrassed about the appearance of the wound; a wound that has an odor is very embarrassing for the affected patient and may lead him or her to avoid others for fear that someone else may notice the smell.

The nurse who provides comprehensive wound care in a holistic manner must address these and other psychological concerns affecting the patient. Needs may change over time, particularly if the wound takes many months to heal. For example, a wound that once affected a patient’s mobility by limiting how much he or she could walk may have healed enough that walking is no longer an issue. However, with time, the patient may have started to feel more anxiety about losing his or her job because of the work time taken off to care for the wound.


Each assessment should have some component that checks the patient’s emotional wellbeing. If the patient is able to talk about his or her feelings related to the wound, the nurse should be able to respond with resources for helping the patient through his or her feelings, whether it is through nursing interventions or by referring the patient to another professional, such as a psychological counselor.

The nurse can come up with many practical solutions for helping a patient through the sometimes-difficult emotions that accompany a wound. Wound care measures have changed from large, bulky dressings to those that are more likely to be low profile; the nurse may help the patient who has fears about the appearance of his or her wound with finding wound care items or articles of clothing that minimize the wound instead of drawing attention to it. When odor is present, the nurse can investigate the possible source; this may be through working with the physician and obtaining a prescription for antibiotics if the odor is caused by infection. In other cases, consulting with a wound care expert, such as a certified wound, ostomy and continence nurse, is often a source of support to find dressings or to develop a wound management regimen that will control wound odor and can ease the patient’s mind.

Some patients who suffer from anxiety or depression may have more difficulties accepting a wound and/or working with the nurse for wound management. The patient who has a diagnosed mental health condition as well as a chronic wound will need to continue to see his or her diagnosing provider for further management of the condition. However, when a wound develops, the patient may also benefit from added short-term counseling or therapy for help with managing the many emotions that are associated with a setback such as a wound.


Other measures that the nurse may consider when providing emotional support for the patient with a wound include helping the patient to think about the positive elements of his or her life and what creates a sense of happiness or of hope and optimism for the future. Additionally, the nurse may encourage the patient to come up with alternative activities that he or she enjoys and that can be performed even though the wound is present, and providing the patient with information about support groups for those who are struggling with body image or chronic illness. Additionally, the nurse may provide the patient with information about stress management and what signs or symptoms that the patient should look for that indicate that he or she may be developing some emotional issues that needs to be addressed.

Above all, the nurse needs to provide compassionate care to the patient that includes discussion of his or her emotional health and assistance with problem solving if the patient identifies difficult feelings associated with the healing wound. The nurse provides support by demonstrating competence in wound care measures, respecting the patient’s privacy and showing empathy for the patient’s feelings.

Preparing Patients for Wound Care at Home

Patients who are at home while healing from wounds should be taught principles of skin care and wound management as well as what factors or activities to avoid that could lead to wound complications such as infection.A patient with a wound needs to rest to avoid excess stress, which can impair wound healing. He or she should be taught to avoid putting pressure on the wound. For instance, a diabetic client with a foot ulcer on the ball of the foot should not walk and put pressure on the affected foot while the wound is healing. The patient may need to use crutches or a specialized type of shoe instead. When a wound is in an extremity, the patient should rest the area and elevate it on a pillow or blankets. This is particularly important with


certain kinds of ulcers and wounds, as rest and elevation can help with venous return of blood to the heart and prevent venous stasis.

A patient with a venous ulcer who needs to wear compression stockings should be taught about how the stockings work and their effects on circulation. The nurse should instruct the patient about how to put the stockings on and the patient should be able to demonstrate how to put the stockings on as well. Because the patient will most likely need to wear compression stockings for a long period of time, he or she should also have access to resources of where more pairs of stockings can be obtained, and should be taught about how long to wear the stockings and to replace them every 4 to 6 months. The stockings are typically ordered by prescription and the nurse may work with the patient to make arrangements for gathering more pairs of compression stockings when replacements are needed.

Some patients will need to be at home with devices that protect the skin around the wound and that are designed to promote safe healing of a wound. This is more likely the case in a situation where the wound is in an extremity. Examples include casts, specialized boots or shoes that cover the dressing and the wound and prevent excess pressure on the site, or foam mattress covers placed on the bed to reduce the risks of further damage of pressure ulcers. The nurse should review the signs of a developing wound with the patient; teaching involves educating the patient to look for signs of skin redness that does not go away, areas of skin that were once firm becoming soft or spongy, pain or symptoms of poor circulation in the lower legs, particularly while walking, and, numbness, tingling, or loss of sensation in the extremities.

A patient who needs to change a dressing on the wound will need education about the process of the dressing change and the principles of infection control. This education may be provided to the patient as well as to family


members who may be helping with dressing changes in the home. The nurse first should review the process of a dressing change with the patient in a step-by-step fashion, demonstrating how to change the wound dressing. This is followed by the patient demonstrating how they would change the dressing so that any information may be covered again, or raised for further teaching, by the nurse.

Because of the variety of dressings available that the patient may use, the content of the teaching will vary slightly in terms of when and how to remove the old dressing and the process of applying the new one. However, several principles apply and should be included as part of teaching, regardless of the type of dressing the patient is using. The nurse should include information about the importance of hand hygiene both before and after caring for the wound, as well as why hand washing prevents the spread of germs and can prevent a wound infection. The patient should also be taught about what to look for as signs of infection in the wound while changing the dressing, including the most common signs, such as redness, odor, purulent drainage, and inflammation or breakdown of the skin surrounding the wound. Further, if these signs or symptoms develop, the nurse must provide instructions and information about how to contact the provider to have the wound evaluated.

The patient may also need help with getting the appropriate supplies to perform dressing changes and wound care at home. If a patient uses a specialty dressing for his or her wound, the nurse may need to work with a wound care specialist to help the patient gain access to the appropriate supplies for changing the dressing at home. If a patient requires a cast or other mobility products, he or she may be able to access certain materials through a medical supply company or pharmacy. Medications and ointments may also be provided through the pharmacy. Some patients with significant wounds require a visiting nurse or home health care nurse to make a certain


number of visits to the home to check the wound, change dressings, and check on the patient’s overall health. It should be noted that a patient who is sent home with a healing wound most likely has a stable wound without significant infection. The patient should also have care elements in place before being discharged to home. For instance, if a patient has a wound on the outer malleolus of the ankle that requires dressing changes, he or she should understand how to change the dressings and should have other components set up for wound care, such as a specialized walking boot that will protect the ankle during the healing process. A patient who has an unstable wound that needs more consistent care either needs to be monitored much more closely by a home health nurse or needs inpatient treatment for regular care of not only the wound, but any other underlying components, such as chronic disease management.

Wound Prevention

While there are many forms of wound care treatments, procedures, and specialized products that can help wounds to heal, the best form of skin care management is to prevent wounds from healing in the first place. Nursing interventions designed to prevent wound development focus on skin protection, management of chronic conditions that contribute to skin breakdown and wound development, and use of methods that will protect the patient from complications.

Nursing Interventions

Nursing interventions vary, depending on the patient’s background condition and cause of the wound. Some nursing interventions are general and focus on aspects that can lead to skin breakdown in any condition. These interventions include such activities as protecting the skin and mucous membranes, promoting circulation, and assisting with mobility and position


changes. Most interventions that are performed to protect the skin will also prevent its breakdown. In addition to general interventions for skin protection, there are also specific interventions to include that focus on preventing wounds from developing because of specific causes. These include interventions aimed at controlling chronic diseases, such as diabetes or venous insufficiency.

Skin protection

Skin protection interventions are performed to keep the skin healthy and intact. On a given day, a patient may encounter various entities that can contribute to skin breakdown, including excess moisture, pressure, poor circulation, or trauma. By reducing or eliminating these factors, the nurse can better protect the patient’s skin, provide education to the patient and his or her family about how best to care for the patient’s skin, and prevent skin breakdown that leads to wounds.

Because many patients with immobility must spend more time in bed, introduction of a mattress that can protect the skin may be beneficial in certain situations. Some specialty mattresses are designed to prevent pressure ulcers; this type of mattress and bedding may be available in some facilities, particularly in areas where patients are at higher risk of developing these types of wounds. Most mattresses used on beds in hospitals and long-term care facilities can contribute to increased pressure in certain areas and ultimately, to pressure ulcers if the patients who use these beds are not turned or repositioned regularly.5

The type of mattress to use with a particular patient depends on the patient’s condition, the pressure of skin breakdown and wounds, and whether he or she is able assist with repositioning or move within the bed. Some options involve a type of overlay that is placed on top of a standard


mattress but that provide a barrier between the patient and the mattress itself, thereby reducing excess pressure on the skin. This type of barrier between the patient and the mattress is relatively low-tech but can provide quality results for patients who are able to shift or reposition while in bed and take weight off some areas of the body that may be more likely to develop wounds from too much pressure. Examples of overlays that act as barriers include sheepskin covers, conformable foam mattress covers, and water- or gel-filled mattress covers.5

Specialty beds may also be available in some locations; these beds have specialized mattresses that provide protection for wounds and can prevent pressure ulcers. They utilize high-tech equipment above and beyond the standard type of mattress used in most healthcare facilities and are best used for patients who have difficulty repositioning in bed at all or without placing excess pressure on areas of skin breakdown while turning. They are also useful in those situations where patients have wounds that, despite utilizing other interventions, are still not healing well. When caring for a patient with skin breakdown and particularly someone with mobility issues, the nurse should assess whether a specialized mattress on one of these kinds of bed is necessary, if it would be available.

Rather than using an overlay that goes between the patient and the standard mattress, a specialty bed contains a mattress specifically designed to promote circulation to the tissues and to prevent moisture buildup. Some beds mechanically turn patients from side to side on a rotating basis, thereby continuously moving and repositioning the patient. These types of beds are useful not only for preventing excess pressure in certain areas from sustained periods of immobility, but they also relieve some of the work of the nursing staff in consistently turning and repositioning the affected patient. However, despite the effectiveness of these types of beds in repositioning


patients, the nurse is still responsible for moving or turning the patient when needed and should not completely rely on the bed to perform all of the work.

Another type of bed may help to prevent skin breakdown by using a layer of air or water to circulate just under the patient. This consistent circulation moves and shifts the mattress slightly under the patient on a regular basis and continuously changes areas of pressure so that no one area receives too much pressure for too long. There are also types of beds that have mattresses that work in a manner similar to sequential compression devices used on the legs to prevent blood clots. These beds routinely inflate and then deflate underneath the patient to promote circulation and prevent excess pressure in concentrated areas.5

Because excess skin moisture can contribute to softening of the skin and maceration, the nurse should provide regular skin care of the high-risk patient to control skin moisture. Excess moisture on the skin surface can also increase the patient’s risk of infection, as increased moisture has a dilutional effect on the skin’s acidity levels. This changes the skin’s ability to control bacterial buildup on the surface and the patient may be more prone to infection.

The nurse should carefully consider use of linens with the patient, as standard linens often found in healthcare environments may contribute to increased moisture staying on the skin, even after the patient’s skin has recently been cleaned and dried. Wrinkles in the sheets of standard bed linens may also cause skin damage in a high-risk patient; when the patient lies on top of a wrinkled section of a sheet for a prolonged period, the wrinkled area also contributes to increased pressure.4 The nurse must routinely monitor the areas of wrinkles or bunching in the linen and strive to keep sheets and blankets straight and flat, particularly in the bottom sheets that lie just on top of the mattress and underneath the patient.


Sheets and linens must be further considered when turning or moving a patient in bed, as friction contributes to skin breakdown if the patient is moved up in bed or slides down in bed against the material of the linens. Certain areas that have bony prominences must also be protected against bed sheets and friction or shear forces. For example, the heels are areas where skin breakdown can routinely develop, as they often lie directly on the bed and the blood vessels supplying their oxygenated blood may be compressed under pressure. Heels should be lifted and supported so that they do not rest directly on the mattress surface for long periods of time. Further, when moving a patient in bed, the nurse must consider the effects of bony prominences, such as the heels, when the patient is moved. For example, when moving a patient up in bed, without careful protection for the heels, they may drag along the surface of the bed while the patient is being moved. This happens even when the nurse works to protect other areas of the patient’s body against the forces of friction and shear.

When caring for a patient who uses multiple medical devices, such as in an intensive care unit, the nurse should consider the effects of equipment on the patient’s skin and its contribution to wound development. For example, an endotracheal tube that has not been positioned properly can apply pressure to the corner of the mouth or to an area of the lip, thereby causing skin breakdown from tissue ischemia underneath the tube. Further, frequent skin care to remove excess secretions from tubes also helps to keep the skin clean and dry. Alternatively, when a patient has secretions from trach or endotracheal tubes or leakage around other types of tubing, such as an intravenous or gastrostomy tube, maceration and skin breakdown are more prone to occur in those areas.

Incontinence


Preventing excess moisture that can cause skin breakdown is also essential when caring for clients who suffer from incontinence. Allowing urine or stool to remain on the skin, even for a short period of time, can lead to skin maceration and wound development. The nurse may apply barrier creams to the patient’s skin that act as a protective layer between the skin and the urine or stool, preventing the wastes from contacting and breaking down the skin tissue.

According to the book Wound Healing: Evidence-Based Management, the best method of cleansing and protecting the skin from breakdown as a result of incontinence is to provide regular hygienic care for the patient by cleaning after episodes of incontinence. The nurse should use a system that not only cleans the patient but that also protects the skin. The ideal product, which may often be available in healthcare facilities where there are patients at risk of skin breakdown, includes a cleanser that has qualities that can easily lift dirt and debris from the patient’s skin to clear it away, as well as moisturize the skin to maintain adequate hydration. It should be noted that skin cleansers that are used to clean a patient who has been incontinent should not be used as wound cleansers. These items do not contain the same ingredients that they could be used in both situations and when applied to a wound, standard skin cleansers used for incontinence could cause cell damage and further skin breakdown.20

The final intervention in preventing incontinence-related skin breakdown is the application of a barrier to prevent future wastes from incontinence from repeatedly contacting the skin.6 Liquid skin protectants, sometimes referred to as skin sealants, contain a combination of additives that adhere to the skin when the liquid dissolves. The protectant is applied to the skin and after it dries, it provides a thin barrier against collection of debris or waste products on the skin that can lead to skin breakdown.


Moisturizing lotions may be used on areas of dry skin to preserve moisture levels and prevent cracks in the skin, which can increase the risk of infection. Regular bathing and hygiene practices are also necessary to preserve skin function and are a necessary component of nursing care that promotes self-esteem, confidence, and a sense of self-worth. The nurse can help the patient to bathe using warm water and mild soap, following the bath with a moisturizer, if needed. While assisting the patient with bathing, the nurse should inspect the skin for areas of redness, areas that seem to be at higher risk of skin breakdown and, of course, for wounds that have already developed.

Repositioning

The National Pressure Ulcer Advisory Panel (NPUAP) has given guidelines for how often a nurse should assist a patient with repositioning in order to effectively prevent skin breakdown from excessive pressure. A patient who is confined to bed should be repositioned and turned while in bed at a minimum of every two hours. A patient who is sitting in a chair should be repositioned and assisted to shift his or her weight on the seat at least every one hour. A patient who is sitting in a chair should not sit on an inflatable ‘donut’ pillow, as these types of devices place excess pressure on bony prominences and areas where the patient sits. When turning or repositioning a patient, the nurse should take measures to avoid applying extra forces against the patient’s skin that contribute to injury and skin breakdown. Friction against the skin occurs when the surface of the skin is dragged across another surface. Friction may occur when a patient slides down in bed because the head of the bed has been raised to a high level. The force of friction can cause an abrasion on the surface of the skin, with the potential for the introduction of pathogens into the break in the skin surface, as well as further skin breakdown and a larger wound.


Shear is another type of force that can lead to skin breakdown. Shear describes the parallel force of the upper layers of the skin moving away from the lower layers, in which there is a break in the skin structure and damage to the elements found in the skin. For example, a patient may have excess moisture on the surface of his or her skin, which is not cleansed or dried before a caregiver tries to move the patient. As the caregiver moves the patient by pulling him or her up in bed, the outer layer of skin moves with the caregiver’s action because of the external layer of moisture. However, the underlying tissues may remain in place or sluggishly catch up with the surface of the skin. With shear forces, the layers of skin move on a parallel plane but at different paces or in opposite directions from each other, thereby disrupting the connections between skin layers and causing injury.

Shear is often associated with friction and the two forces may occur at the same time. Shear results in damage to structures found in the dermal layer; the blood vessels may be stretched with the force and then rupture and bleed into the skin. This damage also decreases blood flow to surrounding tissues, further perpetuating ischemia and promoting skin breakdown.7 Shear forces may often cause deep tissue injuries, as described above.

The nurse must make sure to protect bony prominences for the patient who is immobile and/or who cannot lift up or reposition areas that are prone to skin breakdown. Various cushions and positioning devices are available for parts of the body that may be prone to skin breakdown, such as elbow guards to protect the elbows or cushioned boots to protect the heels. Although moisturizing dry skin is recommended to keep skin moist and to prevent drying, the nurse should avoid massaging over bony prominences and should never massage an area that already has skin breakdown or destroyed tissue.7


The patient may be able to help in some situations where repositioning is necessary. Depending on the patient’s condition, the patient may be able to assist by pulling his or her body up using the arms and the side rails while the nurse assists with lifting. If an overbed trapeze is available, the patient may also use the device to hang on and help with moving up in bed. Alternatively, some patients are unable to help with repositioning or turning while in bed. These patients may be at highest risk of skin breakdown if they cannot relieve areas of pressure that results in tissue destruction. In these cases, the nurse or caregiver is responsible for regular turning and positioning, assessing the skin for signs of damage, and providing care measures that protect skin integrity. The head of the bed should not be placed at an angle higher than 30 degrees for a patient who has difficulty repositioning in bed.7 An angle higher than 30 degrees may cause the patient to slide down in bed and not be able to correct the situation.

Venous ulcer prevention measures

Prevention of venous ulcers focuses on improving the patient’s circulation to promote venous return and to prevent pooling of blood in the extremities that can lead to skin breakdown. The nurse should be familiar enough with the patient’s disease process to understand the cause of the wound, in order to best avoid performing treatment measures that could possibly make the condition worse. For example, compression stockings are often used in management of venous ulcers but can worsen wounds and ulcers that have developed from arterial insufficiency.9 By thorough history taking and practicing focused assessments, the nurse should know what interventions are most appropriate for each situation, which can vary depending on the cause of the wound.


Compression stockings promote venous return and reduce pooling of blood in the extremities that contributes to wounds. The nurse can help the patient to apply compression stockings by measuring for the correct size, applying the stockings correctly, and teaching the patient how to apply the stockings if he or she is able. The patient who starts to use compression stockings for venous insufficiency should know other practical factors of their use, including taking the stockings off at night, washing them regularly, and replacing them after approximately 6 months because they can lose their elasticity.

While the patient is in bed, the nurse can raise the level of the feet to promote venous blood return. The nurse may also teach the patient about how to exercise the calf muscles. The Wound Healing Society states that increasing calf muscle pump function has been shown to decrease venous ulcer development.56

The calf muscle has a thick layer of fascia that works as a form of compression to squeeze the veins as they return blood toward the heart and prevent venous stasis. The calf muscle and the veins that run through it form the calf muscle pump, which forces blood against hydrostatic pressure so that it can return to the heart.57 Regular exercise, including that involving the calf muscles can increase function of the calf muscle pump and can prevent venous ulcer formation. Additionally, the patient should be taught to avoid prolonged periods of standing or sitting with the legs crossed. This position avoids use of the calf muscle pump and causes blood to pool in the lower extremities, further contributing the venous ulcer development.


If a patient has had deep vein thrombosis and post-thrombotic syndrome, he or she may be at higher risk of developing a venous ulcer. When this happens, it may be necessary to place the patient on prophylactic anticoagulant medications to reduce the risk of another blood clot. Further, a patient who has venous insufficiency has an increased lifetime risk of developing a DVT or pulmonary embolism.58 Because of this risk, long-term prophylaxis is most likely necessary to reduce the risk of occlusion and further skin damage from decreased tissue perfusion.

If the patient has developed lipodermatosclerosis as a result of venous insufficiency, administration of anabolic steroids along with compression therapy may help to minimize the effects of the condition. Other measures include treatment of edema and prophylactic administration of antibiotics to prevent development of cellulitis in the tissues. Continued management of venous insufficiency is also necessary and includes promoting good skin hygiene; and encouraging the patient to adopt healthy lifestyle habits, such as quitting smoking and increasing exercise.

Arterial insufficiency interventions

Prevention of arterial insufficiency ulcers is similar to prevention of complications associated with peripheral arterial disease. A patient with arterial insufficiency and who has peripheral arterial disease is at higher risk of cardiovascular complications, which should be addressed as part of ongoing care. This may involve administration of medications such as cardiac drugs, including ACE inhibitors, beta-blockers, or anticoagulant medications to strengthen cardiac contractility and to enhance circulation.


The nurse may perform an ankle-brachial index (ABI) test on a high-risk patient who has arterial insufficiency. The ABI is a comparison of the systolic blood pressure in the ankle to the systolic blood pressure in the arm. An ABI of less than 0.9 can indicate peripheral arterial disease and should continue to be monitored closely for development of symptoms associated with the condition, with repeat measurements of ABI over time to determine if there are increases or decreases in measurement.72 Regular monitoring of the skin in the lower extremities can indicate if there are problems with circulation and blood flow reaching these distal points. Indications of decreased arterial circulation include poor hair growth on the lower legs and feet, shiny, dry skin, pale, cool skin that may appear purple in color, and thickened toenails. Regular, daily administration of aspirin as an anti-platelet medication can reduce the risk of blood clots, myocardial infarction, and stroke, and it slows the progression of atherosclerosis associated with arterial insufficiency. If the patient receives a prescription or recommendation from the physician about daily aspirin therapy, the nurse should provide teaching and instruction about the dose, access to the medication, and potential side effects, as well as how aspirin affects the cardiovascular system.

While passive warming of the extremities has been shown to be helpful in some patients with arterial insufficiency, the nurse should avoid applying any


form of heating element, such as a heating pad, to the lower extremities. While the heat may feel comfortable for the patient, appliances such as heating pads can burn the skin and cause further tissue damage. A heating pad should not be applied directly over the site of a present wound.7 Other interventions should focus on preventing trauma to the lower legs and feet, as injury can lead to wounds that heal poorly because of poor tissue perfusion. This involves educating the patient about how to protect the feet, to avoid walking barefoot, and to avoid engaging in activities that could lead to damage to the feet or lower legs, such as by wearing poorly fitting shoes.

As with other types of interventions for chronic disease states, the nurse should provide education and teaching to the client about lifestyle interventions that will improve health and wellness and that can decrease the potential for ulcer formation because of arterial insufficiency. Making personal changes, such as by quitting smoking, increasing daily exercise, losing weight when necessary, and controlling cholesterol intake can all decrease the risk of atherosclerosis that can cause arterial insufficiency and potential wound development.

Diabetic ulcer interventions

While many standard prevention measures can be implemented into averting diabetic wound development, there are some methods of prevention that are specific to this type of condition. First and foremost, good control of blood glucose levels is essential in preventing diabetic ulcers; if a patient has developed an ulcer as a result of poor glucose control, it is still important to improve and stabilize glucose levels from that point forward. The patient should be taught home-care measures that involve regular inspection of the skin, particularly the skin on the feet, to look for signs of injury or impending ulcer development. Good skin care and hygiene may need to be taught, with certain principles being reviewed on a regular


basis. For example, a patient may be educated about the importance of keeping the feet clean; however, the nurse may also need to review other important aspects of cleaning the feet as well, such as using warm or tepid water instead of hot water, using mild soap, and avoiding lotion between the toes.

Other principles that should be included as part of foot care for diabetic ulcer prevention include:

Checking the feet at least daily for signs of injury or infection Wearing shoes that fit properly and clean, moisture-wicking socks Avoiding walking around barefoot, which could cause injuries to the

feet Trimming toenails carefully or having a healthcare provider perform

this task Avoiding trimming or cutting calluses or ingrown toenails and

having these conditions treated by a healthcare provider Having the feet inspected by a healthcare provider at regular check-

ups for diabetic care and treatment

Other nursing interventions that may be implemented in the diabetic patient include checking the ABI on a regular basis and performing repeat tests to determine if the index is increasing or decreasing over time; monofilament testing, which assesses pain and sensation in the lower extremities of the patient with diabetic neuropathy; and regularly checking laboratory outcomes to monitor for changes in glucose levels, such as the hemoglobin A1C test.

Nursing Continuing Education

Because there are new developments and ongoing research in the field of wound care management and prevention, continuing education in this specific area will help the nurse to stay up to date about the best methods of


treatment for various types of wounds. By undergoing continuing education, the nurse may not only achieve education credits needed for licensure, but may also learn a great deal about advances in wound care technology as well as a review of the basics of wound and skin care. Many continuing education opportunities are available for learning about wound care and management. These options often provide the latest data about procedures and methods of caring for wounds, such as through types of advanced dressings, methods of dressing changes and debridement, and alternative forms of therapy that were once unheard of. Additionally, continuing education can offer a review of the principles of skin care, and list recommendations from various credentialing entities about how best to perform skin hygiene.

Continuing education credit is available through a number of resources that offer online courses, as well as in-person conferences and classes. Examples of organizations that offer continuing education specifically in the areas of wound care, ostomy site care, and incontinence management include the Wound Ostomy and Continence Nurses Society™, the Wound Ostomy Continence School of Nursing associated with the Cleveland Clinic, and the National Alliance of Wound Care and Ostomy®.

Certification

A nurse who is experienced in working with wound care patients may consider certification through a specialty organization. Certification solidifies the knowledge and skills of a nurse who works in wound care. It recognizes the insight and education that a nurse with experience in wound care may have and supports this experience through specialized credentials. Certification typically requires rigorous study and testing, but having the certification credentials is worth it to establish credibility as a wound care nurse.


WOCNCB

The Wound, Ostomy, and Continence Certification Board (WOCNCB) is one of the most common certifying entities in the field of wound care nursing. The WOCNCB states that it has certified over 6,700 nurses in the fields of wound, ostomy, and continence care since 1978.73 To become certified through this organization, the nurse must demonstrate professional knowledge and skills in the areas of skin care by taking a certification exam. After passing the exam, the nurse receives a CWOCN® credential to practice as a specialized wound, ostomy, and continence nurse.

To be eligible for WOCNCB certification, the nurse must have at least a bachelor’s degree and must have graduated from an accredited Wound Ostomy and Continence (WOC) nursing education program. These types of programs range from approximately 9 to 16 weeks of clinical experience specifically in the fields of skin, wound, and ostomy care. Alternatively, the nurse may substitute professional clinical experience in the areas of wound and skin care and be able to demonstrate such experience before taking the exam. After passing the examination and becoming certified, the nurse must renew certification within five years. The WOCNCB is unique in the fact that it also offers certification in wound, ostomy, and continence care to advanced practice nurses, such as nurse practitioners. These certifications are designated as credentials listed specifically for an advanced practice nurse along with the added scope of practice that the advanced training as a nurse practitioner provides.

ABWM

The American Board of Wound Management (ABWM) also offers certification specifically in wound care. Certification is offered through this institution based on the level of expertise and training that the healthcare professional


has achieved. For example, the organization offers certification as a Certified Wound Care Associate® (CWAC), which would be offered to a healthcare clinician who has at least 3 years of experience in wound care and who is an RN, LPN, or healthcare assistant. The group also offers credentialing as a Certified Wound Specialist® (CWS), which is offered for a clinician with at least 3 years of experience in wound care but who also has a bachelor’s, master’s, or doctoral degree in healthcare. Finally, the organization offers certification as a Certified Wound Specialist Physician® (CWSP), which is offered only to physicians and podiatrists.74

The ABWM offers certification in wound management to a variety of healthcare specialties beyond nurses. The certification process is designed to recognize professionals who have the knowledge and specific skill sets needed for quality wound care. Once a nurse meets the certification requirements of having at least 3 years of experience, he or she can submit an application to take the exam, along with a signed code of ethics for the organization and letters of reference. Upon passing the exam, the nurse is then certified and receives a pin to wear as a form of recognition. If the nurse passes the examination and becomes certified through the ABWM, he or she will have to recertify after 10 years. Additionally, the nurse must demonstrate competence through continuing education by achieving at least 6 hours of continuing education credits annually to maintain certification.

Summary

Whether a nurse is certified as a wound care specialist or simply works with populations of patients who need management and treatment of wounds, wound care is a complex process that can be ongoing for many months or years. The nurse who works with wound care patients should continue to learn about the forthcoming treatments and methods that can minimize wound complications and that could help to promote better wound healing. Further, the nurse must be aware of the holistic approach to wound healing


that involves not only physical care of the patient’s wound and/or chronic condition involved, but also the psychosocial elements that are part of regular assessment and treatment of this special group of patients. By understanding the necessity of all of these elements, the nurse can continue to grow in knowledge and skill of caring for patient wounds.

Please take time to help the NURSECE4LESS.COM course planners evaluate nursing knowledge needs met following completion of this course by completing

the self-assessment Knowledge Questions after reading the article.Correct Answers, page 39.

1. The wound patient should be provided with information about the nutrients that are important for wound healing. In this regard, the following is/are true:a. less protein is needed when a patient has a significant wound, such

as a burn wound.b. the patient who is considered relatively healthy does not need

nutritional guidance.c. the patient needs an average energy intake each day to promote

wound healing and should strive for 35 to 40 kcal/kg each day.d. a person who is obese does not suffer from malnutrition.

2. True or False: As part of the comprehensive and holistic wound care assessment of a patient, lupus is one of the medical conditions that must be considered.

a. True. b. False. 3. A diabetic patient with a foot ulcer on the ball of the foot should a. walk and put pressure on the affected foot while the wound is healing to promote circulation. b. rest the area and elevate it on a pillow or blanket when the wound is in an extremity.

c. rest, and be informed that elevation hurts with venous return of blood to the heart and encourages venous stasis

d. a., and c., above. 4. Compression stockings are often used in management of venous ulcers, but


a. the nurse, not the patient, must apply the stockings because applying them correctly is important for healing.

b. when stockings are applied while the patient is in bed, the nurse should lower the level of the feet to promote venous blood return.

c. a nurse should be aware that compression stockings can worsen wounds and ulcers that have developed from arterial insufficiency.

d. none of the above.5. Other principles that should be included as part of foot care for diabetic ulcer prevention are: a. Checking the feet at least daily for signs of injury or infection b. Avoiding walking around barefoot, which could cause injuries to the feet

c. Avoiding trimming or cutting calluses or ingrown toenails and having these conditions treated by a healthcare provider.

d. All of the above.

CORRECT ANSWERS1. c2. a3. b4. c5. d

Footnotes:1. Katz, M. J., Kirr, C. A. (2012). Wound care. Retrieved from

http://www.nursingceu.com/courses/395/index_nceu.html2. Kifer, Z. A. (2012). Fast facts for wound care nursing: Practical wound management in

a nutshell. New York, NY: Springer Publishing Company, LLC3. Cooper, K. L. (2013, Dec.). Evidence-based prevention of pressure ulcers the intensive

care unit. Critical Care Nurse 33(6): 57-66. Retrieved from http://www.aacn.org/wd/Cetests/media/C1363.pdf

4. Falconio-West, M. (2013, Sep.). Kennedy Terminal Ulcer (KTU) is now recognized by CMS for long-term acute care hospitals (LTAC or LTCH). Retrieved from


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5. Covidien AG. (2008, Jan.). Support services and the prevention of pressure ulcers. Retrieved from http://www.patientcare-edu.com/imageServer.aspx?contentID=20368&contenttype=application/pdf

6. Brunner, M., Droegemueller, C., Rivers, S., Deuser, W. E. (2012). Prevention of incontinence-related skin breakdown for acute and critical care patients. Urology Nurse 32(4): 214-219. Retrieved from http://www.medscape.com/viewarticle/769850_2

7. DeMarco, S. (n.d.). Wound and pressure ulcer management. Retrieved from http://www.hopkinsmedicine.org/gec/series/wound_care.html

8. Lippincott Nursing Center.com. (2009). Wound watch: Assessing pressure ulcers. LPN2009 5(1): 20-23. Retrieved from http://www.nursingcenter.com/lnc/static?pageid=844487

9. Hess, C. T. (2010, Sep.). Arterial ulcer checklist. Advances in Skin and Wound Care 23(9): 432. Retrieved from http://journals.lww.com/aswcjournal/Fulltext/2010/09000/Arterial_Ulcer_Checklist.11.aspx

10. Hess, C. (2012). Clinical guide to skin and wound care (7th ed.). Ambler, PA: Lippincott Williams & Wilkins

11. Bhutani, S., Vishwanath, G. (2012, Sep.). Hyperbaric oxygen and wound healing. Indian Journal of Plastic Surgery 45(2): 316-324. Retrieved from http://www.ijps.org/article.asp?issn=0970-0358;year=2012;volume=45;issue=2;spage=316;epage=324;aulast=Bhutani

12. Lopez Rowe, V. (2014, Jul.). Diabetic ulcers. Retrieved from http://emedicine.medscape.com/article/460282-overview

13. Medfocus guidebook on: Diabetic foot ulcers. (2011). Princeton, NJ: Medfocus.com, Inc.14. American Diabetes Association. (2014, Oct.). Foot complications. Retrieved from

http://www.diabetes.org/living-with-diabetes/complications/foot-complications/15. Jain, A. K. C. (2012). A new classification of diabetic foot complications: A simple and

effective teaching tool. The Journal of Diabetic Foot Complications 4(1): 1-5. Retrieved from http://jdfc.org/wp-content/uploads/2012/01/v4-i1-a1.pdf

16. Cruciani, M., Lipsky, B. A., Mengoli, C., de Lalla, F. (2013). Granulocyte-colony stimulating factors as adjunctive therapy for diabetic foot infections (review). Hoboken, NJ: John Wiley & Sons, Ltd.

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18. University of Rochester Medical Center. (2008, Mar.). How diabetes drives atherosclerosis. Science Daily. Retrieved from http://www.sciencedaily.com/releases/2008/03/080313124430.htm

19. Rogers, L. C., et al. (2011, Sep.). The Charcot foot in diabetes. Diabetes Care 34(9): 2123-2129. Retrieved from http://care.diabetesjournals.org/content/34/9/2123.full

20. McCullogh, J. M., Kloth, L. C. (2010). Wound healing: Evidence-based management (4th ed.). Philadelphia, PA: F. A. Davis Company

21. Cowan, L. (2013). Wound series part 2: Approaches to treating chronic wounds. Retrieved from http://www.ceufast.com/courses/viewcourse.asp?id=269#Wound_Cleansing

22. Medline Industries, Inc. (2007). The wound care handbook [Chapter 8]. Mundelein, IL: Medline

23. Foster, C. (2010, Apr.). Non-traumatic wound debridement. Ostomy Wound Management 56(4): 8. Retrieved from http://www.polymem.com/pearls/pearls4practice0410.pdf?line_id=410

24. Sussman, C., Bates-Jensen, B. M. (1998). Wound care collaborative practice manual for physical therapists and nurses. [Excerpt]. New York, NY: Aspen Publishers. Retrieved from http://www.medicaledu.com/whirlpoo.htm

25. Dale, B. A., Wright, D. H. (2011). Say good-bye to wet-to-dry wound care dressings: Changing the culture of wound care management within your agency. Home Healthcare Nurse 29(7): 429-440. Retrieved from http://journals.lww.com/homehealthcarenurseonline/Fulltext/2011/07000/Say_Goodbye_to_Wet_to_Dry_Wound_Care_Dressings_.8.aspx

26. Ramundo, J., Gray, M. (2008, Jun.). Enzymatic wound debridement. Journal of Wound, Ostomy, and Continence Nursing 35(3): 273-280. Retrieved from http://www.nursingcenter.com/lnc/journalarticle?Article_ID=794501

27. Swezey, L. (2012, Jul.). Wound debridement techniques 6: Biological debridement. Retrieved from http://woundeducators.com/wound-debridement-techniques-6-biological-debridement/

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