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Wound Care:

Part IV

Jassin M. Jouria, MD Dr. 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.

Abstract

Although 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. Clinicians who opt to specialize in wound care provide an

important skillset to patients suffering from chronic or acute injury, disease,

or medical treatment. Often, a holistic approach is adopted, with

coordination of health team efforts to ensure that all aspects of a patient's

health are considered during the course of initial and ongoing wound care

management. Wound care clinicians also serve as a resource to prepare the

patient to continue care at home.


Policy 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. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 3 hours. Nurses may only claim credit

commensurate with the credit awarded for completion of this course activity.

Statement of Learning Need

As wound care is a rapidly advancing field, continuing education is necessary

to ensure that clinicians caring for patients with wounds stay on top of the

latest treatment techniques and strategies to achieve wound healing.

Certification in the field of wound care is available for clinicians wanting to

specialize in their area of practice to best; causes of skin breakdown, types

of wounds, treatment of acute and chronic wounds and, importantly, wound

prevention, are all key areas for clinicians to commit to continuous learning

and practice improvement.

Course Purpose

To provide clinicians with knowledge of wound risk, and phases of wound

development and healing.


Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

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

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.


1. The guidelines for a nursing clinician providing education about nutrition to wound care patients is:

a. That is the role of a registered dietitian, not a nurse b. Malnutrition is an issue, unless the patient is obese. c. Wounds are more likely to develop without adequate vitamins and

nutrients. d. Body mass index (BMI) is reflective of nutritional intake.

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 on the affected foot to promote circulation. b. rest the foot and elevate it on a pillow or blanket. c. avoid compression stockings. d. let the sore dry out so it may heal faster.

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. Skin barriers help to

a. prevent waste from incontinence from repeatedly contacting the skin.

b. protect the skin through liquid skin protectants. c. protect against skin breakdown. 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 clinicians 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 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 wound care encounter.

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 clinician 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 clinician on an ongoing basis.

Medication Management and Patient Education

Management of the medications administered to the wound patient,

discussed in Part III of this series, 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 clinician is providing.

For example, a patient may believe that hydrogen peroxide should be

applied to a wound every day to prevent infection even though regular

dressing changes are being done. When discussing medications used for

wound healing, the clinician 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 clinician may have the patient

demonstrate the proper method for applying the medicine before being

expected to do it independently.

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 health clinician. The

clinician 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 health clinician.

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 clinician must provide education to the patient about the importance of

nutrition related to wound care; teaching should include 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 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 clinician 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 clinician 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 health

clinician should first determine the amount of protein and other nutrients

needed in the patient’s diet before advising the patient to 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, such 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 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 clinician 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 clinician 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 health clinician 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 medical or nursing clinician 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 clinician 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 clinician 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 to work toward

wound healing.

Wounds International developed an expert working group that discussed

wound care healing and the wellbeing of patients. The group had defined

wellbeing 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 wellbeing 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 may be very embarrassing and may lead

the patient to avoid being around others.

The clinician 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 an ability to 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 potential job loss because of the time away from work to care

for the wound. Each assessment should have some component that checks

the patient’s emotional wellbeing. If the patient is able to express feelings

related to wound health, the clinician should be able to respond with

resources to help the patient through his or her feelings, whether it is done

during clinical encounters or a referral to another professional, such as a

psychological counselor.

The clinician can come up with many practical solutions to help a patient

through anticipated 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 clinician may help the patient with fears about

the appearance of a 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 clinician can investigate the possible source and need for

an antibiotic prescription if the odor is caused by infection. In other cases,

consulting with a wound care expert, such as an advanced practice nurse or

certified wound, ostomy and continence nurse, provides needed support to

determine the type of dressings or wound management regimen needed to

control wound odor, and providing patient comfort.

Some patients who suffer from anxiety or depression may have more

difficulties accepting a wound and/or working with wound care professionals

for wound management. The patient who has a diagnosed mental health

condition as well as a chronic wound will need continuous clinical support for

management of such a condition. When a wound first develops, the patient

may benefit from added short-term counseling or therapy for help to

manage the many emotions associated with the setbacks associated with

acute wound care.

Other measures that the clinician may consider when providing emotional

support for the wound care patients include helping them think about the

positive elements of their life, what creates a sense of happiness or hope

and optimism for the future. Additionally, the clinician may encourage a

patient to come up with alternative activities of enjoyment that can be

performed even while undergoing wound treatment, and providing

information about support groups available for patients struggling with body

image or chronic illness. Additionally, the clinician may provide patients with

information about stress management and the signs or symptoms that

indicate they may be developing emotional issues related to wound care that

need to be addressed.


Above all, the clinician 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

wound healing. The clinician 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 or 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 affects 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 clinician 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, providing resources to

obtain additional pairs of stockings and education will be needed (i.e., how

long to wear the stockings and replacing them every 4 to 6 months). The


stockings are typically ordered by prescription and the patient may need

support to arrange for additional 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 with an extremity wound; examples

include casts, specialized boots or shoes that cover the dressing and the

wound and prevent excess pressure on the site. Foam mattress covers

placed on the bed to reduce the risks of further damage of pressure ulcers

are often recommended. The clinician should review the signs of a

developing wound with the patient, and educate the patient to observe for

signs of persistent skin redness, areas of skin 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 affected body area.

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

clinician first should review the process of a dressing change with the patient

in a step-by-step fashion, and demonstrating how to change the wound

dressing. This should be followed with the patient demonstrating to the

clinician how they would change the wound dressing, so that any information

may be reviewed again.

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 clinician 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

clinician must provide contact information and instruct how to be reached by

the patient for wound evaluation.

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 wound care, the clinician may need to work with a

wound care specialist to help the patient gain access to the appropriate

supplies to change the dressing at home. If a patient requires a cast or other

mobility products, certain materials may only be accessed 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 health care processes 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. Clinical

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 for the wound patient will 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 breakdown. In addition to

general interventions for skin protection, there are also specific interventions

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

family members 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 will depend on

the patient’s condition, the pressure of skin breakdown and wounds, and

whether the patient is able to assist with repositioning or move themself.

Some mattress 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 to take weight off areas of the body to avoid pressure wounds.

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 available if indicated to avoid pressure wounds.

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 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. When moving a

patient up in bed without careful protection for the heels, the heels may drag

along the surface of the bed while changing the patient’s position. This may

happen 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

tracheostomy 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 patients 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 waste secretions 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 health facilities where there are patients at risk of

skin breakdown, includes a cleanser with qualities to easily lift and clear

away dirt and debris from the patient’s skin, as well as moisturize the skin to

maintain adequate hydration.

It should be noted that skin cleansers used to clean a patient who has been

incontinent should not be used as wound cleansers. These items do not

contain the same ingredients to be used in both situations, and standard

skin cleansers used for incontinence could cause cell damage and further

skin breakdown when in contact with a wound.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, 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, simultaneously 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 body 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 to introduce pathogens into a 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; it 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 skin surface that has not been cleaned or dried off before

the patient is moved in bed or repositioned. As the nurse moves the patient,

for example, pulling the patient up in bed, the skin surface may slide easily

during being pulled up in bed because of the external layer of moisture while

the underlying skin tissue remains static or sluggish, causing shear forces to

occur. 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 over-bed trapeze is available, the patient

may also use the device to grasp 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 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 able to do so. 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 every 6 months because they can lose

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 to venous ulcer development.

If a patient has had deep vein thrombosis and post-thrombotic syndrome,

there is a 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.

The patient that has developed lipodermatosclerosis as a result of venous

insufficiency will require administration of anabolic steroids along with

compression therapy to help 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 for

daily aspirin therapy, the nurse should provide teaching and instruction

about the dose 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 an existing 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 blood

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 patient 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 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 health clinician perform this

task

• Avoiding trimming or cutting calluses or ingrown toenails and

having these conditions treated by a health clinician.

• Having the feet inspected by a health clinician at regular check-ups

for diabetic care and treatment

Other nursing interventions that may be implemented in the diabetic patient

include 1) checking the ABI on a regular basis and performing repeat tests

to determine if the index is increasing or decreasing over time,

2) monofilament testing, which assesses pain and sensation in the lower

extremities of the patient with diabetic neuropathy, and 3) 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, and having the

certification credentials establishes 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 Certified Wound Ostomy Continence Nurse

(CWOCN) credential to practice as a specialized 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

examination. 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 and clinical nurse specialists. 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 by achieving at least 6 hours of continuing

education credits annually to maintain certification.


Summary

Whether a clinician 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 medical or nursing clinician 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. Specifically, wound care clinicians 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 patient population. By understanding the necessity

of all of these elements, clinicians can continue to grow in their knowledge

and skills in wound care.

A major part of the nursing role when caring for the patient with a wound is

providing 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 wound healing. The nursing

clinician provides support by demonstrating competence in wound care

measures, respecting the patient’s privacy and showing empathy for the

patient’s feelings throughout the course of their treatment and recovery.

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1. The guidelines for a nursing clinician providing education about nutrition to wound care patients is:

a. That is the role of a registered dietitian, not a nurse. b. Malnutrition is an issue, unless the patient is obese. c. Wounds are more likely to develop without adequate vitamins and

nutrients. d. Body mass index (BMI) is reflective of nutritional intake.



a. True b. False


a. walk on the affected foot to promote circulation. b. rest the foot and elevate it on a pillow or blanket. c. avoid compression stockings. d. let the sore dry out so it may heal faster.

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. Skin barriers help to


b. protect the skin through liquid skin protectants. c. protect against skin breakdown. d. All of the above


6. 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 7. 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

a. measuring for the correct size. b. applying the stockings correctly and teaching the patient how to

apply the stockings, if able. c. explain the practical factors of use, i.e., replacing stockings in

approximately 6 months because they can lose elasticity. d. All of the above

8. The ABI is a comparison of the systolic blood pressure in the

ankle to the systolic blood pressure in the arm. An ABI a. less than 0.25 can indicate peripheral arterial disease. b. less than 0.9 can indicate peripheral arterial disease. c. may not be performed by a nurse; only by a MD. d. symptoms are usually absent so that trending the ABI is not

helpful. 9. Indications of decreased arterial circulation include

a. poor hair growth on the lower legs and feet. b. shiny, dry skin, pale, cool skin. c. purple skin color and thickened toenails. d. All of the above

10. Regular, daily administration of aspirin as an anti-platelet

medication can reduce the risk of a. blood clots. b. myocardial infarction and stroke. c. progression of atherosclerosis associated with arterial insufficiency. d. All of the above


11. According to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, a patient who is confined to bed should be repositioned and turned a. every hour. b. a minimum of every two hours. c. three times every 8 hours. d. as often as the patient requests.

12. A patient sitting in a chair should be repositioned and assisted

to shift weight on the seat at least every a. 30 minutes. b. 30 – 60 minutes. c. hour. d. 2 hours.

13. True or False: 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.

a. True b. False

14. Vitamin E deficiency has a negative effect on the body because

Vitamin E a. has anti-inflammatory properties. b. can control inflammation in and around a wound. c. is an antioxidant. d. All of the above

15. True or False: The body mass index (BMI) is a highly specific and

accurate reflection of a person’s specific nutrient intake or lack thereof. a. True b. False


16. Zinc and iron, are important micronutrients when a patient is healing from a chronic wound. Deficiencies of zinc in the diet can cause a. increased fibroblast production in the wound bed. b. decreased fibroblast production in the wound bed. c. increased epithelialization. d. collagen production.

17. Iron deficiencies

a. can lead to serious deficits in wound healing. b. are more likely in patients who suffer from chronic illnesses such as

alcoholism, iron-deficiency anemia, and gastrointestinal disorders. c. Can be avoided by taking recommended supplement and diet

improvements, i.e., increased intake lean beef/turkey, seeds, beans and lentils, eggs and dried fruit.

d. All of the above 18. The Wound, Ostomy, and Continence Certification Board

(WOCNCB) certifies nurses a. after passing an exam. b. with one year of experience practicing as a specialized wound,

ostomy, and continence nurse. c. with two years of experience practicing as a specialized wound,

ostomy, and continence nurse. d. only who are licensed independent providers.

19. A true vitamin E deficiency is uncommon, partly because

a. it can be easily supplemented through vitamin preparations or

foods. b. is in food such as almonds and peanuts, and green, leafy

vegetables, i.e., broccoli and spinach. c. is in vegetable oils, such as corn, sunflower, and soybean oils. d. All of the above


20. The American Board of Wound Management (ABWM) offers certification based on a. the level of expertise and training of a healthcare professional. b. as a Certified Wound Care Associate® (CWAC) to a clinician with at

least 1 year of experience in wound care. c. to a RN only, and not to LPN or healthcare assistant. d. Answers b., and c., are correct

21. True or False: The ABWM offers credentialing as a Certified

Wound Specialist® (CWS), to 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. a. True b. False

22. For patients unable to help when they are being repositioned or

turned in bed, the head of the bed should not be placed at an angle higher than ____ degrees. a. 15 b. 30 c. 45 d. 50

23. Excess intake of fatty foods can cause

a. hypertriglyceridemia. b. low LDL. c. high HDL. d. poor wound healing in certain ethnic groups.

24. ___________________ is important to protect the immune

system and to support collagen synthesis in the wound bed. a. Vitamin D b. Vitamin E c. Vitamin C d. Zinc


25. True or False: Specialty beds help prevent excess pressure in certain areas from sustained periods of immobility, and alleviate the nurse from having to move or turn the patient. a. True b. False

26. To prevent skin breakdown due to incontinence or urine or stool,

the nurse may

a. insert a urinary catheter. b. educate the patient about the benefit of a colostomy. c. apply barrier creams to the patient’s skin. d. line the bed with absorbent padding.

27. Nurses that provide compassionate care to the patient

a. respect the patient’s privacy and show empathy of their feelings. b. avoid problem solving to allow the patient to identify their own

feelings associated with the healing wound. c. avoid discussion of his/her emotional health. d. should have advanced licensure to provide wound care.

28. True or False: A nurse may decide to utilize a new type of

dressing to promote wound healing, however the patient may be more concerned with the appearance of the dressing or its bulk that appears underneath clothing. a. True b. False

29. 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 a. 15 to 20 kcal/kg each day. b. 35 to 40 kcal/kg each day. c. 25 kcal/kg minimum each day. d. 30 kcal/kg minimum each day.


30. Nursing interventions designed to prevent wound development focus on a. skin protection. b. management of chronic conditions that contribute to skin

breakdown and wound development. c. use of methods that will protect the patient from complications. d. All of the above

31. A patient with an unstable wound that needs more consistent

care either needs to be monitored for the wound as well as for chronic disease management much more closely by a. a home health nurse. b. care aide. c. nurse practitioner. d. wound certified MD.

32. Normal protein requirements are approximately 1.5 g/kg of

body weight a. per day. b. per every 3 days. c. per every week. d. per every other week.

33. A patient with deep vein thrombosis and post-thrombotic

syndrome, may be at higher risk of developing a/an ______________. When this happens, it may be necessary to place the patient on _____________________ medications to reduce the risk of another blood clot. a. arterial ulcer; daily baby aspirin. b. venous ulcer; prophylactic anticoagulant. c. unsightly hypertrophied veins; daily aspirin 325 mg tablet. d. aortic aneurysm; daily baby aspirin.


34. Once certified through the ABWM, a nurse must demonstrate competence through continuing education by achieving at least __ hours of CE credits annually to maintain certification. a. 6 b. 12 c. 15 d. 20

35. Making personal changes to decrease the risk of atherosclerosis,

includes a. quitting smoking. b. increasing daily exercise and losing weight when necessary. c. controlling cholesterol intake. d. All of the above

Correct Answers: 1. The guidelines for a nursing clinician providing education about

nutrition to wound care patients include:

c. Wounds are more likely to develop without adequate vitamins and nutrients. “… teaching provides information about how wounds can be more likely to develop in the absence of adequate vitamins and nutrients...”



a. True “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;…”



b. rest the foot and elevate it on a pillow or blanket. “For instance, a diabetic client with a foot ulcer on the ball of the foot should not walk or put pressure on the affected foot while the wound is healing…. When a wound is in an extremity, the patient should rest the area and elevate it on a pillow or blankets.”

4. Compression stockings are often used in management of venous ulcers, but

c. a nurse should be aware that compression stockings can worsen wounds and ulcers that have developed from arterial insufficiency. “For example, compression stockings are often used in management of venous ulcers but can worsen wounds and ulcers that have developed from arterial insufficiency.”

5. Skin barriers help to


b. protect the skin through liquid skin protectants. c. protect against skin breakdown. d. All of the above [correct answer]

“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. 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.”


6. 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 health clinician. d. All of the above [correct answer]

“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; Avoiding walking around barefoot, which could cause injuries to the feet; Avoiding trimming or cutting calluses or ingrown toenails and having these conditions treated by a health clinician.”

7. 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

a. measuring for the correct size. b. applying the stockings correctly and teaching the patient how to

apply the stockings, if able. c. explain the practical factors of use, i.e., replacing stockings in

approximately 6 months because they can lose elasticity. d. All of the above [correct answer].

“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... 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 elasticity.”


8. The ankle-brachial index (ABI) is a comparison of the systolic blood pressure in the ankle to the systolic blood pressure in the arm. An ABI

b. less than 0.9 can indicate peripheral arterial disease. “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 ….”

9. Indications of decreased arterial circulation include

a. poor hair growth on the lower legs and feet. b. shiny, dry skin, pale, cool skin. c. purple skin color and thickened toenails. d. All of the above [correct answer]

“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.”

10. Regular, daily administration of aspirin as an anti-platelet medication can reduce the risk of

a. blood clots b. myocardial infarction and stroke. c. progression of atherosclerosis associated with arterial

insufficiency. d. All of the above [correct answer]

“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.”


11. According to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, a patient who is confined to bed should be repositioned and turned

b. a minimum of every two hours. “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.”

12. A patient sitting in a chair should be repositioned and assisted to shift weight on the seat at least every

c. hour. “A patient who is sitting in a chair should be repositioned and assisted to shift body weight on the seat at least every one hour.”

13. True or False: 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.

a. True “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.”

14. Vitamin E deficiency has a negative effect on the body because Vitamin E

a. has anti-inflammatory properties. b. can control inflammation in and around a wound. c. is an antioxidant. d. All of the above [correct answer]

“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.”


15. True or False: The body mass index (BMI) is a highly specific and accurate reflection of a person’s specific nutrient intake or lack thereof.

b. False “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.”

16. Zinc and iron, are important micronutrients when a patient is

healing from a chronic wound. Deficiencies of zinc in the diet can cause

a. increased fibroblast production in the wound bed.

“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.”

17. Iron deficiencies

a. can lead to serious deficits in wound healing. b. are more likely in patients who suffer from chronic illnesses such

as alcoholism, iron-deficiency anemia, and gastrointestinal disorders.

c. Can be avoided by taking recommended supplement and diet improvements, i.e., increased intake lean beef/turkey, seeds, beans and lentils, eggs and dried fruit.

d. All of the above [correct answer]

“Deficiencies in [iron and zinc] 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.”


18. The Wound, Ostomy, and Continence Certification Board (WOCNCB) certifies nurses

a. after passing an exam. “After passing the examination and becoming certified, the nurse must renew certification within five years.”

19. A true vitamin E deficiency is uncommon, partly because

a. it can be easily supplemented through vitamin preparations or

foods. b. is in food such as almonds and peanuts, and green, leafy

vegetables, i.e., broccoli and spinach c. is in vegetable oils, such as corn, sunflower, and soybean oils. d. All of the above [correct answer]

“A true vitamin E deficiency is uncommon, partly because it can be easily supplemented into the diet through vitamin preparations or foods.”

20. The American Board of Wound Management (ABWM) offers

certification based on

a. the level of expertise and training of a healthcare professional. “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.”

21. True or False: The ABWM offers credentialing as a Certified

Wound Specialist (CWS), to 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.

a. True “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.”


22. For patients unable to help when they are being repositioned or turned in bed, the head of the bed should not be placed at an angle higher than ____ degrees.

b. 30 “If an over-bed trapeze is available, the patient may also use the device to grasp and help with moving up in bed. Alternatively, some patients are unable to help with repositioning or turning while in bed…. 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.”

23. Excess intake of fatty foods can cause

a. hypertriglyceridemia. “… excess intake of fatty foods can cause hypertriglyceridemia and can impact liver function.”

24. ___________________ is important to protect the immune

system and to support collagen synthesis in the wound bed.

c. Vitamin C “… vitamin C is important to protect the immune system and to support collagen synthesis in the wound bed.”

25. True or False: Specialty beds help prevent excess pressure in certain areas from sustained periods of immobility, and alleviate the nurse from having to move or turn the patient.

b. False “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.”


26. To prevent skin breakdown due to incontinence or urine or stool, the nurse may

c. apply barrier creams to the patient’s skin. “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.”

27. Nurses that provide compassionate care to the patient

a. respect the patient’s privacy and show empathy of their feelings.

“…A major part of the nursing role when caring for the patient with a wound is providing 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 wound healing. The nursing clinician provides support by demonstrating competence in wound care measures, respecting the patient’s privacy and showing empathy for the patient’s feelings throughout the course of their treatment and recovery.”

28. True or False: A clinician may decide to utilize a new type of

dressing to promote wound healing, however the patient may be more concerned with the appearance of the dressing or its bulk that appears underneath clothing.

a. True “For example, although a clinician 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.”


29. 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

b. 35 to 40 kcal/kg each day. “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.”

30. Interventions designed to prevent wound development focus on

a. skin protection. b. management of chronic conditions that contribute to skin

breakdown and wound development. c. use of methods that will protect the patient from complications. d. All of the above [correct answer] “… 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.”

31. A patient with an unstable wound that needs more consistent

care either needs to be monitored for the wound as well as for chronic disease management much more closely by

a. a home health nurse. “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.”


32. Normal protein requirements are approximately 1.5 g/kg of body weight

a. per day. “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.”

33. A patient with deep vein thrombosis and post-thrombotic syndrome, may be at higher risk of developing a/an ______________. When this happens, it may be necessary to place the patient on _____________________ medications to reduce the risk of another blood clot.

b. venous ulcer; prophylactic anticoagulant. “If a patient has had deep vein thrombosis and post-thrombotic syndrome, there is a 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.”

34. Once certified through the ABWM, a nurse must demonstrate competence through continuing education by achieving at least __ hours of CE credits annually to maintain certification.

a. 6 “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.”


35. Making personal changes to decrease the risk of atherosclerosis, includes

a. quitting smoking. b. increasing daily exercise and losing weight when necessary. c. controlling cholesterol intake. d. All of the above [correct answer] “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.”

References Section The References below include published works and in-text citations of published works that are intended as helpful material for your further reading. 1. Katz, M. J., Kirr, C. A. (2012). Wound care. Retrieved from

http://www.nursingceu.com/courses/395/index_nceu.html 2. Kifer, Z. A. (2012). Fast facts for wound care nursing: Practical wound

management in a nutshell. New York, NY: Springer Publishing Company, LLC

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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 http://mkt.medline.com/clinical-blog/channels/clinical-solutions/kennedy-terminal-ulcer-ktu-is-now-recognized-by-cms-for-long-term-acute-care-hospitals-ltac-or-ltch/

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

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78. Medline Plus. (2014, Jun.). How wounds heal. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000741.htm

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80. Morgan, N. (2013, Jan.). How to do a Semmes-Weinstein monofilament exam. Retrieved from http://woundcareadvisor.com/apple-bites-vol2-no1/

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