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Wound Care:
Part II
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.
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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 3.5 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.
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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.
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1. In the initial assessment, a nurse should consider, examine, determine and/or document the following?
a. Underlying conditions that could delay wound healing b. The patient’s subjective pain levels are not relevant c. Probe suspected foreign objects in wound site. d. All of the above
2. True or False: Dry necrotic tissue has a yellow or gray
appearance. a. True b. False
3. The use of sterile, medical-grade maggots placed in the
wound bed a. is a new form of debridement. b. is an example of biological debridement. c. with the wound site kept uncovered. d. All of the above
4. The concept of wound bed preparation has been devised as a
structured approach a. to promote healthy tissue within the wound bed. b. most often used for healing acute wounds. c. that focuses on keeping the wound bed dry. d. exclusively to prevent infection.
5. TIME is a mnemonic used to best manage a wound and to
promote healing: It stands for
a. Tunneling-Infection-Moisture-Edge of the Wound. b. Tissue–Infection or Inflammation–Moisture–Edge of the
Wound. c. Tissue-Induration or Inflammation-Moisture-Edge of the
Wound. d. Tissue-Infection-Medication-Elasticity of tissue.
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Introduction
Assessment is the first step in the management of a wound. It should
be performed during the initial stages, such as when a patient seeks
care for treatment of a wound or when a clinician or caregiver
discovers that a wound has developed. Continual assessment is
important throughout the treatment process to discern how well the
wound is healing and to determine if treatment measures are being
effective. This course discusses key aspects of the assessment
process, preparation of the wound area for treatment, and basic
wound dressing types to manage exudate and to facilitate healing.
Wound Assessment
Wound assessment involves ongoing observation whereby a clinician
inspects the wound and notes characteristics present. During
observation of the wound, the clinician takes the time to identify the
overall appearance, its approximate size, and whether any other tissue
or drainage is present, such as granulation tissue or slough. Other
characteristics of the wound that a clinician may determine upon
inspection include the approximate size and depth of the wound,
where it is located on the body, whether tunneling or undermining are
present, what type of drainage is present, if any, and if the skin or
tissue is infected or necrotic.
The clinician may also measure the size and depth of the wound by
examining its width and length. To measure the wound, the clinician
uses a flexible tape measure and measures the width and length at the
longest portions of the wound; this information is then documented in
the patient’s chart. The depth of the wound can be measured by
inserting a cotton-tipped applicator and very carefully touching the
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base of the wound. This method may be necessary if the wound is
unstageable or the clinician is unable to see if underlying structures,
such as fascia or muscle tissue, are exposed at the base of the wound.
When tunneling is evident, a cotton-tipped applicator or a gloved
finger can be used to assess the length and the area of tunneling. For
instance, if tunneling appears from one side of the wound to an
underlying area, the clinician can use this method to measure how
deep the tunneling extends. If infection is apparent, a sample may be
collected for a wound culture during the assessment and measuring
process.
The clinician should also talk with the patient and obtain subjective
information about the wound and the patient’s medical history.
Information about how the wound developed, how long it has been
present, and whether the patient has taken measures to treat the
wound are important aspects to note and document in the initial
assessment. The nurse should also determine if the patient has any
underlying conditions that would contribute to wound development or
delayed wound healing, such as diabetes, malnutrition, or immobility.
The patient’s report of pain from the wound is also important to note.
A wound may cause a range of reactions from patients, from mild
discomfort to excruciating pain. An infected wound may cause pain
when inflammation is present as well. The clinician should assess the
patient’s level of pain by asking the patient to identify pain intensity
and describe the type of pain present. Treating pain associated with
the wound is part of overall wound care management.8
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Foreign Bodies
A foreign body is an object in the skin that is not supposed to be part
of the wound. A foreign body may be in a chronic wound if the ulcer
was exposed to some sort of material or object that inadvertently
became embedded in the wound. An example of this might be when a
patient with a healing diabetic ulcer on the foot walks barefoot without
a covering on the wound and an object is embedded in the wound.
A foreign body may also enter the skin as part of the cause of the
wound. An accident or injury that causes the wound may leave
retained objects associated with the injury causing mechanism inside
the skin as part of the wound. When the objects are not found and
removed, the body recognizes them as foreign, thereby starting the
inflammatory process in response. Foreign objects that become
embedded in the skin can come from any number of items and can
range from shards of glass, pieces of wood from splinters, dirt, sand,
rocks, or various other materials.
Assessment of foreign bodies must be part of the initial examination of
the wound. If the object is not removed right away, the wounded area
can become reddened and the tissue can become inflamed. If an
infection does not develop in spite of the foreign body, the wound may
start to heal around the object, leaving a lump or nodule under the
skin that is very painful.
An article in The Nurse Practitioner: The American Journal of Primary
Healthcare describes other factors that can indicate if a foreign body is
present in a wound, which affects its healing process. The wound may
have continuous purulent drainage or may develop an abscess, which
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indicate that infection has developed around the item. If a patient is
allergic to a substance that enters the wound, the body may respond
with substantial inflammation, itching, and skin breakdown. A wound
with a retained fragment that has not been found and that develops an
infection may not respond well to antibiotic therapy as it normally
should.69
Assessment for a foreign body within a wound may be demonstrated
as increased patient pain with skin palpation, decreased circulation,
and diminished sensation in the region distal to the wound. The object,
if large enough, may compress the blood vessels or nerves and
ultimately affect sensation and blood flow, causing pain, numbness,
tingling, pallor, and poor peripheral pulses.69
Identification of a foreign object may require diagnostic tests, such as
an X-Ray or MRI. The type of test ordered depends on the patient’s
history and physical, the potential factors of what the foreign object
might be, and whether or not the object is visible through examination
of the wound. If the practitioner suspects a foreign object in the
wound but cannot visualize it, he or she should not blindly probe the
wound to search for it to be removed, as this can cause further trauma
to the tissue and could lead to increased bleeding or infection.
When the object is identified and should be removed, removal often
requires exposing the wound bed, if possible, and irrigating the wound
with normal saline. The clinician may then pull the object from the
wound if it is accessible. In some cases, a foreign object cannot be
removed without significant tissue trauma, in which case, surgical
intervention is necessary. When working with a wound that contains a
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foreign object, pain medication and comfort care for the patient is
necessary, as the process can be quite painful and can produce
significant anxiety.
Once the object has been removed, the wound should be cleaned and
covered with a dressing for further protection. The clinician may order
antibiotic ointment or a specialized dressing to protect the wound. The
clinician should monitor the wound closely during the period following
foreign body extraction, as the wound can still develop an infection
after exposure to the item. Frequent assessment for skin changes,
including an increase in drainage, skin redness, inflammation, and
increased pain can all indicate a developing infection after the foreign
object has been removed. Further treatments with regular dressing
changes, cleansing, and balance of moisture are also necessary to
promote healing long after the object is out of the wound.
Sensation
Some patients, particularly those with neuropathy associated with
diabetes, have decreased sensation in the lower extremities. When this
occurs, the patient may be unable to sense an injury to the skin or
that breakdown is happening at all unless he or she checks the feet
and legs on a regular basis. Assessment of sensation is important to
determine if the patient is at risk of skin breakdown because of
decreased feeling in the lower extremities.
One of the most common forms of testing for sensation is by using the
Semmes-Weinstein monofilament test. To perform the test, the
patient’s feet are exposed and a 5.07 monofilament is used to press
against the patient’s skin for one second at a time. Without watching
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what the clinician is doing, the patient tells the clinician when he or
she feels the filament against the skin.
The monofilament exerts approximately 10g of pressure against the
skin, making this a useful test for determining loss of sensation.104 The
clinician should press the monofilament into various locations in the
lower legs and feet, avoiding calloused or thickened areas of skin. A
patient who cannot consistently detect the monofilament during the
test should receive further evaluation for decreased sensation due to
neuropathy.
The monofilament test should be combined with checking the foot for
signs of injury, ulceration, decreased blood flow, or decreased
sensation, as well as checking the patient’s history for reports of
decreased sensation, numbness, tingling, pain, or decreased
movement in the lower extremities.
Blood Flow
Assessment of blood flow to the affected area is combined with
information gained from the patient’s history description of the cause
of the wound. Wounds are significantly impacted by proper blood flow;
decreased blood flow to an area results in deoxygenation of tissues
and increased risk of skin and tissue breakdown. It is therefore
important that part of the focused exam include assessment of blood
flow to the area.
Arterial insufficiency leads to ulcers that most commonly develop in
the lower extremities, so when a patient presents with a wound and
has a condition that impacts circulation, the clinician should assess for
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adequate blood flow to the affected area. This includes assessing and
noting skin color, such as whether it is pink and looking healthy or if it
is pale or cyanotic, as well as patterns of hair growth in the lower
extremities. Assessment of capillary refill can be performed in various
areas by lightly depressing an area of the skin with a finger to cause it
to blanch and then counting how long it takes for blood to return to
the area and for color to be restored.
The clinician may also assess pulses, both proximal and distal to the
wound site. Assessing pulses in various locations also provides a more
comprehensive view of the patient’s circulatory status. For example, if
a patient presents with a wound on the lower leg on the calf, the
clinician may assess the popliteal pulse behind the knee as well as the
dorsalis pedis and posterior tibial pulses in the ankle and foot. Use of a
doppler to assess pulse may be necessary if it cannot be found
through palpation.
Signs and symptoms associated with peripheral artery disease, such as
poor skin color, pain in the lower legs, and intermittent claudication,
can also appear when a patient has arterial insufficiency and should be
assessed when the patient presents with a wound that has developed
from diminished arterial circulation.
Erythema, or redness of the skin and mucous membranes, occurs
when the capillaries near the surface of the skin dilate and blood flow
is increased to an affected area. Erythema that is blanchable should
briefly turn white when the skin is compressed and then return to a
red color. An early wound, such as a stage I pressure ulcer, occurs as
non-blanchable erythema, in which the skin does not change color
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when it is compressed slightly during the assessment. When skin has
non-blanchable erythema present, it is a sign that tissue damage has
occurred under the surface, even if the outer layers of skin remain
intact.8
When assessing erythema, the clinician should note the size of the
reddened area, measuring it, if possible. If the area blanches when
pressed and then fills in with redness again (which is a test of capillary
refill) the clinician should note the length of time it takes for color to
return. Capillary refill should be brief; the longer it takes for the tissue
to return to its color after finger pressure, the greater the risk of
damage to the skin.8 A slow return of color to the affected area
indicates that blood flow is sluggish and the skin could become
ischemic. If the clinician provides an early assessment and catches a
situation where non-blanchable erythema is present, the condition
may still be reversed before permanent damage ensues.
It may be difficult to assess areas of erythema among patients who
have dark skin. In these cases, skin may appear to have purple
undertones and the skin surface may be shiny and firm. The clinician
can use a direct light over the affected area for assessment and look
for other signs of injury beyond erythema, such as tissue swelling and
warmth.8
Development Of A Treatment Plan
The development of wounds within the hospital environment is an
unacceptable complication that can occur with some patients who are
at high risk. Some patients, particularly those who are immobile and
require multiple devices for their care, such as ventilators and
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hemodynamic monitoring, are at greater risk of wounds developing in
the healthcare environment. The development of severe wounds such
as stage III and stage IV pressure ulcers that occur in a healthcare
facility has actually been classified as a never event. In 2008, the
Centers for Medicare and Medicaid Services announced that it would
no longer pay for treatment measures for pressure ulcers that have
developed while patients were in the hospital.3 Beyond the obvious
effects of preventing pain and infection as a result of wounds, this
statement is another form of evidence that prevention and treatment
of wounds is important to avoid costly consequences for the healthcare
facility.
When a wound is found to have developed, the wound must undergo
cleansing and evaluated for a method of clearing away debris and/or
unviable tissue so that healthy tissue can form. The following section
outlines wound care options that may be found in the patient’s
treatment plan.
Wound Cleansing
Wound cleansing is a routine
procedure that reduces the amount
of debris and bacteria that can build
up in the wound. Wound cleansing
should be performed regularly when
a clinician changes the wound
dressing and both before and after
wound debridement. If a skin graft
has been placed, the clinician should
cleanse the skin around the graft but
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should not disturb the graft itself.20
Cleansing is done gently, both for comfort of the patient, as the wound
can be extremely painful, and to prevent further trauma to the wound.
It should be noted that trauma could occur during cleansing both by
physical and chemical means. Vigorous scrubbing of a wound can
cause physical trauma, but gentle application of a harsh chemical to
the wound can also cause tissue trauma. The type of cleanser and
method of administration is determined by the health clinician and
typically considers such factors as the amount of necrotic tissue
present, the amount and type of exudate present, and the area of the
body affected by the wound. When applying a cleanser and cleaning
the wound, the clinician should stimulate the tissue enough that debris
and excess drainage is removed but that the healthy, growing tissue is
not disturbed.
The clinician applies the cleanser to the wound, which is designed to
break up debris and to collect drainage, which is then rinsed away.
While commercial cleansers that contain additives effective for
cleansing may be ordered, normal saline has also been effectively used
as part of wound cleaning. When normal saline is added to a wound
bed with the correct amount of pressure, it can lift and wash away
wound debris and exudate without damaging the wound. Alternatively,
wound cleansers that contain antimicrobial agents, such as hydrogen
peroxide or povidone-iodine can cause cytotoxicity and could more
likely damage the tissue instead of adequately cleaning it.20,21
Once a wound has been cleaned, the clinician should assess for
whether odor is present in the wound, which can indicate infection.
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Odor should be assessed after wound cleansing, as the presence of
odor before the wound is cleaned could be caused by dead tissue that
must be removed but that is not infecting the wound. When odor is
present after a wound has been cleaned, the clinician should assess
further for other signs of infection.
If odor or other signs of infection are present in the wound, the patient
may benefit from a short-term cleansing regimen of antimicrobial
wound cleansing products, despite their potential cytotoxicity.
Examples of these types of agents include Dakin’s solution, Hibiclens,
and hydrogen peroxide. These agents should not be used on clean
wounds with regular cleansing, but their application to contaminated
or infected wounds may be considered on a case-by-case basis.20
Debridement
Debridement is the process of removing dead tissue from the wound in
order to promote new growth, reduce infection, and promote wound
healing. The wound bed should be evaluated during the assessment
phase and the clinician should understand the various types of
drainage and tissue that indicate growth and healing, particularly
before embarking on the debridement process, in which healthy new
growth could otherwise be accidentally removed.
Necrotic tissue is one element that should be removed from the wound
during debridement. When moist, necrotic tissue may appear as yellow
or gray; and, when dry, necrotic tissue has the appearance of black,
tough eschar that may be thick or leathery. An area of necrotic tissue
may be covering an infection or a collection of fluid. When the necrotic
tissue is removed with debridement, the underlying area is exposed,
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which may cause fluid drainage or could reveal an infection. Eschar
differs from a scab, however, and the clinician should be familiar with
the differences in appearance and the make-up of these two wound
components.
While eschar consists of necrotic skin that has hardened into a tough
layer, a scab is made up of dried blood and exudate from the wound. A
scab may or may not need to be removed during the healing process,
but the clinician should understand that the terms eschar and scab are
not interchangeable and they should not be treated as such. A scab is
not associated with tissue necrosis and it is not dead tissue.22
Before starting the process of debridement, the clinician should be able
to identify necrotic tissue, as compared to granulation or epithelial
tissue, which indicates that the wound is healing. As stated, necrotic
tissue is tough and black. Fibrin is another element that must be
removed as part of debridement; it appears as white, yellow or gray in
color and might look stringy or rubbery. Slough is also yellow or gray
and has a similar, stringy texture.
Necrotic tissue must be removed through debridement when it is
present, as failure to remove it can lead to proliferation of bacteria and
increased risk of infection. A wound that contains necrotic tissue will
be unable to synthesize new tissue in a normal manner and necrotic
tissue prohibits the skin cells from communicating with each other to
form new granulation tissue.
The only exception to when eschar should be removed is when it is
found intact on a wound on the heel. The Agency for Healthcare
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Research and Quality (AHRQ) has issued guidelines that state that it is
better to leave this type of eschar in place, rather than trying to
remove it through debridement.22 The eschar must be flat and well
adhered to the heel, without evidence of surrounding edema,
sponginess, or drainage. If the eschar is found to be intact without
surrounding signs of infection or disease, it should remain in place, as
the structure of the heel does not allow the clinician to determine the
depth of the ulcer. In other words, a clinician may view a heel wound
with solid eschar covering it, but the clinician may not know if the
wound is relatively superficial or if it extends down to the connective
tissue and bone of the heel. In this case, it is safer to leave the eschar
in place if the wound is not infected.21
When this occurs, instead of removing the eschar on the heel, the
clinician should keep it in place as a method of sealing off the wound.
Skin care is still required in this area, even without debridement. The
clinician should take pressure off of the heel by elevating the area
when the patient is at rest; this method of pressure relief, called off-
loading, is the standard form of treatment in place of debridement of
this type of heel wound.22
There are several different forms of debridement. The decision of
which type to perform is based on the type of wound, the medical
clinician’s orders, and surrounding circumstances that affect the
removal of wound tissue, such as the presence of infection or
inflammation in the wound. The types of debridement that may be
used include surgical, autolytic, mechanical, enzymatic, and biological
debridement.
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Sharp Debridement
Surgical debridement is an effective form of wound management, and
is used for some particular wounds, such as diabetic foot ulcers. It is
used with a scalpel or scissors to cut away dead tissue and is often
performed in a surgical suite, depending on the extent of the wound. A
surgeon or physician typically performs surgical debridement under
sterile conditions. Surgical debridement quickly removes the dead skin
and eschar that are covering the wound to expose the underlying
portion to heal. A surgeon, advanced practice nurse, or specially
trained RN may perform conservative sharp debridement as a method
of removing dead tissue through cutting. This type of procedure can be
performed in an operating suite or it could be done at the bedside.
Sharp debridement carries an increased risk of wound bleeding
following the procedure.22
Autolytic Debridement
Autolytic debridement uses the body’s own tissues and cells to break
down necrotic tissue for removal. Autolytic debridement utilizes the
fluid found in the wound as a healing mechanism to remove dead
tissue. The fluid within the wound contains such components as
macrophages and neutrophils that work to support the immune system
and to tackle foreign pathogens that have invaded a portion of the
body. To perform autolytic debridement, the clinician applies a
dressing over the wound to keep the wound bed moist. The fluid
released from the wound liquefies the dead tissue so that it can be
cleared away.23 Autolytic debridement is one of the most painless
forms of removing dead tissue; however, because it can take longer
when compared to some other forms of debridement, the patient may
be at a greater risk of infection with this process.
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Mechanical Debridement
Mechanical debridement includes physical means of removing dead
skin tissue. Examples of mechanical debridement are using a force of
water to eliminate dead tissue, such as with a whirlpool; and, using
wet-to-dry dressings, and performing wound irrigation.
Using a whirlpool provides a form of mechanical debridement, as the
use of warm water with a slight pressure can soften eschar and make
it easier to remove necrotic skin. A whirlpool tub may be available at a
fixed location in a health center or it could be a portable device used to
take between patients who need this type of debridement. The
whirlpool utilizes warm water and the patient either submerges the
wounded area or his entire body into the water.
Whirlpools, when used as a form of mechanical debridement, have not
only been shown to effectively remove necrotic wound tissue, but also
to improve circulation by promoting vasodilation, reducing instances of
infection by removing exudate, and providing comfort for a patient
during the debridement process. To use, the wound care patient is
taken to the whirlpool for the number of minutes prescribed by the
physician. The temperature of the water is well controlled and a
patient with cardiovascular disease or peripheral neuropathy should
not use water with temperatures over 38°C.24 After using the whirlpool
for the prescribed time, the clinician rinses the patient’s wound with
enough vigor to remove the softened, necrotic skin and exudate from
the wound bed.
A whirlpool treatment should not be used for all wound patients, and
not everyone can tolerate time in a whirlpool for debridement. A
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patient who is immobile may not be able to get out of bed or move
much to get to the whirlpool, even if the tank is portable. Some
patients have clinical conditions in which they do not tolerate high
water temperature or they would not be able to endure the time spent
in the water. Further, whirlpool treatment should not be performed on
certain types of wounds, such as venous insufficiency wounds. Placing
the affected extremity in a dependent position in a whirlpool when a
venous ulcer is present is not helpful; the fibrous tissue sometimes
formed in a venous ulcer is relatively unchanged by whirlpool
debridement and this form of therapy is usually not successful at
removing it.
Finally, whirlpool tubs, because they are often used for more than one
patient, may carry a risk of infection if they are not properly cleaned
and maintained. All facilities should have protocols in place for
cleaning and disinfecting whirlpool tanks, and a facility should use this
form of treatment very carefully when working with wound care
patients to prevent the development of healthcare-acquired wound
infections that are transmitted between whirlpool tanks.
Another type of mechanical debridement that can be done at the
bedside and regularly performed by the clinician is the use of wet-to-
dry dressings. This type of dressing change, while serving as a form of
mechanical debridement, has come under fire in recent years as to its
purpose and its potential for negating some of the factors associated
with wound healing. When using a wet-to-dry dressing, the clinician
places a saline-soaked piece of gauze onto the wound bed. The gauze
eventually dries and once dried, the clinician pulls it off, taking debris
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and dead tissue with it. The process is then repeated as the wound
heals; it is sometimes performed up to four times per day.
Although the process of pulling off a dry piece of gauze can be efficient
in removing eschar and dead tissue from the wound bed, this type of
debridement unfortunately also can remove healthy tissue as well,
which slows and impairs the healing process.25 It is also extremely
painful for the patient when the clinician pulls the dressing off. The
wound itself may already be painful, but then pulling off a piece of
gauze that has dried and become stuck to the wound bed can be
agonizing. Some clinicians, in an attempt to provide comfort, have
wetted the gauze before removal so that it might be less painful for
the patient, but this actually negates the process of debridement.
Wet-to-dry dressings are warranted in some situations that require
mechanical debridement and they may be ordered as such. However,
there are a number of various debridement techniques and dressings
available as treatment for wound care such that wet-to-dry dressings
are becoming less common in favor of other measures. While still
used, this type of mechanical debridement may not be the best choice
for some wound care patients.
Irrigation is a third type of mechanical debridement; like the whirlpool,
irrigation uses hydrotherapy to soften necrotic tissue and cleanse the
wound bed of debris. Irrigation involves using a syringe or catheter to
irrigate the wound at a certain level of pressure to loosen and wash
away debris and dead tissue.22 Irrigation may be performed at the
bedside by the clinician; it must be done at a pressure between 4 psi
and 15 psi in order to be effective: pressures less than 4 psi are not
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strong enough to loosen tissue and pressures greater than 15 psi have
been shown to damage healing skin and to drive debris deeper into the
tissues.
Irrigation by hand with a syringe can be performed relatively easily as
long as the clinician places a basin next to the wound to collect the
drainage and irrigant solution. This type of debridement is most
effective for wounds that are not infected or that only have minor
infections, those that do not contain significant amounts of debris, and
those that do not have thick eschar, as the pressures used with
irrigation are not high enough to loosen and remove very thick or
tough eschar.20
Another more technical form of irrigation is pulsatile lavage with
suction, which is designed to mechanically irrigate and cleanse a
wound to remove debris, exudate, and slough tissue from the wound
bed while simultaneously suctioning the fluid and output. This type of
irrigation may be more likely to stimulate granulation tissue formation
because of its action of slight pressure with irrigation combined with
negative pressure of suction. McCullogh and Kloth, in the book Wound
Healing, cited a study that showed that wound care patients who
received pulsatile lavage with suction had an over 12 percent increase
in granulation tissue formation per week when compared to 4.8
percent increase among those who used whirlpool therapy.20
Further, pulsatile lavage with suction can be used on many different
types of wounds and it is site specific, meaning a patient does not
have to have an extremity or the entire body submerged in a tub of
water to derive the benefits of debridement. Pulsatile lavage has been
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used for successful debridement of diabetic wounds, venous ulcers,
surgical wounds, pressure ulcers, and wounds that have become
infected. It can also be used on complicated wounds where tunneling
or undermining is present.20 Pulsatile lavage can be performed by a
clinician and it does not require advanced training, although it should
be done by someone who has some experience with the procedure;
however, when a patient has a significant wound, such as one that
extends to the bone or that is near a great vessel, it is better to have
an advanced practice nurse or physician perform the procedure.
Enzymatic Debridement
Enzymatic debridement is a form of topical debridement that may be
combined with other forms, such as surgical or sharp debridement.
Enzymatic debridement is done when a formulation of enzymes is
applied to the wound bed, which breaks down necrotic tissue so that it
can be removed. The process is performed once or twice daily and it
can easily be done at the bedside without excess equipment or the use
of a surgical suite. The advantages of enzymatic debridement include
its use in patients with bleeding or clotting disorders. Other forms of
debridement may increase the risk of bleeding in the wound, which
can be harmful to a patient who has difficulties with blood clotting.
Enzymatic debridement can also be used among patients who have
various types of wounds and it has been used successfully among
patients with such wounds as diabetic ulcers, burn wounds, venous
ulcers, wounds that are infected, and wounds that contain large
amounts of slough and eschar.26
To perform enzymatic debridement, the clinician first cleanses the
wound site with normal saline or with a cleansing agent. The clinician
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then applies the exogenous enzymes directly to the wound bed. If
black eschar is present, a process called cross-hatching is first
required, which involves cutting a crisscross pattern into the surface of
the eschar with a scalpel. This ensures that the enzymatic solution is
more likely to reach the wound bed under the layer of thick eschar.26
The process typically causes little pain to the patient, particularly when
compared with some other forms of debridement.
The goal of enzymatic debridement is to soften and liquefy necrotic
tissue to the point that it can be easily removed after a short time
spent with the application of enzymes. The process of cross-hatching
the eschar prior to administration may be painful for the patient, but
the process otherwise does not typically cause significant pain.
Enzymatic debriding agents are available by prescription only and may
be available through the healthcare pharmacy. Examples of enzymatic
debridement preparations include collagenase, Panafil, and papain and
urea (Accuzyme).
Biological Debridement
Perhaps one of the most interesting and oldest forms of debridement
is the use of biological substances on the wound surface to break down
and loosen debris in order for it to be quickly removed. One of the
most common forms of biological debridement is the use of medical-
grade maggots placed in the wound bed. Several sterile maggots —
the number of maggots used is determined by the size of the wound —
are placed in the wound bed and then covered with a light dressing or
gauze. The maggots sit in the wound bed and digest necrotic tissue.
Use of maggots is beneficial in that they focus on digesting necrotic
tissue only and they leave healthy tissue alone.
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After hours or days of the maggots being in the wound bed, the
covering is removed and the maggots are rinsed away. The process of
using maggots for debridement has been in use for hundreds of years
and was a relatively common form of wound debridement during the
American Civil War. Its popularity declined in the following period but
has gained interest again, starting in about the 1990s with the rise of
more and more resistant organisms. The maggots work not only by
digesting the necrotic tissue, but they also release a type of enzyme
that works to break down dead tissue in the wound, making it easier
to remove.
The practice of using medical-grade maggot as a form of biological
debridement has other benefits as well. Its use has been shown to
decrease wound odor and increase the rate of generation of
granulation tissue.27 Most patients suffer only minor discomfort with
this type of debridement; they may state that they do not notice the
maggots or only feel a slight tingling sensation. Some people, although
they do not experience much physical discomfort, instead feel
uncomfortable with the idea of using maggots in a wound bed, which
can be a barrier to this type of treatment and must be further explored
if biological debridement is to be used in a chronic wound.
There may be times when it is better for a wound not to be debrided.
As stated, the AHRQ has specified that dry heel wounds that are
covered with eschar should not be debrided because it may be difficult
to determine the depth and extent of the wound. Additionally, patients
who have severe peripheral vascular disease that significantly
compromises circulation to the area of the wound should not have
wounds debrided. Further, a condition known as dry gangrene, which
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develops as a result of poor blood flow rather than an infectious
process, is also considered a contraindication to debridement because
of the potential for infection and lack of blood flow to the affected
site.22
Moist Wound Bed and Healing
A wound requires a moist wound bed in order to best promote healing.
Moisture is necessary throughout the body for the cells to function
properly; however, moisture must be controlled and kept within a
delicate balance. In the case of a wound, the wound bed should be
kept moist but without affecting the surrounding tissues, as excess
moisture in areas outside of the wound bed can lead to maceration
and skin and tissue breakdown.
A moist wound bed is required for new granulation tissue to form in
the wound bed. As the cells migrate toward each other during healing,
they must have moisture. If the wound bed is too dry, the cells are
unable to move together to heal the wound and to close the edges. In
order for the wound to heal in a timely manner, the wound bed must
remain moist, or the wound will heal much more slowly when
compared with other wounds that are kept moist.29
The idea of keeping the wound bed moist originated in the 1960s when
Dr. George Winter, a urologist, determined that moisture was an
essential component of epithelialization and that open wounds healed
at a faster rate when kept moist.29 Prior to this time period, many
practitioners believed in keeping wounds open and/or uncovered;
today, many people still believe in keeping a wound open to air as it
heals, but this process actually negates the healing process because it
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causes the cells to dry out. Moisture is also important for keeping the
wound at an appropriate temperature that is best for healing. Finally, a
moist wound bed reduces the risk of infection, as it is necessary to
support debridement. During enzymatic or autolytic debridement, for
example, the moist wound bed supports the environment for the
process to work. In other words, application of a debridement solution,
such as that used for enzymatic debridement, will have a much more
positive effect on healing when it is applied over a moist wound bed
instead of trying to get the solution to work to debride a dry wound
bed.
The concept of wound bed preparation has been devised as a
structured approach to promoting healthy tissue within the wound bed
while supporting the effectiveness of other forms of therapy and
treatment. Preparation of the wound bed allows the clinician to
determine if there are factors that are affecting the process of wound
healing; this concept is most often used when dealing with a chronic
wound that is not healing.28 Wound bed preparations focuses on
maintaining moisture levels in the wound bed, promoting new tissue
growth, and preventing infection.
The clinician can implement the mnemonic TIME when considering how
to best manage the wound and provide an optimal wound bed for
healing. The TIME mnemonic is described as follows:28
• T - Tissue:
This step describes whether the tissue is healing or is not
viable and needs debridement. When assessing a wound, a
look at the wound bed will tell the provider of the presence of
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eschar or slough that needs to be removed. Performing
debridement then provides a healthier wound bed in which
new tissue can grow.
• I - Infection or Inflammation:
Infection and inflammation may be apparent when assessing
certain types of wounds, as some signs, such as odor, can
indicate a pathologic process going on. However, signs of
infection or inflammation in a wound may also be subtle and
difficult to accurately determine without a wound culture and
examination by a trained eye. Following wound culture, the
patient may need antibiotics in the form of topical or systemic
treatments to control bacterial growth. If inflammation is
present, anti-inflammatory medications can control continued
irritation and swelling.
• M - Moisture:
Wound moisture requires a careful balance to avoid both an
overly dry wound bed, which can delay healing, as well as an
overly moist wound bed, which can lead to maceration of
surrounding tissues. To balance appropriate moisture levels,
the nurse must use the appropriate types of dressings that
will retain a moist wound base from which to work without
causing excess moisture on the edges of the wound or the
surrounding tissues.
• E - Edge of the wound:
Normal wound healing results in the wound edges migrating
together to form a solid framework that indicates the wound
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has healed. When the edges are not coming together, there
may be excess necrotic tissue still in the wound that needs to
be debrided, or there may be other systemic factors that
should be considered that are causing delayed wound healing,
such as with the presence of certain types of chronic disease.
Wound edges that are rolled or rounded may not migrate
properly and can cause delayed healing. There may be
evidence of other damage or disease processes associated
with the wound, such as skin maceration or undermining of
the wound edges. Ultimately, after management measures
are taken, the wound edges should begin to migrate and fill in
the wound tissue in a healthy and responsive manner.
The base of the wound, or the wound bed, should remain moist to
promote new tissue growth. Alternatively, the skin surrounding the
wound should be dry to prevent maceration and further skin
breakdown. It is therefore important to concentrate on keeping the
wound bed at the base of the wound moist while cleaning and drying
other areas.
Wound Protection And Dressing Types
Wound dressings are applied to the wound to keep the wound bed
moist. This moist, warm environment can be maintained for wound
healing by the application of the right type of dressing that retains
moisture, is semi-occlusive to allow for wound drainage, and that will
not stick to the wound bed.29
Foam dressings are thickened dressings that contain foam as a type of
padding to protect the wound. Used in a number of different wound
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types, foam dressings can be packed into very deep wounds to fill
space or they may be placed on top of superficial wounds to provide
padding and protection from further injury. Foam dressings often have
adhesive borders around the outside edge of the foam sheet. The
adhesive allows the dressing to stick to the skin surrounding the
wound and hold it in place. They may be changed several times a
week, depending on the condition of the wound and the clinician
should take care to examine the surrounding skin to ensure it is not
being damaged by regular addition and removal of the adhesive from
the dressing.21,30
Impregnated dressings are those that are typically made up of gauze
and are infused with a type of chemical, such as petroleum, silver, or
collagen. Impregnated dressings are designed to keep the wound bed
moist while promoting wound healing. They are available as either flat
sheets of dressing that come in various sizes or they may be available
in small strips that can be packed into wounds, such as in cases where
wound tunneling is present.21 Impregnated dressings are often applied
once per day. The gauze dressing is placed in the wound bed. It is
typically flexible enough that it can be pressed lightly into the wound
bed without needing to cut down the size of the gauze sheet. A larger
dressing is then placed over the wound site for protection and to help
keep the impregnated dressing place. Examples of impregnated
dressings available include Vaseline gauze and Xeroform.21,30
Transparent dressings are not typically used for wound healing, but
they are included here as a type of wound dressing in that they can be
placed over the wound and provide a barrier to prevent pathogens
from entering the wound bed. Because they are transparent, these
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types of dressings allow the clinician to visualize the wound bed and to
identify changes that can signify infection or complications.
Transparent dressings are semi-occlusive in that they allow some
oxygen to reach the wound, which decreases the risk of anaerobic
microbes from growing in the wound bed to cause an infection. They
do not absorb excess fluid from the wound and they are not intended
for deep wounds. However, transparent dressings can be placed over
shallow wounds and superficial skin tears, as long as neither type of
wound is infected.30 Examples of transparent dressings include
Tegaderm, Op-Site, Blisterfilm, and AcuDerm.
Hydrogel dressings are designed to maintain a moist wound
environment because they contain a certain amount of gel within the
dressing that maintains moisture but they can also absorb some
exudate and drainage from the wound. Hydrogel dressings also work
as a form of autolytic debridement in that they are placed in the
wound bed, and they further keep the environment moist and thereby
soften and break down necrotic tissue that can be removed when the
dressing is changed.
Hydrogel dressings are made of polymers that can maintain wound
moisture, but they may also have added components that can provide
moisture control, such as silicone, polyethylene oxide, or glycerin.21
These types of dressings are placed on the wound bed; if the size
available is larger than the size of the wound, it may be cut with sterile
scissors down to fit the size and shape of the wound bed. Adhesive
backing is often present on the dressing, which is removed after the
dressing is placed on the wound to provide a non-occlusive surface
that permits some airflow and fluid distribution. Once placed on the
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wound bed, the dressing is then covered with a larger dressing, such
as a gauze pad, to provide protection. The hydrogel is typically
changed every day. Examples of hydrogel dressings available on the
market include DuoDERM, Vigilon, and Saf-Gel, although there are
many more brands available for use.21,30
Wound Exudate and Dressing Selection
Exudate is a type of drainage that comes from the wound. It is
necessary for a wound to create exudate, as this process can help to
keep the wound bed moist. Exudate contains many important
properties that are essential to the health of the wound, including
electrolytes, protein, growth factors, and inflammatory mediators. It is
usually clear or pale yellow in color and has a watery composition.
Exudate plays a critical role in keeping the wound bed moist to
facilitate migration of skin cells across the wound during healing.33
Exudate may vary in its appearance, depending on how the wound is
healing and if infection is present. The clinician should note whether
exudate is present as well as its color and consistency. For example,
exudate may drain from a wound and be described as a moderate
amount of serous drainage. When an infection is present, exudate may
have an odor and may be thick and purulent. Wound dressings are
applied to absorb exudate and to promote wound healing. Some
examples of dressings that may be applied to absorb exudate include
dry dressings and pads, hydrocolloid dressings, alginates, and
hydrofiber dressings.
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Dry Dressing
Dry dressings consist of gauze in the form of a gauze pad or bandage
that is applied to the wound as a covering. Dry gauze may be placed
on the wound bed and then covered with tape or wrapped with a
bandage. The gauze is designed to absorb small amounts of exudate
and then it can be removed; however, when large amounts of exudate
are present, the gauze may either become saturated and if not
changed quickly enough can lead to a wet layer of drainage covering
the wound, or it may stick to the wound bed and cause damage when
the nurse tries to remove it.30
Gauze dressings are often used for surgical wounds, but they may be
applied to many different types of wounds from various causes; the
use of gauze to cover a wound is based on the patient’s condition, how
the wound is healing, and whether there are other factors to consider
that can affect wound healing. Gauze is useful because it not only
absorbs small amounts of exudate but it also protects the wound from
infection by providing a barrier that prevents bacteria from entering
the wound, particularly when the gauze dressing is sterile.
Gauze pads are available in various sizes and may come in containers
in which they are packed together for multiple use or they may be
wrapped individually. Gauze is also available as a wrap, which is
flexible and comes in a large roll that can be wrapped around an
extremity or other area covering a wound to hold the underlying
dressing in place. Examples of dry gauze dressings that may be used
for wounds include a number of different products manufactured by
various companies under different brand names and that come in
various sizes and thicknesses for a multitude of purposes. Telfa is
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another type of gauze dressing contains a coating so that it will not
stick to a wound.
Wet-to-dry Dressing
Wet-to-dry dressings are also a form of dressing that is used for
absorbing exudate from wounds. These types of dressings are used for
mechanical debridement when they are saturated with saline, placed
on the wound bed, and then allowed to dry, absorbing excess exudate
and dead skin tissue along with it. The dried exudate is removed when
the dressing is removed. As stated, wet-to-dry dressings, while still
commonly ordered among many facilities as a form of mechanical
debridement, are being replaced with other forms of treatment that
are less damaging to the skin tissue and that are less painful for the
patient.
Hydrocolloid Dressing
Hydrocolloid dressings are another form of dressing material that is
designed to absorb exudate from the wound bed when the dressing is
placed on the wound. Hydrocolloid dressings typically contain polymers
and other elements such as pectin or carboxymethylcellulose, and they
are waterproof. The hydrocolloid dressing is applied to the wound — it
may need to be cut to fit the size of the wound — and it absorbs
exudate from the wound bed without drying the tissue too much.
Some types of dressings have a mark that indicates when the dressing
has become saturated. When the dressing has absorbed enough
exudate, it should be changed. Hydrocolloid dressings are changed
anywhere from every 2 to 7 days, depending on the amount of
exudate and how fast the dressing absorbs fluid.21,30 The dressing
should not be left in place if it becomes saturated.
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Alginate Dressing
Alginate dressings are designed for wounds that absorb large amounts
of exudate; these types of dressings can be placed in the wound bed
to rapidly absorb excess fluid while preventing the wound from drying
out. An alginate dressing is made up of either brown seaweed or a
combination of elements such as calcium or sodium salts. The dressing
is not pre-moistened, but instead, it becomes a gel when it is exposed
to moisture in the wound. For this reason, alginate dressings are best
used for wounds that produce significant exudate, rather than those
that are mostly dry or only slightly moist.
Its important for the clinician to be aware that if there is not enough
moisture in the wound bed, the alginate dressing may not keep its gel-
like features and it may end up drying out the wound. Alginate
dressings are available in many sizes of sheets, as well as ropes or
pads. This type of dressing is applied to the wound bed and then
covered with another dressing to keep it in place. In addition to
wounds that excrete large amounts of exudate, alginate dressings are
most useful for wounds that consistently ooze, such as those that have
just had surgical or sharp debridement because they contribute to
hemostasis and can staunch blood flow when oozing is present.21,30
Hydrofiber Dressing
Hydrofiber dressings work in a manner similar to alginate dressings in
that they expand upon contact with excess moisture. This action
makes hydrofiber dressings useful for wounds that create large
amounts of exudate. Unlike alginate dressings, though, hydrofiber
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dressings do not contribute to hemostasis, so they are not necessarily
the best type of dressings to use when wounds are oozing blood.30
Hydrofiber dressings are made up of carboxymethylcellulose, which
acts as an absorptive agent to collect exudate as it comes from the
wound bed. When placed in the wound bed, the hydrofiber dressing
wicks excess moisture away from the wound and collect it within the
dressing, where it becomes a gel when it is exposed to the moisture.
In some cases, hydrofiber dressings should be moistened with saline
before application; they come in sheets that can be cut to the
appropriate size, which should be slightly larger than the wound bed.
Some hydrofiber dressings are also impregnated with antibiotics, such
as silver, so they work to prevent or treat infection while also
controlling moisture levels in the wound.21,30
Additional Considerations for the Management of Exudate
After the clinician has applied a dressing to the wound, it may be
helpful to then apply a barrier cream or emollient to the surrounding,
intact skin in order to protect it from skin breakdown and to keep it
healthy and dry. Management of exudate is important to keep
surrounding skin healthy and dry but it has also been shown to reduce
instances of infection, reduce the number of dressing changes needed
in a wound, and improve patient quality of life, according to a review
from Wounds International.33
The amount of exudate produced by a wound is related to the size of
the wound. As a wound heals, it typically tends to produce less
exudate; however, a very large wound may produce large amounts of
exudate that require special dressings for control of fluid volume. For
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example, a patient who has been burned may have one or more large
wounds that cover a significant area of the body. Because of the size
of these wounds, they typically produce much more exudate that
needs to be controlled and maintained when compared to another type
of wound, such as a small pressure ulcer on the heel.33 If a patient has
a wound with a significant amount of exudate, the clinician should
determine the most appropriate type of dressing that will absorb
excess fluid and keep the wound clean and moist.
There are many indicators that demonstrate that exudate is not being
well controlled, such as saturated dressings or changes in the
appearance of the dressing on the outside of the wound, delayed
wound healing, skin breakdown on the areas surrounding the wound,
patient pain and embarrassment over the appearance, odor, or
characteristics of the wound, electrolyte imbalances in the patient from
loss of electrolytes and protein in the exudate, the need for frequent
dressing changes, and soiling of clothing and linens near the wound
dressing.
Control of exudate is important to prevent skin breakdown and further
destruction of wound tissue that cannot only delay healing but can
cause the condition to worsen. While it is important to keep the wound
bed moist, the balance of moisture is imperative to maintain, as too
little moisture, such as by absorbing every ounce of exudate until the
wound bed is completely dry, will delay healing and can cause tissue
damage. Alternatively, too much moisture and lack of exudate control
will keep the wound and surrounding tissue too moist, which can lead
to softening of the skin, maceration, and skin breakdown.
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Summary A treatment plan for wound care revolves around the assessment and
preparation of the wound for successful treatment and healing.
Prevention of wound development is primary to safe and appropriate
skin care. Early recognition of wound development allows for prompt
assessment and interventions to prepare the wound through cleaning
and removal of unviable tissue through a type of debridement. There
are various types of debridement that may be initiated depending on
the wound type and the level of professional skill and training required
for the debridement procedure.
Wound protection through initial selection of the type of dressing
requires knowledge of the varied wound products. The management of
exudate is basic to wound healing. Exudate plays a critical role in
keeping the wound bed moist to facilitate migration of skin cells across
the wound during the healing process. The primary goal in the initial
treatment of a wound is to promote healthy tissue within the wound
bed and wound healing through ongoing treatment and therapy.
Ongoing and advanced treatment and therapy options used to promote
wound healing are worthy of further study, and are covered in Wound
Care Part III of this series. Its important to assess all factors that
could affect the process of wound healing, such as wound bed
moisture levels and new tissue growth.
Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement.
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1. In the initial assessment, a nurse should consider, examine, determine and/or document the following?
a. Underlying conditions that could delay wound healing b. The patient’s subjective pain levels are not relevant c. Probe suspected foreign objects in wound site. d. All of the above
2. True or False: Dry necrotic tissue has a yellow or gray
appearance. a. True b. False
3. The use of sterile, medical-grade maggots placed in the
wound bed a. is a new form of debridement. b. is an example of biological debridement. c. with the wound site kept uncovered. d. All of the above
4. The concept of wound bed preparation has been devised as a
structured approach a. to promote healthy tissue within the wound bed. b. most often used for healing acute wounds. c. that focuses on keeping the wound bed dry. d. exclusively to prevent infection.
5. TIME is a mnemonic used to best manage a wound and to
promote healing: It stands for
a. Tunneling-Infection-Moisture-Edge of the Wound. b. Tissue–Infection or Inflammation–Moisture–Edge of the
Wound. c. Tissue-Induration or Inflammation-Moisture-Edge of the
Wound. d. Tissue-Infection-Medication-Elasticity of tissue.
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6. Impregnated dressings are those that are typically made up of gauze that are infused with
a. fertile maggots. b. an enzyme from maggots that breaks down dead tissue. c. a chemical, i.e., petroleum, silver, or collagen. d. silicone, polyethylene oxide, or glycerin.
7. The only exception to removal of eschar is when it is found
intact on a a. dry heel wound b. facial wound c. back wound d. anything other than a limb wound.
8. True or False: The Agency for Healthcare Research and
Quality (AHRQ) stated “dry gangrene” that is also a contraindication to debridement.
a. True b. False
9. Impregnated dressings are often applied
a. twice per day. b. once per day. c. once every other day. d. once every three days.
10. If the clinician suspects a foreign object in the wound but
cannot visualize it, the clinician should
a. probe the wound site to find it. b. apply a hydrocolloid dressing. c. use an X-Ray or MRI to find any foreign object. d. use a dressing impregnated with antibiotics.
11. True or False: Alginate dressings require dryness in the
wound bed to maintain its gel-like features during wound treatment. a. True b. False
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12. When assessing erythema on a person with dark skin, the nurse should note a. the reddened area for size. b. that the skin may appear to have purple undertones. c. that erythema is easier to detect. d. capillary refill is quicker.
13. True or False: Identification of a foreign object may require
X-Ray or MRI to diagnose cause of a wound. a. True b. False
14. Pulsatile lavage with suction can be used on
a. many different types of wounds. b. only deep types of wounds. c. requires full body submersion in a tub of water. d. most deep wounds except for diabetic wounds or surgical
wounds. 15. Collagenase, Panafil, and papain and urea (Accuzyme) are
examples of a. alginate dressings. b. enzymatic debridement preparations. c. impregnated dressings. d. None of the above
16. Irrigation by hand with a syringe is type of debridement
most effective for a. infected wounds. b. wounds with thick eschar. c. non-infected/minor wounds. d. site specific wounds, such as digits.
17. Autolytic debridement is
a. a very painful form of debridement. b. a painless form of removing dead tissue. c. faster than other forms of debridement. d. very effective with a low infection rate.
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18. A wound requires a ____________ wound bed in order to best promote healing. a. moist b. dry c. closed d. < 5 cm diameter
19. ________________ dressings are another form of
dressing material that is designed to absorb exudate from the wound bed when the dressing is placed on the wound. a. Hydrocolloid b. Gauze c. Seaweed d. Impregnated
20. A study showed that pulsatile lavage with suction had an
over _____ percent increase in granulation tissue formation per week when compared to 4.8 percent increase among those who used whirlpool therapy. a. 7.5 b. 12 c. 25 d. 40
21. ________________ is an essential component of
epithelialization and ____________ wounds heal at a faster rate. a. Dryness; open b. Moisture; open c. Granulation; dressed d. Cleaning; dressed
22. Unlike alginate dressings, hydrofiber dressings
a. contribute to hemostatis. b. expand upon contact with excess moisture. c. are the best type of dressings for wounds that ooze blood. d. are not useful for wounds with large amounts of exudate.
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23. Irrigation of a wound must be done at a pressure between ___________________ in order to be effective. a. 3 psi and 5 psi b. 5 psi an 10 psi c. 4 psi and 15 psi d. 2.5 and 15 psi
24. One of the most common forms of testing for sensation is
by using the a. sharp needle poke test. b. monofilament test. c. pinch test. d. ice to skin test.
25. If a patient does not have sensation during properly
performed testing, this may indicate a. wound infection formation. b. blood clot formation. c. that the wound is healing. d. neuropathy.
26. A common form of biological debridement is the use of a. medical-grade seaweed granules. b. medical-grade sponge. c. medical-grade maggots. d. medical grade charcoal granules.
27. When signs of wound infection occur, the patient may
benefit from a. a short-term antimicrobial wound cleansing product. b. Dakin’s solution. c. hydrogen peroxide. d. All of the above
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28. Foam dressings are a. thickened dressings with foam padding for wound protection. b. used for superficial to moderate thickness wounds only. c. not intended to fill space. d. must be changed daily.
29. True or False: Preparation of the wound bed focuses on
maintaining moisture levels in the wound bed, promoting new tissue growth, and preventing infection. a. True b. False
30. Signs and symptoms associated with peripheral artery
disease include a. poor skin color. b. pain in the lower legs. c. intermittent claudication. d. All of the above
31. Surgical debridement is an effective form of wound
management, and is used for a. diabetic foot ulcers. b. superficial burns. c. cutting away of dead tissue. d. Answers a., and c., are correct
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Correct Answers: 1. In the initial assessment, a clinician should consider,
examine, determine and/or document the following?
a. Underlying conditions that could delay wound healing “Information about how the wound developed, how long it has been present, and whether the patient has taken measures to treat the wound are important aspects to note and document in the initial assessment. The clinician should also determine if the patient has any underlying conditions that would contribute to wound development or delayed wound healing, such as diabetes, malnutrition, or immobility.”
2. True or False: Dry necrotic tissue has a yellow or gray
appearance.
b. False “Necrotic tissue is one element that should be removed from the wound during debridement. When moist, necrotic tissue may appear as yellow or gray; and, when dry, necrotic tissue has the appearance of black, tough eschar that may be thick or leathery.”
3. The use of sterile, medical-grade maggots placed in the
wound bed
b. is an example of biological debridement. “Perhaps one of the most interesting and oldest forms of debridement is the use of biological substances on the wound surface to break down and loosen debris in order for it to be quickly removed. One of the most common forms of biological debridement is the use of medical-grade maggots placed in the wound bed. Several sterile maggots — the number of maggots used is determined by the size of the wound — are placed in the wound bed and then covered with a light dressing or gauze.”
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4. The concept of wound bed preparation has been devised as a structured approach
a. to promote healthy tissue within the wound bed. “The concept of wound bed preparation has been devised as a structured approach to promoting healthy tissue within the wound bed while supporting the effectiveness of other forms of therapy and treatment. Preparation of the wound bed allows the clinician to determine if there are factors that are affecting the process of wound healing; this concept is most often used when dealing with a chronic wound that is not healing. Wound bed preparations focuses on maintaining moisture levels in the wound bed, promoting new tissue growth, and preventing infection.”
5. TIME is a mnemonic used to best manage a wound and to
promote healing: It stands for
b. Tissue–Infection or Inflammation–Moisture–Edge of the Wound. “The clinician can implement the mnemonic TIME when considering how to best manage the wound and provide an optimal wound bed for healing. The TIME mnemonic is described as follows: Tissue … Infection or Inflammation … Moisture … Edge of the Wound.”
6. Impregnated dressings are those that are typically made up
of gauze that are infused with
c. a chemical, i.e., petroleum, silver, or collagen. “Impregnated dressings are those that are typically made up of gauze and are infused with a type of chemical, such as petroleum, silver, or collagen.”
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7. The only exception to removal of eschar is when it is found intact on a
a. dry heel wound “There may be times when it is better for a wound not to be debrided. As stated, the AHRQ has specified that dry heel wounds that are covered with eschar should not be debrided because it may be difficult to determine the depth and extent of the wound.”
8. True or False: The Agency for Healthcare Research and
Quality (AHRQ) stated “dry gangrene” that is also a contraindication to debridement.
a. True “… a condition known as dry gangrene, which develops as a result of poor blood flow rather than an infectious process, is also considered a contraindication to debridement because of the potential for infection and lack of blood flow to the affected site.”
9. Impregnated dressings are often applied
b. once per day. “Impregnated dressings are often applied once per day.”
10. If the practitioner suspects a foreign object in the wound
but cannot visualize it, the practitioner should
c. use an X-Ray or MRI to find any foreign object.
“Identification of a foreign object may require diagnostic tests, such as an X-Ray or MRI…. If the clinician suspects a foreign object in the wound but cannot visualize it, he or she should not blindly probe the wound to search for it to be removed, as this can cause further trauma to the tissue and could lead to increased bleeding or infection.”
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11. True or False: Alginate dressings require dryness in the wound bed to maintain its gel-like features during wound treatment.
b. False “… alginate dressings are best used for wounds that produce significant exudate, rather than those that are mostly dry or only slightly moist.”
12. When assessing erythema on a person with dark skin, the clinician should note
b. that the skin may appear to have purple undertones. “It may be difficult to assess areas of erythema among patients who have dark skin. In these cases, skin may appear to have purple undertones and the skin surface may be shiny and firm. The clinician can use a direct light over the affected area for assessment and look for other signs of injury beyond erythema, such as tissue swelling and warmth.”
13. True or False: Identification of a foreign object may require
X-Ray or MRI to diagnose cause of a wound.
a. True “Identification of a foreign object may require diagnostic tests, such as an X-Ray or MRI.”
14. Pulsatile lavage with suction can be used on
a. many different types of wounds. “Further, pulsatile lavage with suction can be used on many different types of wounds and it is site specific, meaning a patient does not have to have an extremity or the entire body submerged in a tub of water to derive the benefits of debridement. Pulsatile lavage has been used for successful debridement of diabetic wounds, venous ulcers, surgical wounds, pressure ulcers, and wounds that have become infected. It can also be used on complicated wounds where tunneling or undermining is present.”
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15. Collagenase, Panafil, and papain and urea (Accuzyme) are examples of
b. enzymatic debridement preparations. “Examples of enzymatic debridement preparations include collagenase, Panafil, and papain and urea (Accuzyme).”
16. Irrigation by hand with a syringe is a type of debridement most effective for
c. non-infected/minor wounds. “Irrigation by hand with a syringe … is most effective for wounds that are not infected or that only have minor infections, those that do not contain significant amounts of debris, and those that do not have thick eschar, as the pressures used with irrigation are not high enough to loosen and remove very thick or tough eschar.”
17. Autolytic debridement is
b. a painless form of removing dead tissue. “Autolytic debridement is one of the most painless forms of removing dead tissue; however, because it can take longer when compared to some other forms of debridement, the patient may be at a greater risk of infection with this process.”
18. A wound requires a ____________ wound bed in order to
best promote healing.
a. moist “A wound requires a moist wound bed in order to best promote healing.”
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19. ________________ dressings are another form of dressing material that is designed to absorb exudate from the wound bed when the dressing is placed on the wound.
a. Hydrocolloid “Hydrocolloid dressings are another form of dressing material that is designed to absorb exudate from the wound bed when the dressing is placed on the wound.”
20. A study showed that pulsatile lavage with suction had an
over _____ percent increase in granulation tissue formation per week when compared to 4.8 percent increase among those who used whirlpool therapy.
b. 12
“… wound care patients who received pulsatile lavage with suction had an over 12 percent increase in granulation tissue formation per week when compared to 4.8 percent increase among those who used whirlpool therapy.”
21. __________ is an essential component of epithelialization and __________ wounds heal at a faster rate.
b. Moisture; open “… moisture was an essential component of epithelialization and that open wounds healed at a faster rate when kept moist.”
22. Unlike alginate dressings, hydrofiber dressings
b. expand upon contact with excess moisture. “Hydrofiber dressings work in a manner similar to alginate dressings in that they expand upon contact with excess moisture. This action makes hydrofiber dressings useful for wounds that create large amounts of exudate. Unlike alginate dressings, though, hydrofiber dressings do not contribute to hemostasis, so they are not necessarily the best type of dressings to use when wounds are oozing blood.”
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23. Irrigation of a wound must be done at a pressure between ___________________ in order to be effective.
c. 4 psi and 15 psi “Irrigation may be performed at the bedside by the nurse; it must be done at a pressure between 4 psi and 15 psi in order to be effective: pressures less than 4 psi are not strong enough to loosen tissue and pressures greater than 15 psi have been shown to damage healing skin and to drive debris deeper into the tissues.”
24. One of the most common forms of testing for sensation is
by using the
b. monofilament test. “One of the most common forms of testing for sensation is by using the Semmes-Weinstein monofilament test.”
25. If a patient does not have sensation during properly performed testing, this may indicate
d. neuropathy. “A patient who cannot consistently detect the monofilament during the test should receive further evaluation for decreased sensation due to neuropathy.”
26. A common form of biological debridement is the use of
c. medical-grade maggots. “One of the most common forms of biological debridement is the use of medical-grade maggots placed in the wound bed.”
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27. When signs of wound infection occur, the patient may benefit from
a. a short-term antimicrobial wound cleansing product. “If odor or other signs of infection are present in the wound, the patient may benefit from a short-term cleansing regimen of antimicrobial wound cleansing products, despite their potential cytotoxicity.”
28. Foam dressings are
a. thickened dressings with foam padding for wound protection. “Foam dressings are thickened dressings that contain foam as a type of padding to protect the wound. Used in a number of different wound types, foam dressings can be packed into very deep wounds to fill space or they may be placed on top of superficial wounds to provide padding and protection from further injury.”
29. True or False: Preparation of the wound bed focuses on
maintaining moisture levels in the wound bed, promoting new tissue growth, and preventing infection.
a. True “Wound bed preparations focuses on maintaining moisture levels in the wound bed, promoting new tissue growth, and preventing infection.”
30. Signs and symptoms associated with peripheral artery
disease include
a. poor skin color. b. pain in the lower legs. c. intermittent claudication. d. All of the above [correct answer]
“Signs and symptoms associated with peripheral artery disease, such as poor skin color, pain in the lower legs, and intermittent claudication, can also appear when a patient has arterial insufficiency and should be assessed when the client
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presents with a wound that has developed from diminished arterial circulation.”
31. Surgical debridement is an effective form of wound management, and is used for
a. diabetic foot ulcers. b. superficial burns. c. cutting away of dead tissue. d. Answers a., and c., are correct [correct answer]
“Surgical debridement is an effective form of wound management, and is used for some particular wounds, such as diabetic foot ulcers. It is used with a scalpel or scissors to cut away dead tissue and is often performed in a surgical suite, depending on the extent of the wound.”
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
3. Cooper, K. L. (2013, Dec.). Evidence-based prevention of pressure ulcers the intensive care unit. Critical Care Nurse 33(6): 57-66. Retrieved from http://www.aacn.org/wd/Cetests/media/C1363.pdf
4. Falconio-West, M. (2013, Sep.). Kennedy Terminal Ulcer (KTU) is now recognized by CMS for long-term acute care hospitals (LTAC or LTCH). Retrieved from 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-
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edu.com/imageServer.aspx?contentID=20368&contenttype=application/pdf
6. Brunner, M., Droegemueller, C., Rivers, S., Deuser, W. E. (2012). Prevention of incontinence-related skin breakdown for acute and critical care patients. Urology Nurse 32(4): 214-219. Retrieved from http://www.medscape.com/viewarticle/769850_2
7. DeMarco, S. (n.d.). Wound and pressure ulcer management. Retrieved from http://www.hopkinsmedicine.org/gec/series/wound_care.html
8. Lippincott Nursing Center.com. (2009). Wound watch: Assessing pressure ulcers. LPN2009 5(1): 20-23. Retrieved from http://www.nursingcenter.com/lnc/static?pageid=844487
9. Hess, C. T. (2010, Sep.). Arterial ulcer checklist. Advances in Skin and Wound Care 23(9): 432. Retrieved from http://journals.lww.com/aswcjournal/Fulltext/2010/09000/Arterial_Ulcer_Checklist.11.aspx
10. Hess, C. (2012). Clinical guide to skin and wound care (7th ed.). Ambler, PA: Lippincott Williams & Wilkins
11. Bhutani, S., Vishwanath, G. (2012, Sep.). Hyperbaric oxygen and wound healing. Indian Journal of Plastic Surgery 45(2): 316-324. Retrieved from http://www.ijps.org/article.asp?issn=0970-0358;year=2012;volume=45;issue=2;spage=316;epage=324;aulast=Bhutani
12. Lopez Rowe, V. (2014, Jul.). Diabetic ulcers. Retrieved from http://emedicine.medscape.com/article/460282-overview
13. Medfocus guidebook on: Diabetic foot ulcers. (2011). Princeton, NJ: Medfocus.com, Inc.
14. American Diabetes Association. (2014, Oct.). Foot complications. Retrieved from http://www.diabetes.org/living-with-diabetes/complications/foot-complications/
15. Jain, A. K. C. (2012). A new classification of diabetic foot complications: A simple and effective teaching tool. The Journal of Diabetic Foot Complications 4(1): 1-5. Retrieved from http://jdfc.org/wp-content/uploads/2012/01/v4-i1-a1.pdf
16. Cruciani, M., Lipsky, B. A., Mengoli, C., de Lalla, F. (2013). Granulocyte-colony stimulating factors as adjunctive therapy for diabetic foot infections (review). Hoboken, NJ: John Wiley & Sons, Ltd.
17. Beldon, P. (2007). What you need to know about skin grafts and donor site wounds. Wound Essentials, Vol. 2: 149-155. Retrieved from http://www.woundsinternational.com/pdf/content_196.pdf
18. University of Rochester Medical Center. (2008, Mar.). How diabetes drives atherosclerosis. Science Daily. Retrieved from
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http://www.sciencedaily.com/releases/2008/03/080313124430.htm
19. Rogers, L. C., et al. (2011, Sep.). The Charcot foot in diabetes. Diabetes Care 34(9): 2123-2129. Retrieved from http://care.diabetesjournals.org/content/34/9/2123.full
20. McCullogh, J. M., Kloth, L. C. (2010). Wound healing: Evidence-based management (4th ed.). Philadelphia, PA: F. A. Davis Company
21. Cowan, L. (2013). Wound series part 2: Approaches to treating chronic wounds. Retrieved from http://www.ceufast.com/courses/viewcourse.asp?id=269#Wound_Cleansing
22. Medline Industries, Inc. (2007). The wound care handbook [Chapter 8]. Mundelein, IL: Medline
23. Foster, C. (2010, Apr.). Non-traumatic wound debridement. Ostomy Wound Management 56(4): 8. Retrieved from http://www.polymem.com/pearls/pearls4practice0410.pdf?line_id=410
24. Sussman, C., Bates-Jensen, B. M. (1998). Wound care collaborative practice manual for physical therapists and nurses. [Excerpt]. New York, NY: Aspen Publishers. Retrieved from http://www.medicaledu.com/whirlpoo.htm
25. Dale, B. A., Wright, D. H. (2011). Say good-bye to wet-to-dry wound care dressings: Changing the culture of wound care management within your agency. Home Healthcare Nurse 29(7): 429-440. Retrieved from http://journals.lww.com/homehealthcarenurseonline/Fulltext/2011/07000/Say_Goodbye_to_Wet_to_Dry_Wound_Care_Dressings_.8.aspx
26. Ramundo, J., Gray, M. (2008, Jun.). Enzymatic wound debridement. Journal of Wound, Ostomy, and Continence Nursing 35(3): 273-280. Retrieved from http://www.nursingcenter.com/lnc/journalarticle?Article_ID=794501
27. Swezey, L. (2012, Jul.). Wound debridement techniques 6: Biological debridement. Retrieved from http://woundeducators.com/wound-debridement-techniques-6-biological-debridement/
28. Dowsett, C., Newton, H. (2005). Wound bed preparation: TIME in practice. Retrieved from http://woundsinternational.com/pdf/content_86.pdf
29. Martin, B. (2011, Apr.). Moist wound healing. Ostomy Wound Management 57(4): 10. Retrieved from
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31. Bjarnsholt, T. (2011). Biofilm infections. New York, NY: Springer Science+Business Media, LLC
32. Southwesthealthline.ca. (2011, Dec.). Levine method for wound stab for culture & sensitivity. Retrieved from http://www.southwesthealthline.ca/healthlibrary_docs/B.7.3.LevineWoundSwabMethod.pdf
33. Romanelli, M., Vowden, K., Weir, D. (2010). Exudate management made easy. Wounds International 1(2): 1-6. Retrieved from http://www.woundsinternational.com/pdf/content_8812.pdf
34. Organogenesis, Inc. (2010). What is Apligraf? Retrieved from http://www.apligraf.com/professional/what_is_apligraf/index.html
35. DermNetNZ. (2013, Dec.). Bioengineered skin. Retrieved from http://www.dermnetnz.org/procedures/bioengineered-skin.html
36. Troy, J., Karlnoski, R., Payne, W. G. (2013). The use of EZ Derm® in partial-thickness burns: An institutional review of 157 patients. Eplasty 13(4). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3593337/
37. Organogenesis, Inc. (2013). Proven DFU results and extensive DFU experience. Retrieved from http://www.dermagraft.com/proven-results/
38. KCI. (2013). Science behind wound therapy. Retrieved from http://www.kci1.com/KCI1/sciencebehindwoundtherapy
39. Martindell, D. (2012, Jun.). Safety monitor: The safe use of negative-pressure wound therapy. American Journal of Nursing 112(6): 59-63. Retrieved from http://www.nursingcenter.com/lnc/JournalArticle?Article_ID=1353037
40. Alumia, R. (2013, Sep.). Improving outcomes with non-contact low-frequency ultrasound. Retrieved from http://woundcareadvisor.com/improving-outcomes-with-noncontact-low-frequency-ultrasound/
41. Bryant, R. A., Nix, D. P. (2012). Acute & chronic wounds: Current management concepts (4th ed.). St. Louis, MO: Elsevier Mosby
42. Westgate, S., Cutting, K. F., DeLuca, G., Asaad, K. (2012, Mar.). Collagen dressings made easy. Wounds UK 8(1): 1-4. Retrieved from http://www.wounds-uk.com/made-easy/collagen-dressings-made-easy/page-1
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43. DermNetNZ. (2013, Dec.). Keratin-based dressings for chronic wounds. Retrieved from http://www.dermnetnz.org/procedures/keratin-dressings.html
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46. Parsons, D., Bowler, P. G., Phil, M., Myles, V., Jones, S. (2005). Silver antimicrobial dressings in wound management: A comparison of antibacterial, physical, and chemical characteristics. Wounds 17(8): 222-232. Retrieved from http://www.medscape.com/viewarticle/513362
47. Adkins, C. L. (2013, May). Wound care dressings and choices for care of wounds in the home. Home Healthcare Now 31(5): 259-267. Retrieved from http://www.nursingcenter.com/lnc/CEArticle?an=00004045-201305000-00006&Journal_ID=54023&Issue_ID=1547910
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49. Schwartz, A. (2012). Ozone therapy and its scientific foundations. Revista Española de Ozonoterapia 2(1): 199-232. Retrieved from http://www.xn--revistaespaoladeozonoterapia-7xc.es/index.php/reo/article/view/27/30
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54. Wounds International. (2012). International consensus: Optimising wellbeing in people living with a wound. An expert working group review. London, UK: Wounds International
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56. The Wound Healing Society. (2009). Chronic wound prevention guidelines. Bethesda, MD: The Wound Healing Society
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58. Weiss, R. (2014, Oct.). Venous insufficiency. Retrieved from http://emedicine.medscape.com/article/1085412-overview
59. Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed.). St. Louis, MO: Elsevier Mosby
60. Abreu, A. M., Baptista de Oliveira, B. R., Manarte, J. J. (2013, Apr.). Treatment of venous ulcers with an Unna boot: A case study. Online Brazilian Journal of Nursing 12(1): 198-208.
61. Collins, L., Seraj, S. (2010, Apr.). Diagnosis and treatment of venous ulcers. Am Fam Physician 81(8): 989-996. Retrieved from http://www.aafp.org/afp/2010/0415/p989.html
62. Vazquez, S. R., Kahn, S. R. (2010). Postthrombotic syndrome. Circulation 121: e217-e219. Retrieved from http://circ.ahajournals.org/content/121/8/e217.full
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64. Milne, J., Vowden, P., Fumarola, S., Leaper, D. (2012, Nov.). Postoperative incision management. Wounds UK 8(4). Retrieved from http://www.wounds-uk.com/made-easy/postoperative-incision-management
65. Johns Hopkins Medicine. (n.d.). Surgical site infections. Retrieved from http://www.hopkinsmedicine.org/innovation_quality_patient_care/areas_expertise/infections_complications/SSI.html
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68. Bergstrom, K. J. (2011). Assessment and management of fungating wounds. Journal of Wound, Ostomy, and Continence Nursing 38(1): 31-37
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The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com. The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare.
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