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Wound Care:
Part III
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
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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.
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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. When infection is present in a wound
a. granulation tissue begins to develop at the base of the wound
and slowly fills in the opening.
b. the granulation tissue often appears bumpy and may look
grainy, shiny, or beefy red.
c. granulation tissue may bleed or break down easily and it can
appear crumbly, dark red, or dull in texture.
d. the granulation tissue slowly increases in size to fill in the
wound.
2. The body’s ability to fight off infection using the immune
system is dependent on several factors that include
a. whether the patient is immunocompromised, such as in the
case of a cancer diagnosis.
b. the patient’s age.
c. the patient’s mobility.
d. All of the above
3. True or False: The clinician may collect a tissue specimen to
test for a culture.
a. True
b. False
4. Which of the following best states the use of apligraf as a
treatment for diabetic foot ulcers and venous ulcers?
a. Apligraf does not contain sweat glands or hair follicles.
b. Apligraf exactly replicates skin over the wound.
c. The provider cannot suture the Apligraf or use steri-strips to
apply Apligraf.
d. The nurse should know not to use compression stockings or
compression therapy with Apligraf.
5. Wound infection that spreads to fascia and other
subcutaneous tissue can
a. be treated as a superficial wound.
b. develop to cellulitis.
c. generally does not spread to surrounding areas
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d. is considered localized.
Introduction
The wound care team must be familiar with the fine balance of keeping
the wound bed healthy while controlling excess fluid production. The
clinician can evaluate the appearance and characteristics of exudate to
better understand how well the wound is healing or if there are other
measures that should be implemented into caring for the wound.
Despite its importance in keeping the wound bed moist, there must be
proper control of exudate to maintain a healthy wound site and to
promote wound healing through subsequent steps and phases of tissue
restoration.
Wound Healing And Tissue Restoration
This course on wound healing begins with a discussion on granulation
tissue formation, which begins to develop at the base of the wound
and slowly fills in the opening. It is what develops as part of wound
repair and tissue restoration during the fibroblastic stage of healing in
the wound. Granulation tissue often appears bumpy and may look
grainy, shiny, or beefy red. When infection is present, granulation
tissue may bleed or break down easily and it can appear crumbly, dark
red, or dull in texture. Alternatively, as a wound is healing, the
granulation tissue slowly increases in size to fill in the wound.8,20
As the wound heals and granulation tissue fills in the wound base,
epithelialization occurs with development of new epithelial tissue,
which migrates over the granulation tissue. This is the process of
building a new epidermal layer on the surface of the skin over the
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wound. Epithelial tissue may appear pink or pale in color and different
from the surrounding, undamaged skin.
Because granulation tissue indicates that a wound is healing, the
clinician should take steps to promote formation of granulation tissue
while caring for a patient’s wound. The breakdown of granulation
tissue increases the risk of infection and causes delayed wound healing
and further complications. Granulation tissue does form in the
presence of bacteria in the wound, as wounds can contain a certain
amount of chronic bacterial colonization. Because certain types of
bacteria can trigger the inflammatory stage of healing, the wound is
actually dependent on a certain amount of bacteria present for
development of some granulation tissue.20 However, the clinician must
pay careful attention to the granulation tissue. Its appearance often
presents a relatively clear indication of the presence or absence of
infection. It is important to assess for changes and indications that
chronic bacterial colonization has not shifted to a stage of critical
colonization or infection.
To best protect granulation tissue formation, the clinician must keep
the wound clean and perform debridement and dressing changes as
ordered, as well as monitor for signs and symptoms that indicate
infection. New granulation tissue, as it fills in the wound bed, must be
protected from further trauma and infection by protecting the space,
using appropriate wound dressings and keeping them covered. This
may involve the use of not only standard forms of wound dressings
designed to control exudate and maintain a moist wound bed, but also
other measures may be employed that will protect growth of
granulation tissue, such as use of vacuum-assisted wound closure or
tissue substitutes.
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Skin Grafting
There may be times when a skin graft may be necessary as part of
treatment of an extensive wound. A skin graft takes a sample of skin
and places it over the healing wound site, where it will become the
new skin at the site. A section of skin that includes the epidermis and
the dermis is separated from its blood supply when it is removed. It is
placed over the wound site where it is sutured in place. The place
where the skin is removed for the graft is called the donor site, while
the receiving area is the recipient site. An advantage of using a skin
graft is that once the graft is in place, it provides a clean site of skin
growth instead of the healed tissue that has recovered after a wound.
The sample skin from the graft may come from another part of the
patient’s body (autologous graft) or it could come from another
source, such as from a cadaver.
Grafting is often done when the scar from the healing wound would
otherwise be extensive and unsightly, the wound is difficult to close, or
if the patient would otherwise have physical or emotional problems
because of the scar without the graft. The donor graft may be either a
split-thickness or full-thickness graft, depending on the skin available
for donation and the patient’s health. A split-thickness graft harvests
the epidermis and the upper levels of the dermis, but leaves the
deepest portion of the dermis, where it can heal on its own.
Alternatively, a full-thickness graft includes the epidermis and the
dermis. While this type of graft can be very successful in covering a
wound, it leaves behind an area that requires surgical closure after it
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has been harvested.17 This type of graft is more commonly used in
areas such as the face and neck, as the skin is less likely to tighten
and contract. The surgeon typically must consider the benefits and
disadvantages of each type of skin sample when preparing a graft for a
patient.
Growth Factors
Granulocyte-macrophage colony-stimulating factor (G-CSF) is a type
of growth factor that promotes the release of white blood cells
(neutrophils) from the bone marrow. It has been used among patients
with diabetes to stimulate the production of and increase the efficacy
of neutrophils in the body. It can be used to reduce the instance of
infection by enhancing the work of antibiotic therapy and may improve
the body’s immune response to infection.16
Granulocyte-macrophage colony-stimulating factor is injected
subcutaneously, rather than being applied as a topical agent. A review
of several clinical research studies by Cruciani, et al., showed that GCSF may not be significant in the specific healing of diabetic ulcers, but
its effects can enhance immune function of the affected patient. It is
associated with increased numbers of white blood cells, specifically
leukocytes, and it has been shown to significantly reduce the numbers
of amputations when used as treatment of severe wounds, such as
among those patients with diabetic ulcers.16
At this point in time, G-CSF is not a first-line form of therapy for
patients who are healing from wounds. Although it is still in the
experimental stage, G-CSF may become a positive factor that can
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someday be administered for the prevention of infection among
patients with wounds.
Treatment of Infections
Wounds that become infected take longer to heal and require further
intervention for management beyond standard forms of wound
treatment. When a bacterial infection develops in a wound, the
increased number of bacteria in the wound bed may be overwhelming
for the body’s natural immune function. A wound may be
contaminated when pathogens such as bacteria congregate on the
surface of the wound or on the skin near the wound.2 The number of
pathogens that are contaminating a wound’s surface are known as the
bioburden.
Wound infections may be considered superficial in that they affect only
the upper layers of the skin; or they may spread very deep to the
subcutaneous tissue and underlying structures. Superficial infections in
wounds are typically localized to the upper layers of skin, affecting the
epidermis and the dermis and they more likely occur in shallow
wounds. Alternatively, when a wound infection spreads to infect the
fascia and other subcutaneous tissue, the patient can develop cellulitis.
This may demonstrate symptoms in the wound bed but it can also
spread to surrounding areas and cause skin redness and swelling of
the skin surrounding the wound bed. Further infection that runs even
deeper to infect the bone is osteomyelitis. When this occurs, the
infection can become widespread and can affect other parts of the
body; severe forms of the condition may require amputation to
prevent the infection from spreading and to best manage the bone
infection.
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There is a difference in the organisms present in the wound;
colonization refers to the invasion or growth of microorganisms in a
space. Although there may be bacteria present in a wound, it does not
necessarily mean that the wound is infected. For example, chronic
bacterial colonization is present in most chronic wounds in that there is
a certain amount of bacteria present in the wound, but they do not
necessarily cause signs of infection, such as redness or warm, tender
skin. When chronic bacterial colonization is present but is not causing
wound infection symptoms, the wound may heal on its own without
intervention.21
Alternatively, critical colonization describes increased levels of bacteria
within a wound that may not necessarily cause the signs of infection,
but that still affect the wound’s ability to heal. If a wound has reached
the stage of critical colonization and it is not healing, it must be
addressed by adding antibiotic intervention.21,31 To determine if critical
colonization or wound infection is present, the clinican may collect a
wound culture specimen to measure the amount of organisms within
the wound sample.
A nursing clinician may collect a wound culture using a swab
technique, since this is the method that most likely falls within the
nursing scope of practice and can be performed relatively quickly at
the bedside. Alternatively, a physician or advanced-care practitioner is
required to collect a tissue specimen for a culture test. Cutting a small
piece of tissue from the wound, in a manner similar to a biopsy
procedure, and then checking it for microorganism growth is how the
specimen is obtained. The generally accepted definition of an infection
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is when the growth of bacteria is greater than 105 colony-forming units
(CFU) per gram of tissue.21,21
A swab technique used to obtain a wound culture that may be
commonly used is known as the Levine Method for wound swab culture
and sensitivity. The clinician first rinses the wound with normal saline
solution, blotting any excess solution before swabbing so that the
saline does not affect the culture sample. Using the swab tip, the
nurse should swab the area to be cultured by rotating the tip in a 1
cm2 area of granulation tissue. Areas of necrotic tissue, such as eschar
or slough, should not be swabbed, as these are considered dead tissue
and are an inaccurate reflection of the wound tissue being cultured.
The clinician should press down lightly with the swab to absorb some
of the exudate being released by the pressure. Following the swab, the
end of the swab tip is inserted into a transport culture tube where it is
taken to the appropriate location for analysis. The culture tube should
be taken to the lab as soon as possible and it should never be
refrigerated or stored before being tested.
Many wounds are contaminated, particularly when they occur as a
result of an injury in which debris enters the wounded area. When the
contaminated area is not cleaned properly and the pathogens are not
removed, colonization occurs. Colonization refers to the multiplication
of the pathogens that have contaminated the skin or the wound, which
is when the body must respond with cells from the immune system.
Depending on the levels of contamination and colonization, the body’s
immune system may be unable to keep up with protection against
infection.
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The body’s ability to fight off infection using the immune system is
dependent on several factors that are associated with both the
immune system function and the type of pathogens that could infect
the wound. If the patient is already immunocompromised, such as in
the case of a cancer diagnosis, older age, or immobility, he or she will
most likely have a difficult time fighting off an infection and will need
further medical measures, such as antibiotic therapy and nursing
interventions to prevent further spread of the infection.
The type of pathogen contaminating the wound and causing an
infection also affects the success of treatment. The rise of resistant
organisms in the community has led to greater difficulties with finding
treatment options for eliminating certain types of infections and
preventing their spread. Obviously, a wound infection with a resistant
organism, such as methicillin-resistant Staphylococcus aureus (MRSA),
will be much more difficult to manage when compared to infection with
an organism that has not been shown to be resistant to antibiotic
therapy. If more than one species is present in the wound, treatment
measures may be successful in controlling the spread of one type over
another.
The clinician may need to culture the wound to differentiate the
specific types of organisms present in order to provide treatment that
will target and control the present pathogens. A wound culture should
be performed in a wound that does not heal despite wound
management interventions and measures taken toward healing. A
wound culture should also be performed on a wound that has obvious
signs of infection.7
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Under normal circumstances, when a wound develops, the body
responds by increasing blood flow to send white blood cells such as
neutrophils and macrophages to the site. These cells are responsible
for overtaking pathogens in the area to reduce the amount of debris.
The body continues to send white blood cells to the injured site;
however, cells such as neutrophils may only have a 24-hour life span
before they die. When an infection develops and there are increased
numbers of bacteria present, the body continues to send neutrophils,
even though there are still dead cells in the area. This process is what
forms pus; the collection of dead white blood cells that have congested
within the area of the wound.1
As more pus develops within a wound, healing through granulation
tissue formation is slowed, which delays wound healing. This slowed
healing process may give bacteria a chance to multiply and the body is
unable to fight off the infection without some assistance, such as
through administration of antibiotics. A wound culture determines what
type of pathogen is causing the infection. By identifying the type of
organism, the provider can often prescribe antibiotics that are
designed to eliminate that specific pathogen.
Signs and symptoms of wound infection may vary. The process of the
wound healing may appear similar to wound infection itself and the
clinician should be familiar with the appearance of wound healing, the
signs and symptoms of infection, and methods for determining if
infection is present when working with a patient who has a wound. For
example, when a healing wound produces new granulation tissue, the
base of the wound may appear pink or yellow in color, which could be
confused with a wound infection.
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The signs and symptoms of an infection to look for in a wound care
patient include wound-specific symptoms such as the presence of pus
in or around the wound, an abnormal smell coming from the wound,
and patient complaints of severe wound pain. Granulation tissue may
be filling in the wound bed, but instead of its normal appearance and
texture, it may appear deep red or purple and may bleed easily. The
patient may also experience cellulitis around the wound, which
appears as reddened and warm skin, edema, and tenderness.1 The
patient may also experience general symptoms of infection, such as
fever, fatigue, and general malaise.
A wound that has become infected needs regular care and
management through external methods, such as dressing changes,
application of topical antibiotics, or the use of systemic antibiotics. If
the infection developed in a wound that was originally closed through
primary intention, the wound may need to be opened and drained of
pus and infectious materials. The wound may then need to be left
open to heal by secondary intention.
Wounds that are very dirty to begin with, such as when caused by an
injury that leaves debris in the wound, may be more likely to become
infected and need to be thoroughly cleaned. Topical antibiotics and
antifungal preparations may be applied directly to the skin. In some
cases, this type of medication is applied in addition to administration
of systemic antibiotics; alternatively, some wounds, such as burn
wounds, may focus more on topical preparations. Topical antibiotics
and antifungals are products that prevent the growth of pathogens on
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the skin or in the wound. They may be available as creams, lotions,
powders, or gels placed on the skin or even directly on the wound.
Antibiotic therapy is a critical component of managing a wound
infection. The type of medication and route of administration depends
on the patient’s condition and the pathogen causing the wound
infection. If a wound culture has been collected, the clinician could
prescribe a broad-spectrum antibiotic for management of infection and
prevention of its spread. Once the wound cultures return with
specificity of the type of organism present, the provider could change
the prescription to a medication designed to specifically target the
present organism. This is necessary in cases where the initial infection
is not responding to a broad-spectrum antibiotic.
Antibiotics can be administered orally, in which case the patient could
take the doses at home. Alternatively, intravenous administration of
antibiotics in the treatment of a wound infection typically requires
hospitalization for the infusion. The patient may also start out in the
hospital receiving intravenous antibiotics but then switch to oral doses
for the remainder of the prescription before going home. An antibiotic
may be prescribed to be taken on a short-term basis, typically 3 to 7
days duration, for a minor wound infection that is localized to the
wound bed. If the infection has spread to involve surrounding tissues,
a longer course of antibiotics is necessary, which may last several
weeks.13
Cleaning, Debridement and Pain Control
Skin breakdown from a wound can be very uncomfortable for the
affected patient. Many of the standard forms of treatment, such as
cleaning and debridement, can be very painful. Further, some chronic
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diseases may also cause continued discomfort and may contribute to
wound development, such as the pain of tissue ischemia from
decreased blood flow or the burning sensation sometimes felt from
diabetic neuropathy. As part of standard interventions of care, the
clinician should take steps to reduce the patient’s discomfort and help
him or her to feel more relief.
Compression Therapy
Compression therapy promotes blood flow by increasing venous return
of the blood to the heart. The compression on the veins squeezes
them to force the blood forward against hydrostatic pressure. This
process is typically used for patients who have venous insufficiency but
it is contraindicated in patients with arterial insufficiency. The most
common form of compression therapy is use of compression stockings.
Compression stockings are worn for management of venous ulcers to
promote blood flow and to prevent blood pooling among patients who
have venous insufficiency. A patient who has venous hypertension will
need to wear compression stockings every day.56 The constant wearing
of compression stockings in a patient with venous hypertension
prevents future venous ulcer formation.
Compression stocking therapy is a prescription therapeutic use of
elastic stockings that are worn either on the lower legs and feet or that
extend from the foot to the mid-thigh. The amount of compression
applied may vary slightly with the type of stocking, but typical use
provides 30 to 50 mmHg of pressure in the lower leg, which then
decreases toward the upper leg.58 The use of compression stockings in
this manner is most commonly ordered for patients who have venous
insufficiency in order to restore normal blood flow, particularly when
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the superficial veins are affected. Alternatively, use of elastic wraps
such as an ACE bandage, tight stockings, or nylon pantyhose are not
sufficient for compression therapy and should not be recommended to
the patient.
The Unna boot, named after dermatologist Dr. Paul Gerson Unna, is a
type of bandage that may be useful in providing inelastic compression
therapy for the treatment of venous ulcers and venous insufficiency.
The Unna boot is actually a bandage that is impregnated with several
products to promote wound healing, including zinc oxide, calamine,
castor oil, glycerol, and gum acacia.60 The addition of these products
to the bandage, cause it to form a mold around the extremity; the
molding is not as firm as a plaster cast, but it is still solid enough to
hold its shape and to provide compression. The patient wears the Unna
boot for about a week before it is changed and replaced. The bandage
can be placed on a wound if granulation tissue is present and there are
no signs of infection. Similar to other forms of compression therapy,
the Unna boot should not be used on patients who have arterial
insufficiency.
The Unna boot is most therapeutic when the patient is ambulatory.
The bandage creates higher pressure when the patient uses the
muscles. For example, an Unna boot is activated to provide
compression to the calf muscle when it is applied to the lower leg and
the patient uses the muscle for walking. The Unna boot is a valid form
of compression therapy that can be considered for some patients with
recurring venous ulcers or venous ulcers that are refractory to other
forms of therapy. A study by Abreu, et al., from the Online Brazilian
Journal of Nursing showed that use of an Unna boot was effective in
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treating venous ulcers that were not infected by reducing pain and
edema, as well as contributing to wound healing in the affected
extremity.60
Sequential-compression devices (SCDs) are mechanized forms of
compression therapy that involve applying a special type of wrap to
the leg; the wrap is connected to a generator that produces air to
inflate the wraps and then releases the air to deflate the wraps. The
SCDs work on a continuous basis, with alternative compression and
release. Sequential-compression devices are more commonly used in
the inpatient environment to prevent thrombosis, particularly after a
medical procedure and when a patient is immobilized. They are less
likely to be used in the home and they are not used when the patient
is mobile. Instead, the patient must be lying down or sitting with the
legs elevated in order to effectively use an SCD. However, for the
person who is receiving inpatient care, an SCD can provide some form
of compression therapy on a short-term basis.
Elevation of the affected extremity above the level of the heart is
useful when combined with compression therapy for venous
insufficiency ulcers. To elevate the legs, the nurse places pillows under
the legs or raises the foot end of the bed while the patient is lying
down. Some patients are not able to tolerate leg elevation for long
periods of time; however, even brief periods of elevation, for 30 to 40
minutes several times per day, may be effective when combined with
compression therapy.61 Leg elevation can reduce edema, improve
circulation and venous return, and can lead to faster wound healing.
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Pain Management
A patient with a wound is likely to have some amount of pain
associated with the condition. Pain stems from the tissue breakdown of
the wound itself or it may be related to other factors involved with
wound management, such as dressing changes, movement of the
affected limb, or poor circulation to the area. An article by Mudge and
Orsted in Wounds International classifies wound pain into several
different categories, based on the events that are occurring in
conjunction with the existence of the wound; these are outlined
below:70

Background Pain
Background pain is ongoing pain that is part of having the
wound. It exists because of the tissue breakdown from the
wound and its affect on underlying structures. Background pain
may be constant or intermittent; it may be described in various
ways, including sharp, burning, aching, or dull.

Incident Pain
The wound care patient is more likely to feel incident pain as a
sharp increase in discomfort with certain activities of daily living.
For instance, the patient may feel pain when he or she gets up
to walk and places pressure on the affected extremity.

Procedural Pain
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Procedural pain is associated with procedures performed for
wound healing, such as dressing changes and minor
debridement.

Operative Pain
Operative pain describes the increase in discomfort that the
patient experiences after undergoing a surgical procedure for
wound treatment. It may include pain associated with sharp
debridement, or pain felt while recovering from wound surgery.
In addition to the pain a patient feels from different wound care
methods and activities of daily living, pain may be classified as being
nociceptive or neuropathic in origin. Nociceptive pain is that which is
felt with trauma or damage to the tissues. The patient with a surgical
wound may be experiencing nociceptive pain. Alternatively,
neuropathic pain is pain that stems from nerve damage. Pain from a
wound in a patient with diabetic neuropathy is an example of
neuropathic pain.
Additionally, an infected wound has the potential to cause significant
pain in an individual. When an infection develops, the wound becomes
inflamed and the skin is reddened, warm, and very tender. A patient
who previously experienced very little wound pain may suddenly feel
intense pain at the site, which can indicate an infection.
Pain Assessment
A pain assessment should accompany each wound assessment from
the nurse. The pain assessment should include the location, duration,
and intensity of the pain. The location may or may not be in the wound
bed itself. In some cases, the patient may experience acute pain in the
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affected wound tissue, while in other situations, the patient may
complain of pain surrounding the wound, pain below the wound in the
deep underlying tissues, or pain that is shooting or radiating to other
areas.
The duration of the pain includes how long the pain has occurred. It
may have started when the wound formed and it may be a type of
chronic pain, in which the patient experiences a consistent, dull ache
all the time at the site of the wound. Alternatively, a sudden increase
in intense pain that is different from the “normal” pain is a cause for
further assessment and examination of the wound, as this can indicate
a potential complication, such as a wound infection.
The intensity of the pain describes how much pain the patient is
experiencing. The clinician can assess the patient’s pain intensity by
asking him to rate his pain on a scale of 0 to 10, with 0 being “no
pain” and 10 being “the worse pain imaginable.” This type of numeric
pain rating scale is frequently used for assessing all types of pain in
clinical situations, but it may not be appropriate for every patient.
Other types of pain scales, such as the Visual Analog Scale or the
Wong-Baker FACES scale may also be used to provide more of a visual
analysis of the patient’s pain.
Pain management involves assessing the type of pain the patient is
experiencing and providing treatment for that pain. It also may mean
increasing analgesia in certain situations when the patient’s pain
changes. Pain management begins with accurate assessment of the
patient’s pain. If the patient is suffering from background or incidental
pain, the nurse may need to provide pain medication that is taken on a
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regular schedule to give a form of constant and ongoing relief of some
of the pain.
When preparing to perform a procedure, such as a dressing change or
debridement, the clinician should provide analgesia before the
procedure and continue to assess the patient’s level of pain during and
after the procedure. Certain procedures can be quite painful for the
patient, causing a large increase in the amount of pain experienced
and a greater need for pain control measures. The clinician may have
orders to provide prn (as needed) pain medications for situations such
as this and should identify those times when extra pain medicine is
needed the most, such as before starting a potentially painful
procedure, in order to provide the best pain control for the patient.
Because infection can cause an increase in pain, the clinician may need
to increase analgesia and non-pharmacologic pain control methods
when a wound becomes infected. Treatment of the infection through
antibiotics can also eventually control the pain when the wound
responds to antimicrobial therapy and the infection is resolved.
However, it may take several days before the patient experiences pain
relief from resolution of the infection after taking antimicrobial
medications. In the meantime, the clinician should provide other pain
relief measures to help control the patient’s pain.
Pain impacts a wound care patient’s quality of life in many ways. The
patient with wound pain may experience isolation and loneliness, as he
may be unable to meet with friends or spend time with family because
of his discomfort with traveling or leaving his home. Pain can make
regular activities of daily living difficult to complete and the patient
may then experience self-care deficit, in addition to sleep
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disturbances, feelings of depression or anxiety; and, fear over
perceived or actual changes associated with the wound, such as
potential job changes.
Part of holistic wound care is providing emotional support for the
patient in pain. Holistic care is discussed in more depth in the final
course, Part IV of the Wound Care series. In addition to treating the
physical discomfort of the pain, the clinician must be aware of the
patient’s feelings and emotions surrounding the pain and help the
patient to identify what factors need to be remedied. For example, if a
patient is experiencing sleep deprivation because of chronic pain, the
clinician should not only help the patient’s pain by providing analgesia
and other non-pharmacologic pain control methods, but should also
address the sleep issue by discussing solutions with the patient about
how he or she can improve sleep habits, or by finding resources for
helping the patient to get better sleep at night.
Advanced Therapies of Wound Care
Although there are a number of dressings and standard forms of
wound treatments available for healthcare providers to use, research
continues to develop advanced therapies as forms of treatment or
management of complications of wounds. When a wound is considered
chronic and it is slow to heal or has stalled in its healing, other
measures beyond standard dressings and topical medications may be
necessary to enhance wound healing and to hasten the process.
Hyperbaric Oxygen Therapy
Hyperbaric oxygen therapy utilizes high pressures of 100% oxygen
that is above atmospheric pressure. The use of hyperbaric oxygen
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therapy has been successful for many years in the treatment and
management of decompression sickness among deep-sea divers.
Historically, there have also been a multitude of trials in which
scientists and researchers have tried to use hyperbaric oxygen therapy
as treatment for a number of clinical conditions, including cancer
treatments and use during heart surgery.11 Hyperbaric oxygen therapy
is now also commonly used in the management of wounds, particularly
chronic wounds that are healing slowly.
When a patient uses hyperbaric oxygen therapy, he or she is taken to
a specialized chamber used to administer the treatment. Hyperbaric
chambers are becoming more common across the U.S., and, as more
facilities use this type of treatment, it may be easier for healthcare
providers to prescribe hyperbaric treatment and for clinicians to
administer it.
Hyperbaric chambers are typically of two different types: monoplace
chambers and multiplace chambers. Monoplace chambers are designed
to hold one patient at a time for the therapy. The patient enters the
chamber and lies on a surface similar to a cot that is surrounded by a
plastic cover. Through this method, the clinician who is controlling the
settings on the chamber can continue to monitor the patient
throughout the therapy. A multiplace hyperbaric chamber is designed
to accommodate more than one patient at a time. The size of the
multiplace chamber may vary, depending on the manufacturer and
what the facility has available. Some multiplace chambers are
designed as about the size of a small room and are connected to an
area of the healthcare unit through a separate doorway. Other types of
multiplace chambers are freestanding and while still designed to hold
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more than one person, they may be more of the size of a walk-in
closet and are positioned as a room within a room.
When a patient uses a multiplace chamber, he or she wears a cover
that administers the specific amount of oxygen needed. A multiplace
chamber may also be useful when a patient requires intensive care
monitoring, as he or she could be placed in the chamber with more
room and with a hood or covering placed, rather than attempting to
transfer the patient from a bed to a monoplace unit. However, critical
care equipment may not be used in some areas, and may need to be
kept outside of the chamber. Depending on the type of equipment
needed for the patient, use of a monoplace or multiplace chamber will
have to be decided, taking into consideration the availability of the
chamber and other practical measures.
How often and how long the patient receives hyperbaric therapy is
determined by physician prescription. The treatments may be
administered several times, for a period of about 60 to 90 minutes for
each session.11 If the wound develops as a result of certain factors,
such as because of radiation burns, more treatments would be
necessary. The prescribing provider will determine how many sessions
are required based on the patient’s condition and the cause of the
wound.
Under normal circumstances, a person breathes room air of
approximately 21 % oxygen. In this method, a wound is normally
exposed to 21 % oxygen in room air as well. During hyperbaric oxygen
administration, the patient receives a much greater amount of oxygen;
100 % oxygen compared to the 21 % found in room air. Additionally,
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normal atmospheric pressure exerts 14.7 psi over a given surface, but
when hyperbaric oxygen therapy is used, the pressure administered is
2 to 3 times higher than normal atmospheric pressure, in addition to
the increased oxygen administration.
The increase in pressure causes more oxygen to be dissolved in the
patient’s bloodstream and the tissues. This saturates the patient’s
bloodstream with oxygen and results in increased amounts of oxygen
being delivered to the tissues, including to the wound tissue that is
undergoing healing. This process can resolve some tissue ischemia
that may occur near the wound. It also supports the activity of white
blood cells at the wound site. Hyperbaric oxygen therapy has been
shown to demonstrate other positive results in healing wounds, such
as decreased tissue edema and increased angiogenesis at the wound
site.71
Hyperbaric oxygen therapy is not without risks, which must be
considered when administering this type of treatment. The medical
clinician will prescribe the time and amount of treatments for the
patient. The time for use is limited because too much oxygen can also
negatively impact tissues and can lead to central nervous system
toxicity and alter the cells of the respiratory and ocular systems. Most
patients undergo hyperbaric treatment one time per day for several
days; the standard form of treatment often does not last longer than
10 days duration.
Future trends toward increased used of hyperbaric oxygen therapy
look promising in the treatment and management of a number of
conditions. A review article by Bhutani and Vishwanath in the Indian
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Journal of Plastic Surgery listed areas of research in using this form of
therapy that have been met with some success and that continue to be
investigated. In addition to wound care and treatment, hyperbaric
oxygen therapy is being studied in the treatment of migraine
headaches, glaucoma, brain injuries, myocardial infarction, multiple
sclerosis, and stroke.11
Bioengineered Tissue Substitutes
At one time, a patient who developed a large wound or who suffered
an extensive injury that caused severe wounds required extreme
measures such as amputation to prevent the wound tissue from
becoming necrotic. A burn patient who may have suffered significant
burns over a large area of the body could undergo debridement and
wound treatment therapy with some success, but if the wounds failed
to heal in a timely manner, they were classified as chronic wounds.
Instead of healing and developing new tissue in place of the wound,
they made little to any progress in the act of healing and new tissue
development.
The development of bioengineered tissue substitutes started as an
answer to treatment of chronic wounds that otherwise did not respond
to conventional forms of therapy. Bioengineered skin is developed as a
substitute for skin when it is not otherwise forming new granulation
and epithelial tissue as part of the healing process. Bioengineered skin
often is designed to mimic the layers of natural skin cells, including the
epidermal and the dermal layers. It contains actual skin tissue and not
a synthetic form.
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The bioengineered skin is grown either from the patient’s own skin or
from a skin sample from a donor. The skin sample is designed to be
used in place of the patient’s skin in the wounded area and to perform
the functions of skin while the wound is healing. These types of skin
substitutes adhere to the wound and permit granulation tissue
formation and cell migration during the epithelialization stage of
repair. They can be applied easily at the bedside and they represent a
legitimate skin substitute that is less painful and less invasive than
harvesting and placing skin grafts in a wound.35
There are a number of bioengineered skin and tissue products
available that may be used for various types of wounds.
Apligraf is a bioengineered skin substitute that contains living skin
cells; it is known as a bi-layered skin substitute because it contains
two different layers within one product. The lower layer of the Apligraf
dressing consists of collagen taken from bovine samples as well as
human fibroblast skin cells. These human cells continue to create
proteins that maintain strength and skin integrity. The upper layer of
the Apligraf tissue is an epidermal layer that continues to replicate
cells to form the structure of the epidermis over the wound.34
The U.S. Food and Drug Administration (FDA) has approved Apligraf
for the treatment of diabetic foot ulcers and venous ulcers. While it is
considered living, bioengineered tissue, it does not necessarily produce
a complete layer that exactly replicates skin over the wound. For
instance, Apligraf does not contain sweat glands or hair follicles, so
these structures would be missing and would never develop in the area
where Apligraf has been used over a wound.34 Alternatively, Apligraf
can be successfully used in a situation in which standard forms of
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treatment through debridement and dressing changes do not result in
complete wound closure or appropriate healing time.
To apply Apligraf, the nurse first cleanses the wound and clears
necrotic tissue through debridement. The clinician must ensure that
bleeding from debridement is under control before applying the
Apligraf. The clinician moistens the sample with saline first and then
applies it to the wound layer. The lower, fibroblastic layer should be
placed directly against the wound bed; this allows the tissue sample to
stay in contact with the wound bed for healing. The physician may
choose to suture the Apligraf or use steri-strips to keep the layer in
place. A larger bandage should be applied over the site to protect the
wound. The clinician then applies compression stockings or starts
compression therapy on the lower extremities, as Apligraf is designed
for use in conjunction with compression therapy for treatment of
chronic wounds.34
Another product, EZ Derm, is produced by Mölnlycke Health Care and
has been created for management of partial-thickness wounds
associated with burns, venous ulcers, diabetic ulcers, and pressure
ulcers. EZ Derm is created from porcine collagen tissue that has been
chemically altered into a flexible and durable graft that is placed on
the wound bed. Once the EZ Derm has been placed on the wound, the
patient can move freely, as the graft is quite flexible and is much less
painful with application when compared to an autologous skin graft.36
EZ Derm uses porcine skin, which shares many similar characteristics
to human skin in terms of thickness of the epidermal layer and the
structure of collagen in the dermal layer, and is one of the most
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commonly used types of skin for xenografts. EZ Derm is more likely to
cause wound complications, such as infection and increased
evaporative loss, when it is not properly adhered to the wound.
Alternatively, EZ Derm has been shown to provide significant benefits
to patients who use this type of graft during wound repair. A study by
Troy, et al., in the journal Eplasty demonstrated that use of EZ Derm
among patients with partial-thickness wounds was well tolerated by
patients with few complications when the dressings were applied and
adhered correctly. EZ Derm was associated with decreased patient
pain, favorable wound bed preparations, and favorable wound
outcomes among the wound care participants studied.36
Dermagraft, a bioengineered skin product is used as a wound dressing.
It is created from human fibroblast cells, has been approved by the
FDA for the treatment of full-thickness diabetic foot ulcers and wounds
that have developed as a result of epidermylosis bullosa.35 Dermagraft
uses skin cells derived from neonatal foreskin that has been cultured
for several weeks to release collagen matrix proteins. The sample
contains a network of human fibroblasts that are based on a mesh
scaffold, which is placed on the wound and the scaffold is eventually
absorbed.37
Dermagraft, like other bioengineered skin substitutes, has the
potential for complications, which may be associated with application
of the tissue, as well as with the patient’s medical background and the
condition of the wound. The most common complications associated
with Dermagraft are infection, wound enlargement, cellulitis, and
peripheral edema. However, Dermagraft has also been successful to
increase the success rate of wound closure among patients with
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diabetic foot ulcers by 64% when it is used with conventional therapy,
as compared to conventional therapy alone.37
Prior to applying Dermagraft, the wound bed must be cleaned and
debrided to remove necrotic tissue. Dermagraft is cryopreserved, so it
must be thawed before use, which only takes a few minutes. The size
of the wound is measured and the clinician must cut the Dermagraft
down to fit the wound size. The plastic backing is peeled away from
both sides of the graft using sterile technique and the piece is placed
into the wound. The wound and the graft are then covered with a
larger dressing for protection. The Dermagraft needs to be changed
approximately every 72 hours.37
Bioengineered skin tissues provide a valid alternative to autologous
skin grafts for some patients with wounds because they require less
work and pain for harvesting and placing grafts. These tissue samples
are also often readily available and as a product, they may last for
months being shelf stable before placement on a wound.
Bioengineered skin substitutes have been approved by the FDA for a
number of conditions; in addition to those listed, they may also be
used for the treatment of arterial insufficiency wounds, ulcers caused
by vasculitis, systemic sclerosa, pyoderma gangrenosum; and for
situations when tissue is removed for surgery for cancer, such as with
skin cancer tissue removal or breast reconstruction surgery.35 Other
examples of bioengineered tissues include Alloderm®, Integra,
Laserskin, and TransCyte.
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Negative Pressure Wound Therapy
Negative pressure wound therapy (NPWT) is a relatively new method
of wound treatment that has been successfully used for certain types
of wounds, including wounds caused by trauma, grafting wounds, and
surgical wounds. Negative pressure wound therapy is also referred to
as vacuum-assisted closure; it involves application of a specialized
machine to a wound site, which provides continuous suction of fluid
draining from the wound. Vacuum-assisted closure also benefits the
wound healing process by keeping the wound covered to prevent
invasion of bacteria; the negative pressure applied to the site also has
positive effects on tissue healing within the wound.
The negative pressure system typically contains a vacuum unit, which
provides suction. The suction from the vacuum unit can be set to
intermittent or continuous suction, based on the physician’s
preference. The vacuum system is connected to the wound site
through tubing that is attached to a specialized dressing that has been
placed in the wound. The wound dressing is designed to promote
healing in the wound by promoting granulation tissue formation and
preventing edema formation.38 When a wound occurs, the area is
cleaned and debrided, if necessary, to ensure that there is wound base
from which to work that the negative-pressure system can be attached
to.
Once the wound is exposed and ready, the nurse inserts a piece of
foam gauze that has been cut to the appropriate size into the wound
bed. The foam has a connector embedded within it, which will be
attached to the tubing. A piece of adhesive film is then placed on top
of the foam; over this adhesive, the nurse then attaches the tubing to
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the connector within the foam. The other end of the tube is connected
to the vacuum, which is set for a prescribed amount of pressure and
whether it should be on continuous or low-intermittent suction. The
suction level is typically set between 60 and 125 mmHg.39 Once the
vacuum is started, the gentle suction is applied to the wound bed, and
the process removes exudate, debris, dead tissue, and blood that are
formed in the wound.
An article in the American Journal of Nursing stated that NPWT has
been shown to have many benefits and it is a comparable form of
therapy to use with certain types of wounds when making a choice
about which method is the best form of treatment. The article stated
that NPWT reduces healing time, decreases the amount of clinical care
required for maintenance of the system, and has resulted in shorter
hospital stays.39 While it does have many benefits, negative-pressure
therapy must be used very carefully, as it can lead to excess bleeding
and wound infection. It is also not available for use among pediatric or
neonatal populations and should only be used for adults.
Despite reports of incidents with NPWT that have led to patient wound
complications, the negative pressure applied with the system has
resulted in so many benefits because of the changes it causes at the
cellular level of the healing wound. NPWT helps the skin cell migration
process when the negative pressure pulls the wound edges toward
each other, improving approximation of wound edges. The negative
suction stretches the skin cells in the wound bed, which ends up
stimulating creation of more granulation tissue in the wound bed. The
pressure also stimulates blood flow to the wound, which reduces
edema; finally, this type of wound treatment system decreases the
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risk of wound infection because the system not only carries away
excess fluid, but the covered system requires fewer dressing changes,
thereby decreasing the time that the wound is open to be exposed to
pathogenic microorganisms.39
When caring for a patient with a NPWT device in place, the nurse must
be familiar with the directions for its use and if not, to work with
someone who has used the device in the past. There are a number of
different systems manufactured for negative-pressure therapy and not
all are the same. Some of the various systems that are available that
may be used in the healthcare environment include V.A.C. Therapy
Units by KCI, PICO by Smith & Nephew, and the Venturi system by
Talley Group.
The clinician must perform an accurate and thorough patient
assessment before applying the wound-vacuum system. Although in
some cases, this type of wound-care system may already be in place
by the time the nurse receives the patient for care, such as in the case
of application of NPWT for a surgical wound while the patient is still in
the surgical suite, the nurse must still be familiar with those factors
that can affect wound healing through this type of system. A patient
who is at risk of bleeding, such as with someone who uses
anticoagulant medications; a patient whose wound contains poor,
friable granulation tissue that bleeds easily; someone with a very deep
infection, such as cellulitis or osteomyelitis, or a patient that has such
a significant wound that underlying organs are present is probably not
the best candidate for negative-pressure wound therapy.39
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When caring for a patient who uses this therapy, the clinician should
regularly assess the dressing site, even if she does not need to
perform a dressing change. The dressing should be within the wound
bed and not covering the surrounding skin of the wound. The
connection tube should be firmly attached at the site of the wound.
The clinician should assess for such signs or symptoms of infection,
bleeding, or the edges of the dressing becoming displaced from the
wound bed. Additionally, regular assessment of the vacuum
component of the system is also required to ensure that it is working
at the prescribed level. The clinician must routinely ensure that suction
is set as intermittent or continuous as ordered and that the level of
suction has not migrated too high or too low.
The wound dressing is typically changed every 2 days. To change the
dressing, the nurse turns off the negative suction and removes the
dressing to inspect the wound bed. Signs of infection or bleeding
should be identified and any signs of tissue breakdown near the edges
of the wound, such as inflammation or skin maceration, should be
addressed with the physician. If the wound is infected, the medical
clinician or surgeon may order more frequent dressing changes but the
patient may still be able to use the system. Before applying the next
dressing, the wound may need to be irrigated with normal saline;
however, this practice may depend on facility policy and the amount of
time the pressure system has been turned off for the dressing change.
The amount of time to use the NPWT varies with each patient. In some
situations, the provider may order that the patient wear the system
until the wound is completely healed. Alternatively, some patients may
wear the NPWT for a while and then it is removed and standard forms
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of treatment, including use of different types of dressings, are
instituted until the wound has healed. The amount of time then varies
with how long it takes for the wound to heal. Generally, the NPWT is
used until a certain amount of granulation tissue has filled into the
wound that indicates healing.39 The system may also be discontinued if
the patient develops a severe infection or has complications associated
with its use, such as excess bleeding, erythema, or tissue swelling.
When this occurs, the NPWT system should be discontinued and other
forms of wound treatment should be instituted instead.
Advanced Dressings and Therapies
Although there are standard forms of therapy that are often successful
with wound healing processes, such as use of various dressings, and
frequent cleaning and debridement, there are times when wounds
become stalled in their healing processes. Stalled wounds have not
developed complications, nor are they worsening, but they are not
necessarily improving or getting better. When this occurs and a wound
is stuck in a non-healing stage, advanced dressings and therapies may
need to be implemented to get the healing process moving forward
once again.
Advanced therapies are those that are implemented when standard
forms of treatment for wounds have not resulted in wound healing.
The clinician may choose from a variety of advanced dressings to use
on the wound as well as many other forms of therapy that serve as
methods of debridement, restructuring of skin cells to promote
healing, or prevention of infection.
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Collagen Products
Collagen is a useful component of wound healing; collage presents a
fibrous network that serves as a matrix for new cells to form when a
wound heals. Collagen normally is a type of protein that is found in
connective tissue; it is also infused into many different types of
advanced wound dressings to be used as part of a system that
promotes new tissue growth in the wound.
The layer of the dermis known as the extracellular matrix provides a
structure for cell growth, support for growth factors, and other
elements needed for a wound to heal. Collagen is a major component
of this extracellular matrix. Although there are over 20 different types
of collagen found throughout the body, types I and III are significant
for wound healing. A wound normally contains matrix
metalloproteinases (MMPs), which break down unhealthy tissue so that
a wound can heal. A stalled wound may be more likely to have higher
levels of MMPs, so that they continue to break down elements of the
extracellular matrix and the wound and the healing process is slowed
or even stopped.42
Collagen products used on stalled wounds provide another source of
collagen for MMPs to consume, rather than destroying the extracellular
matrix. This allows the wound to build up the extracellular matrix once
again when the MMPs are kept busy, so to speak, with consuming the
collagen from the dressing. Collagen dressing preparations are created
in various forms and may be applied as dressings or as solutions that
are applied to the wound and then covered. The collagen used in most
preparations comes from either bovine or porcine sources.
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Depending on the type of dressing and the source of the collagen, the
preparation is placed on a clean wound bed, with the area kept moist.
A secondary dressing is placed over the collagen dressing for
protection and then the area is secured to keep both dressings in
place. Dressings made with collagen may be changed several times
per week, depending on levels of exudate from the wound. As with
other types of dressings, when caring for a patient who uses a
collagen-based dressing the clinician must continue to assess for
complications of wound healing, such as bleeding or infection in the
wound bed. The clinician may measure the wound site with each
assessment to determine if the wound is still stalled or if the collagen
therapy has started the healing process again.
Keratinocyte Dressings
Keratinocytes are found within skin cells and are important
components of the wound healing process. Researchers have
developed specialized dressings that contain keratin that may promote
wound healing when the dressing is placed in a stalled wound. Keratin
is produced by keratinocytes, which are skin cells found in the
epidermal layer. As an organ, skin provides a barrier to the rest of the
body to keep out infectious pathogens and foreign invaders that could
cause illness. Keratin is one of the main components that make up this
function of skin as a barrier.
The theory behind keratinocyte dressings is that because keratinocytes
migrate at the edges of the wound bed during healing, application of a
dressing that contains these cells can enhance wound healing, speed
up the process, and move the wound beyond the stage where it has
stalled in healing. Once keratinocytes affect the wound bed with
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dressing application and the skin cells begin migration from the wound
edges, the next phases of wound healing can then take place,
including collagen production and granulation tissue formation.43
Keratin dressings have been used successfully for a variety of different
wound types, including treatment of venous ulcers, pressure ulcers,
skin graft donor sites, lesions associated with epidermolysis bullosa,
and diabetic foot wounds.43 Although keratin comprises different forms
in the skin, only activated or functional keratin is typically used in
dressings. The keratin protein used for the dressings comes from a
specific type of sheep wool. In the United States, keratin dressings
approved by the U.S. FDA are created by Keraplast Technologies and
consist of keramatrix, kerasorb, and keragel, which are the various
forms that deliver the keratine technology known as Replicine
Functional Keratin.44
The method of application of the keratin technology to the wound bed
may vary slightly, depending on the type of substance used. Before
applying the substance, the clinician cleans and debrides the wound to
get rid of dead tissue such as eschar or slough that may be present in
the wound bed. The times of dressing changes vary between patients,
based on the type of keratin applied and the amount of exudate in the
wound.
Kerasorb is a type of keratin dressing that comes in a sheath that is
placed on the wound. It is designed for wounds that create large
amounts of exudate. The dressing is flexible and is fit directly into the
wound bed to adhere to the wound base. A dressing is placed over the
kerasorb dressing to keep it in place and to provide protection. The
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dressing contains a layer of keratin and a layer of foam. Over time, the
keratin is absorbed into the wound while the foam remains in place.
The foam is the portion removed with each dressing change and it is
replaced with a new dressing with a fresh source of keratin.45
Keragel is a gel product that is placed directly into the wound bed as a
source of keratin for wound healing. The clinician applies the gel to the
wound and then covers the wound with a dressing. Keragel is best
designed for use on wounds that need a moist wound bed. The gel is
absorbed over time and when the dressing is changed, more gel is
applied and the wound is covered again.
Keramatrix is another type of dressing that acts in a manner similar to
an alginate dressing. When the keramatrix dressing is placed in the
wound bed, it turns into a gel when it comes in contact with exudate
and then releases the keratin into the wound. This type of dressing is
designed for wounds that create exudate, but it is not as efficient on
dry wounds. Once the dressing is applied, the clinician covers the
wound with a non-adherent dressing for protection. The keramatrix
dressing should be changed every 7 days or less, depending on the
amount of exudate produced. The dressing can become saturated if
there is too much exudate, in which case it will not be effective, and
the dressings should be changed more often. When the top layer of
the dressing is removed, there may be some of the keratin gel still
within the wound, which should be left in place, as it will continue to
be absorbed over time.45
The development of keratin-based dressings has created a new
process of helping chronic or stalled wounds to heal more quickly.
These types of dressings are relatively cost effective, and based on
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their work, they can reduce overall costs by decreasing the length of
time for wound healing. They are also easy to use when compared to
other types of dressings and their use can improve patient quality of
life, especially if they reduce overall healing time and allow a patient to
live with a healed wound.
Silver Dressings
Silver is a substance that is often used for management of infection,
particularly among certain populations of patients with wounds, such
as burn patients. Some patients develop delayed wound healing
because their wounds have stalled due to critical colonization; others
who develop infections have more complications and slower wound
healing that also needs to be managed.
When critical colonization or infection occurs, advanced wound
dressings that are impregnated with antibiotic preparations, such as
silver, may be used. Silver has long been used as a form of
antimicrobial therapy. Silver has been shown to be effective against
microorganisms as a broad-spectrum antibiotic. It is also effective
against some forms of resistant organisms as well, including MRSA and
VRE.46 Silver is effective against other types of pathologic organisms
that can cause infections, including certain types of yeast and fungi.
Although it is a metallic compound, silver demonstrates very little
toxicity toward cells of the human body when it is administered in the
small amounts needed for antimicrobial activity.
Silver can be applied to a wound as either a topical agent, such as with
a cream or gel preparation, or it may be impregnated into a dressing
that is used to cover the wound. When silver is included as part of a
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dressing, the amount added may vary, depending on the
manufacturer. In terms of the amount of silver within the dressing,
more is not always more effective. An article by Parsons, et al., in the
journal Wounds reviewed various wound care products that consisted
of several structural forms, including gauze, fibrous dressings, foam
dressings, and hydrogel. All of the dressings were impregnated with
some amount of silver to use as an antimicrobial in a chronic wound,
and the total amounts of silver varied between each dressing, with
some having 10 times the amount of silver present when compared to
other dressings in the study. The study showed that although some
dressing types contained higher amounts of silver within their
dressings, they were not necessarily any more effective as
antimicrobial agents when compared to dressings that contained lower
levels of silver.46 This information is presented to bear in mind when
selecting dressing types for wound care.
Because there are many different preparations of silver dressings
available, the clinician must read the manufacturer’s instructions for
application of each specific dressing to the wound bed. There is not
one set method for applying silver-impregnated dressings or for
changing them and directions vary with each brand. Some silver
dressings are considered alginates and can last longer between
dressing changes. There are some alginate silver dressings that state
they do not need to be changed more often than every 21 days;
however, the clinician should again check on this to compare against
the manufacturer’s directions and should always change the dressing
before 21 days if it becomes saturated with exudate.47
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Some people have sensitivity to silver compounds and it may cause
skin redness or irritation on the periwound skin. One preparation,
silver sulfadiazine, has been used extensively on wounds, particularly
as a topical ointment for burn patients. However, this drug should not
be used for patients who have an allergy to sulfa antibiotics, as the
preparation contains sulfa and can cause a severe allergic reaction. As
with all other types of dressings, the clinician who uses silver
preparations for wound care should routinely check the patient’s
wound for complications or signs of infection and should provide care
as needed.
Radio-frequency therapy
A method of sending energy into the wound bed and its surrounding
areas, pulsed radio-frequency electromagnetic field (PEMF) therapy
has had some success with wound healing and is being introduced into
more situations that require care of chronic wounds. According to a
2013 product review in Wounds International, PEMF has been shown
to increase the rate of healing among chronic wounds, as well as
control pain and edema among patients with wounds treated with this
method.48 PEMF may stimulate cell proliferation in the wound bed after
the wound tissue has been exposed to the therapy. Of particular
importance is the activation of mitogen-activated proteins found in
fibroblasts in the skin, which stimulate skin cell responses and increase
the rate of cell proliferation.
The PEMF is delivered when a device that sends the energy is used
over or as part of a wound dressing. The dressing is applied to the
wound and the PEMF delivers pulses to the wound over a short period,
approximately 30 minutes at a time, twice daily. Because the device is
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incorporated into a wound dressing, it is not always feasible for the
patient to have regular sessions of PEMF, despite its success in wound
healing. Some clinicians are looking into other methods that make the
device more portable and that can be used at home. Because chronic
wounds may take weeks or months to heal, it is not otherwise practical
for the patient to come into the healthcare center for two sessions
each day of the therapy.48 If a device were created to be used at
home, the patient could routinely administer the PEMF after some
training.
Alternatively, PEMF has not demonstrated any side effects when it is
used correctly. While the device may not be widely available as an
adjunct for wound care, it could become a rising form of technology
that can be incorporated into patient visits for treatments of wounds.
Further, if advances in technology can increase accessibility of this
type of treatment to be used in the home, a patient could wear it for
longer periods each day, as side effects tend to be minimal. While this
may not completely negate other processes used as part of wound
healing, the PEMF therapy can be incorporated regularly to speed up
the process of healing and to reduce time spent with stalled wounds or
other delays.
Ozone Oxygen Therapy
Ozone is a form of oxygen gas that has no color or odor, but that can
be applied to some wounds for chronic wound healing. Ozone therapy
in wounds has been questioned as to its safety and efficacy for use
among wounds, for instance, many clinicians questioned its use
because of concerns about toxicity; however, it is becoming more
accepted as a method of wound treatment.
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Ozone oxygen therapy has been used for many years for treatment of
various maladies; conditions that have been treated with ozone have
ranged from various forms of cancer, gout, whooping cough, tetanus,
and insomnia. In World War I, Dr. Albert Wolff successfully used ozone
therapy for the treatment of gangrene and trench foot, which is an
infection that develops after long periods of being in wet or damp
conditions.49
The theory behind ozone therapy is that it can activate the antioxidant
system within the body, which can result in more rapid healing of
certain conditions, including wounds. Ozone is also thought to prevent
damage from oxidative stress and to disinfect what it comes in contact
with.51 Ozone is administered using a generator that can be set for
certain concentrations of the gas to be given. Tubing connects the
generator to the patient, whose wound is covered with a plastic sleeve
or bag that contains the ozone. The technique of administering the
ozone in this way is known as bagging. For example, if a patient has a
diabetic foot ulcer, a bag is placed around the entire foot to receive the
ozone gas after it is connected to the generator. The process of
administration of ozone takes approximately 30 minutes. It can be
administered for wounds that are infected, in which case, higher
concentrations of the ozone may be necessary. Alternatively, a stalled
or clean wound may still benefit from ozone therapy but would need a
much lower concentration.
Ozone, when applied, should be used very carefully to avoid tissue
damage and toxicity. The clinician who administers ozone therapy
must be trained in its application to avoid damage. Although it may be
used in other countries, the U.S. FDA does not technically approve it
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for treatment of wounds or for other medical therapies. A statement
issued by the FDA states that “ozone is a toxic gas with no known
useful medical application in specific, adjunctive, or preventive
therapy.”50 Despite this statement, various clinicians throughout the
U.S. utilize ozone therapy for treatment of wounds and other medical
conditions. Its use should be considered carefully as an alternative
form of treatment, but only after further research and thought that
specifically reflects its purposes for the wound to be healed.
Ultrasound Therapy
Ultrasound therapy is not necessarily a type of dressing, but it is an
alternative form of debridement that can be used on some types of
wounds to improve healing. Ultrasound therapy in this situation is
known as non-contact low-frequency ultrasound (NLFU) which is
delivered in the method in which it sounds: the ultrasound probe emits
a low-frequency sound wave to the wound without actually contacting
the wound tissue.40 NLFU has the advantage of reaching the deep
tissues both within the wound and underneath the base of the wound
bed. Ultrasound can be used on a wound to promote healing by
sending sound waves deep into the tissues. The form of ultrasound
used for wound tissue healing differs slightly from the type of
ultrasound used for diagnostic purposes. The therapeutic ultrasound
uses a much lower frequency of sound waves. When the sound waves
penetrate the tissues, it mechanically stimulates the skin cells through
rapid vibration. There is no gel that must be placed on the skin or the
wound to act as a conduit for the ultrasound transducer. NLFU uses a
saline mist and the transducer hovers several inches above the
wound.40
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Non-contact low-frequency ultrasound is performed at the bedside by
a trained technician or clinician. The patient may need the ultrasound
therapy up to several times a week and the physician prescribes the
length of each session. Because the ultrasound transducer does not
come in contact with the wound, the process is typically painless for
the patient. Throughout the process of using NLFU, the nurse
continues to assess the wound bed, not just before and after
ultrasound, but during the overall length of time that the patient
receives this type of therapy, which may be several weeks. The
clinician should assess the wound each time the patient is about the
have the ultrasound; measurements may be taken with each session
so that the clinician can see if the therapy is having any benefit and if
the wound is getting smaller. The clinician must also assess and
document any clinical signs of infection or other wound complications
as part of the therapeutic process.
Ultraviolet Light Therapy
Ultraviolet light therapy may be used to control bioburden in the
wound bed; it is a technique that is easy to use and can positively
impact wound healing by reducing the potential for infection.41
Ultraviolet light therapy is administered through a special lamp; the
size of the lamp used depends on the area of the wound. For instance,
an extensive burn wound that covers a significant portion of the body
may require a full-body ultraviolet lamp, roughly similar in size to a
tanning bed. Alternatively, small lamps can direct ultraviolet light
toward specific areas of the body, with some options available as
hand-held lamps that the patient can use.
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Ultraviolet (UV) light is classified into three main components, each of
which is categorized according to the frequency of wavelength: UV-A,
UV-B, and UV-C light. UV-C light has the shortest wavelength when
compared to UV-A or UV-B, and UV-C light is the type most often used
in the treatment of wounds.41 Ultraviolet light that is administered to a
wound alters cell function by increasing the permeability of the cell
walls. It also stimulates secretion of prostaglandins that are involved
with inflammation and bleeding in the wound. The exposure to the UV
light causes skin erythema, which in turn increases blood flow to the
wound site. The increased blood flow from vasodilation results in
increased oxygenation of the wound bed and the greater propensity
for production of granulation tissue and wound healing factors.
Because UV-C has the shortest frequency when compared to UV-A or
UV-B lights, it does not penetrate past the epidermal layer of skin. In
fact, in the environment, UV-C from the sun does not reach the body
at all because it is blocked by the earth’s atmosphere.41 In the case of
administration of UV-C light by a lamp or source for wound care, the
UV-C light reaches the higher levels of wound tissue that have gone
through permanent healing and are at the forefront of the wound bed.
According to Bryant and Nix, authors of the book Acute & Chronic
Wounds: Current Management Concepts, UV-C light has been
successfully used in the treatment of wounds to increase
epithelialization, improve formation of granulation tissue and its
growth, improve tissue perfusion and increase release of growth
factor.
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Ultraviolet light C also has properties that kill bacteria, which prevents
infection in the wound bed. UV-C alters the DNA of bacteria to prevent
their growth and replication. UV-C has even been shown to be
bactericidal toward resistant organisms, including methicillin-resistant
Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus
(VRE), so it may be particularly useful as a form of treatment among
patients who have wounds colonized with these types of organisms.41
Treatment with ultraviolet light for wound care involves placing a lamp
over the affected area of skin; the lamp is placed very close to the skin
at a distance of approximately 1 inch. The skin is exposed to the light
for 1 to 2 minutes and then the lamp is removed. The patient and the
clinician administering the treatment must wear eye protection that
blocks UV light. The dose of light and the time to administer it is
prescribed by the physician and depends on the size and depth of the
wound, as well as any other medical factors based on the patient’s
background. Absolute contraindications for ultraviolet therapy include
a patient’s history of skin cancer, a patient diagnosis of sarcoidosis or
lupus, and recent radiation therapy for the patient.41 Other conditions,
while not considered to be absolute contraindications for UV therapy,
should be considered before administration of the light, as they may
worsen with exposure to the therapy. Examples include
immunocompromised patients, such as those with human
immunodeficiency virus (HIV) or recent organ transplant, and patients
with a history of severe cardiac or renal disease.
Summary
A fine balance exists between keeping the wound bed healthy and
controlling excess fluid production. The clinician providing wound care
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must provide ongoing observation and document exudate
characteristics and wound treatment measures that promote tissue
granulation and wound healing. Vigilance to prevent infection of the
wound during the healing phase is essential to avoid complications and
delayed restoration.
Advanced therapies may be implemented when standard forms of
wound treatment have not resulted in wound healing. A variety of
advanced dressings may be used on the wound as well as other forms
of therapy that promote prevention of infection and healing. Relatively
new methods of wound treatment have been successfully used for
certain types of wounds, including wounds caused by trauma, grafting
wounds, and surgical wounds. Varied methods of wound healing exist
that must be individualized to meet the patient’s condition.
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1. When infection is present in a wound
a. granulation tissue begins to develop at the base of the wound
and slowly fills in the opening.
b. the granulation tissue often appears bumpy and may look
grainy, shiny, or beefy red.
c. granulation tissue may bleed or break down easily and it can
appear crumbly, dark red, or dull in texture.
d. the granulation tissue slowly increases in size to fill in the
wound.
2. The body’s ability to fight off infection using the immune
system is dependent on several factors that include
a.
b.
c.
d.
whether the patient is already immunocompromised.
the patient’s age.
the patient’s mobility.
All of the above
3. True or False: The nurse may collect a tissue specimen to
test for a culture.
a. True
b. False
4. Which of the following best states the use of apligraf as a
treatment for diabetic foot ulcers and venous ulcers?
a. Apligraf does not contain sweat glands or hair follicles.
b. Apligraf exactly replicates skin over the wound.
c. The provider cannot suture the Apligraf or use steri-strips to
apply Apligraf.
d. The nurse should know not to use compression stockings or
compression therapy with Apligraf.
5. Wound infection that spreads to fascia and other
subcutaneous tissue
a.
b.
c.
d.
can be treated as a superficial wound.
can develop to cellulitis.
generally does not spread to surrounding areas.
is considered localized.
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6. Silver is a metallic compound that is often used for the
management of infection because
a. it does not cause skin redness or irritation on the periwound
skin.
b. in small amounts it demonstrates very little toxicity toward
human body cells.
c. the more silver used the more effective the treatment will be.
d. All of the above
7. A sample skin from the graft may come from another part of
the patient’s body is called
a.
b.
c.
d.
an epidermal graft.
a xenograph.
an autologous graft.
a full-thickness graft.
8. Granulocyte-macrophage colony-stimulating factor (G-CSF)
a type of growth factor that
a.
b.
c.
d.
is applied to the patient’s skin topically.
is used in lieu of antibiotic therapy.
can enhance a patient’s immune system.
is a significant, direct factor in healing diabetic ulcers.
9. Bioengineered tissue is used as a substitute for skin
a.
b.
c.
d.
since it does not contain actual skin tissue.
since it contains synthetic skin.
that may mimic epidermal cells but not the dermal layers.
when new granulation and epithelial tissue is not forming.
10. Negative pressure wound therapy (NPWT) is
a.
b.
c.
d.
a new procedure used in place of vacuum-assisted closure.
helpful in preventing bacteria from entering the wound site.
especially effective on pediatric or neonatal patients.
used to promote granulation tissue and edema formation.
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11. Sequential-compression devices are more commonly used
a.
b.
c.
d.
for immobilized patients to help prevent thrombosis.
as long-term treatment in the home.
with a patient’s legs lowered for increased circulation.
as a compression and release for stalled wound treatment.
12. Hyperbaric oxygen therapy is usually administered once a
day
a.
b.
c.
d.
with standard treatments lasting more than 2 weeks.
when using monoplace chambers.
and does not require a physician’s prescription.
for 60 to 90 minute sessions.
13. True or False: A multiplace hyperbaric chamber is a mobile
unit that may be used at multiple locations in a hospital
setting.
a. True
b. False
14. Pain classified as ____________ pain is defined as ongoing
pain that is part of having the wound.
a.
b.
c.
d.
background
incidental
chronic
operative
15. Collagen is a useful component of wound healing and is
a.
b.
c.
d.
a porous network that serves as a matrix for new cells.
a type of protein found in connective tissue.
a gelatinous compound in dressings that promotes cell healing.
None of the above
16. Dermagraft is a bioengineered skin product created from
human fibroblast cells approved as
a.
b.
c.
d.
a permanent wound-graft covering.
a pressure wrap for the wound area.
a treatment for full-thickness diabetic foot ulcers.
an autologous skin graft.
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17. Which of the following describe the proper use or
application of a Keramatrix dressing?
a. Once the dressing is applied, the wound is left uncovered.
b. It is cost effective and easy to use.
c. When outer dressing is removed, keratin gel still within the
wound should be removed.
d. It works best on dry wounds.
18. True or False: Ozone therapy is thought to activate the
antioxidant system within the body, resulting in more rapid
healing of certain conditions, including wounds.
a. True
b. False
19. EZ Derm is created from ___________ collagen tissue.
a.
b.
c.
d.
porcine
human cadaver
synthetic
shark
20. A wound normally contains ___________________, which
break down unhealthy tissue so that a wound can heal.
a.
b.
c.
d.
keratin
collagen products
extracellular material
matrix metalloproteinases (MMPs)
21. Some alginate silver dressings do not need to be changed
more often than every ____ days.
a.
b.
c.
d.
5
10
14
21
22. True or False: Nociceptive pain is defined as pain that
stems from nerve damage.
a. True
b. False
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23. Pulsed radio-frequency electromagnetic field (PEMF)
therapy has been shown to
a.
b.
c.
d.
increase the rate of healing of chronic wounds.
stall mitogen-activated proteins.
cause pain in acute wound cases.
encourage edema formation.
24. Cells such as neutrophils may only have a ______ life span
before they die.
a.
b.
c.
d.
12-hour
24-hour
36-hour
48-hour
25. True or False: Pain from a wound in a patient with diabetic
neuropathy is an example of neuropathic pain.
a. True
b. False
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Correct Answers:
1. When infection is present in a wound
c. granulation tissue may bleed or break down easily and it
can appear crumbly, dark red, or dull in texture.
“When infection is present, granulation tissue may bleed or
break down easily and it can appear crumbly, dark red, or dull
in texture. Alternatively, as a wound is healing, the
granulation tissue slowly increases in size to fill in the
wound.”
2. The body’s ability to fight off infection using the immune
system is dependent on several factors that include
a.
b.
c.
d.
whether the patient is already immunocompromised.
the patient’s age.
the patient’s mobility.
All of the above
“The body’s ability to fight off infection using the immune
system is dependent on several factors that are associated
with both the immune system function and the type of
pathogens that could infect the wound. If the patient is
already immunocompromised, such as in the case of a cancer
diagnosis, older age, or immobility, he or she will most likely
have a difficult time fighting off an infection and will need
further medical measures, such as antibiotic therapy and
nursing interventions to prevent further spread of the
infection.”
3. True or False: The clinician may collect a tissue specimen to
test for a culture.
b. False
“The nursing clinician may collect a wound culture using a
swab technique, since this is the method that most likely falls
within the nursing scope of practice and can be performed
relatively quickly at the bedside. Alternatively, a physician or
advanced-care practitioner is required to collect a tissue
specimen for a culture test.”
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4. Which of the following best states the use of apligraf as a
treatment for diabetic foot ulcers and venous ulcers?
a. Apligraf does not contain sweat glands or hair follicles.
“The U.S. Food and Drug Administration (FDA) has approved
Apligraf for the treatment of diabetic foot ulcers and venous
ulcers. While it is considered living, bioengineered tissue, it
does not necessarily produce a complete layer that exactly
replicates skin over the wound. For instance, Apligraf does
not contain sweat glands or hair follicles, so these structures
would be missing and would never develop in the area where
Apligraf has been used over a wound. Alternatively, Apligraf
can be successfully used in a situation in which standard
forms of treatment through debridement and dressing
changes do not result in complete wound closure or
appropriate healing time…. The physician or surgeon may
choose to suture the Apligraf or use steri-strips to keep the
layer in place. A larger bandage should be applied over the
site to protect the wound. The clinician then applies
compression stockings or starts compression therapy on the
lower extremities, as Apligraf is designed for use in
conjunction with compression therapy for treatment of
chronic wounds.”
5. Wound infection that spreads to fascia and other
subcutaneous tissue
c. generally does not spread to surrounding areas.
“Alternatively, when a wound infection spreads to infect the
fascia and other subcutaneous tissue, the patient can develop
cellulitis. This may demonstrate symptoms in the wound bed
but it can also spread to surrounding areas and cause skin
redness and swelling of the skin surrounding the wound bed.”
6. Silver is often used for the management of infection,
b. in small amounts it demonstrates very little toxicity toward
human body cells.
“When silver is included as part of a dressing, the amount
added may vary, depending on the manufacturer. In terms of
the amount of silver within the dressing, more is not always
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more effective…. Silver has long been used as a form of
antimicrobial therapy. Silver has been shown to be effective
against microorganisms as a broad-spectrum antibiotic….
Although it is a metallic compound, silver demonstrates very
little toxicity toward cells of the human body when it is
administered in the small amounts needed for antimicrobial
activity. Some people have sensitivity to silver compounds
and it may cause skin redness or irritation on the periwound
skin.”
7. A sample skin from the graft may come from another part of
the patient’s body is
c. an autologous graft.
“The sample skin from the graft may come from another part
of the patient’s body (autologous graft) or it could come from
another source, such as from a cadaver.”
8. Granulocyte-macrophage colony-stimulating factor (G-CSF)
a type of growth factor that
c. can enhance a patient’s immune system.
“Granulocyte-macrophage colony-stimulating factor (G-CSF) is
a type of growth factor that promotes the release of white
blood cells (neutrophils) from the bone marrow…. It can be
used to reduce the instance of infection by enhancing the work
of antibiotic therapy and may improve the body’s immune
response to infection…. Granulocyte-macrophage colonystimulating factor is injected subcutaneously, rather than
being applied as a topical agent…. G-CSF may not be
significant in the specific healing of diabetic ulcers, but its
effects can enhance immune function of the affected patient.”
9. Bioengineered tissue is used as a substitute for skin
d. when new granulation and epithelial tissue is not forming.
“Bioengineered skin is developed as a substitute for skin when
it is not otherwise forming new granulation and epithelial tissue
as part of the healing process. Bioengineered skin often is
designed to mimic the layers of natural skin cells, including the
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epidermal and the dermal layers. It contains actual skin tissue
and not a synthetic form.”
10. Negative pressure wound therapy (NPWT) is
b. helpful in preventing bacteria from entering the wound site.
“Negative pressure wound therapy is also referred to as
vacuum-assisted closure…. Vacuum-assisted closure also
benefits the wound healing process by keeping the wound
covered to prevent invasion of bacteria…. The wound dressing
is designed to promote healing in the wound by promoting
granulation tissue formation and preventing edema formation.”
11. Sequential-compression devices are more commonly used
a. for inpatients to prevent thrombosis
“Sequential-compression devices are more commonly used in
the inpatient environment to prevent thrombosis, particularly
after a medical procedure and when a patient is immobilized;
… the patient must be lying down or sitting with the legs
elevated in order to effectively use an SCD. However, for the
person who is receiving inpatient care, an SCD can provide
some form of compression therapy on a short-term basis.”
12. Hyperbaric oxygen therapy is usually administered once a
day
d. for 60 to 90 minute sessions.
“Hyperbaric oxygen therapy utilizes high pressures of 100%
oxygen that is above atmospheric pressure…. Hyperbaric
chambers are typically of two different types: monoplace
chambers and multiplace chambers. Monoplace chambers are
designed to hold one patient at a time for the therapy…. How
often and how long the patient receives hyperbaric therapy is
determined by physician prescription. The treatments may be
administered several times, for a period of about 60 to 90
minutes for each session…. Most patients undergo hyperbaric
treatment one time per day for several days; the standard
form of treatment often does not last longer than 10 days
duration.”
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13. True or False: A multiplace hyperbaric chamber is a mobile
unit that may be used at multiple locations in a hospital
setting.
b. False
“A multiplace hyperbaric chamber is designed to accommodate
more than one patient at a time.”
14. Pain classified as ____________ pain is defined as ongoing
pain that is part of having the wound.
a. background
“Background pain is ongoing pain that is part of having the
wound. It exists because of the tissue breakdown from the
wound and its affect on underlying structures.”
15. Collagen is a useful component of wound healing and is
b. a type of protein found in connective tissue.
“Collagen is a useful component of wound healing; collage
presents a fibrous network that serves as a matrix for new
cells to form when a wound heals.”
16. Dermagraft is a bioengineered skin product created from
human fibroblast cells approved as
c. a treatment for full-thickness diabetic foot ulcers.
“Dermagraft, a bioengineered skin product used as a wound
dressing. It is created from human fibroblast cells, has been
approved by the FDA for the treatment of full-thickness
diabetic foot ulcers and wounds that have developed as a
result of epidermylosis bullosa…. The Dermagraft needs to be
changed approximately every 72 hours.… Bioengineered skin
tissues provide a valid alternative to autologous skin grafts for
some patients with wounds because they require less work and
pain for harvesting and placing grafts.”
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17. Which of the following describe the proper use or
application of a Keramatrix dressing?
b. It is cost effective and easy to use.
“Keramatrix … dressing is designed for wounds that create
exudate, but it is not as efficient on dry wounds. Once the
dressing is applied, the clinician covers the wound with a nonadherent dressing for protection. The keramatrix dressing
should be changed every 7 days or less, depending on the
amount of exudate produced. When the top layer of the
dressing is removed, there may be some of the keratin gel still
within the wound, which should be left in place, as it will
continue to be absorbed over time…. These types of dressings
are relatively cost effective, and based on their work, they can
reduce overall costs by decreasing the length of time for
wound healing. They are also easy to use when compared to
other types of dressings….”
18. True or False: Ozone therapy is thought to activate the
antioxidant system within the body, resulting in more rapid
healing of certain conditions, including wounds.
a. True
“The theory behind ozone therapy is that it can activate the
antioxidant system within the body, which can result in more
rapid healing of certain conditions, including wounds.”
19. EZ Derm is created from ___________ collagen tissue.
a. porcine
“EZ Derm uses porcine skin, which shares many similar
characteristics to human skin in terms of thickness of the
epidermal layer and the structure of collagen in the dermal
layer, and is one of the most commonly used types of skin for
xenografts.”
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20. A wound normally contains ___________________, which
break down unhealthy tissue so that a wound can heal.
d. matrix metalloproteinases (MMPs)
“A wound normally contains matrix metalloproteinases (MMPs),
which break down unhealthy tissue so that a wound can heal.
A stalled wound may be more likely to have higher levels of
MMPs, so that they continue to break down elements of the
extracellular matrix and the wound and the healing process is
slowed or even stopped.”
21. Some alginate silver dressings do not need to be changed
more often than every ____ days.
d. 21
“There are some alginate silver dressings that state they do
not need to be changed more often than every 21 days;
however, the clinician should again check on this to compare
against the manufacturer’s directions and should always
change the dressing before 21 days if it becomes saturated
with exudate.”
22. True or False: Nociceptive pain is defined as pain that
stems from nerve damage.
b. False
“Nociceptive pain is that which is felt with trauma or damage
to the tissues. The patient with a surgical wound may be
experiencing nociceptive pain. Alternatively, neuropathic pain
is pain that stems from nerve damage.”
23. Pulsed radio-frequency electromagnetic field (PEMF)
therapy has been shown to
a. increase the rate of healing of chronic wounds.
“A method of sending energy into the wound bed and its
surrounding areas, pulsed radio-frequency electromagnetic
field (PEMF) therapy has had some success with wound healing
and is being introduced into more situations that require care
of chronic wounds. According to a 2013 product review in
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Wounds International, PEMF has been shown to increase the
rate of healing among chronic wounds, as well as control pain
and edema among patients with wounds treated with this
method.48 PEMF may stimulate cell proliferation in the wound
bed after the wound tissue has been exposed to the therapy.
Of particular importance is the activation of mitogen-activated
proteins found in fibroblasts in the skin, which stimulate skin
cell responses and increase the rate of cell proliferation.”
24. Cells such as neutrophils may only have a ______ life span
before they die.
b. 24-hour
“… cells such as neutrophils may only have a 24-hour life span
before they die.”
25. True or False: Pain from a wound in a patient with diabetic
neuropathy is an example of neuropathic pain.
a. True
“Pain from a wound in a patient with diabetic neuropathy is an
example of neuropathic pain.”
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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/clinicalblog/channels/clinical-solutions/kennedy-terminal-ulcer-ktu-isnow-recognized-by-cms-for-long-term-acute-care-hospitals-ltacor-ltch/
5. Covidien AG. (2008, Jan.). Support services and the prevention of
pressure ulcers. Retrieved from http://www.patientcareedu.com/imageServer.aspx?contentID=20368&contenttype=appli
cation/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.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
64
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Retrieved from http://www.ijps.org/article.asp?issn=09700358;year=2012;volume=45;issue=2;spage=316;epage=324;aul
ast=Bhutani
Lopez Rowe, V. (2014, Jul.). Diabetic ulcers. Retrieved from
http://emedicine.medscape.com/article/460282-overview
Medfocus guidebook on: Diabetic foot ulcers. (2011). Princeton,
NJ: Medfocus.com, Inc.
American Diabetes Association. (2014, Oct.). Foot complications.
Retrieved from http://www.diabetes.org/living-withdiabetes/complications/foot-complications/
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
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.
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
University of Rochester Medical Center. (2008, Mar.). How
diabetes drives atherosclerosis. Science Daily. Retrieved from
http://www.sciencedaily.com/releases/2008/03/080313124430.ht
m
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
McCullogh, J. M., Kloth, L. C. (2010). Wound healing: Evidencebased management (4th ed.). Philadelphia, PA: F. A. Davis
Company
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
Medline Industries, Inc. (2007). The wound care handbook
[Chapter 8]. Mundelein, IL: Medline
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
Sussman, C., Bates-Jensen, B. M. (1998). Wound care
collaborative practice manual for physical therapists and nurses.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
65
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
[Excerpt]. New York, NY: Aspen Publishers. Retrieved from
http://www.medicaledu.com/whirlpoo.htm
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/201
1/07000/Say_Goodbye_to_Wet_to_Dry_Wound_Care_Dressings_.
8.aspx
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=7945
01
Swezey, L. (2012, Jul.). Wound debridement techniques 6:
Biological debridement. Retrieved from
http://woundeducators.com/wound-debridement-techniques-6biological-debridement/
Dowsett, C., Newton, H. (2005). Wound bed preparation: TIME in
practice. Retrieved from
http://woundsinternational.com/pdf/content_86.pdf
Martin, B. (2011, Apr.). Moist wound healing. Ostomy Wound
Management 57(4): 10. Retrieved from
http://www.polymem.com/pearls/pearls4practice0411.pdf?line_id
=411
ATI Nursing Education. (n.d.). Dressing and bandage types.
Retrieved from
http://www.atitesting.com/ati_next_gen/skillsmodules/content/w
ound-care/equipment/dressing_and_bandage_types.html
Bjarnsholt, T. (2011). Biofilm infections. New York, NY: Springer
Science+Business Media, LLC
Southwesthealthline.ca. (2011, Dec.). Levine method for wound
stab for culture & sensitivity. Retrieved from
http://www.southwesthealthline.ca/healthlibrary_docs/B.7.3.Levin
eWoundSwabMethod.pdf
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
Organogenesis, Inc. (2010). What is Apligraf? Retrieved from
http://www.apligraf.com/professional/what_is_apligraf/index.html
DermNetNZ. (2013, Dec.). Bioengineered skin. Retrieved from
http://www.dermnetnz.org/procedures/bioengineered-skin.html
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
66
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=135
3037
40. Alumia, R. (2013, Sep.). Improving outcomes with non-contact
low-frequency ultrasound. Retrieved from
http://woundcareadvisor.com/improving-outcomes-withnoncontact-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-dressingsmade-easy/page-1
43. DermNetNZ. (2013, Dec.). Keratin-based dressings for chronic
wounds. Retrieved from
http://www.dermnetnz.org/procedures/keratin-dressings.html
44. Keraplast Technologies, LLC. (n.d.). A new paradigm in wound
care. Retrieved from http://www.keraplast.com/woundcare#Kerasorb
45. Keraplast Technologies, LLC. (2014, Jul.). User’s guide for
treatment of chronic wounds with Keraplast’s range of Replicine™
Functional Keratin® advanced wound healing products. Retrieved
from
http://www.keraplast.com/images/stories/pdfs/users_guide_for_a
ll_products_for_chronic_wounds.pdf
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): 259267. Retrieved from
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
67
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
http://www.nursingcenter.com/lnc/CEArticle?an=00004045201305000-00006&Journal_ID=54023&Issue_ID=1547910
Rawe, I. (2012). Technology update: Pulsed radio-frequency
electromagnetic field (PEMF) therapy as an adjunct wound healing
therapy. Wounds International 3(4). Retrieved from
http://www.woundsinternational.com/product-reviews/pulsedradio-frequency-electromagnetic-field-pemf-therapy-as-anadjunct-wound-healing-therapy
Schwartz, A. (2012). Ozone therapy and its scientific foundations.
Revista Española de Ozonoterapia 2(1): 199-232. Retrieved from
http://www.xn--revistaespaoladeozonoterapia7xc.es/index.php/reo/article/view/27/30
U. S. Food and Drug Administration. (2014, Sep.). CFR-Code of
Federal Regulations Title 21. Retrieved from
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRsearc
h.cfm?fr=801.415
Sarabahi, S., Tiwari, V. K. (Eds.). (2012). Principles and practice
of wound care. New Dehli, India: Jaypee Brothers Medical
Publishers, Ltd.
European Wound Management Association. (EWMA). (2008).
Position document: Hard-to-heal wounds: A holistic approach.
London, UK: MEP, Ltd.
Wild, T., Rahbarnia, A., Kellner, M., Sobotka, L. (2010, May).
Basics in nutrition and wound healing. Nutrition 26: 862-866.
Wounds International. (2012). International consensus:
Optimising wellbeing in people living with a wound. An expert
working group review. London, UK: Wounds International
Wound Care Centers. (n.d.). Living with a wound: Psychological
considerations. Retrieved from
http://www.woundcarecenters.org/article/living-withwounds/living-with-a-wound-psychological-considerations
The Wound Healing Society. (2009). Chronic wound prevention
guidelines. Bethesda, MD: The Wound Healing Society
Vein Center of North Texas. (2012). About venous disease.
Retrieved from http://www.veincenternorthtexas.com/avd-calfmuscle-pump.html
Weiss, R. (2014, Oct.). Venous insufficiency. Retrieved from
http://emedicine.medscape.com/article/1085412-overview
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
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.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
68
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
63. World Health Organization. (2005). Wound management.
Retrieved from
http://www.who.int/surgery/publications/WoundManagement.pdf
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/postoperativeincision-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
66. Pudner, R. (Ed.). (2010). Nursing the surgical patient (3rd ed.).
New York, NY: Elsevier
67. Macmillan Cancer Support. (2013, Jan.). Fungating cancer
wounds (malignant wounds). Retrieved from
http://www.macmillan.org.uk/Cancerinformation/Livingwithandaft
ercancer/Symptomssideeffects/Othersymptomssideeffects/Fungati
ngwounds.aspx
68. Bergstrom, K. J. (2011). Assessment and management of
fungating wounds. Journal of Wound, Ostomy, and Continence
Nursing 38(1): 31-37
69. Winland-Brown, J. E., Allen, S. (2010, Jun.). Wound care: Foreign
bodies in the skin. The Nurse Practitioner: The American Journal
of Primary Healthcare 35(6): 43-47. Retrieved from
http://www.nursingcenter.com/lnc/static?pageid=1037067
70. Mudge, E., Orsted, H. (2010, May). Wound infection and pain
management. Wounds International 1(3): 1-6. Retrieved from
http://www.woundsinternational.com/pdf/content_8902.pdf
71. Kent Hospital. (2011). Hyperbaric oxygen therapy fact sheet.
Retrieved from http://www.kentri.org/woundcare/hyperbaricoxygen-therapy-facts.cfm
72. Bjork, R. (2013, Jan.). Bedside ankle-brachial index testing:
Time-saving tips. Retrieved from
http://woundcareadvisor.com/best-practices_abi_vol2_no1/
73. Wound, Ostomy, and Continence Nursing Certification Board
(WOCNCB). (n.d.). Wound, ostomy, and continence certification.
Retrieved from https://www.wocncb.org/certification/woundostomy-continence
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
69
74. American Board of Wound Management. (2015). How to apply:
CWCA, CWS, and CWSP. Retrieved from
http://www.abwmcertified.org/abwm-certified/how-to-apply/
75. Wound Source.com. (2014). Unna boots. Retrieved from
http://www.woundsource.com/product/unna-boots
76. Hartmann USA. (2013). Debridement procedure for wound
cleansing. Retrieved from
http://us.hartmann.info/Debridement_procedure_for_wound_clea
nsing.php
77. Rosenfield Injury Lawyers. (2014). Bedsore FAQ. Retrieved from
http://www.bedsorefaq.com/
78. Medline Plus. (2014, Jun.). How wounds heal. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/00
0741.htm
79. Cottonwood Podiatry. (2014). Charcot foot. Retrieved from
http://cottonwoodpodiatry.com/charcot-foot
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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