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September/October 2014 • Volume 3 • Number 5

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2 www.WoundCareAdvisor.com September/October 2014 • Volume 3, Number 5 • Wound Care Advisor

staffGroup Publisher

Gregory P. OsbornePublisher

Tyra LondonEditor-in-Chief

Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

Managing EditorCynthia Saver, RN, MS

EditorKathy E. Goldberg

Copy EditorKaren C. Comerford

Art DirectorDavid Beverage

Production ManagerRachel BargeronAccount ManagersSusan Schmidt Renee Artuso

PuBlished ByHealthCom Media

259 Veterans Lane, Doylestown, PA 18901Telephone: 215/489-7000Facsimile: 215/230-6931Chief Executive OfficerGregory P. Osborne

Executive Vice President, SalesBill MulderryWeb ProducerWinston PowellBusiness ManagerConnie Dougherty

Wound Care Advisor (ISSN 2168-4421) is published byHealthCom Media, 259 Veterans Lane, Doylestown, PA18901. Printed in the USA. Copyright © 2014 by Health-Com Media. All rights reserved. No part of this publica-tion may be reproduced, stored, or transmitted in anyform or by any means, electronic or mechanical, includ-ing photocopy, recording, or any information storageand retrieval system, without permission in writing fromthe copyright holder. Send communication to Health-Com Media, 259 Veterans Lane, Doyles town, PA 18901.

The opinions expressed in the editorial and advertis-ing material in this issue are those of the authorsand advertisers and do not necessarily reflect theopinions or recommendations of the National Al-liance of Wound Care and Ostomy®; the EditorialAdvisory Board members; or the Publisher, Editors,and the staff of Wound Care Advisor.

Editorial Mission: Wound Care Advisor providesmultidisciplinary wound care professionals withpractical, evidence-based information on theclinical management of wounds. As the officialjournal of the National Alliance of Wound Careand Ostomy®, we are dedicated to deliveringsuccinct insights and information that our read-ers can immediately apply in practice and useto advance their professional growth.

Wound Care Advisor is written by skin and woundcare experts and presented in a reader-friendly elec-tronic format. Clinical content is peer reviewed.

The publication attempts to select authors who areknowledgeable in their fields; however, it does notwarrant the expertise of any author, nor is it responsi-ble for any statements made by any author. Certainstatements about the use, dosage, efficacy, and charac-teristic of some drugs mentioned here reflect the opin-ions or investigational experience of the author. Anyprocedures, medications, or other courses of diagnosisor treatment discussed or suggested by authors shouldnot be used by clinicians without evaluations of theirpatients’ conditions and possible contraindications ordanger in use, review of any applicable manufacturer’sprescribing information, and comparison with the rec-ommendations of other authorities.

editor-in-chief

Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMSCo-Founder, Wound Care Education Institute

Lake Geneva, WI

editorial advisory Board

Nenette L. Brown, RN, PHN, MSN/FNP, WCCWound Care Program CoordinatorSheriff’s Medical Services Division

San Diego, CA

Debra Clair, PhD, APN, RN, WOCN, WCC, DWC Wound Care Provider

Alliance Community HospitalAlliance, OH

Kulbir Dhillon, NP, WCCWound Care SpecialistSkilled Wound CareSacramento, CA

Fred BergVice President, Marketing/Business DevelopmentNational Alliance of Wound Care and Ostomy

Glendale, WI

Catherine Jackson, RN, MSN, WCCClinical Nurse Manager

Inpatient and Outpatient Wound CareMacNeal Hospital

Berwyn, IL

Jeffrey Jensen, DPM, FACFASDean and Professor of Podiatric Medicine & Surgery

Barry University School of Podiatric MedicineMiami Shores, FL

Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, WCCDirector of Clinical Education

RecoverCare, LLCLouisville, KY

Jeff Kingery, RNVice President of Professional Development

RestorixHealthTarrytown NY

Jeri Lundgren, RN, BSN, PHN, CWS, CWCNVice President of Clinical Consulting

Joerns Charlotte, NC

Courtney Lyder, ND, GNP, FAAN Dean and Professor

UCLA School of NursingLos Angeles

Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMSCo-Founder, Wound Care Education Institute

Plainfield, IL

Steve Norton, CDT, CLT-LANACo-founder, Lymphedema & Wound Care Education, LLC

President, Lymphedema Products, LLCMatawan, NJ

Bill Richlen, PT, WCC, CWS, DWCOwner

Infinitus, LLCChippewa Falls, WI

Lu Ann Reed, RN, MSN, CRRN, RNC, LNHA, WCCAdjunct Clinical InstructorUniversity of Cincinnati

Cincinnati, OH

Stanley A. Rynkiewicz III, RN, MSN, WCC, DWC, CCSAdministrator

Deer Meadows Home Health and Support Services, LLCBHP Services

Philadelphia, PA

Cheryl Robillard, PT, WCC, CLTClinical SpecialistAegis TherapiesMilwaukee WI

Donald A. Wollheim, MD, WCC, DWC, FAPWCAOwner and Clinician, IMPLEXUS Wound Care Service, LLC

Watertown, WIInstructor, Wound Care Education Institute

Plainfield, IL

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CONTENTS


FEATURES 11 Guidelines for safe negative-pressure wound therapy By Ron Rock, MSN, RN, ACNS-BC Rule of thumb: Assess twice, dress once

36 How dietary protein intake promotes wound healing By Nancy Collins, PhD, RD, LD/N, FAPWCA, and Allison Schnitzer Careful assessment and adequate intake ensure patients’ protein needs are met.

43 Understanding stoma complications By Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, WCC, OMS; and Judith LaDonna Burns, LPN, WCC, DFC Learn how to identify and manage stoma hernias, trauma, mucocutaneous separation, necrosis, prolapse, retraction, and stenosis.

DEPARTMENTS 6 From the Editor Best of the best, the sequel

8 Clinical Notes Apple Bites 16,30 How to apply a spiral wrap • Understanding the crusting procedure • How to assess wound exudate • What you need to know about collagen wound dressings

19 Best Practices The DIME approach to peristomal skin care • It takes a village: Leading a wound team • Managing venous stasis ulcers

34 NAWCO News 40 Business Consult Becoming a wound care diplomat • How to set up an effective wound care formulary and guideline

48 Clinician Resources

51 2014 WilD ON WOUNDS ExhiBiTORS GUiDE Guide to the Wound Care Education Institute National Conference

September/October 2014 • Vol. 3, No. 5www.WoundCareAdvisor.com

Official journal of®

PRACTICAL ISSUES IN WOUND, SKIN, AND OSTOMY MANAGEMENT

Bestof theBest 2014

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Welcome to our second annual“Best of the Best” issue ofWound Care Advisor, the official

journal of the National Alliance of WoundCare and Ostomy (NAWCO). This may bethe first time you have held Wound CareAdvisor in your hands because normallywe come to you via the Internet. Using adigital format for this peer-reviewed jour-nal allows us to bring you practical infor-mation that you can access anytime, any-where and gives you the ability to accessvideos and other links to valuable re-sources for you and your patients. However, it’s still nice sometimes to hold

a print version of a journal, so last year westarted our “Best of the Best” issue, whichgives you a compendium of our most pop-ular articles to create a resource you canturn to again and again.If you are new to Wound Care Advisor,

this is an opportunity for you to experiencewhat you’ve been missing. If you are a reg-ular reader, this print edition gives you theopportunity to revisit some of our best arti-cles: We’ve chosen the ones readers haveviewed most frequently online over thepast 12 months. Within these pages you’ll find feature arti-

cles, best practices, step-by-step how-to’s,clinical resources, and news. Along withwound-related topics, such as how dietaryprotein improves wound healing and man-aging venous stasis ulcers, you’ll find avariety of other topics, ranging from safeuse of negative-pressure wound therapy tounderstanding stoma complications. You’llalso sharpen valuable skills you can apply

in practice by reading articles on how toapply a spiral wrap, understanding thecrusting procedure, how to assess woundexudate, and what you need to know aboutcollagen wound dressings. And, you’ll learnnonclinical skills that can make you a moreeffective clinician through a useful article onhow to become a wound care diplomate.Also included as part of this special edi-

tion is an exclusive directory of the 2014Wild on Wounds Exhibitors Guide. Wild onWounds (aka WOW) is an annual, multidis-ciplinary national wound conferencepresented by the Wound Care EducationInstitute. The exhibitor guide featuresnames, products, and contact informationfor many different manufacturers and com-panies that can offer solutions to assist incaring for your patients.In keeping with our digital format, this

compendium will also be available elec-tronically at our website, www.woundcareadvisor.com, where you’ll be able to down-load resources and access links to in struc -tional and informational videos, clinicalresources, and much more. Thanks to our readers, Wound Care

Advisor is already winging its way to itsthird anniversary. We appreciate your sup-port and thank you for your passion forwound, ostomy, and skin care.

Donna Sardina, RN, MHA, WCC, CWCMS,DWC, OMS

Editor-in-ChiefWound Care Advisor


From theEDiTOR

Best of the best, the sequel

http://www.woundcare.com

http://www.woundcare.com

http://recovercare.com

http://joerns.com

Wound photography maymotivate patients

Having patients view photographs of theirwounds can motivate them to becomemore involved in managing those wounds,according to a study in InternationalWound Journal, particularly when woundsare in difficult-to-see locations. In the wound care clinic where the

study took place, 86% of patients had dif-ficult-to-see wounds and only 20% moni-tored their wounds for healing progress,relying instead on clinicians. “Patient perception of wound photographyA”

notes that patients report a loss of autono-my when they can’t view their wound,81% said photographing the wound wouldhelp them track its progress, and 58% saidphotography would give them more in-volvement in their own care.

Lymphedema after surgery forendometrial cancer

The risk of developing lower-extremitylymphedema is 23% for women with en-dometrial cancer who undergo lym-phadenectomy compared with hysterecto-

my alone, with an overall prevalence of47%, according to “Lymphedema after surgeryfor endometrial cancer: Prevalence, risk factors,and quality of lifeB.”The study in Obstetrics and Gynecology,

which included 1,048 patients, also foundthat multiple quality-of-life scores wereworse in women who developed lower-extremity lymphedema.

Diabetic sensorimotorneuropathy may explainGI complaints

A study in the Journal of Diabetesand Its Complications concludesthat in patients with diabetes andsensorimotor neuropathy, there’s “substan-tial evidence of concomitant cutaneous,cardiac and visceral autonomic neu-ropathies.” The authors of the study addthat diabetic sensorimotor neuropathy canreduce quality of life and may explain thehigher prevalence of GI complaints. “Association between visceral, cardiac and

sensorimotor polyneuropathies in diabetes melli-tusC” studied 20 patients with sensorimotorneuropathy and diabetes and 16 healthycontrol subjects.

Growth factor therapy mayimprove healing time for partial-thickness burns

Topical application of growth factor (GF)therapy in patients with partial-thickness


ClinicalNOTES

http://www.sciencedirect.com/science/article/pii/S1056872713002754



http://www.ncbi.nlm.nih.gov/pubmed/25004343



http://onlinelibrary.wiley.com/doi/10.1111/iwj.12293/abstract

burns reduces healing time compared withstandard wound care alone, according to ananalysis in International Wound Journal. The authors of “Growth factor therapy in pa-

tients with partial-thickness burns: A systematicreview and meta-analysisD” analyzed 13 stud-ies comprising a total of 1,924 participantswith 2,130 wounds to evaluate the effectsof fibroblast growth factor (FGF), epider-mal growth factor (EGF), and granulocytemacrophage-colony stimulating factor onpartial-thickness burns. In addition to de-creased healing time, scar improvementwas noted with FGF and EGF.Patients who received GFs had no sig-

nificant increase in adverse events.

Factors associated with infectionin patients with extremitylymphedema

“Factors associated with reported infection andlymphedema symptoms among individuals withextremity lymphedemaE” found that the fol-lowing factors are associated with infec-tion: male gender, self-report of heavi-ness, and lower-extremity as opposed toupper-extremity involvement. Factors as-sociated with symptoms include infection,lower knowledge level of self-care, andpresence of secondary lower-extremitylymphedema. Factors associated with both infection

and symptoms include decreased annualhousehold income and decreased self-care, according to the survey of 1,837 par-ticipants, which was published in Rehabil-itation Nursing.

Fitzpatrick Skin TypeScale studied

“The Fitzpatrick Skin TypeScale: A reliability and validitystudy in women undergoing radi-ation therapy for breast cancerF,”in the Journal of Wound Care,found that only the Sun Exposure subscaleof the Fitzpatrick Skin Type Scale hasgood reliability and validity. Analysis for other subscales, Genetic

Disposition and Tanning Habits, found is-sues with both internal reliability and con-struct validity, yet the tool continues to beused in clinical practice.

Caffeine may hinder woundhealing

A study in International Wound Journalreports that caffeine, which has antioxi-dant properties, restricts cell proliferationof keratinocytes and delays cell migration,which may inhibit wound healing and ep-ithelialization. Both effects are dose de-pendent. The authors, who used primaryhuman keratinocytes, HaCaT cell line, and

Wound Care Advisor • September/October 2014 • Volume 3, Number 5 www.WoundCareAdvisor.com 9

http://www.journalofwoundcare.com/cgi-bin/go.pl/library/abstract.html?uid=105647










an ex vivo model of human skin for thestudy, noted that cell adhesion and differ-entiation weren’t affected. “The effects of caffeine on wound healingG”

concludes that the findings “are more insupport of a role for caffeine as adeno-sine-receptor antagonist that would negatethe effect of adenosine in promotingwound healing.”

Very low-carb, low saturated fatdiet improves glycemic controland may reduce CVD risk inpatients with diabetes

“A very low carbohydrate, low saturated fat diet fortype 2 diabetes management: A randomized trialH,”which compared this diet to a high–unrefined carbohydrate, low-fat diet, foundthat both diets resulted in “substantial” im-provements for several clinical glycemiccontrol and cardiovascular disease (CVD)risk markers, but the very low-carbohydratediet resulted in greater benefit. The authors of the study, which includ-

ed 93 obese adults and was published inDiabetes Care, also reported that reduc-tions in glycemic variability andantiglycemic medication requirementswere greatest with the very low-carbohy-drate diet. Both diets were hypocaloric.

Purse-string technique afterileostomy closure

“Systematic review and meta-analysis of pub-lished randomized controlled trials comparing

purse-string vs conventional linear closure of thewound following ileostomy (stoma) closureI”concludes that purse-string closure is asso-ciated with a reduced risk of surgical-siteinfection without affecting duration of theoperation and length of hospital stay. The authors of the study in Gastroen-

terology Report analyzed three randomized,controlled trials for a total of 105 patientsin the purse-string closure group and 101patients in the conventional closure group.

Cost effectiveness of NPWT

“Evaluation of wound care and health-care use costsin patients with diabetic foot ulcers treated withnegative pressure wound therapy (NPWT) versus ad-vanced moist wound therapy (AMWT)J” found thatNPWT was more cost effective than AMWTin patients with “recalcitrant” wounds thatdidn’t close during a 12-week period. The study, published in the Journal of

the American Podiatric Medical Associa-tion, included 169 patients who receivedNPWT and 166 who received AMWT. Theresearchers concluded that the lower ex-penditures on procedures and use ofhealthcare resources accounted for thelower costs associated with NPWT. n

Online ResourcesA. http://onlinelibrary.wiley.com/doi/10.1111/iwj.12293/abstract

B. http://www.ncbi.nlm.nih.gov/pubmed/25004343

C. http://www.sciencedirect.com/science/article/pii/S1056872713002754

D. http://onlinelibrary.wiley.com/doi/10.1111/iwj.12313/abstract

E. http://www.ncbi.nlm.nih.gov/pubmed/25042377

F. http://www.journalofwoundcare.com/cgi-bin/go.pl/library/abstract.html?uid=105647

G. http://onlinelibrary.wiley.com/doi/10.1111/iwj.12327/abstract

H. http://care.diabetesjournals.org/content/early/2014/07/29/dc14-0845.abstract

I. http://www.ncbi.nlm.nih.gov/pubmed/25011379

J. http://www.ncbi.nlm.nih.gov/pubmed/24725034










http://care.diabetesjournals.org/content/early/2014/07/29/dc14-0845.abstract

http://care.diabetesjournals.org/content/early/2014/07/29/dc14-0845.abstract



Since its introduction almost 20years ago, negative-pressurewound therapy (NPWT) has be-come a leading technology in the

care and management of acute, chronic,dehisced, traumatic wounds; pressure ul-cers; diabetic ulcers; orthopedic trauma;skin flaps; and grafts. NPWT applies con-trolled suction to a wound using a suctionpump that delivers intermittent, continu-ous, or variable negative pressure evenlythrough a wound filler (foam or gauze).Drainage tubing adheres to an occlusivetransparent dressing; drainage is removedthrough the tubing into a collection canis-ter. NWPT increases local vascularity andoxygenation of the wound bed and re-duces edema by removing wound fluid,exudate, and bacteria. Every day, countless healthcare

providers apply NPWT devices during pa-tient care. More than 25 FDA Class II ap-proved NPWT devices are available com-mercially. If used safely in conjunctionwith a comprehensive wound treatmentprogram, NPWT supports wound healing.But improper use may cause harm to pa-tients. (See Risk factors and contraindica-tions for NPWT.) Lawsuits involving NPWT are increas-

ing. The chance of error rises when inex-perienced caregivers use NPWT. Simplyapplying an NPWT dressing without criti-cally thinking your way through theprocess or understanding contraindica-tions for and potential complications ofNPWT may put your patients at risk and

increase your exposure to litigation. Proper patient selection, appropriate

dressing material, correct device settings,frequent patient monitoring, and closelymanaged care help minimize risks. So be-fore you flip the switch to initiate NPWT,read on to learn how you can use NPWTsafely.

Understand the equipment and its useConsult your facility’s NPWT protocols,policies, and procedures. If your facilitylacks these, consult the device manufactur-er’s guidelines and review NPWT indica-tions, contraindications, and how to recog-nize and manage potential complications.Ideally, facilities should establish trainingprograms to evaluate clinicians’ skills. En-hanced training should include compre-hension of training materials, troubleshoot-

Guidelines for safe negative-pressure wound therapy Rule of thumb: Assess twice, dress once By Ron Rock, MSN, RN, ACNS-BC


ing, and correct operation of the device, asshown by return demonstration of the spe-cific NPWT device used in the facility.

Assess the patient thoroughly The prescribing provider is responsible forensuring patients are assessed thoroughlyto confirm they’re appropriate NPWT can-didates. Aspects to consider include co-morbidities, contraindicated wound types,high-risk conditions, bleeding disorders,nutritional status, medications that prolongbleeding, and relevant laboratory values.The pain management plan also should beevaluated and addressed.

Assess the orderBefore NPWT begins, make sure you

have a proper written order. The ordershould specify:• wound filling material (foam or gauzedressing and any wound adjunct, suchas a protective nonadherent, petrolatum,or silver dressing)

• negative pressure setting (from -20 to -200 mm Hg)

• therapy setting (continuous, intermittent,or variable)

• frequency of dressing changes.

Follow all parts of the order as pre-scribed. Otherwise, you may be held re-sponsible if a complication arises—for ex-ample, if you apply a nonadherentdressing when none is ordered and thisdressing becomes retained, requiring sur-

Since 2007, the Food and DrugAdministration (FDA) has re-ceived 12 reports of death and174 reports of injury related di-rectly to negative-pressurewound therapy (NPWT). Thedeaths occurred in patients’homes and long-term care fa-cilities. The most serious com-plications were bleeding andinfection. Patients taking anti-coagulants and those who hadvascular grafts or infectedwounds were most at risk. In32 of the injuries, dressingshad adhered to tissue and foamwas embedded or retained inthe wound; most of these pa-tients had to be readmitted forsurgical removal of foam, man-agement of dehisced wounds,and antibiotic therapy. Infectionfrom the original wound or re-tained foam was reported in 27additional injury cases.

These reports compelled theFDA in 2011 to recommend thatclinicians use extreme carewhen prescribing NPWT. The

agency stressed that cliniciansshould know that NPWT is con-traindicated for specific woundtypes and should thoroughlyconsider all patient risk factorsbefore prescribing it. OnceNPWT has been applied, clini-cians must assess and monitorthe patient in an appropriatesetting. Monitoring frequencydepends on the patient’s condi-tion, wound status, wound lo-cation, and comorbidities. Mostimportantly, clinicians must bevigilant in checking for poten-tially life-threatening complica-tions and be prepared to re-spond appropriately.

The Pennsylvania PatientSafety Authority reported 419adverse events linked to NPWTbetween January 2008 and December 2009. Assessmentand monitoring deficiencies accounted for nearly half; de-layed or incorrect dressing application accounted for an-other 21%.Contraindications

Contraindications for NPWT in-clude:

• inadequately debridedwounds

• necrotic tissue with eschar

• untreated osteomyelitis

• cancer in the wound

• untreated coagulopathy

• nonenteric and unexploredfistulas

• exposed vital organs.

Patient risk factorsFactors that increase the risk ofharm from NPWT include:

• increased risk for bleedingand hemorrhage

• anticoagulant or platelet ag-gregation inhibitor therapy

• friable or infected blood ves-sels

• spinal cord injury

• enteric fistulas.

Risk factors and contraindications for NPWT

View: FDA information on NPWT adverse eventsA

http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm244211.htm






gery for removal; or if you set a defaultpressure when none is ordered and thepatient suffers severe bleeding or fistulaformation as a result.

Assess the woundIf you know what your patient’s woundneeds, you can take proactive measures.What is the wound “telling” you? Withadept assessment, you can become a“wound whisperer”—a clinician who under-stands wound-healing dynamics and caninterpret what the wound is “saying.” Thisallows you to see the wound as a wholerather than just maintaining it as a “hole.”• If the wound tells you it’s too wet, takesteps to absorb fluid or consider increas-ing negative pressure, as ordered.

• If it’s telling you it’s dry, consider de-creasing negative pressure, as ordered.If the wound bed remains dry, youmight want to take a NPWT “time out”.Apply a moisture dressing for severaldays and assess the patient’s hydrationstatus before restarting NPWT.

• If the wound says it’s moist, maintainthe negative pressure.

• If it tells you it’s infected, treat the infection.

• If it tells you it’s dirty, debride it.• If it says it’s malnourished, feed it.

The DIM approachTo establish a baseline evaluation, devel-op a systematic approach for assessing the wound before NPWT. This will helpoptimize wound-bed preparation, enhanceNPWT efficacy, and prevent delayedwound healing. (See Assessing with DIM.)

Take a time-outBefore you apply the NPWT dressing, bea STAR—Stop, Think, Act, and Reviewyour action. This time-out allows you tocritically think your way through the ap-plication process and consider potentialconsequences of your actions.

Ongoing patient assessment andmonitoring Follow these guidelines to help ensuresafe and effective NPWT:• Follow the device manufacturer’s in-structions and your facility’s NPWT pro-

To assess your patient’swound, use the acronym DIM—Debridement, Infection and In-flammation control, and Mois-ture balance.

Debridement. This procedurereestablishes a viable woundbase with a functional extracel-lular matrix. Necrotic or devital-ized tissue harbors bacteria andcells, which impede woundhealing. It also prevents NPWTfrom being distributed equallyacross the wound bed, whichreduces NPWT efficacy and pre-vents effective exudate re-moval. In wound beds withmore than 20% nonviable tissue

consider debridement (surgical,mechanical, enzymatic, chemi-cal, or autolytic) before initialNPWT application. The debride-ment method will vary depend-ing on the patient’s condition.

Infection and inflammationcontrol. Infection and inflam-mation delay wound healing.Antimicrobial (silver) dressingsare effective in localized infec-tions and inflamed wounds dueto their anti-inflammatory ef-fects. Wound debridement alsoreduces bacterial burden, in-cluding biofilm. NPWT then canremove surface wound fluid–containing contaminants.

Moisture balance. Moisturebalance allows cells within thewound to function effectively.If the wound is too moist,wound edges may becomemacerated, turning white. Onthe other hand, too little mois-ture may inhibit cellulargrowth and promote escharformation. NPWT helps pre-serve a moist environment andreduces edema, contributing toimproved tissue perfusion. In-cremental increases or de-creases in negative pressuremay be needed to ensure amoist wound environment.

Assessing with DIM






tocol, policy, and procedures.• Identify and eliminate factors that canimpede wound healing (poor nutritionalstatus, limited oxygen supply, poor cir-culation, diabetes, smoking, obesity, for-eign bodies, infection, and low bloodcounts).

• Evaluate the patient’s nutritional statusto ensure protein stores are adequate forhealing.

• Assess and manage the patient’s painaccordingly.

• Protect the periwound from direct con-tact with foam or gauze.

• Prevent stretching or pulling of the trans-parent drape to secure the seal andavoid shear trauma to surrounding tissue.

• Prevent stripping of fragile skin by mini-mizing shear forces from repetitive orforceful removal of transparent drapes.

• Use protective barriers, such as multi-ple layers of nonadherent or petrola-tum gauze, to protect sutured bloodvessels or organs near areas beingtreated with NPWT.

• Don’t overpack the wound too tightlywith foam. Compressing the foam pre-vents negative pressure from reachingthe wound bed, causing exudate to ac-cumulate.

• Position drainage tubing to avoid bonyprominences, skinfolds, creases, and

weight-bearing surfaces. Otherwise, adrainage tubing related pressure woundmay develop.

• Bridge posterior wounds to the lateralor anterior surface to minimize drainagetubing related pressure wounds to thesurrounding tissue.

• Count and document all pieces of foam,gauze, or adjunctive materials on theouter dressing and in the medicalrecord, to help prevent retention of ma-terials in the wound.

• Ensure the foam is collapsed and theNPWT device is maintaining the pre-scribed therapy and pressure at the timeof initial patient assessment and whenrounding.

• Address and resolve alarm issues. If youcan’t resolve these issues and the deviceneeds to be turned off, don’t let it stayoff more than 2 hours. While the deviceis off, apply a moist-to-dry dressing.

• With a heavily colonized or infectedwound, consider changing the dressingevery 12 to 24 hours.

• Monitor the patient frequently for signsand symptoms of complications.

Evaluate patient comprehensionof teaching A proactive approach to education canease the patient’s anxiety about NPWT.Unfamiliar sounds and alarms may height-en anxiety and cause unwarranted con-cerns, so inform patients in advance thatthe device may make noise and causesome discomfort. An educated and em-powered patient can participate activelyin treatment. Improved communicationmay enhance outcomes and help identifyerrors in technique before they causecomplications. Be prepared to answer patients’ ques-

tions, which may include: • Am I using the device correctly?• How long will I have to use it?• What serious complications could occur?• What should I do if a complication oc-

Don’t overpack the

wound too tightly with

foam. Compressing the

foam prevents negative

pressure from reaching

the wound bed.


curs? Whom should I contact?• How do I recognize bleeding?• How do I recognize a serious infection?• How do I tell if the wound’s conditionis worsening?

• Do I need to stop taking aspirin or oth-er medicines that affect my bleedingsystem or platelet function? What arethe possible risks of stopping or avoid-ing these medicines?

• Can you give me written patient instruc-tions or tell me where I can find them?

Be a STARTo avoid patient harm and potential litiga-tion, be a STAR and a wound whisperer. Ifyou’re in doubt about potential complica-tions of NPWT or how to assess and moni-tor patients, stop the therapy and seek ex-pert guidance. “Listen” to the wound andassess your patient. This may take a littletime, but remember—monitoring NPWT,the wound, and the patient is an ongoingprocess. You can’t rush it. Sometimes, togo fast, you need to go slowly.

Access more information about NPWTC. n

Selected referencesAgency for Healthcare Research and Quality. Tech-nology Assessment: Negative Pressure Wound Thera-py Devices. Original: May 26, 2009; corrected No-vember 12, 2009. Available online at: www.ahrq.gov/research/findings/ta/negative-pressure-wound-therapy/negative-pressure-wound-therapy.pdf. Accessed January 30, 2014.

Daeschlein G. Antimicrobial and antiseptic strate-gies in wound management. Int Wound J. 2013;10(Suppl 1):9-14.

Food and Drug Administration. Guidance for Indus-try and FDA Staff—Class II Special Controls Guid-ance Document: Non-powered Suction ApparatusDevice Intended for Negative Pressure WoundTherapy. November 10, 2010. Available at:www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm233275.htm.Accessed January 30, 2014.

Food and Drug Administration. FDA PreliminaryPublic Health Notification: Serious ComplicationsAssociated with Negative Pressure Wound TherapySystems. November 13, 2009. Available at: www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm190658.htm. AccessedJanuary 30, 2014.

FDA Safety Communication: UPDATE on SeriousComplications Associated with Negative PressureWound Therapy Systems. February 24, 2011. Availableat: /www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm244211.htm. Accessed January 30, 2014.

Fife CE, Yankowsky KW, Ayello EA, et al. Legal issues in the care of pressure ulcer patients: key con-cepts for healthcare providers—a consensus paperfrom the International Expert Wound Care AdvisoryPanel©. Adv Skin Wound Care. 2010;23(11):493-507.

Improving the Safety of Negative-Pressure WoundTherapy. Pa Patient Saf Advis. 2011;8(1):18-25.Available at: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/mar8(1)/Pages/18.aspx. Accessed January 29, 2014.

Krasner D. Why is litigation related to negativepressure wound therapy (NPWT) on the rise?Wound Source. Posted November 11, 2010. Avail-able at: www.woundsource.com/article/why-litigation-related-negative-pressure-wound-therapy-npwt-rise. Accessed January 30, 2014.

Lansdown AB. A pharmacological and toxicological pro -file of silver as an antimicrobial agent in medical de-vices. Adv Pharmacol Sci. 2010; Article ID 910686. Avail -able at: www.hindawi.com/journals/aps/2010/910686/

Lipsky BA, Hoey C. Topical antimicrobial therapyfor treating chronic wounds. Clin Infect Dis. 2009;49(10):1541-9.

Sibbald RG, Goodman L, Woo KY, et al. Specialconsiderations in wound bed preparation 2011: Anupdate©. Adv Skin Wound Care. 2011;24(9):415–36.

Sibbald RG, Woo KY, Ayello EA. Clinical PracticeReport Card: A Survey of Wound Care Practices inthe U.S.A. Ostomy Wound Manage. April 2009 Sup-pl:12-22.

Online resourcesA. http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm244211.htm

B. http://my.clevelandclinic.org/heart/disorders/vascular/negative-pressure-wound-therapy.aspx

C. http://onlinelibrary.wiley.com/doi/10.1111/iwj.2013.10.issue-s1/issuetoc

Ron Rock is the nurse manager and clinicalnurse specialist for the WOC nursing team inthe Digestive Disease Institute of the ClevelandClinic in Cleveland, Ohio.

View: Patient EducationB

http://my.clevelandclinic.org/heart/disorders/vascular/negative-pressure-wound-therapy.aspx


http://onlinelibrary.wiley.com/doi/10.1111/iwj.2013.10.issue-s1/issuetoc


How to apply aspiral wrap By Nancy Morgan, RN, BSN, MBA, WOC, WCC,DWC, OMS

Each issue, Apple Bites brings you a toolyou can apply in your daily practice.

DescriptionThe spiral wrap is a technique used forapplying compression bandaging.

ProcedureHere’s how to apply a spiral wrap to thelower leg. Please note that commercialcompression wraps come with specific in-structions for proper bandaging technique.Be sure to follow these instructions to pro-vide safe and effective compression.1 With the foot flexed at 90 degrees, startthe bandage at the center of the ball ofthe foot, with the lower edge of thebandage at the base of the toes.

2 Wrap either laterally or medially, usingtwo turns around the foot to anchor thebandage.

3 Once the bandage is secure, take itacross the foot towards the heel. Keepthe bandage low on the heel, just takingin a small area of the sole of the foot.

4 Complete the turn around the heel,coming back towards the foot.

5 Enclose the foot, sealing the gap at thebase of the heel.

6 Bring the bandage across the top of the

foot to the ankle.7 Complete the turn around the ankle.8 Stretch the bandage to 50% capacity

and wrap up the leg in a circular fash-ion, with each turn overlapping theprevious layer by 50%.

9 Avoid wrinkles and creases in the band-age as this may cause skin breakdownand uneven compression pressures.

10 Finish 1 inch below the knee.11 Upon reaching the knee, cut off any ex-

cess bandage and secure the bandagewith tape. Note: Do not wrap down theleg with any remaining bandage as thiswould result in a tourniquet effect,pushing the blood flow back toward the foot instead of toward the heart.

12 If another application of the wrap is desired, cut the bandage and beginreapplying from the base of the toes,moving up the leg as before. n

Online resourceA. http://www.youtube.com/watch?v=fTsrol9u1H8

AppleBiTESBiTES

Dose from WCEI


View: Spiral wrap applicationA

http://www.youtube.com/watch?v=fTsrol9u1H8



Understandingthe crustingprocedureBy Nancy Morgan, RN, BSN, MBA, WOC, WCC,DWC, OMS

The crusting procedure produces a dry surface and absorbs moisture from

broken skin through an artificial scabthat’s created by using skin barrier pow-der (stoma powder) and liquid polymerskin barrier. The crusting procedure ismost frequently used on denuded peris-tomal skin to create a dry surface foradherence of an ostomy pouching systemwhile protecting the peristomal skin fromeffluent and adhesives. Crusting canincrease pouching-system wear time,resulting in fewer pouch changes and lessdisruption to irritated peristomal skin. Thecrusting procedure can also be used forother denuded partial-thickness weepingwounds caused by moisture. Here’s an overview of the procedure.

Indications• Denuded or weeping peristomal skin• Need for absorption of moisture frombroken skin around the stoma

Contraindications• Allergy to products used to create theartificial scab

• Not indicated for prevention of skinproblems

Equipment• Skin barrier powder (antifungal pow-der may be substituted)

• Alcohol-free polymer skin barrierwipes or spray

• Clean 4" × 4" gauze pads or tissue fordusting excess powder

Steps1 Clean the peristomal skin with water(avoid soap) and pat the area dry.

2 Sprinkle skin barrier powder onto thedenuded skin.

3 Allow the powder to adhere to themoist skin.


4 Dust excess powder from the skin us-ing a gauze pad or soft tissue. Thepowder should stick only to the rawarea and should be removed from dry,intact skin.

5 Using a blotting or dabbing motion,apply the polymer skin barrier overthe powdered area, or lightly spray thearea if you’re using a polymer skinbarrier spray.

6 Allow the area to dry for a few sec-onds; a whitish crust will appear. Youcan test for dryness of the crust bygently brushing your finger over it; itshould feel rough but dry.

7 Repeat steps 2 through 6 two to fourtimes to achieve a crust.

8 You may apply a pouching systemover the crusted area.

9 Stop using the crusting procedurewhen the skin has healed and is nolonger moist to the touch.

10Watch a videoA of the crusting proce-dure. n

Selected referencesBryant RA, Rolstad BS. Management of drainingwounds and fistulas. In: Bryant RA, Nix DP, eds.Acute And Chronic Wounds: Current ManagementConcepts. 4th ed. St. Louis, Mo: Elsevier Mosby;2012:514-533.

Doughty D. Principles of ostomy man agement in theoncology patient. J Supportive Oncology.2005;3(1):59–69.

Online resourceA. https://www.youtube.com/watch?v=v83hWZDMpgE

Nancy Morgan, cofounder of the Wound CareEducation Institute, combines her expertise as aCertified Wound Care Nurse with an extensivebackground in wound care education and pro-gram development as a nurse entrepreneur.

Information in Apple Bites is courtesy of the WoundCare Education Institute (WCEI), copyright 2014.


http://www.elastogel.com

http://www.wcei.net/


https://www.youtube.com/watch?v=v83hWZDMpgE

The DIMEapproach toperistomal skincare By Catherine R. Ratliff, PhD, APRN-BC, CWOCN, CFCN

I t’s estimated that about 70% of the 1million ostomates in the United States

and Canada will experience or have ex-perienced stomal or peristomal complica-tions. Peristomal complications are morecommon, although stomal complications(for example, retraction, stenosis, and mu-cocutaneous separation) can often con-tribute to peristomal problems by makingit difficult to obtain a secure pouch seal.This article will help you differentiatetypes of peristomal complications, includ-ing how to prevent and manage them.

The basicsPeristomal (or parastomal) is the term usedto describe the skin around a stoma. In theimmediate postoperative period, the peris-tomal skin may be ecchymotic or erythe-matous as a result of trauma from the sur-gical creation of the stoma. However, afterthis immediate postoperative period, theperistomal skin should be free from erythe-ma, ulcerations, blisters, or rashes. To more easily remember and educate

others on the types of peristomal compli-cations, you can divide them into four ba-sic categories using the mnemonic DIME.D is disease-related complications, I is in-fection-related complications, M is me-chanical-related complications, and E isexposure of the peristomal skin to effluentor chemical preparations. Here’s a closerlook at each category.

D: Disease-relatedcomplicationsDisease-related peri-stomal complica-tions include peri-stomal varices,pyoderma gan-grenosum, andmucosal transplan-tation. Peristomalvarices (caputmedusae) are dilatedveins due to portal hypertension that oc-cur at the mucocutaneous junction on theperistomal skin. The peristomal skin ap-pears as a purplish blue discoloration and,as the name “caput medusae” suggests,the dilated veins are similar in appearanceto the snake-haired Medusa in Greekmythology. Peristomal varices are fre-quently associated with sclerosing cholan-gitis, liver cancer, and cirrhosis. Gentle pouch removal and peristomal

skin care are important since pulling andrubbing can increase the risk of traumatiz-ing the skin, with resultant bleeding. Two-piece systems are generally avoided sincethe flange can rub against the varices, in-creasing the chance of bleeding. Assessment of peristomal bleeding fol-

lowed by such management techniques asapplying pressure and cauterizing bleed-ing areas with silver nitrate can help con-


BestPRACTiCES

Peristomal varices (caput medusae)

trol this peristomal complication; themainstay of therapy is to treat the underly-ing systemic disease. Advise patients withportal hypertension that they are at in-creased risk for GI bleeding. If bleedingoccurs, patients should use conservativemeasures, such as applying cold com-presses and pressure to the peristomalarea. If bleeding persists after pressure hasbeen applied, patients should seek imme-diate medical attention. Pyoderma gangrenosum (PG) is a rare

inflammatory disease believed to start asone or more pustules that become in-durated and form painful full-thickness ulcers on the peristomal skin. The ulcersmay appear raised, with dusty red to pur-plish, irregularly shaped wound margins.Diseases associated with PG include ulcer-ative colitis and Crohn disease. Once thesystemic disease improves, PG usually im-proves as well. Peristomal management should include

decreasing peristomal inflammation withtopical preparations, such as steroids andabsorptive powders and dressings, toavoid effluent coming in contact with PGperistomal ulcers. Mucosal transplantation (also known

as seeding) occurs when intestinal mu-cosa is transplanted to the peristomal skinduring the formation of the stoma, usuallyby suturing the bowel to the epidermisinstead of the dermis. Mucosal transfor-mation may result in persistent mucus se-cretion and friable intestinal mucosa, andpatients may experience a burning sensa-tion when the mucosa comes in contactwith some adhesive ostomy products.Conservative management includes theuse of absorptive powders to maintain aneffective pouch seal. Other diseases that affect the peristomal

skin include malignancy, herpes virus in-fections, psoriasis, and pemphigus.

I: Infection-related complicationsInfection-related peristomal complica-tions include candidiasis and folliculitis.Peri stomal candidiasis is an overgrowthof Candida organisms, with Candida al-bicans being the most common. Expo-sure to urine or fecal effluent provides amoist environment, which promotes theovergrowth of Candida organisms. Thecondition starts as pustules, which areabraded during pouch changes. Patientsmay complain of burning and itching.Treatment is aimed at keeping the peris-tomal skin dry and applying antifungalpowder. Folliculitis in the peristomal area is an

inflammation of the hair follicles common-ly due to shaving of the peristomal skin;it’s usually caused by Staphylococcus au-reus. Prevention is key and involves clip-ping rather than shaving the skin, usingantibacterial soap to cleanse the peristom-al skin, gently removing the pouch, andusing adhesive pouch-removal products todecrease the pulling of peristomal skinhairs when the pouch is removed.

M: Mechanical-relatedcomplications Mechanical peristomal injuries can be re-lated to pressure, friction, and epidermalstripping caused by the pouching system


Candidiasis

being too tight and rubbing against theperistomal skin. Other possible causes in-clude traumatic removal of the pouchand too-aggressive cleansing of the peris-tomal skin during pouch changes. Theperistomal skin may be erythematous ordenuded or, in the case of pressure-relat-ed injuries, there may be a circumscribedulcer. Preventive measures include careful re-

moval of the pouch, with gentle cleansingof the peristomal skin, or the use of amore flexible pouch if the pouching sys-tem rubs against the peristomal skin. Once the injury has occurred, skin barri-

er powders may be applied over the de-nuded skin with a skin sealant. It’s impor-tant to reevaluate the pouching system toprevent mechanical injury from recurring.

E: Exposure of the peristomal skinto effluentExposure to effluent on the peristomalskin such as from an ileostomy can causethe skin to become erythematous in lessthan an hour, with skin breakdown in sev-eral hours. Urine can also cause problemsbecause of the irritating effects of alkalineurine containing ammonium phosphates.Pseudoverrucous wartlike lesions may ap-pear around urostomies that are chronical-ly exposed to urine effluent, leading tothickening of the epidermis. Use of chemical preparations (such as

cleansers, liquid skin barriers, soaps, and

adhesives) can also break down the peris-tomal skin. This type of skin breakdown isreferred to as an irritant contact dermati-tis; for example, if the soap used to cleanthe peristomal skin hadn’t been complete-ly removed before the ostomy pouch wasapplied, the peristomal skin at the next

pouch change may be erythematous dueto the soap residue irritating the peristom-al skin. Some ostomates may develop an allergic

contact dermatitis from hypersensitivity tocertain chemicals in the ostomy products.Patch testing to determine which product


Epidermal stripping Pseudoverrucous lesion

Irritant contact dermatitis

Allergic contact dermatitis

is causing the allergen, then discontinuingthe product, usually resolves the allergicdermatitis. Treatment of exposure problems is aimed

at finding the cause of the problem and es-tablishing a secure pouching system thatprotects the peristomal skin from contactwith the effluent or chemical preparation.

Be proactiveUnfortunately, many ostomates will expe-rience peristomal skin complications. Toproactively treat the signs of peristomalskin complications, clinicians and patientsmust be able to recognize them. Accu-rately describing the peristomal skin com-plication is important to determiningwhich treatment works best for the osto-mate and benchmarking treatment inter-

ventions that can be applied globally.Mnemonics such as DIME will help en-sure that complications are caught earlyand patients receive the treatment theyneed.

All images courtesy of the Wound, Ostomy andContinence Nurses SocietyTM Image Library.Reprinted with permission. n

Selected referenceGray M, Colwell JC, Doughty D, et al. Peristomalmoisture-associated damage in adults with fecal ostomies: a comprehensive review and consensus. J Wound Ostomy Continence Nurs. 40(4):389-399.

Catherine R. Ratliff is a clinical associate profes-sor of nursing and program director of theWound, Ostomy, and Continence Graduate Pro-gram at the University of Virginia School ofNursing in Charlottesville.


http://www.celleraterx.com

It takes a village:Leading a woundteam By Jennifer Oakley, BS, RN, WCC, DWC, OMS

I used to think I could do it alone. I tookthe wound care certification course,

passed the certification exam, and took allof my new knowledge—and my newWCC credential—back to the long-termcare facility where I worked. I was readyto change the world. It didn’t take me long to figure out that

I couldn’t change the complex world ofwound care alone. I needed a team ofspecialists who could manage my pa-tient’s troubles with nutrition, swallowing,activities of daily living, positioning, bodyimage issues, and many other areas thatrequired expertise I didn’t have. A team consists of a group of people

who are working together toward a com-mon goal. A team has members whoseskills complement each other. A success-ful team maximizes individuals’ strengthsand establishes a strong sense of mutualcommitment. That success begins with ef-fective leaders. Here are tips that willhelp you become one of those effectiveleaders.

Recruit the right players for yourteamAs wound care clinicians, we must alwaystreat the whole patient, not just the holein the patient. Treating the patient holisti-cally requires input from everyone on thehealthcare team or, in essence, the “vil-lage.” At a minimum, your village shouldinclude a certified wound care clinician,

physical therapist, occupational therapist,dietician, nurse manager, nurse aide, so-cial worker, speech language pathologist,minimum data set coordinator or utiliza-tion review specialist, the director of nurs-ing for the facility, the patient’s prescriberand, of course, the patient.

Understand leadership characteristics Good leaders believe in themselves andare “authentic.” Authentic leaders under-stand themselves and their strengths andweaknesses. They are honest, act with integrity, and can articulate the vision orgoal of the team to its members. Effectiveleaders embrace the future and let go of the past; they understand that change


TAKE ACTION: Take a quiz to see how authentic a leader you are A.

http://www.jblearning.com/samples/0763749761/ClarkAssessmentChecklist.pdf

http://www.jblearning.com/samples/0763749761/ClarkAssessmentChecklist.pdf

is an essential part of health care today.Leaders see possibilities, not just prob-lems, and are able to communicate clearly. Leaders depend on the goodwill of

their team to get things done (rather thanauthority from the top down), use theword “We” instead of “I,” ask for action,and say, “Lets go do this together.” Lead-ers use their influence, supported by evidence-based practice, to change minds,

shape opinions, and move others to act.Whether you focus on preventing pres-

sure ulcers, developing product formula-ries, or implementing ankle-brachial indextesting, you’ll find that combining a posi-tive attitude with best practices and beingauthentic will help you lead the team inachieving its goals.

Keep the team motivated Keeping your team motivated can be dif-ficult. How do you inspire people everyday? Most facilities don’t have the budgetfor raises or bonuses; in reality, otherways are more effective for helping your

team keep their workplace passion. Here are some ideas to get you started.

Offer positive praise for a job well done,say “thank you,” give awards and certifi-cates, catch members “doing the rightthing” and post their pictures on bulletinboards, celebrate success with parties, orhost a break-time brunch or pizza partylunch. The goal is to foster an environ-ment that rewards positivity rather thanone that focuses on negativity. Remember that knowledge is power, so

if you educate your team, amazing thingswill happen. Members will be able notonly to identify when there is a problembut also solve that problem on their ownwithout intervention from management,creating pride in a job well done. We are social creatures, so get out from

behind your desk and be “present” on theunit or in the clinic. Team members ap-preciate a leader who is visible and will-ing to answer questions. Take time to get to know your staff

and team members on a personal level,too. What we do for a living is muchmore than just a job for most of us. Ifyou ask me to tell you about myself, Iwould start by saying, “I’m a wound carenurse”; many of us associate a large partof our identity with our careers. Whenyou help your staff find camaraderie inteamwork and pride in the job they do,it’s a win-win for all involved and pro-motes successful outcomes.

Plan how to manage conflict As the leader, you will have to interactwith all types of personalities on yourteam and maximize their strengths whileminimizing their weakness. Keep in mindthat few teams run smoothly all the time.Challenges the team might encounter in-


Remember that

knowledge ispower, so if you

educate your team,

amazing things

will happen.

clude a lack of trust among members,passivity, lack of commitment or account-ability, members who make excuses orcling to the past, negative attitudes, fearof conflict, and actual conflict. You will need to address potential and

actual conflicts to ensure the team’s suc-cess. Two strategies are compromising,where each party gives in a little bit tomeet in the middle, and collaborating,where each party works together tocome up with a solution. These methodsfoster teamwork and better working rela-tionships. Whichever strategy you use, be sure

you have all the facts, that everyone’semotions are in check, and that the tim-ing is appropriate for discussing the con-flict. Use effective communication, makeeye contact, be sure your body languageis “open,” use “I feel” statements andopen-ended questions, and thank eachparty when finished. Addressing—andsolving—problems quickly will put yourteam back on track to the real problem athand: healing those wounds!

Reap the benefitsAn effective team leader chooses theright team members, understands leader-ship characteristics, encourages and moti-vates each team member, and addressesconflicts appropriately. If you accomplishall this, your reward will likely be betterpatient outcomes and personal satisfac-tion from working with your village ofprofessionals. n

Online resourceA. http://www.jblearning.com/samples/0763749761/ClarkAssessmentChecklist.pdf

Jennifer Oakley is a clinical instructor for theWound Care Education Institute in Plainfield, Ill.

Managing venousstasis ulcers Compression therapy,local wound care,dressings, antibiotics,surgery, and adjunctivemethods play a role inmanagement.By Kulbir Dhillon, MSN, FNP, APNP, WCC

Venous disease, which encompassesall conditions caused by or related

to diseased or abnormal veins, affectsabout 15% of adults. When mild, it rarelyposes a problem, but as it worsens, it canbecome crippling and chronic.Chronic venous disease often is over-

looked by primary and cardiovascularcare providers, who underestimate itsmagnitude and impact. Chronic venousinsufficiency (CVI) causes hypertensionin the venous system of the legs, leadingto various pathologies that involve pain,swelling, edema, skin changes, stasis der-matitis, and ulcers. An estimated 1% ofthe U.S. population suffers from venous


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stasis ulcers (VSUs). Causes of VSUs in-clude inflammatory processes resulting inleukocyte activation, endothelial damage,platelet aggregation, and intracellularedema. Preventing VSUs is the most im-portant aspect of CVI management. Treatments for VSUs include compres-

sion therapy, local wound care (includingdebridement), dressings, topical or sys-temic antibiotics for infected wounds,other pharmacologic agents, surgery, andadjunctive therapy. Clinicians should beable to recognize early CVI manifesta-tions and choose specific treatmentsbased on disease severity and the pa-tient’s anatomic and pathophysiologicfeatures. Management starts with a fullhistory, physical examination, and risk-factor identification. Wound care clini-cians should individualize therapy as ap-propriate to manage signs and symptoms.

Compression therapy Treatment focuses on preventing new ulcers, controlling edema, and reducingvenous hypertension through compres-sion therapy. Compression therapy helpsprevent reflux, decreases release of in-flammatory cytokines, and reduces fluidleakage from capillaries, thereby control-ling lower extremity edema and VSU re-currence. Goals of compression therapyare to reduce symptoms, prevent second-ary complications, and slow disease progression. In patients with severe cellulitis, com-

pression therapy is delayed while infec-tion is treated. Contraindications forcompression therapy include heart fail-ure, recent deep vein thrombosis (DVT),unstable medical status, and risk factorsthat can cause complications of com-pression therapy. Ultrasound screening

should be done to rule out recent DVT.Arterial disease must be ruled out bymeasuring the ankle-brachial index (ABI).Compression is contraindicated if signifi-cant arterial disease is present, becausethis condition may cause necrosis or ne-cessitate amputation.High compression levels should be

used only if the patient’s ABI ranges from0.6 to 1.0. With an ABI between 0.9 and1.25, the patient likely can tolerate treat-ment with four-layer compression or along-stretch compression wrap. For pa-tients with an ABI between 0.75 and 0.9,use single-layer compression with castpadding and a Coban wrap in a spiral formation. Keep in mind that use of a compres-

sion wrap depends on the patient’s com-fort level and degree of leg edema. Inpatients who have mixed venous and ar-terial insufficiency with an ABI between0.5 and 0.8, monitor for complications ofarterial disease. Don’t apply sustainedhigh levels of compression in patients


Compression stockings should exert a pressureof at least 20 to 30 mm Hg at the ankle to be ef-fective. Antiembolism stockings exert a pres-sure of 8 to 10 mm Hg at the ankle, makingthem inadequate and not recommended fortreating venous insufficiency. Use of graduatedcompression stockings varies with patient fac-tors, including signs and symptoms. For latex-sensitive patients, compression stockings with-out elastic are available.

Description of pressure mm Hg (range)

Very light 7 to 15

Low 16 to 20

Moderate 20 to 30

High 30 and higher

Comparing compression levels

with ABIs below 0.5. (See Comparingcompression levels.)

Pneumatic compression The benefits of intermittent pneumaticcompression are less clear than those ofstandard continuous compression. Pneu-matic compression generally is reservedfor patients who can’t tolerate continuouscompression.

Local wound care Wound debridement is essential in treat-

ing chronic VSUs. Removing necrotic tissue and bacterial burden through de-bridement enhances wound healing.Types of debridement include sharp (using a curette or scissors), enzymatic,mechanical, biologic (for instance, usinglarvae), and autolytic. Maintenance de-bridement helps stimulate conversion ofa chronic static wound to an acute heal-ing wound.

Dressings Dressings are used under compressionbandages to promote healing, control ex-udate, improve patient comfort, and pre-vent the wound from adhering to thebandage. Vacuum-assisted wound-closuretherapy can be used with compressionbandages. A wide range of dressings are avail-

able, including: • hydrofiber dressings• acetic acid dressings• silver-impregnated dressings, whichhave become more useful than topicalsilver sulfadiazine in treating VSUs

• calcium alginate dressings• proteolytic enzyme agents• synthetic occlusive dressings• extracellular matrix dressing• bioengineered skin substitutes. Severalhuman-skin equivalents created fromhuman epidermal keratinocytes, humandermal fibroblasts, and connective tis-sue proteins are available for VSUtreatment. These grafts are applied inoutpatient settings.

Antibiotics Common in patients with VSUs, bacterialcolonization and infection contribute topoor wound healing. Oral antibiotics arerecommended only in cases of suspected


Besides antibiotics, pharmacologic agents usedto treat venous stasis ulcers (VSUs) include thefollowing:

• Pentoxifylline is a useful adjunct to compres-sion bandaging and may be effective evenwithout compression. It works by reducingplatelet aggregation and thrombus forma-tion. The drug also can be used as mono -therapy in patients who can’t tolerate com-pression bandaging. However, it’s not thepreferred treatment for VSUs.

• Calcium-channel blockers, such as diltiazem,nifedipine, and verapamil, are particularly effective against large-vessel stiffness andvenous hypertension.

• Aspirin combined with compression therapyspeeds ulcer healing and reduces ulcer size,compared to compression therapy alone.Adding aspirin therapy to compression band-aging generally is recommended in patientswith VSUs, unless contraindicated.

• Dermatologic topical corticosteroids, suchas triamcinolone, fluocinolone, and be-tamethasone, may reduce erythema, inflam-mation, pruritus, and vesicle formation.

Be aware that oral zinc, a trace metal, has potential anti-inflammatory effects. But recentstudies found it has no benefit in treating VSUs.Also, diuretics may be prescribed for patientswith other medical conditions that exacerbatelower-extremity edema (such as heart failure).

Other drugs used to treat VSUs

wound-bed infection and cellulitis. I.V.antibiotics are indicated for patients withone or more of the following signs andsymptoms of infection:• increased erythema of surrounding skin• increased pain, local heat, tenderness,and leg swelling

• rapid increase in wound size • lymphangitis • fever.

Progressive signs and symptoms of in-fection associated with fever and othertoxicity symptoms warrant broad-spectrumI.V. antibiotics. Suspected osteo myelitis re-quires an evaluation for arterial diseaseand consideration of oral or I.V. antibioticsto treat the underlying infection.

Other pharmacologic agents A wide range of other drugs also can beused to treat VSUs. (See Other drugsused to treat VSUs.)

Surgery Surgery can reduce venous reflux, hastenhealing, and prevent ulcer recurrence.Surgical options for treatment of venousinsufficiency include saphenous-vein ab-lation, interruption of perforating veinswith subfascial endoscopic surgery, andtreatment of iliac-vein obstruction withstenting and removal of incompetent su-perficial veins by phlebectomy, stripping,sclerotherapy, or laser therapy. Patients should be evaluated early for

possible surgery. An algorithm based ona review of literature indicates that pa-tients whose wounds don’t close at 4weeks are unlikely to achieve completewound healing and may benefit from sur-gery or other therapy. To help determine if surgery may be

warranted, assess venous reflux using du-plex ultrasonography, which can revealCVI, assess physiologic dysfunction, andidentify abnormal venous dilation. Con-sider a vascular consult for surgical man-agement of patients with superficial ve-nous reflux disease or perforator refluxdisease. Surgery aims to correct valve incompe-

tence leading to increased intraluminalpressures. (Venous valve injury or dys-function may contribute to CVI develop-ment and progression.) Surgical recon-struction of deep vein valves may beoffered to selected patients with ad-vanced severe and disabling CVI whohave recurrent VSUs. The literature shows that surgical vein

stripping isn’t superior to medical man-agement. Endovenous laser ablation(EVLA), a minimally invasive procedure,yields greater benefits than vein strippingand other types of surgery.

Skin grafting Skin grafting may be done in patientswith large or refractory venous ulcers. Itmay involve an autograft (skin or cellstaken from another site on the same pa-tient), an allograft (skin or cells takenfrom another person), or artificial skin (ahuman skin equivalent). Skin graftinggenerally isn’t effective if the patient has


Adequate skin care with emollients or barrierpreparations (such as petroleum jelly or zinc oxide cream, ointment, or paste) helps avoidskin irritation and maintain intact skin. Teach pa-tients to apply moisturizer to the affected skinonce or twice daily. However, caution them notto use lanolin-based moisturizers. Be aware thatstasis dermatitis, an intense manifestation of ad-vanced chronic venous insufficiency (CVI), cancause blistering and skin irritation with oozing.

Skin care for CVI patients

persistent edema (common with venousinsufficiency) unless the underlying ve-nous disease is addressed.

Adjunctive therapies Adjunctive therapies, such as ultrasound,pulsed electromagnetic fields, and electri-cal stimulation, can aid in treating VSUsthat fail to close despite good conventionalwound care and compression therapy.

Patient education Be sure to teach patients with VSUs abouttreatment and prevention to promote suc-cessful management. Advise them to:• elevate their legs above heart level for30 minutes three to four times daily(unless medically contraindicated), to minimize edema and reduce intra -abdominal pressure. Increased intra -abdominal pressure in severely and morbidly obese patients can increaseiliofemoral venous pressure, whichtransmits via incompetent femoralveins, causing venous stasis in thelegs.

• perform leg exercises regularly toimprove calf muscle function

• use graduated compression stockingsas ordered to prevent dilation of lower-extremity veins, pain, and a heavysensation in the legs that typicallyworsen as the day progresses

• minimize stationary standing as muchas possible

• treat dry skin, itching, and eczematouschanges with moisturizers and topicalcorticosteroids as prescribed. (See Skincare for CVI patients.)

Also help patients identify risk factorsfor CVI (such as smoking and over-weight), which can affect management.

Teach them about therapeutic compres-sion stockings, including their use, bene-fits, and care instructions. Remind them to wear stockings every day toprevent venous edema and VSU recur-rence. Finally, urge them to adhere tothe plan of care and get regular follow-up care. n

Selected referencesAbbade LP, Lastória S. Venous ulcer: epidemiology,physiopathology, diagnosis and treatment. Int J Dermatol. 2005;44(6):449–56.

Alguire PC, Mathes BM. Medical management oflower extremity chronic venous disease. Availabe at:www.uptodate.com/contents/medical-management-of-lower-extremity-chronic-venous-disease. Accessed December 4, 2013.

Baranoski S, Ayello EA. Wound Care Essentials:Practice Principles. 2nd ed. Philadelphia, Pa: Lip-pincott Williams & Wilkins; 2007.

Bryant R, Nix D. Acute and Chronic Wounds: Cur-rent Management Concepts. 4th ed. St. Louis, Mo:Mosby; 2011.

Habif TB. Clinical Dermatology: Expert Consult. 5thed. St. Louis, Mo: Mosby; 2009.

Kimmel HM, Robin AL. An evidence-based algo-rithm for treating venous leg ulcers utilizing theCochrane Database of Systematic Reviews. Wounds.2013:25(9);242-50.

Kistner RL, Shafritz R, Stark KR, et al. Emergingtreatment options for venous ulceration in today’swound care practice. Ostomy Wound Manage.2010;56(4):1-11.

O’Meara S, Al-Kurdi D, Ologun Y, et al. Antibioticsand antiseptics for venous leg ulcers. CochraneDatabase Syst Rev. 2010;(1):CD003557.

Patel NP, Labropoulos N, Pappas PJ. Current man-agement of venous ulceration. Plast Reconstr Surg.2006;117(7 Suppl):254S-60S.

Wollina U, Abdel-Naser MB, Mani R. A review ofthe microcirculation in skin in patients with chronicvenous insufficiency: the problem and the evidenceavailable for therapeutic options. Int J Low ExtremWounds. 2006:5(3);169-80.

Kulbir Dhillon is a wound care nurse practition-er at Mercy Medical Group, Dignity Health Med-ical Foundation in Sacramento, California.



How to assesswound exudate By Nancy Morgan, RN, BSN, MBA, WOC, WCC,DWC, OMS

Each issue, Apple Bites brings you a toolyou can apply in your daily practice.

Exudate (drainage), a liquid produced bythe body in response to tissue damage, ispresent in wounds as they heal. It con-sists of fluid that has leaked out of bloodvessels and closely resembles blood plas-ma. Exudate can result also from condi-tions that cause edema, such as inflam-mation, immobility, limb dependence,and venous and lymphatic insufficiency. Accurate assessment of exudate is im-

portant throughout the healing processbecause the color, consistency, odor, andamount change as a result of variousphysiologic processes and underlyingcomplications. Consistent terminology is crucial to en-

sure accurate communication among cli-nicians. Here are terms you should keepin mind when observing the wound anddocumenting your findings.

Type • Serous—thin,clear, wateryplasma, seenin partial-thicknesswounds and

venous ulcera tion. A mod er ate to heavyamount may indicate heavy bio-burdenor chronicity from a subclinical infec-tion. Serous exudate in the acute in-flammatory stage is normal.

• Sangui neous—bloody drain -age (freshbleeding)seen in deeppartial-thick-ness and full-thickness wounds during angiogenesis.A small amount is normal in the acuteinflammatory stage.

• Serosangui -neous—thin,watery, palered to pinkplasma withred bloodcells. Smallamounts may be seen in the acute in-flammatory or acute proliferative heal-ing phases.

• Purulent—thick, opaquedrainage thatis tan, yellow,green, orbrown. Puru-lent exudateis never normal and is often associatedwith infection or high bacteria levels.

Amount • None—Wound tissues are dry.• Scant—Wound tissues are moist, but

AppleBiTESBiTES

Dose from WCEI

there is no measurable drainage. • Small/minimal—Wound tissues are verymoist or wet; the drainage covers lessthan 25% of the dressing.

• Moderate—Wound tissues are wet; thedrainage involves more than 25% to 75%of the dressing.

• Large or copious—Wound tissues arefilled with fluid that involves more than75% of the dressing.

Consistency • Low viscosity—thin, runny• High viscosity—thick or sticky; doesn’tflow easily

Odor • No odor noted • Strong, foul, pungent, fecal, musty, orsweet

Use the following terms to describe thecondition of primary and secondarywound dressings:• Dry—The primary dressing is unmarkedby exudate; the dressing may adhere tothe wound.

• Moist—Small amounts of exudate are vis-ible when the dressing is removed; theprimary dressing may be lightly marked.

• Saturated—The primary dressing is wetand strikethrough occurs.

• Leaking—The dressings are saturated, andexudate is leaking from primary and sec-ondary dressings onto the patient’s clothes.

A useful resource to help you withyour assessment is the Bates-Jensen WoundAssessment ToolA. n

Online resourceA. http://www.geronet.med.ucla.edu/centers/borun/modules/Pressure_ulcer_prevention/puBWAT.pdf

What you need toknow aboutcollagen wounddressings By Nancy Morgan, RN, BSN, MBA, WOC, WCC,DWC, OMS

DescriptionCollagen, the protein thatgives the skin its tensilestrength, plays a key rolein each phase of wound healing. Itattracts cells, such as fibroblasts and ker-atinocytes, to the wound, which encour-ages debridement, angiogenesis, and reep-ithelialization. In addition, collagenprovides a natural scaffold or substrate fornew tissue growth. Collagen dressings stimulate new tissue

growth and encourage the depositionand organization of newlyformed collagen fibers andgranulation tissue in the woundbed. These dressings chemicallybind to matrix metalloproteinases(MMPs) found in the extracellularfluid of wounds. MMPs normally attackand break down collagen, soit’s thought that wound dress-ings containing collagen giveMMPs an alternative collagensource, leaving the body’snatural collagen available fornormal wound healing.

CA EG


C

http://www.geronet.med.ucla.edu/centers/borun/modules/Pressure_ulcer_prevention/puBWAT.pdf

http://www.geronet.med.ucla.edu/centers/borun/modules/Pressure_ulcer_prevention/puBWAT.pdf

IndicationsExamples of wounds that may benefitfrom a collagen dressing include:• partial- and full-thickness wounds • wounds with minimal to heavy exudate• skin grafts and skin donation sites• second-degree burns• granulating or necrotic wounds• chronic nonhealing wounds (to jump-start wounds that are stalled in the in-flammatory phase by reducing media-tors of inflammation).

ContraindicationsDon’t use collagen dressings in the follow-ing circumstances:• third-degree burns• patient sensitivity to bovine (cattle),porcine (swine), or avian (bird) products

• wounds covered in dry eschar.

How to applySome collagen products will require a sec-ondary cover dressing. Application tech-nique varies based upon manufacturerrecommendations.

Frequency of dressing changesThe frequency of dressing changes varies

depending on the brand, but ranges fromdaily to every 7 days.

Formulations A variety of topical formulations of col-lagen are available, such as freeze-driedsheets, pastes, pads, powder, and gels.Some dressings include alginates or evenantimicrobial additives. The collagensource varies—bovine, porcine, or avian.

Examples BGC Matrix®; BIOSTEPu Collagen Matrix;Catrix® Wound Dressing; CellerateRX® Gelor Powder; ColActive® Plus; Excellagen®;FIBRACOL® Plus; Promogran Prisma® Ma-trix; Puracol® Plus; Stimulen™ CollagenGel, Lotion, Powder, or Sheets; Triple He-lix Collagen Dressing The HCPCS (Healthcare Common Pro-

cedure Coding System) codes for collagendressings are A6021-A6024. n

Nancy Morgan, cofounder of the Wound CareEducation Institute, combines her expertise as aCertified Wound Care Nurse with an extensivebackground in wound care education and pro-gram development as a nurse entrepreneur.

Information in Apple Bites is courtesy of the WoundCare Education Institute (WCEI), copyright 2014.


Collagen provides a naturalscaffold or substrate

for new tissuegrowth.

Collagen, theprotein that gives the

skin its tensilestrength, plays a keyrole in each phase of

wound healing.



http://vaculta.com


NAWCONEWSWhy I became a certified DWC®

I obtained Diabetic Wound Certification(DWC) in February 2014. In addition toWCC® and OMS certifications that I currentlyhold, I felt this was an important next stepin advancing my knowledge of wound careand treatment options. Diabetes is becoming more prevalent.

Currently, 246 million people in the worldhave diabetes, and by 2030, it is expectedthat 438 million will have the disease. OfAmericans, 8.3% have diabetes and 27% donot even know they have the disease.As the number of patients with diabetes

increases, so does the number of patientswith diabetes-related wounds. One in everysix people in the United States who has dia-betes will develop a wound, and a stagger-ing 85% of those will go on to require am-putation. Of those amputations, the vastmajority could have been prevented withproper wound care and treatment. The numbers are eye opening, and the

drain on the healthcare system and insur-ance industry is great. Having a chronicnonhealing diabetic wound is life alteringfor a patient and his or her family. Preven-tion of the wound is best and includesproper education on diet, pressure relief,checking feet daily, weight management,maintaining a healthy blood glucose level,regular checkups with the appropriate careprovider, and shoes custom-molded to thepatient’s irregularly shaped foot. If a woundshould develop, knowledge of how to besttreat this wound is paramount in preventingan amputation and lifelong disability. Insummary, diabetic lesions require special-ized care.As healthcare professionals with a passion

for healing, we are responsible for knowingthe latest information. Not only are we edu-

cating patients and familiesbut on many occasions weare also educating physi-cians, physician assistants,and nurse practitionerswho order wound care.Substandard care still hap-pens too often and is not acceptable.I encourage everyone who has the privi-

lege of being a certified wound care clini-cian to consider the DWC program. You willgain valuable knowledge in the preventionand care of diabetic wounds, and will be anasset to your patients, coworkers, communi-ty, and the wound care world. You will alsohave the backing and strength of the Na-tional Alliance of Wound Care and Ostomy.I am proud to represent them.

— Janie Hollenbach, RN, WCC, OMS,DWC, DAPWCA, FACCWS,

Wound and Ostomy Nurse Consultant, West Penn Allegheny Health Network

NAWCO Certifications

WCC® Wound Care Certified When considering wound care certification,choose the credential that aligns best withyour lifestyle. The WCC certification is thenumber one wound care credential in theUnited States. There are thousands of multi-discipline WCC clinicians making a differ-ence in the lives of their patients and im-proving the quality of wound care every day. The WCC clinician provides direct patient

wound and skin care in acute-care, long-termcare, and home-care settings. The WCC clini-cian plays an important role as a direct careprovider, educator, and resource for optimum

patient outcomes in wound and skin caremanagement. The WCC clinician’s scope ofpractice is performed in accordance withscope of practice as determined by each re-spective professional state regulatory board.Learn more hereA.

DWC® Diabetic Wound Certified The role of the DWC clinician is based up-on expert evidence-based clinical knowl-edge and skills that are practiced in acute-care, outpatient, long-term care, andhome-care settings. The focus of the DWCclinician is on high-quality care to achieveoptimum patient outcomes and cost controlin diabetic wound management and preven-tion of complications. To ensure appropriateand thorough diabetic wound management,a holistic comprehensive approach is used.All factors affecting healing, including con-sideration of systemic, psychosocial, and lo-cal factors, are reviewed. Learn more hereB.

LLE® Lymphedema Lower Extremity Lymphedema lower-extremity, edema, andwound management is a specialized areathat focuses on overall skin care and pro-motion of an optimal wound environmentthrough reduction of edema and lymphede-ma. This therapeutic approach includes in-tensive rehabilitative interventions followedby education in self-care measures to pre-vent disease progression.Lymphedema lower-extremity and edema

management requires the skills of the inter-

disciplinary team, which includes the physi-cian, nurse, LLE-certified clinician, dietitian,physical therapist, occupational therapist,social worker, and other healthcare disci-plines or providers depending on each pa-tient assessment. Learn more hereC.

OMS Ostomy Management Specialist The National Alliance of Wound Care and Os-tomy is proud to offer the first multidiscipli-nary Ostomy Management Specialist (OMS)certification in the United States. We believeour thousands of WCCs and other certificantswho work with ostomy patients or are con-sidering ostomy as a career direction willgreatly benefit from the new OMS program.The role of the OMS clinician is based on ex-pert, evidence-based clinical knowledge andskills that are practiced in acute-care, outpa-tient, long-term care, and home-care settings. The focus of the OMS clinician is on

high-quality care to achieve optimum pa-tient outcomes and cost control in ostomymanagement and prevention of complica-tions. To ensure appropriate and thoroughostomy management, a holistic comprehen-sive approach is used. All factors affectinghealing, including considerations of sys-temic, psychosocial, and local factors, arereviewed. Learn more hereD. n

Online ResourcesA. http://www.nawccb.org/library/documents/Handbooks/CandidateHandbook%201.25.10-FINALPRINTER.pdf

B. http://www.nawccb.org/library/documents/Handbooks/DWC%20handbook%20MAIN%202012.pdf

C. http://www.nawccb.org/library/documents/Handbooks/LLE%20Candidate%20handbook.pdf

D. http://www.nawccb.org/library/documents/Handbooks/OMS%20Candidate%20handbook.pdf


http://www.nawccb.org/library/documents/Handbooks/OMS%20Candidate%20handbook.pdf

http://www.nawccb.org/library/documents/Handbooks/LLE%20Candidate%20handbook.pdf

http://www.nawccb.org/library/documents/Handbooks/DWC%20handbook%20MAIN%202012.pdf

http://www.nawccb.org/library/documents/Handbooks/CandidateHandbook%201.25.10-FINALPRINTER.pdf


Nutrition is a critical factor inthe wound healing process,with adequate protein intakeessential to the successful heal-

ing of a wound. Patients with both chronicand acute wounds, such as postsurgicalwounds or pressure ulcers, require an in-creased amount of protein to ensure com-plete and timely healing of their wounds. Elderly patients with wounds pose a

special challenge because of their de-creased lean body mass and the likelihoodof chronic illnesses and insufficient dietaryprotein intake. To promote a full recovery,wound care clinicians must address the in-creased protein needs of wound patients,especially elderly patients.

Understanding protein structureand function Protein comes from the Greek word pro-tos, which means “first” or “primary,” re-flecting the body’s fundamental need forthis nutrient. Amino acids, the basic con-stituents of protein, are required for manywide-ranging body functions. Proteinsfunction as enzymes for chemical reac-tions; hormones for chemical messaging;buffers to regulate acid-base balance; anti-bodies for the immune system; trans-porters, such as albumin, hemoglobin,transferrin, and retinol-binding protein, ofsubstances in the blood; and acute-phaseresponders that guide the body’s responseduring acute critical illness.

Proteins also play structural roles, as the contractile proteins actin and myosinfound in cardiac, skeletal, and smoothmuscle and as the fibrous proteins colla-gen, elastin, and keratin. During the prolif-erative phase of wound repair, collagendeposition is crucial to increase thewound’s tensile strength. Forty percent ofthe body’s protein occurs in skeletal mus-cle—the major component of lean bodymass, the metabolically active tissues ofthe body. Lean body mass declines withage and critical illness, significantly com-promising the body’s ability to carry out all the necessary functions of protein.

How dietary protein intake promotes wound healing Careful assessment and adequate intake ensure patients’ protein needs are met. By Nancy Collins, PhD, RD, LD/N, FAPWCA, and Allison Schnitzer


Amino acidsAll of the body’s 20 amino acids have thesame basic structure—a central carbon, atleast one amino group (-NH2), at least onecarboxylic acid group (-COOH), and a sidechain group that makes each amino acidunique and determines its functional rolein the body.

Sometimes classified by their proper-ties, such as net charge and polarity,amino acids commonly are classified as either essential (or indispensable) ornonessential (or dispensable). The nine essential amino acids are histi-

dine, isoleucine, leucine, lysine, methio -nine, phenylalanine, threonine, tryptophan,and valine. Because the body can’t synthe-size essential amino acids, it’s necessary toobtain them from the diet. The 11 remaining amino acids are

nonessential because the body can syn-thesize them using existing carbon skele-tons and free amino groups. However,some nonessential amino acids are con-sidered conditionally essential when aspecific condition prevents the body from synthesizing a particular amino acid, including genetic conditions, such asphenylketonuria, and immature organfunction during infancy and adulthood. In some individuals, demand for theseamino acids rises during times of meta-bolic stress (as when a patient has achronic wound) and the body’s produc-tion may not keep up with increased de-mands. Requirements for the nonessentialamino acids glutamine and arginine in-crease during wound healing, althoughspecific recommendations for dietary in-take amounts are not yet established. Glu-tamine acts as a precursor for nucleotidesynthesis, which is essential for rapidlyproliferating cells during wound healing.Arginine promotes wound healing by in-creasing collagen deposition and improv-ing both nitric oxide production and ni-trogen retention and immune function.

Assessing patients’ protein needs The recommended amount of 0.8 g pro-tein/kg body weight is based on the needsof healthy adults. Elderly patients may re-quire a higher baseline protein intake of 1 g/kg. However, many patients, includingthose with wounds, don’t fall into the“healthy adult” category and have evenhigher protein needs. It’s known that adequate protein is cru-

cial for proper wound healing, but the pre-cise amount isn’t established. Postsurgically,1 to 1.5 g protein/kg is recommended, butthis may vary with the extent of the surgical

wound. For patients with pressure ulcers,the recommendation is also 1 to 1.5 g/kg;those with deep ulcers or multiple pressure-ulcer sites may need 1.5 to 2 g/kg. For pa-tients with large burn wounds, protein re-quirements sometimes reach 1.5 to 3 g/kgto offset extensive protein loss throughurine and burn-wound exudate. When determining the protein needs of

a wound patient, it’s necessary to consideradditional factors, such as preexisting pro-tein-energy malnutrition, renal impairment,or other critical illnesses. The best strategyis to evaluate the patient as a whole anduse clinical judgment based on:• a physical examination for signs of catabolism

• a dietary history to determine typicalprotein intake

• a weight history to find out if unintend-ed weight loss has occurred

• laboratory values, such as serum albumin,to identify catabolism and inflammation.

It’s also necessary to consider the depth

it’s known that adequateprotein is crucial forproper wound healing.


and total body surface areas of the pa-tient’s wounds.

Helping patients meet their proteinneedsPatients who aren’t eating a well-balanceddiet probably aren’t consuming enoughprotein to heal their wounds. Gettingenough protein is particularly problematicin elderly patients for a variety of reasons—the higher cost of high-protein foods,strong food preferences and intolerances,difficulty chewing or swallowing fibrousfoods, and fear of consuming high-fat andhigh-cholesterol protein. Also, loneliness,fatigue, depression, polypharmacy, dentalproblems, and other problems can interferewith meal preparation and oral intake. To promote adequate protein intake, cli-

nicians should give patients flexibility intheir diet and encourage them to consumefoods they enjoy that are easy to prepareand economically feasible. A diet that’s toorestrictive may seem unappealing andcould lead to decreased intake and unin-tended weight loss. Keep in mind that ad-equate calories are also important forwound healing; otherwise, the body uses

protein calories to provide glucose for en-ergy production instead of tissue repair.

Complete vs. incomplete proteinsAnimal products are complete proteins be-cause they contain all the essential aminoacids. Whole eggs, with their full amino-acid profile, are the gold-standard proteinagainst which all other protein sources arecompared. Eggs generally are cheaper thanother high-protein foods, making them aconvenient and easy-to-prepare choice forelderly patients. Other complete proteinsinclude beef, poultry, fish, milk, cheese,and yogurt. Soy products are unique among plant

foods in that they’re complete proteinsources. Most plant proteins are consideredincomplete because they contain too littleof one or more of the essential aminoacids, which are termed the “limiting”amino acids. Combining foods with differ-ent limiting amino acids can improve thequality of plant protein sources, such ascombining grains with legumes or legumeswith seeds. It isn’t necessary to combine in-complete proteins at each meal, but it’s im-portant to eat them the same day at othermeals. (See Protein content of food groups.)

Strategies to boost protein intakeThe best way to increase protein intake isto treat your patients as individuals and findout what foods they would accept and pre-fer. Tips for increasing protein include:• adding diced meat to soups, salads, andcasseroles

• using milk powder in hot cereals,scrambled eggs, and mashed potatoes

• choosing desserts that contain eggs,such as sponge cake, custard, and breadpudding.

To consume the higher protein amountsneeded for wound healing, some patientsmay require supplementation. The mostcommon way to supplement protein is touse an oral nutritional supplement bever-

This table shows the amount of protein per serv-ing for each of the six food groups.

Protein source Protein content (g)

Meat, poultry, eggs, 7 gfish (1 oz)

Milk (8 fl oz) 8 g

Breads and starches* 3 g

Vegetables (½ C)* 0 to 2 g (legumes have highest content)

Fruits (½ C)* Trace amounts

Fats 0

*Incomplete protein

Protein content of food groups


age or protein module, such as proteinpowder or liquid protein. (See Comparisonof oral nutritional supplements.) When evaluating these products for

cost-effectiveness, keep in mind that8 fl oz of whole milk has 150 calories and8 g protein. Variety in supplementation iskey, because most patients tire quickly ofthe same supplement day after day. Manydifferent protein supplement products areavailable, including high-protein cookies,gelatins, and nutrition bars. Adding proteinpowder to soups, sauces, and milk shakesis an easy way to increase protein intake.Patient education that emphasizes the

importance of protein intake can help pa-tients achieve the highest level of dietarycompliance and the best clinical out-comes. n

Selected referencesChernoff R. Protein and older adults. J Am Coll Nutr.2004;23(6 suppl):627S-630S.

Escott-Stump S. Nutrition and Diagnosis-Related Care. 7thed. Baltimore, MD: Lippincott Williams & Wilkins; 2011.

Gropper SS, Smith JL. Advanced Nutrition and HumanMetabolism. 6th ed. Belmont, CA: Cengage Learning;2012.

Mahan LK, Escott-Stump S, Raymond JL. Krause’s Foodand the Nutrition Care Process. 13th ed. St Louis, MO: Elsevier Saunders; 2012.

Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Ther-apy & Pathophysiology. 2nd ed. Belmont, CA: CengageLearning; 2012.

Nancy Collins is founder and executive directorof Nutrition411.com and Wounds411.com, a con-sultant to healthcare facilities, and a medico -legal expert for law firms involved in healthcarelitigation. Allison Schnitzer is a dietetics studentat the University of Nevada, Las Vegas; she willsoon begin an internship.

This chart can help clinicians determine protein intake for patients using nutritional supplements, butthe product label always contains the most accurate information.

Supplement* Kilocalories Protein (g) Serving size

Boost® 240 10 8 fl oz

Boost® High Protein 240 15 8 fl oz

Boost Plus® 360 14 8 fl oz

Carnation® Breakfast Essentials™ Drink 250 14 10 fl oz

Ensure® 250 9 8 fl oz

Ensure Clear™ 180 10 9 fl oz

Ensure® High Protein 210 25 14 fl oz

Ensure® Muscle Health 250 13 8 fl oz

Ensure Plus® 350 13 8 fl oz

Pro-Stat® Sugar Free 90 15 30 mL

Pro-Stat® Sugar Free AWC 100 17 30 mL

*The information in this table was obtained from these product websites:• www.boost.com/nutritional-drinks/boost-original?gclid=COi9_uKDj7gCFegWMgodfWIA1Q• www.carnationbreakfastessentials.com• www.ensure.com• www.pro-stat.com

Comparison of oral nutritional supplements

http://wounds411.com

http://Nutrition411.com

Becoming awound carediplomat By Bill Richlen, PT, WCC, CWS, DWC, and DeniseStetter, PT, WCC, DCCT

The Rolling Stones may have said it bestwhen they sang, “You can’t always get

what you want,” a sentiment that also ap-plies to wound care. A common frustrationamong certified wound care clinicians isworking with other clinicians who havelimited current wound care education andknowledge. This situation worsens whenthese clinicians are making treatment rec-ommendations or writing treatment ordersnot based on current wound-healing princi-ples or standards of care. Frequently, these same clinicians seem

uninterested in listening to what you sayand aren’t receptive to treatment sugges-tions. This is where your skills of diploma-cy will make all the difference. Rarely is ita simple matter of sharing your expertiseto change a person’s mind. Lack of train-ing and knowledge of current best prac-tices may be part of the reason for resist-ance. “We’ve always done it that way” or“The rep told me” are common statementsyou might hear. Other factors include ego,self-image, politics, and the need to be incontrol. Sadly, human nature gets in theway more often than we think.Practicing our diplomacy skills will help

us bridge the gap between resistance andopenness to learning. Here’s what makesa good diplomat.

Communication skills The words you choose and your tone can

make a huge difference in how the infor-mation you give is received. Avoid using“you” in your statements because this gen-erally makes the other person feel defen-sive. Instead use “I” or “we” statementsbeginning with “I think” or “I feel.” Forexample, “Dr. Smith, I see that the treat-ment for Jane Doe is currently wet to dryb.i.d. When we assessed the wound to-day, we noted she had a fair amount ofdrainage and some slough. I think that anabsorptive dressing like an alginate wouldhandle the drainage better and help pro-mote debridement of the slough. It mightbe a better choice for Jane. Would youconsider trying that for a couple of weeksand see what happens?” When discussing opposing viewpoints,

work to get agreement on smaller or moregeneral issues before addressing the mainconcern: “Can we agree that using currentevidence-based practice is what’s best forMrs. Jones?”

Knowledge Be prepared to defend your position withevidence-based practices and, if necessary,provide resources to support your posi-tion. When clinicians refuse to listen oracknowledge facts, it can be a sign thattheir position is more about ego and pow-er than what’s right for the patient. Use open-ended questions to help create

dialogue and the sharing of ideas. Ques-tions such as, “Do you have experiencewith this product? What were your results?”or “This product may not be on your for-


BusinessCONSUlT

mulary, but if I got a sample, would youconsider trying it?” put you on a collegiallevel with the clinician. It becomes a col-laboration rather than a power struggle.When interacting with clinicians who aren’tcertified in wound care, it’s not a goodidea to play your “certification” trump card.This strategy only makes you appear arro-gant, causing the perception that you thinkyou’re superior to the other person, puttingyour colleague on the defensive and seri-ously compromising the potential for fur-ther debate and reaching a solution.

Emotional control We’re all passionate about caring for ourpatients, so it’s easy to take criticism andconflict personally. When emotions runhigh, logical thinking is impaired. We canlose grasp of our objectivity and say thingswe may regret, potentially underminingour integrity and damaging lines of com-munication. Consider scripting communica-tion points or responses to help maintainprofessionalism. Use such phrases as “Haveyou considered...”, “I know we both havethe patient’s best interest at heart…” or,when making a request, finishing with “…does that seem reasonable?”

Ability to compromise Compromise doesn’t mean compromisingon principles or standards of care. Howev-er, we may not get the exact treatment wewant. It’s the old saying, “You aim for theeagle, you bag the pheasant, and youdon’t eat crow.” We need to be creativeand think outside the box to offer treat-ment options that will promote healing asbest as possible and ultimately win theapproval of the person with whom we arecompromising. Sometimes we just have toaccept the lesser of two evils. Our willing-

ness to compromise can set the stage forfuture dialogue and less conflict.

Integrity Become an ambassador for wound care. Bethe same person in public as you are in pri-vate. Always promote best practice and notpersonal gain. It’s no surprise that news trav-els fast, especially bad news. If people figureout that you’re manipulative, dishonest, oregotistical, it won’t be long before your rep-utation will precede you and you’ll lose theconfidence of your colleagues. Perception isreality in the minds of others. How are yourepresenting wound care clinicians?

Sincere appreciation Kill them with kindness. Drawing battlelines and creating conflict over differingopinions doesn’t help our patients. We cancatch more flies with honey than vinegar.But no one wants to hear insincere flatteryor thank-you’s. Take the time to tell othershow much you appreciate their cooperation. In the end, we need to remember that

the patient has to be our focus. Our ownpersonal issues need to be put aside. It’snot ever about winning; it’s about doingwhat’s best for the patient. As the Rolling Stones sang, “You can’t

always get what you want, but if you trysometimes, well you might find, you getwhat you need.” n

Online resourceA. http://www.vitalsmarts.com/resource-center/newsletter/

Bill Richlen is CEO of Infinitus, LLC in Ferdi-nand, Indiana. Denise Stetter is area managerfor southern Indiana for Paragon Rehabilitationin Louisville, Kentucky.


Want to improve your communication skills?Sign up for the free Crucial Skills NewsletterA.

http://www.vitalsmarts.com/resource-center/newsletter/

http://www.vitalsmarts.com/resource-center/newsletter/

How to set up aneffective woundcare formularyand guideline By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN

Navigating through the thousands ofwound care products can be over-whelming and confusing. I suspect

that if you checked your supply roomsand treatment carts today, you would findstacks of unused products. You also wouldprobably find that many products werepast their expiration dates and that youhave duplicate products in the same cate-gory, but with different brand names.Many clinicians order a product by brandname, not realizing that plenty of theproduct is already in stock under a differ-ent brand name. A solution to this problem is to set up a

wound care formulary and guideline. Thisintervention can help clinicians becomecomfortable and clinically competent onwhat products to use when, which promotesbetter outcomes with less product waste.Setting up a wound care formulary can

seem overwhelming. It must be done tact-fully or your clinicians may not have “buyin” for the products you decide to use.Here are some tips that may help youstreamline the process. Keep in mind thatyou can involve staff to help you as youwork through these tips.

Review current suppliesStart the process by going through all yourcurrent supplies. Label bins with the cate-gory of the product, for example, calcium

alginate, hydrogel, and foams. Organizethe brand-name products within the samecategory by placing them into the appro-priate bin. As you check the supplies, putall expired products into an expired bin.You can always use them for teaching anddemonstration purposes.

Evaluate the productsEvaluate the products you have on handwith the appropriate clinicians to deter-mine which products have good perform-ance and outcomes within each category.You may want to work with your medical-supply distributor to obtain pricing on theproducts, especially if you have multiplebrand names within a category that per-form well.

Set up a guidelineOnce you determine what products you’lluse within each category, set up a guide-line on when and how to use them. Speci-fy that nurses should write the prescriber’sorder by category instead of brand name(for example, “apply adhesive foam dress-ing”) and have prescribers do the same.Then have the guideline indicate whichbrand-name product the clinician should


(continued on page 49)


A bout 1 million people in theUnited States have either tem-porary or permanent stomas.A stoma is created surgically

to divert fecal material or urine in pa-tients with GI or urinary tract diseases ordisorders. A stoma has no sensory nerve endings

and is insensitive to pain. Yet several com-plications can affect it, making accurate as-sessment crucial. These complications mayoccur during the immediate postoperativeperiod, within 30 days after surgery, or lat-er. Lifelong assessment by a healthcareprovider with knowledge of ostomy sur-geries and complications is important.Immediately after surgery, a healthy GI

stoma appears red, moist, and shiny. Ede-ma of the stoma is expected for the first 6to 8 weeks. A healthy urinary stoma ispale or pink, edematous, moist, and shiny.Usually, it shrinks to about one-third theinitial size after the first 6 to 8 weeks asedema subsides. The stoma warrants closeobservation as pouching types and sizesmay need to be changed during this time.Teach the patient and family caregivers toreport changes or signs and symptoms ofstoma complications to a healthcareprovider. If complications are recognizedearly, the problem may be resolved with-out surgical intervention. Stoma complications range from a sim-

ple, unsightly protrusion to conditions thatrequire emergency treatment and possiblesurgery. Clinicians must be able to recog-

nize complications and provide necessarytreatment and therapy early. Complicationsinclude parastomal hernias, stoma trauma,mucocutaneous separation, necrosis, pro-lapse, retraction, and stenosis. Althoughone complication can lead to and evenpromote others, all require attention andtreatment.

Parastomal herniaA parastomal hernia involves an ostomy inthe area where the stoma exits the abdom-inal cavity. The intestine or bowel extendsbeyond the abdominal cavity or abdominalmuscles; the area around the stoma ap-pears as a swelling or protuberance. Paras-tomal hernias are incisional hernias in thearea of the abdominal musculature thatwas incised to bring the intestine throughthe abdominal wall to form the stoma.They may completely surround the stoma(called circumferential hernias) or may in-

Understanding stoma complications Learn how to identify and manage stoma hernias, trauma, mucocutaneous separation, necrosis, prolapse, retraction, and stenosis. By Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, WCC, OMS; and Judith LaDonna Burns, LPN, WCC, DFC


vade only part of the stoma.Parastomal hernias can occur any time

after the surgical procedure but usuallyhappen within the first 2 years. Recur-rences are common if the hernia needs tobe repaired surgically. Risk factors may bepatient related or technical. Patient-relatedrisk factors include obesity, poor nutrition-al status at the time of surgery, presurgicalsteroid therapy, wound sepsis, and chroniccough. Risk factors related to technical is-sues include size of the surgical openingand whether surgery was done on anemergency or elective basis. Parastomal hernias occur in four types.

(See Types of parastomal hernias.) Initially,a parastomal hernia begins as an unsightlydistention in the area surrounding thestoma; the hernia enlarges, causing pain,discomfort, and pouching problems result-ing in peristomal skin complications thatrequire frequent assessment. Conservativetherapy is the usual initial treatment. Ad-justments to the pouching system typicallyare required so changes in the shape ofthe pouching surface can be accommodat-ed. Also, a hernia support binder or pouchsupport belt may be helpful. Avoid convexpouching systems; if this isn’t possible, usethese systems with extreme caution. If thepatient irrigates the colostomy, an ostomymanagement specialist should advise thepatient to discontinue irrigation until the

parastomal hernia resolves. Stoma traumaStoma trauma occurs when the stoma is in-jured, typically from a laceration. Lacera-tions usually result from the pouch appli-ance or clothing. Belt-line stomas areeasily traumatized and injury may occurfrom both clothing belts and pouch sup-port belts. Stoma lacerations commonly re-sult from a small opening in the flange ora misaligned pouch opening. Other causesinclude parastomal or stomal prolapse withpossible stoma enlargement or edema. Signs and symptoms of stoma trauma

include bright red bleeding, a visible cut,and a yellowish-white linear discol-oration. Lacerations may heal sponta-neously. If the culprit is the pouchingsystem, make sure nothing within thesystem comes in contact with the stoma.Usually direct pressure controls bleeding,but if bleeding continues, refer the pa-tient to a physician for treatment.

Mucocutaneous separationMucocutaneous separation occurs whenthe stoma separates from the skin at thejunction between the skin and the intestineused to form the stoma. Causes are relatedto poor wound-healing capacity, such asmalnutrition, steroid therapy, diabetes, in-fection, or radiation of the abdominal area.Tension or tautness of the suture line also

The four types of parastomal hernias are based onhernia location within the abdominal tissue:

• intestinal interstitial, in which the hernia lieswithin the layers of the abdominal wall

• subcutaneous, in which the hernia is containedwithin subcutaneous tissue

• intrastomal, in which the herniated intestinepenetrates the stoma (usually confined to anileostomy)

• peristomal, in which the hernia is located withina stoma that has prolapsed.

Types of parastomal hernias

The image shows stoma injury caused by a poorfitting appliance. Photo by Connie Johnson. Used with permission.


can cause mucocutaneous separation. This complication usually arises early

and can lead to other serious conditions,such as infection, peritonitis, and stomalstenosis. The area of the separation maycompletely surround the stoma (knownas a circumferential separation), or theseparation may affect only certain areasof the stoma/skin junction. The separa-tion may be superficial or deep.The first sign of mucocutaneous sepa-

ration may be induration. Treat the sepa-ration as a wound, and apply wound-healing principles: Absorb drainage,reduce dead space, use the proper dress-ing, and promote wound healing. Theproper dressing depends on wounddepth and amount of wound drainage.Be sure to assess the wound, using the“clock method” to describe location;measure the wound area in centimeters;and describe the type of tissue in thewound bed. Be aware that slough maybe present.Treatment of the wound dictates how

often the pouch is changed. A two-piecepouching system commonly is used to re-duce the number of pouch changes. Cov-er the wound dressing with the pouchingsystem unless the wound is infected. Ifinfection is present, let the wound draininto the pouch and heal by secondary in-tention. Don’t use a convex pouchingsystem, because this may cause addition-al injury to the mucocutaneous junction.

Stoma necrosis Blood flow and tissue perfusion are es-sential to stoma health. Deficient bloodflow causes stoma necrosis. A stomamay be affected by both arterial and venous blood compromise. The cause of necrosis usually relates to the surgicalprocedure, such as tension or too muchtrimming of the mesentery, or the vascu-lar system that provides blood flow tothe intestine. Other causes of vascularcompromise include hypovolemia, em-

bolus, and excessive edema. Stoma necrosis usually occurs within

the first 5 postoperative days. The stomaappears discolored rather than red,moist, and shiny. Discoloration may becyanotic, black, dark red, dusky bluishpurple, or brown. The stoma mucosa

This temporary ileostomy secondary to coloncancer has been treated for mucocutaneousseparation.

Closure of the temporary ileostomy. Photos by Connie Johnson. Used with permission.

Blood flow and

tissue perfusionare essential to

stoma health.


may be hard and dry or flaccid. Also, thestoma has a foul odor. Associated com-plications may include stoma retraction,mucocutaneous separation, stoma steno-sis, and peritonitis. Report signs and symptoms to the pri-

mary care provider immediately. Superfi-cial necrosis may resolve with necrotictissue simply sloughing away. But if tis-sue below the fascial level is involved,surgery is necessary. A transparent two-piece pouching system is recommendedfor frequent stoma assessment. Thepouch may need to be resized often.

Stoma prolapseA stoma prolapse occurs when the stomamoves or becomes displaced from itsproper position. The proximal segment ofthe bowel intussuscepts and slides throughthe orifice of the stoma, appearing to tele-scope. This occurs more often in looptransverse colostomies. A prolapsed stomaincreases in both length and size. Prolapse

may be associated with stoma retractionand parastomal hernias.

Causes of stoma prolapse includelarge abdominal-wall openings, inade-quate bowel fixation to the abdominalwall during surgery, increased abdominalpressure, lack of fascial support, obesity,pregnancy, and poor muscle tone. Unless the patient complains of pain,

has a circulatory problem, or has signsor symptoms of bowel obstruction, con-servative treatment is used for uncompli-cated stoma prolapse. The prolapse usu-ally can be reduced with the patient in asupine position. After reduction, apply-ing a hernia support binder often helps.Also, a stoma shield can be used to pro-tect the stoma. A prolapsed stoma mayrequire a larger pouch to accommodatethe larger stoma. Some clinicians usecold compresses and sprinkle table sug-ar on the stoma; the sugar provides os-motic therapy or causes a fluid shiftacross the stoma mucosa and reducesedema.

Stoma retractionThe best-formed stoma protrudes about2.5 cm, with the lumen located at thetop center or apex of the stoma to guidethe effluent flow directly into the pouch.In stoma retraction, the stoma has reced-ed about 0.5 cm below the skin surface.Retraction may be circumferential ormay occur in only one section of thestoma. The usual causes of stoma retraction

are tension of the intestine or obesity.Stoma retraction during the immediatepostoperative period relates to poorblood flow, obesity, poor nutritional sta-tus, stenosis, early removal of a support-ing device with loop stomas, stomaplacement in a deep skinfold, or thickabdominal walls. Late complications usu-ally result from weight gain or adhesions.Stoma retraction is most common in pa-tients with ileostomies.

Unless the patient

complains of pain, has

a circulatory problem,

or has signs or symptoms

of bowel obstruction,

conservative treatment

is used for uncomplicated

stomaprolapse.


A retracted stoma has a concave, bowl-shaped appearance. Retraction causes apoor pouching surface, leading to fre-quent peristomal skin complications. Typ-ical therapy is use of a convex pouchingsystem and a stoma belt. If obtaining apouch seal is a problem and the patienthas recurrent peristomal skin problemsfrom leakage, stoma revision should beconsidered.

Stoma stenosisStoma stenosis is narrowing or constric-tion of the stoma or its lumen. This con-dition may occur at the skin or fasciallevel of the stoma. Causes include hyper-plasia, adhesions, sepsis, radiation of theintestine before stoma surgery, local in-flammation, hyperkeratosis, and surgicaltechnique. Stoma stenosis frequently is associated

with Crohn’s disease. You may notice areduction or other change in effluentoutput with both urinary and GI os-tomies. With GI stoma stenosis, bowelobstruction frequently occurs; signs andsymptoms are abdominal cramps, diar-rhea, increased flatus, explosive stool,and narrow-caliber stool. The initial signis increased flatus. With urinary stomastenosis, signs and symptoms include decreased urinary output, flank pain,high residual urine in conduit, forcefulurine output, and recurrent urinary tractinfections.Partial or complete bowel obstruction

and stoma stenosis at the fascial level require surgical intervention. Conserva-tive therapy includes a low-residue diet,increased fluid intake, and correct use of stool softeners or laxatives forcolosto mies. Most stoma complications are prevent-

able and result from poor stoma place-ment. Up to 20% of patients with stomacomplications require surgical revision ofthe stoma. All patients with ostomies re-quire ongoing, accurate assessment and,

if needed, early intervention by trainedclinicians. n

Selected referencesAl-Niaimi F, Lyon CC. Primary adenocarcinoma inperistomal skin: a case study. Ostomy Wound Man-age. 2010;56(1):45-7.

Appleby SL. Role of the wound ostomy continencenurse in the home care setting: a patient case study.Home Healthc Nurse. 2011:29(3);169-77.

Black P. Managing physical postoperative stomacomplications. Br J Nurs. 2009:18(17):S4-10.

Burch J. Management of stoma complications. NursTimes. 2011;107(45):17-8, 20.

Butler DL. Early postoperative complications follow-ing ostomy surgery: a review. J Wound Ostomy Con-tinence Nurs. 2009:36(5):513-9.

Husain SG, Cataldo TE. Late stomal complications.Clin Colon Rectal Surg. 2008:21(1):31-40.

Jones T, Springfield T, Brudwick M, Ladd A. Fecalostomies: practical management for the home healthclinician. Home Healthc Nurse. 2011;29(5):306-17.

Kann BR. Early stomal complications. Clin ColonRectal Surg. 2008:21(1):23-30.

Nybaek H, Jemec GB. Skin problems in stoma patients.J Eur Acad Dermatol Venereol. 2010;24(3):249-57.

Shabbir J, Britton DC. Stomal complications: a litera-ture overview. Colorectal Dis. 2010;12(10):958-64.

Szymanski KM, St-Cyr D, Alam T, Kassouf W. Exter-nal stoma and peristomal complications followingradical cyctectomy and ileal conduit diversion: a sys-tematic review. Ostomy Wound Manage.2010;56(1):28-35.

Wound, Ostomy, Continence Clinical Practice Osto-my Subcommittee. Stoma Complications: Best Prac-tice for Clinicians. Mt. Laurel, NJ; 2007.

Rosalyn S. Jordan is the senior director of Clini-cal Services at RecoverCare, LLC, in Louisville,Kentucky. Judith LaDonna Burns is currentlypursuing a BSN and plans to gain certificationas an Ostomy Management Specialist.

Most stomacomplicationsare preventable.


ClinicianRESOURCES

Here are a variety of resources you mightwant to explore.

Considering opioid-prescribingpractices

Healthcare providers’ prescribing patternsfor opioids vary considerably by state, ac-cording to a report in Vital Signs from theCenters for Disease Control and Preven-tion (CDC). Here are some facts from thereport: • Each day, 46 people die from an over-dose of prescription painkillers in theUnited States.*

• Healthcare providers wrote 259 millionprescriptions for painkillers in 2012,enough for every American adult tohave a bottle of pills.

• Ten of the highest prescribing states forpainkillers are in the South.

Prescribing clinicians may want to con-sider their own patterns. Nonprescribingclinicians should be alert to possible inap-propriate prescribing and use of opioidsin their patients. Learn more at www.cdc.gov/vitalsigns and

read the full reportA.

Translating diabetes research

A good resource for you and your patientswith diabetes is “Diabetes Public Health Re-sourceB” from the CDC Division of Dia-betes Translation. The division translates diabetes research

into daily practice to help you and yourpatients understand the impact of the dis-ease, influence health outcomes, and im-prove access to quality health care. Topicsinclude:• Diabetes & me, which includes fre-quently asked questions and basic infor-mation

• Data & trends, which includes statisticsand surveillance data

• Publications, which includes fact sheetsand reports

• Education resources, which includes in-tervention tools

• News & resources, which includes dia-betes issues and conferences.

How to prevent pressure ulcers

Access “How-to Guide: Prevent Pressure UlcersC,”from the Institute for Healthcare Improve-ment.The guide describes key evidence-based

care components for preventing pressureulcers, discusses how to implement theseinterventions, and recommends measuresto assess improvement. You will need to create a free account

to access the guide. n

Online ResourcesA. www.cdc.gov/mmwr/preview/mmwrhtml/mm6326a2.htm?s_cid=mm6326a2_w

B. www.cdc.gov/diabetes/

C. www.ihi.org/resources/Pages/Tools/HowtoGuidePreventPres-sureUlcers.aspx

http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventPressureUlcers.aspx

http://www.cdc.gov/diabetes/

http://www.cdc.gov/diabetes/

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6326a2.htm?s_cid=mm6326a2_w


use in that category. This way, if you dochange the brand-name product withinthat category, you don’t have to obtain anew order.

Educate staffSchedule inservices for all licensed staff,physicians, nurse practitioners, and otherprescribers to explain the formulary andguideline. Hold a product fair on how to useand apply the various dressings, so cliniciansbecome familiar with the options and don’torder something not on formulary.

Establish an approval system forproducts not on formularyWork with your medical-supply distributorto set up an approval system if someone

tries to order a product not on formulary.The distributor should also be able to runreports for you of the products being or-dered so you can track them.

Achieving your goalsOnce you have your wound care productformulary and guideline up and running,you should see those piles of expired andunused products disappear and your cur-rent products used appropriately. Andyou’ll be on your way to achieving thegoal of providing good clinical outcomesin a cost-effective manner. n

Jeri Lundgren is director of clinical services atPathway Health in Minnesota. She has been specializing in wound prevention and manage-ment since 1990.

(continued from page 42)

Surfing the web?Check out

www.WoundCareAdvisor.com

• Access journal content...current and archival

• Peer-reviewed, clinical practicalresource for ALL nurses

• Give us your opinion• Sign up for our free e-newsletter

Check the site often for new wound careclinical information, news, and insightfrom authoritative experts.

Advantage Surgical & Wound Care provides superiorprofessional surgical wound care within the nursinghome, SNF, or long term care facility.

We provide treatment to those patients that havedifficulty traveling to a separate facility for wound care.

Surgical treatment that once required lengthy clinicappointments, expensive emergency transfers, or lossof patients to hospitalizations can now be easilyperformed at bedside, with minimal disturbance to thepatient’s daily activities, or the facility’s nursing staff.

www.advantagewoundcare.orgor call: 310-524-1300.

Providing superior bedsidesurgical wound care for

patients in long term health care facilities.

Wound Care Advisor invites you to consider submitting articles for publicationin the new voice for wound, skin, and ostomymanagement specialists.

as the official journal of wcc®s, dwc®s, llesms, and

omssms, the journal is dedicated to delivering

succinct insights and pertinent, up-to-date

information that multidisciplinary wound team

members can immediately apply in their practice

and use to advance their professional growth.

we are currently seeking submissions for these

departments:

• Best Practices, which includes case studies,

clinical tips from wound care specialists, and

other resources for clinical practice

• Business Consult, which is designed to help

wound care specialists manage their careers and

stay current in relevant healthcare issues that affect

skin and wound care.

if you’re considering writing for us, please click hereor visit www.woundcareadvisor.com to review our

author guidelines. the guidelines will help you

identify an appropriate topic and learn how to

prepare and submit your manuscript. following

these guidelines will increase the chance that we’ll

accept your manuscript for publication.

if you haven’t written before, please consider doing

so now. our editorial team will be happy to work

with you to develop your article so that your

colleagues can benefit from your experience.

for more information email the managing editor

at, [email protected].

A guide to diabeticfoot ulcersBy Donna Sardina, RN, MHA, WCC, CWCMS, DWCThis chart explains the differences among

ischemic, neuropathic, and neuroischemic

diabetic foot ulcers, making it easier for you

to select the best treatment for your patient. �

20www.WoundCareAdvisor.com

July/August 2012 • Issue 1, Number 2 • Wound Care Advisor

BestPRACTICES

Ischemic ulcersNeuropathic ulcers

Neuroischemic ulcers

Anatomiclocation• Between toes or tips of toes • Plantar metatarsal heads• Margins of foot, especially on

• Over phalangeal heads• Plantar heel

medial surface of first

• Borders or dorsal aspect of • Over plantar bony prominences metatarsophalangeal joint

feet

and deformities

• Over lateral aspect of fifth

• Areas subjected to weightmetatarsophalangeal joint

bearing on plantar surface• Tips of toes; beneath toenails

• Areas subjected to stress (eg,dorsal portion of hammer toes)

Woundcharacteristics• Deep, pale wound bed

• Red base, with healthy• Pale pink or yellow wound bed

• Even wound marginsgranular appearance

• Even wound margins

• Gangrene or necrosis• Even wound margins

• Rounded or oblong shape over

• Redness at borders of ulcer • Callus formation at bordersbony prominence

• Blanched or purpuricof ulcer

• Callus; may or may not be present

periwound tissue

• Painless, unless complicated • Painless, owing to neuropathy

• Severe painby infection

• Minimal exudate

• Cellulitis• Rounded or oblong shape

• Minimal exudateover bony prominence• Variable exudate

Associatedfindings• Thin, shiny, dry skin• Dry skin

• Thin, shiny, dry skin

• Absent or diminished pulses • Bounding pulses• Absent or diminished pulses

• TBPI < 0.7 mm Hg• TBPI ≥ 0.7 mm Hg

• TBPI < 0.7 mm Hg

• TcPO2 < 30 mmHg• TcPO2 > 30 mm Hg

• TcPO2 < 30 mm Hg

• Skin cool to touch, pale, or • Warm foot• Skin cool to touch, pale, or mottled

mottled

• Evidence of peripheral• Evidence of peripheral neuropathy

• No findings of peripheralneuropathy

• Hair loss on ankle and foot

neuropathy

• Atrophy of small muscles of feet • Thick dystrophic toenails

• Hair loss on ankle and foot • Distended dorsal foot veins • Pallor on elevation; dependent

• Thick dystrophic toenails• Cyanosis

rubor

• Pallor on elevation;dependent rubor• CyanosisSource: Wound Care Education Institute. TBPI = toe brachial pressure index; TcPO2 = transcutaneous oxygen pressure.

Differentiating diabetic foot ulcers

View: Diabetic foot exam

“But I left voicemessages anda note…”By Nancy J. Brent, MS, RN, JD

O ften nurses get named in a lawsuitwhen they are involved in clearlynegligent conduct that causes aninjury to or the death of a patient. Exam-ples include administering the wrong med-ication to the wrong patient or not posi-tioning a patient correctly in the operativesuite prior to surgery. Sometimes, howev-er, the negligent behavior of a nurse is notas clear to the nurse involved in the careof the patient.That was apparently the circumstance inthe reported case, Olsten Health Services,Inc v. Cody.1 In September 2000, Mr. Codywas the victim of a crime that resulted inparaplegia. He was admitted to a rehabili-tation center and discharged on November15, 2000. His physician ordered daily homehealth care services in order to monitor his“almost healed” Stage 2 decubitus pressuresore.2 The home health care agency as-signed a registered nurse (RN) to Mr. Codyand, after Mr. Cody’s health care insurancewould not approve daily visits, a reducedvisit plan was approved by Mr. Cody’sphysician.

A progressive problemOn November 16, 2000, the nurse visitedMr. Cody for the first time. During that visit,she did an admission assessment and notedthat the pressure sore, located at the areaof the tailbone, measured 5 cm by 0.4 cmwide and 0.2 cm deep. She believed thepressure ulcer could be completely healedwithin 3 weeks. The nurse called Mr.Cody’s physician and left him a voice mes-sage concerning her visit and her findings.On November 19, a second visit tookplace and the nurse observed and docu-mented that Mr. Cody’s pressure sore was“100%” pink and no odor was detected.On November 20, she attempted anoth-er visit but did not see Mr. Cody becausethe front gate surrounding his home waslocked. The nurse buzzed the gate door-bell several times to no avail. She left anote on the front gate for the Cody familyand left a voice message for Mr. Cody’sphysician.The next visit took place on November21. The pressure ulcer was now only “90%pink” and had a “fetid” odor; this condi-tion did not improve over the next 24hours. The nurse documented this fact inher nurses’ notes. Again, she left a voicemail message for the physician concerningthese findings.

BusinessCONSULT

32 www.WoundCareAdvisor.com July/August 2012 • Issue 1, Number 2 • Wound Care Advisor

Call for Manuscripts

http://woundcareadvisor.com/author-instructions/

NATIONAL CONFERENCERio Hotel, Las Vegas • September 17-20

20

14

WILD

ON

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HIB

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GU

IDE

EXHIBITORS GUIDE

™

Dear Colleagues,

We’re thrilled to have you at thisyear’s “WOW” WILD ON

WOUNDS℠ national conference!Being wound care clinicians

ourselves, we understand the chal-lenges you face at a time whenreimbursement policies require youto provide quality care with fewerresources. We designed WOW toenhance your knowledge andskills in skin, wound, and ostomycare, which will help you inovercoming these challenges andin providing your patients withthe quality care that theydeserve. We’re committed to bringing

you current standards of care,new prevention and treatmentideas, and tools to help you spread yourknowledge and to make a difference in your patients’ lives. One significant component of being current with wound care is being famil-

iar with new technologies and devices that heal wounds faster. Our exhibitorsare here to provide you with hands-on training and education about their prod-ucts so you can make a measurable impact on wound care outcomes.Wound Care Advisor created this useful Exhibitor Guide for you to carry with

you during exhibit times. We also suggest that you keep it in your wound carelibrary for future reference.We hope you enjoy this Exhibitor Guide and we’ll see you at the exhibitors’

showcase!

Nancy Morgan & Donna SardinaWound Care Education Institute


Wild on WoundsWElCOME

20

14

WIL

D O

N W

OU

ND

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™

Meet with exhibitors,learn about newproducts and have a chance to win agreat prize!

Exhibits are locatedin the Amazon Exhibit Hall of Rio Hotel.

Exhibit hours:Thursday, Sept. 1812:00 pm to 2:00 pm

Friday, Sept. 1912:00 pm to 2:00 pm

A Fashion Hayvin ............................... Registration area hall

Acelity (KCI, LifeCell,Systagenix) .................... 325

Advanced Tissue ............... 327Advantage Wound Care ... 210Amerx Health Care Corporation (Amerigel).. 313

Anacapa Technologies, Inc. ................................ 129

Angelini Pharma, Inc. ....... 310Argentum Medical, LLC(Silverlon) ...................... 311

BSN Medical ...................... 127Calmoseptine, Inc. ............ 411CellerateRX - Wound CareInnovations ................... 111

Central Solutions Inc. ....... 225Coloplast ........................... 126ConvaTec ........................... 122Crawford Healthcare ........ 326DARCO International Inc. 109Derma Sciences, Inc. ........ 231DermaRite Industries ........ 101DM Systems Inc. ............... 114EHOB, Inc. ........................ 229

Ferris Mfg. Corp (Polymem) .................... 113

Globo-Sa Inc. .................... 309GWM Products LLC .......... 408HealGenix - Bio Solutions 104Healogics ........................... 125Hill-Rom ............................ 115HOMELINK ....................... 312Hy-Tape International ...... 106Joerns RecoverCare .......... 425Kiss Healthcare ................. 324KOVEN Technology, Inc. . 230Lantiseptic - Summit Industries ........................ 426

Limbo - Thesis Technology Products Ltd .................. 521

Lohmann & Rauscher, Inc. 517McKesson ........................... 523Medela Inc. ....................... 515Medi USA/Circaid ............. 424Mission Pharmacal ............ 300Monarch Labs .................... 412MPM Medical. Inc. ............ 213MTI .................................... 226National Alliance of WoundCare and Ostomy® ........ 121

Nutricia .............................. 107

Oculus ............................... 329OSNovative Systems Inc. . 207Pesi Healthcare ................. 526Precision Fabrics Group, Inc. ................................ 228

Safe n Simple .................... 413Skil-Care ............................ 209Smith & NephewBiotherapeutics ............. 224

Southwest Technologies, Inc. ................................ 333

Spectrum Healthcare ........ 308Stryker ............................... 233Sundance Solutions .......... 110United Ostomy Association of America .................... 509

VATA Inc. ........................... 524Viniferamine - McCordResearch ........................ 212

Winchester Laboratories (Saljet) ........................... 512

Wolters Kluwer Health -Lippincott Williams & Wilkins........... Registration area hall

WoundRounds ................... 211Wound Care Education Institute ......................... 121


Wild on Wounds2014 ExhiBiTORS

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A Fashion Hayvin, Inc. AFH is a marketing companythat promotes jewelry in over50 conventions annually. Wecater to today’s modern, work-ing professional. Please stopby our booth to view our cur-rent promotion of purchaseany two items in the thirdpiece is free. www.conventionjewelry.com See us in the registration area hall

Acelity (KCI, LifeCell,Systagenix)12930 IH-10 WestSan Antonio, TX 78249Acelity is a global wound careand regenerative medicinecompany, created by unitingthe strengths of KCI, LifeCelland Systagenix. We are com-mitted to advancing the scienceof healing and restoring peo-ple’s lives. Headquartered inSan Antonio, Texas, Acelity de-livers value through our port -folio of innovative and comple-mentary solutions that speedhealing, reduce complicationsand lead the industry in quali-ty, safety and customer experi-ence. We believe in enablingbetter futures for everyone. Acelity.com or call: 800-275-4524.See us at booth 325

Advanced Tissue Co.7003 Valley Ranch DriveLittle Rock, AR 72223www.advancedtissue.com orcall: 866-217-9900.See us at booth 327

Advantage Wound Care863 N. Douglas Ave. #100El Segundo, CA 90245Providing superior bedside sur-gical wound care for patientsin long term health care facili-ties. Advantage Surgical &Wound Care provides superiorprofessional surgical woundcare within the nursing home,SNF, or long term care facility.We provide treatment to thosepatients that have difficultytraveling to a separate facilityfor wound care. Surgical treat-ment that once requiredlengthy clinic appointments,expensive emergency transfers,or loss of patients to hospital-izations can now be easily per-formed at bedside, with mini-mal disturbance to the patient’sdaily activities, or the facility’snursing staff.www.advantagewoundcare.orgor call: 310-524-1300.See us at booth 210

Amerx Health CareCorporation1300 S. Highland Ave.Clearwater, FL 33756Amerx Health Care brings OakTechnology to the practice ofwound management throughAmerigel® Advanced Skin andWound Care Products. Avail-able only in Amerigel prod-ucts, Oakin® delivers thepurest elements naturally pro-duced in select Oak trees topromote wound healing. www.AMERXHC.com or call:800-448-9599.See us at booth 313

Anacapa Technologies, Inc. 301 E. Arrow Hwy. #106San Dimas, CA 91773Anacapa is a veteran-owned,federally-certified small busi-ness based in San Dimas, CA.The company is an FDA-licensed drug and device man-ufacturer engaged in the pro-duction of branded proprietarytopical anti-infective agents.www.anacapa-tech.net or call:909-394-7795.See us at booth 129

Angelini Pharma Inc.8322 Helgerman Court Gaithersburg, MD 20877Angelini Pharma Inc. is theexclusive distributor of BioPadand Silverstream for the treat-ment of chronic wounds. http://angelini-us.com or call: 800 726-2308.See us at booth 310

Argentum Medical, LLC(Silverlon)2571 Kaneville CourtGeneva, IL 60134Silverlon dressings are 7 dayuse metallic silver based an-timicrobial barrier dressingsfor wounds, burns and post-surgical patient care. www.silverlon.com or call:888-551-0188.See us at booth 311

BSN Medical, Inc. 5825 Carnegie Blvd.Charlotte, NC 28209BSN medical, a global medicaldevice company and one ofthe leading suppliers in ofcasting, bandaging, compres-sion therapy and traditionaland advanced wound careproducts. Our well-knownbrands include: Cutimed®

Gypsona®, Orthoglass®, JOBST®,Delta-cast®. www.bsnmedical.com or call:704.554.9933.See us at booth 127

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Calmoseptine, Inc.16602 Burke LaneHuntington Beach, CA 92647www.calmoseptine.com orcall: 714-840-3405.See us at booth 411

CellerateRX – Wound CareInnovations16633 Dallas Pkwy., Suite 250Addison, TX 75001A line of activated collagenproducts that are used foracute and chronic wounds inthe clinic, as well as in surgi-cal closure by many sur-geons around the country.www.celleraterx.com or call: 800-205-7719.See us at booth 111

Central Solutions, Inc.401 Funston RoadKansas City, KS 66115Central Solutions is an FDA andEPA registered formulator ofskin care & infection control offerings, including the BoaVidaline of skin protectant products.www.centralsolutions.com orcall: 913-621-6542.See us at booth 225

Coloplast 1601 West River RoadMinneapolis, MN 55411Coloplast develops productsand services that make lifeeasier for people with verypersonal and private medicalconditions. Our business in-cludes ostomy care, urology,continence care, and wound& skin care. www.coloplast.us or call: 800-533-0464.See us at booth 126

ConvaTec100 Headquarters Park Dr.Skillman, NJ 08558ConvaTec is a global medicalproducts and technologies com-pany with leading market posi-tions in ostomy care, woundtherapeutics, continence andcritical care, and infusion de-vices. Get ready to GO Mold-able! Moldable Technology™,Natura® +, Esteem® +, ConvaTecConcierge™ Service, Sensi-care®,AQUACEL®, AQUACEL® Ag, Flexi-Seal®, Continence Care-Fecal www.convatec.com or call:800-422-8811.See us at booth 122

Crawford Healthcare 2005 South Easton RoadDoylestown, PA 18901 www.crawfordhealthcare.com/usor email: [email protected] us at booth 326

DARCO Internatioanl, Inc.810 Memorial Blvd.Huntington, WV 25701 Darco is a world leader inthe manufacture of post op-erative foot wear and woundcare products. Our offloadingfoot wear enhances the heal-ing process by relieving pres-sure from the wound site.See our offloading productsand request FREE samples ofthe Peg Assist, Ortho Wedge,HeelWedge, Wound CareShoe System.www.darcointernational.comor call: 800-999-8866.See us at the show – booth 109

Derma Sciences, Inc.214 Carnegie Center, Ste. 300Princeton, NJ 08540Derma Sciences, a tissue regen-eration company focused onadvanced wound care, is com-mitted to the development ofintelligent wound managementproducts that address clinicians’needs throughout the continu-um of care. Our full portfolioof products include: MEDI-HONEY®, XTRASORB®, BIO-GUARD®, ALGICELL® Ag, TCC-EZ® and now, AMNIOEXCEL®

www.dermasciences.com orcall: 609-514-4744.See us at booth 231

DermaRite Industries 7777 West Side AvenueNorth Bergen, NJ 07047DermaRite is the trusted man-ufacturer of quality skin,wound and personal careproducts, offered at significantcost savings when comparedwith the other name brands. www.dermarite.com or call:800-337-6296.See us at booth 101

DM Systems Inc.1316 Sherman AvenueEvanston, IL 60201DM Systems’ line of woundcare products include the in-novative Heelift® Glide, theoriginal offloading boot, theHeelift® Suspension Boot, andthe redesigned Heelift® AFO.See for yourself how Heeliftbrand boots can be a vital partof your heel pressure ulcerprevention program. www.heelift.com or call: 800-254-5438.See us at booth 114

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EHOB, Inc.250 N. Belmont AveIndianapolis, IN 46222WAFFLE® Brand Products havebeen used effectively for pres-sure ulcer prevention andhealing therapy for more thantwenty-five years. EHOB, Inc.was founded in 1985 with aspecial interest in soft tissueresearch, education and prod-uct development. www.ehob.com or call: 800-899-5553.See us at booth 229

Ferris Mfg. Corp.5133 Northeast ParkwayFort Worth, TX 76106PolyMem is an innovative,adaptable, drug-free woundcare dressing. PolyMem dress-ings have been shown to re-duce swelling, bruising, andpain associated with bothopen and closed wounds. www.polymem.com or call:817-900-1301.See us at booth 113

Globo-Sa Inc. 5125 W. Oquendo Rd., Unit 11Las Vegas, NV 89118 (Electrical Nerve Stimulator). ATENS unit is designed to mod-ulate pulse width, frequency,and intensity and is used bydoctors, chiropractors, physicaltherapists, and sports rehabili-tators. Its primary functionsare pain relief and muscle re-laxation but it can also beused for strengthening a mus-cle (abs, arms, hips), removingcellulites, and losing weight.See us at booth 309

GWM Products, LLC 8925 Sterling Street, ST 100Irving, TX 75063GWM Products, LLC is themanufacturer and distributor ofthe RTD® Wound Care Dress-ing. This proprietary highly absorbent antimicrobial foamdressing is the only productavailable with three active in-gredients integrated into thefoam matrix; Methylene Blue,Gentian Violet and Silver. www.gwmproducts.net or call: 855-872-2013.See us at booth 408

HealGenix88 Inverness Circle East, Suite K103Englewood, CO 80112HealGenix is a nationwidedistributor of wound careproducts. Our mission is toprovide products that improveoutcomes while reducing thecost of care. We offer curettes,alginates, dressings, NPWT,collagen, & advanced skinsubstitutes. www.healgenix.com or call:800-974-5085.See us at booth 104

Healogics5220 Belfort Road, Suite 130Jacksonville, FL 32256Healogics is the nation’slargest provider of advancedwound care services. We aimto develop wound care lead-ers and promote proven andeffective healing solutions tothose suffering from chronic,non-healing wounds. Stop byour booth and learn abouthow to join our team andmake a difference! Healogics.com or call: 800-379-9774.See us at booth 125

Hill-RomHill-Rom Corporate Offices1069 State Route 46 East Batesville, IN 47006Hill-Rom is a leading world-wide manufacturer and pro -vider of medical technologiesand related services for thehealth care industry, includingpatient support systems, safemobility and handling solu-tions, non-invasive therapeuticproducts for a variety of acuteand chronic medical condi-tions, medical equipment ren -tals, surgical products and in-formation technology solutions.Through our unique combi-

nation of people, process andtechnology, Hill-Rom canhelp you achieve positivesafe skin outcomes for youand your patients in hospi-tals, long-term care facilitiesand in the home.www.hill-rom.com or call:(812) 934-7777.See us at the show – booth 115

HOMELINK1111 West San Marnan DriveWaterloo, IA 50701Homelink, a national ancillaryservice network, in partner-ship with Eo2 Concepts ismarketing the TransCu O2wound device. A low dose tissue oxygenation system forthe treatment of difficult toheal wounds. www.vgmhomelink.com orcall: 800-482-1993.See us at booth 312

Hy-Tape International 25 Jon Barret Rd.Patterson, NY 12563Hy-Tape is a waterproof, latex-free, adhesive tape perfect for securing dressingand ostomy appliances.http://hytape.com or call: 800-248-0101.See us at booth 106

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Joerns RecoverCare2430 Whitehall Park Dr, Suite 100Charlotte, NC 28273www.joerns.comwww.recovercare.comor call: 800-826-0270 or888-750-7828.See us at booth 425

Kiss Healthcare13089 Peyton Drive #C212 Chino Hills, CA 91709www.kisshealthcare.com orcall: 909-632-1361.See us at booth 324

Koven Technology, Inc.12125 Woodcrest ExecutiveDrive, Suite 320 St. Louis, MO 63141Koven vascular Doppler sys-tems for diagnosis and moni-toring of PAD. Koven vascularDopplers are available withsoftware for EHR integration,PPG and PVR for expandedtesting capabilities, and con-form to third-party reimburse-ment guidelines. www.koven.com or call:314-542-2101.See us at booth 230

Lantiseptic (SummitIndustries)839 Pickens Industrial DriveMarietta, GA 30062Serious skin problems? Oneserious solution: Lantiseptic. Trust Lantiseptic: The profes-sional’s trusted product ofchoice for over 20 years, forpreventing and treating a vari-ety of serious skin condition! www.lantiseptic.com or call:800-241-6996.See us at booth 426

LimbO Products16 Laurene Dr., Old Orchard Beach, ME 04064The Limbo waterproof plastercast and bandage protector is comfortable to wear anddoes not restrict blood flowwhen bathing or showering.Allows the user to enjoy thetherapeutic benefit of a bath or shower. The LimbO is allabout improving the quality oflife for the user. We believe inwell made affordable productsand are proud of our excellentcustomer service record, Manu-factured in the UK.www.limboproducts.com orcall: 866-348-4091.See us at booth 521

Lohmann & Rauscher, Inc.6001 SW Sixth Ave., Suite 101Topeka, KS 66615To improve outcomes inwound care, incorporate shortstretch compression bandagingfor the management of edema.Along with our Suprasorb®

line of dressings, Lohmann &Rauscher provides the mostcomprehensive line of com-pression bandaging products.www.lohmann-rauscher.us orcall: 800-279-3863.See us at booth 517

McKesson Medical-Surgical8741 Landmark RoadRichmond, VA 23228McKesson Medical-Surgicalworks with payers, hospitals,physician offices, pharmacies,pharmaceutical companies andothers across the spectrum ofcare to build healthier organi-zations that deliver better careto patients in every setting.McKesson Medical-Surgicalhelps its customers improvetheir financial, operational, andclinical performance with solu-tions that include pharmaceuti-cal and medical-surgical supplymanagement, healthcare infor-mation technology, and busi-ness and clinical services. www.mckesson.com or call: 877-611-0081.See us at booth 523

Medela Inc.1101 Corporate DriveMcHenry, IL 60050Medela, Inc. offers flexible solutions for Negative PressureWound Therapy with a portfolio of products designedto be intuitive, flexible, andpromote patient mobility. Visit booth #227 to learn moreabout Medela’s True NPWT™offering.www.medela.com or call:877-735-1626.See us at booth 515

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Medi USA/Circaid6481 Franz Warner Pkwy.Whitsett, NC 27377medi…I feel better! medi iscommitted to helping people allaround the world live a moreindependent productive andsatisfying life while managingcirculatory issues. medi takesits position as global leader inmedical compression seriouslyby investing in research, educa-tion and innovation providingthe latest technologies in com-pression therapy enabling ourpatients to not only managetheir disease but to enjoy life toits fullest. www.mediusa.com or call:800-633-6334.See us at booth 424

Dr. Smith’s Adult BarrierSpray/Mission Pharmacal 10999 11-1-10 West, 10th Flr.San Antonio, TX 78230Dr. Smith’s® Adult BarrierSpray provides a touch-freeway to treat and prevent in-continence Associated Der-matitis. The zinc oxide 10%spray provides a safe anddiscreet alternative to tradi-tional creams and ointments. http://adultbarrierspray.com/or call: 210-696-8400.See us at booth 300

Monarch Labs17875 Sky Park Circle, Suite KIrvine, CA 92614www.monarchlabs.com or call:949-679-3000.See us at booth 412

MPM Medical, Inc.2301 Crown Ct.Irving, TX 75038MPM Medical, Inc. has been inthe Advanced Skin and WoundCare market for more than 20years. MPM has the ONLY 2%lidocaine hydrogel in the mar-ket, RegenecareHA. MPM alsosells SilverMed, a silver hydro-gel, and has a 100% collagen,Triple Helix, available in pow-der, 2x2, and 12” rope. MPMprovides products to cliniciansand patients to help facilitatewound healing and increasebetter outcomes. www.mpmmed.com or call: 800-232-5512.See us at booth 213

MTI3655 W. Ninigret Dr.Salt Lake City, UT 84104MTI designs and produces themost technologically advanced,durable, reliable, ADA compli-ant and competitively pricedproducts in the industry.Strength in patient care is ourdefining characteristic. MTI isthe largest manufacturer ofpower wound care chairs andtables in the U.S. We producethree models with varying de-grees of power features andlifting capacities up to 800 lbs. www.mti.net or call: 801-887-5114.See us at booth 226

National Alliance ofWound Care and Ostomy®5464 North Port WashingtonRd. #134Glendale, WI 53217 NAWCO® is the largest woundcare and ostomy credentialingboard and member associa-tion in the United States. Weoffer four certification pro-grams. WCC®, Wound CareCertified, DWC®, DiabeticWound Certified, LLE®, Lym-phedema Lower ExtremityCertified, and OMS, OstomyManagement Specialist.www.nawccb.org or call:877-922-6292.See us at the show – booth 121

Nutricia9900 Belward Campus Dr.Suite 100Rockville, MD 20850Nutricia is a global healthcompany that leads the devel-opment and use of advancedmedical nutrition for special-ized care. Nutricia’s special-ized adult nutrition productsinclude Pro-Stat, UTI-Stat,Diff-Stat, and Fiber-Stat. www.pro-stat.com or call:800-221-0308.See us at booth 107

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Oculus Innovative Sciences,Inc. 1129 N. McDowell Blvd.Petaluma, CA 94954Oculus Innovative Sciencemarkets prescription and non-prescription Microcyn-basedproducts, used to treat pa-tients in surgical/advancedwound management, derma-tology and women’s health;addressing the unmet medicalneeds of these markets, whileraising the standard of patientcare and lowering overallhealthcare costs. www.oculusis.com or call:800-759-9305.See us at booth 329

OSNovative Systems Inc. 500 Laurelwood Rd., Suite 1Santa Clara, CA 95054Enluxtra wound dressing is in-tended for use on mostwounds, including diabetic ul-cers, various chronic leg ul-cers, pressure ulcers, and trau-matic and surgical wounds. Itsself-adaptive functionalitymakes it suitable for applica-tion on all wounds. Features: • Simultaneously absorbs andhydrates where needed; •Maintains moist healing envi-ronment for all parts of thewound; • Prevents skin mac-eration; • Does not adhere tothe wound.www.anywound.com or call:888-519-2297.See us at booth 207

Pesi HealthcarePO Box 1000Eau Claire, WI 54702www.pesi.com or call: 715-855-5241.See us at booth 526

Precision Fabrics Group,Inc.301 N. Elm StreetGreensboro, NC 27406www.precisionfabrics.comSee us at booth 228

Safe n SimpleClarkston, MichiganSafe n Simple is an innovatorof high-quality, cost effectiveproducts for Ostomy andWound Care. Our new Simpu-rity Wound Care products in-clude foam dressings, alginatepads and rope, a Collagen padand even a Collagen powder. www.SnS-Medical.com or call: 844-767-6334, toll free.248-214-4877, CustomerService DirectSee us at booth 413

Skil-Care29 Wells AvenueYonkers, NY 10701www.skil-care.com or callMark Patton: 914-963-2040.See us at booth 209

Smith & NephewBiotherapeutics 3909 Hulen St. Fort Worth TX 76107The Biotherapeutics group ofSmith & Nephew is focusedon the development and com-mercialization of novel, cost-effective solutions for dermalrepair and regeneration. Its re-search and development strat-egy is centered around next-generation bioactive therapies.We are also committed to ad-vancing the care and treatmentof wounds through support ofindustry leading continuingeducation from The WoundInstitute®. www.smith-nephew.comSee us at booth 224

Southwest Technologies,Inc., Wound Care Products 1746 Levee Rd.North Kansas City, MO 64116Southwest Technologies, Inc.offers innovative technologies(glycerine-based gel sheets,highly absorbent fillers, sever-al forms of collagen productsand our newly added honeysheets) for simple woundmanagement solutions. www.elastogel.com or call:816-221-2442.See us at booth 333

Spectrum HealthCare 1260 Valley Forge Rd., Suite 111Phoenixville, PA 19460We are a DME company spe-cializing in compression thera-py products. We provide pneu -matic compression pumps andgarments. In home deliveryand education provided.www.spectrumhealthcare.netor call: 888-210-5576.See us at booth 308

Stryker3800 E. Centre Ave.Portage, MI 49002www.stryker.com/en-us/index.htm or call: 269-329-2100.See us at booth 233

Sundance Enterprises, Inc.79 Primrose St.White Plains, NY 10606Sundance Enterprises, Inc. is a leader in the development,manufacturing, and marketingof unique patient positioningproducts, turning and reposi-tioning products heel protec-tion and patient care surfaces. www.sundancesolutions.comor call: 877-560-9871.See us at booth 110

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United Ostomy Associationsof America2489 Rice St., Suite 275Roseville, MN 55113-3797UOAA is national a not forprofit organization that pro-vides support information andadvocacy for people that haveor will have bowel or bladderdiversion surgery(ostomy) andtheir caregivers. UOAA has aover 350 Affiliated SupportGroups and a national head-quarters in the US which arecommitted to helping peoplewith physical and psychologi-cal issues associated with os-tomy and continent diversionsurgery.www.ostomy.org or call: 800-826-0826.See us at booth 509

VATA Inc.308 S. Sequoia ParkwayCanby, OR 97103VATA Wound Care Models arethe most realistic models avail-able anywhere. Otto Ostomy™,Seymour II™, Wilma WoundFoot™, Pat Pressure Ulcer Stag-ing Model™ and Stan Stage IVPressure Ulcer Model™. Thesemodels are great tools to usefor competency testing and theuse of NPWT. www.vatainc.com or call:503-651-5050.See us at booth 524

Viniferamine® 2769 Heartland Dr., Suite 303Coralville, IA 52241The Viniferamine® Skin Well-ness System gives facilities away to improve patient out-comes. The color-coded sys-tem of green, yellow and redmakes Viniferamine® productselection simple. The objec-tive is to empower NA/CNAsto help them recognize theimportance of sharing skinobservations with the nurse. www.viniferamine.com or call: 319-351-3201.See us at booth 212

Winchester Laboratories,LLC1177 Blue Heron Blvd. Suite B-106Riviera Beach, FL 33404Saljet a 30ml, one time use,sterile saline, designed forwound care. It is easy to use,is sterile every use, savesnursing time and helps toachieve better outcomes. www.saljet.com or call: 630-377-7880.See us at booth 512

Wolters Kluwer Health –Lippincott Williams &WilkinsTwo Commerce Square2001 Market StreetPhiladelphia, PA 19103 www.lww.com or call: 215.521.8300.See us in the registration area hall

WoundRounds425 N. Martingale RoadSuite 1250Schaumburg, IL 60173Bedside wound managementand risk prevention solutionwith tools that capture and il-luminate patient wound andrisk data to improve decisionmaking at the bedside and en-terprise level. www.woundrounds.com orcall: 847-519-3500.See us at booth 211

Wound Care EducationInstitute®25828 Pastoral DrivePlainfield, IL 60585WCEI provides comprehen-sive online and onsite cours-es in the fields of Skin,Wound, Diabetic and OstomyManagement. Health careprofessionals who meet theeligibility requirements maysit for the prestigious WCC®,DWC® and OMS™ nationalboard certification examina-tions through the NationalAlliance of Wound Care andOstomy® which is the largestgroup of multidisciplinarycertified wound care profes-sionals in the United States.www.wcei.net or call: 877-462-9234See us at booth 121

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VendorShowcaseExhibits

Meet with exhibitors,participate in hands-onlabs, and learn aboutnew industry products.Chance to win a greatprize!

thursdaySeptember 18, 201412:00 p.m. – 2:00 p.m.

fridaySeptember 19, 201412:00 p.m. – 2:00

Click SHOP on our website to visit either store. Always Open 24 hours a day, 7 days a week.

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NAWCO® Online Clothing Store!Choose from a great collection of high quality clothing for work or home. Select from comfortable shirts, blouses, jackets and embroidered scrubs or lab coats. Embroidery is now always free. Order now and receive a free gift with each order. All proceeds go to a candidate scholarship fund.

The NAWCO Online Print Shop offers custom business materials that you can order online. Each piece is professionally designed to visually promote you and all your active NAWCO credentials. All proceeds go to a candidate scholarship fund.

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Present Your Certifi cationWith Distinction.

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