Clinical Topics Mega Menu

Comprehensive turning programs can avoid a pain in the back

Turning programs are essential to prevent and promote healing of pressure ulcers and to prevent the many negative effects of immobility, ranging from constipation to respiratory infections. However, turning a patient often puts a caregiver’s body in an awkward position, which can lead to musculoskeletal damage, especially back injuries.

According to the U.S. Bureau of Labor Statistics, healthcare workers suffer the highest rate of musculoskeletal disorders for all occupational groups and more than seven times the average rate for all occupations. Direct caregivers are the group most likely to experience musculoskeletal injuries. During turning tasks, excessive forces are imposed on the caregiver’s musculoskeletal structure due to the external load of the patient and the caregiver’s form and position during the task. Fragala and Fragala found that turning patients in bed is one of the highest-risk activities that lead to low back pain.

Reducing the risk

Using safe patient handling equipment reduces the force exerted on musculoskeletal structures and lowers the risk of injury to the caregiver. Leaders should consider investing in the following safe patient handling equipment as part of the organization’s comprehensive turning program:

• grab bars and/or a trapeze on the bed so the patient can participate or become independent in turning

• friction-reducing aids to reduce the force required to turn patients

• mechanical lifts with

• full-body turning/repositioning slings to remove the workload of the caregiver

• a small repositioning sling and a limb lift sling to position and hold a patient in place during care or a dressing change to a wound. (See Lifting aids.)

Investment in this equipment can help reduce costs associated with musculo – skeletal disorders in caregivers.

Caregivers should choose the right equipment for the task at hand and use the equipment appropriately. They should remove slings or friction-reducing aids when the task is complete, so they don’t hinder the pressure redistribution properties of the support surface.

Making safe patient handling equipment available encourages caregivers to comply with turning protocols and leads to better outcomes for both patients and caregivers.

Jeri Lundgren is the president of Senior Providers Resource in Cape Coral, Florida. She can be contacted at

Selected reference

Fragala G, Fragala, M. Improving the safety of patient turning and repositioning tasks for caregivers. Workplace Health Saf. 2014;62(7):268-73.

Access more information about selecting equipment from the Association of Rehabilitation Nurses.

Clinical Notes

Self-management ostomy program improves HRQOL

A five-session ostomy self-care program with a curriculum based on the Chronic Care Model can improve health-related quality of life (HRQOL), according to a study in Psycho-Oncology.

A chronic care ostomy self-management program for cancer survivors” describes results from a longitudinal pilot study of 38 people. Participants reported sustained improvements in patient activation, self-efficacy, total HRQOL, and physical and social well-being. Most patients had a history of rectal cancer (60.5%) or bladder cancer (28.9%).

Assessment scale may help predict pressure ulcer development in patients with fecal incontinence

A study in the International Wound Journal has found that higher scores on the Incontinence-Associated Dermatitis and its Severity (IADS) tool are associated with an increased likelihood of developing a pressure ulcer in patients with fecal incontinence.

The authors of “Prospective study on Incontinence-Associated Dermatitis and its Severity instrument for verifying its ability to predict the development of pressure ulcers in patients with fecal incontinence” suggest that patients with IADS scores higher than 8 points should be classified as being at risk of developing a pressure ulcer and receive “intensive care as a proactive measure” to prevent pressure ulcer development.

Keratin-based products effective for burn treatment

Researchers report in Burns that compared to standard products, novel keratin-based products facilitate healing with minimal scarring in patients with superficial and partial thickness burns.

Keratin-based products for effective wound care management in superficial and partial thickness burns injuries” notes that the keratin products are cost-effective, associated with minimal pain and itch, and easy to use in community-based care.

Sirolimus-eluting stents help wound healing in patients with ischemic PAD

Infrapopliteal sirolimus-eluting stents (SES) accelerate wound healing in patients with ischemic peripheral arterial disease (PAD) compared with balloon angioplasty, according to a study of 200 patients in JACC: Cardiovascular Interventions.

Wound healing outcomes and health-related quality-of-life changes in the ACHILLES Trial: 1-year results from a prospective randomized controlled trial of infrapopliteal balloon angioplasty versus sirolimus-eluting stenting in patients with ischemic peripheral arterial disease” also reported a trend of more quality-of-life gains for patients receiving an SES.

Incontinence of older persons affects QOL of their caregivers

Impact of incontinence on the quality of life of caregivers of older persons with incontinence: A qualitative study in four European countries” concludes that incontinence has a strong effect on the quality of life (QOL) of caregivers.

The study in Archives of Gerontology and Geriatrics included 50 interviews with caregivers in Italy, the Netherlands, the Slovak Republic, and Sweden. The researchers discovered that families need to learn new competencies in caring for the older person with incontinence and that incontinence remains “a taboo and a high stigmatizing condition” for caregivers. The concept that incontinence is unavoidable in older patients, along with shame and embarrassment, prevents caregivers from seeking help at an early stage.

Trauma patients vulnerable to device-related pressure ulcers

Pressure ulcers in trauma patients with suspected spine injury: a prospective cohort study with emphasis on device-related pressure ulcers” reports the incidence of pressure ulcers in 254 patients with suspected spine injury as 28.3%, with 60.7% of those related to devices.

The study, published in the International Wound Journal, found pressure ulcers in 16 different locations on the body. The researchers conclude that the proportion of device-related pressure ulcers is “very high in trauma patients.”

Intensive therapy for patients with diabetes reduces CV complications

Intensive diabetes treatment and cardiovascular outcomes in Type 1 Diabetes: The DCCT/ EDIC Study 30-year follow-up” reports that intensive treatment reduced the incidence of cardiovascular (CV) disease by 30% and the incidence of major CV events (nonfatal myocardial infarction, stroke, or cardiovascular death) by 32%.

Authors of the study, published in Diabetes Care, note that lower HbA1c levels accounted for the observed treatment effect on CV disease risk, and that increased albuminuria was also associated with CV disease risk.

Buzz Report: Latest trends, part 2

Keeping clinicians up-to-date on clinical knowledge is one of the main goals of the Wild on Wounds (WOW) conference held each September in Las Vegas. Every year, I present the opening session, called “The Buzz Report,” which focuses on the latest-breaking wound care news—what’s new, what’s now, and what’s coming up. I discuss new products, practice guidelines, resources, and tools from the last 12 months in skin, wound, and ostomy management.

In the January issue, I discussed some of the updates from my 2015 Buzz Report. Now I’d like to share a few more, along with some of my favorite resources.

Product buzz

Wound dressings with silicone are designed to reduce pain and trauma during dressing changes and to protect the wound. Coloplast’s new Biatain® Silicone Lite does just that, combining an absorbent polyurethane foam dressing with a semipermeable, water- and bacteriaproof top film and a soft silicone woundcontact layer. The thin foam provides a closer fit at skin level, resulting in increased mobility and product comfort.

Anasept® Antimicrobial Wound Irrigation Solution provides a new dimension in antimicrobial wound care and negative-pressure wound therapy (NPWT). This FDA-cleared solution is a clear isotonic liquid that delivers 0.057% broad-spectrum antimicrobial sodium hypochlorite via a NPWT device. Kill studies for Anasept® are fascinating: a 30-second kill time for infections with Clostridium difficile, methicillin-resistant Staphylococcus aureus, vanc o mycinresistant enterococci, Pseudo monas, and many more. Anasept comes with an easyto- use spikable container with an integrated hanger that can be quickly attached to an I.V. pole or NPWT device. It can be used with most NPWT systems that have instillation or infusion capability.

Cutimed® Sorbact® Hydroactive B from BSN Medical provides infection control and fluid management for up to 4 days in a single wound dressing. It helps fight and prevent infection without chemical agents or antibiotics. The bacteria-binding, absorbent gel dressing with an adhesive border absorbs and locks wound exudate and bacteria in a hydropolymer gel core; with each dressing change, bound bacteria are removed. The hydrogel matrix helps maintain a moist wound environment.

No scissors? No problem! Hy-Tape International, maker of the Original Pink Tape®, has come to the rescue with Hy- Tape® Pre-cut Strips and Patches. These latex free, waterproof, zinc–oxide-based adhesive tape products are perfect for extended wear, soothing to delicate skin, and adherent to wet, oily, or hairy skin. The single-use strips measure 1.25″ x 6″ and come in packs of four. They can quickly be used to secure devices or to “picture-frame” wounds or ostomy barriers. The patches are designed to cover a large area. Available in 4″ and 5″ squares, they’re perfect for making hydrocolloid dressings completely occlusive.

The American Diabetes Association’s report “Comprehensive Foot Examination and Risk Assessment” states that all individuals with diabetes should get an annual foot exam to assess peripheral neuropathy and protective sensation, including a test for vibration perception. Typically, the clinician uses a tuning fork to test for vibration sensation, but this can be difficult for those unfamiliar with the feel; also, the results are totally subjective. The new portable, handheld noninvasive Dynamic Neuroscreening Device (DND) from Prosenex provides objective and consistent quantitative testing for vibration sensation. It offers five grades of vibration and temperature discrimination to screen for large- and small-fiber neuropathy. FDA approved and made in the United States, DND was named the 2014 New Hampshire High Tech Product of the Year.

Zinc oxide ointment is a “go-to” product for incontinence-associated dermatitis. But its consistency makes it difficult and messy to spread evenly over the skin. Mission Pharmacal Co. has created a new solution for this—Dr. Smith’s Adult Barrier Spray. This 10% zinc oxide solution comes as an easy, touch-free, spray application, offering accurate, uniform coverage with no rubbing necessary.

Incidence data reveal that the heel is the most common site of facility-acquired pressure ulcers. Once a heel pressure ulcer develops, complete elimination of heel

pressure using a pressure-relief device is critical. The new TruVue™ Heel Protector from EHOB positions a pillow under the Achilles tendon to elevate the heel. Constructed

with an anti-shear pad that serves as a barrier to shearing forces, the device has a deep, V-cut heel well that fully off – loads the heel without product interaction and relieves product-to-heel engagement with foot flexion.

Resource buzz

Accessing the Internet for information using smartphones and tablets has quickly become a huge part of health care. Two major wound care companies have released mobile applications to help healthcare professionals and consumers use and order their products. Several new woundcare books were published in 2015 as well. (See What’s the buzz on books?)

The iOn Healing™ mobile app from Acelity offers a suite of tools to improve customer support. In addition to product guides, features include the ability to connect and consult directly with an Acelity representative, track outcomes to support  documentation of medical necessity, and order V.A.C.® Therapy and instantly transmit the signed prescription to Acelity. The HIPAA-compliant app offers high-security data protection. Designed for use by licensed clinicians in the United States, it’s free to download and available for iOS and Android.

The Johnson & Johnson Wound Care Resource app helps identify new wounds, provides recommendations on wound care treatment, and keeps track of the daily checklists that come with continued treatment. It’s available free for iOS at iTunes and for Android at GooglePlay.

A dream come true for wound care clinicians—an app that measures wounds! With the Mobile Wound Care app from Tissue Analytics, you can take a wound photo with a smartphone camera and stream it directly to your desktop, where you can measure, track, and manage your patients’ wounds on a secure web portal. It’s available for iOS at iTunes and for Android at Google Play.

The Agency for Healthcare Research & Quality (AHRQ) produces evidence that can be used to make health care safer, better, more accessible, more equitable, and more affordable. AHRQ websites offer a wealth of useful information for clinicians A few of my favorites are the Patient Safety Channel on YouTube, Innovations Exchange, Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention, and Service Delivery Innovation Profile, such as this one, which details various healthcare projects around the country.

Donna Sardina is editor-in-chief of Wound Care Advisor and cofounder of the Wound Care Education Institute in Plainfield, Illinois.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution,its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.


Buzz Report: Latest trends, Part 1

We all lead busy lives, with demanding work schedules and home responsibilities that can thwart our best intentions. Although we know it’s our responsibility to stay abreast of changes in our field, we may feel overwhelmed when we try to make that happen.

Keeping clinicians up-to-date on clinical knowledge is one of the main goals of the Wild On Wounds (WOW) conference, held each September in Las Vegas. Each year, I present the opening session of this conference, called “The Buzz Report,” which focuses on the latest-breaking wound care news—what’s new, what’s now, what’s coming up. I discuss innovative new products, practice guidelines, resources, and tools from the last 12 months in skin, wound, and ostomy management. This article highlights the hottest topics from my 2015 Buzz Report.

Guidelines buzz

Although not new in 2015, “Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline” from the National Pressure

Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance is still a buzzing topic. The guideline was released in September 2014, and many facilities and clinicians are still busy trying to incorporate it into their protocols. This can be an arduous task, given the more than 575 specific recommendations. However, the quick-pick system using “thumbs up” and “thumbs down” icons next to each recommendation helps users separate the should do’s from the don’t do’s.

The American College of Physicians released two pressure ulcer guidelines in March 2015. “Treatment of Pressure Ulcers: A Clinical Practice Guideline” and “Risk Assessment and Prevention of Pressure Ulcers” are based on a systematic evidence review and focus on specific aspects of care. Each guideline has just three recommendations.

Although not a guideline per say, the evidence-based consensus document “The Management of Diabetic Foot Ulcers (DFUs) Through Optimal Off-loading” published in the Journal of the American Podiatric Medical Association includes eight specific consensus statements. Here are two of the most notable:

• Consensus statement #4: Total contact casting is the preferred method for off-loading plantar DFUs, as it has most consistently demonstrated the best healing outcomes and is a cost-effective treatment.

• Consensus statement #5: There currently exists a gap between the evidence supporting the efficacy of DFU off-loading and what is performed in clinical practice.

Literature buzz

Thousands of wound and ostomy articles are published each year. Below are just a few of the articles that I believe will have a significant impact at the bedside.

What is the healing time of Stage II pressure ulcers? Findings from a secondary analysis,” in Advances in Skin & Wound Care Journal, describes data collected from a multicenter randomized clinical trial. The authors conclude that achieving complete re-epithelialization in stage 2 pressure ulcers takes approximately 23 days and that on average, small ulcers heal 12 days faster than those with a surface of 3.1 cm2 or greater.

NPUAP released two key papers in 2015.

• “Hand check method: Is it an effective method to monitor for bottoming out?” reviewed the science behind the clinical practice of hand checks for bottoming out on a support surface. NPUAP’s position statement supports use of hand checks with air mattress overlays and chair cushions only. NPUAP stated more research is needed to develop acceptable ways to evaluate the performance of mattress replacements and integrated bed systems; until such time, clinicians should follow the manufacturer’s recommendation and not perform hand checks.

• The white paper “Do lift slings significantly change the efficacy of therapeutic support surfaces?” is designed to increase clinicians’ critical thinking when using lift slings in combination with therapeutic support surfaces. NPUAP recommends clinicians choose a combination of support surface and sling that meets the patient’s needs while focusing on the risks and benefits of leaving a sling beneath a patient.

A 2015 review and analysis of literature on friction and pressure ulcers in the Journal of Wound Ostomy Continence Nursing explained that friction alone doesn’t directly cause pressure ulcers, and cautioned against categorizing friction wounds as pressure ulcers. “Friction-induced skin injuries—are they pressure ulcers? An updated NPUAP white paper” explains that friction can result in shear forces that may lead to a pressure ulcer; however, without shear, friction alone doesn’t lead to pressure ulcers.

Ulcers from sickle cell disease

About 1% to 3% of the U.S. population lives with sickle cell disease (SCD). From 25% to 75% of these people also experience leg ulcers. “Sickle cell disease & wound care: Lower extremity ulcers in ‘crisis,’” published in Today’s Wound Clinic, identified key diagnostic characteristics and treatment protocols to consider. The underlying cause of SCD ulcers remains unknown. Most begin spontaneously or from trauma as small scabbed areas over the medial or lateral malleoli. Scabs progress to round, punched-out lesions with raised margins, deep bases, and necrotic slough, with surrounding brown hyperpigmentation and scaling. Patients typically complain of extreme tenderness or pain at the ulcer site.

Treatment aims to manage SCD and associated anemia and control pain. Local wound care involves moist wound healing, bacteria control, protection from trauma, loose-fitting clothing around the ankles to avoid friction, and pressure dressings, such as an Unna’s boot. In many cases, sharp debridement can’t be done because of intolerable pain. A good alternative is biological debridement.

Infrared skin thermometry

All objects at temperatures above absolute zero release infrared radiation. Heat from wound inflammation, fever, and infection is a form of infrared radiation. By using a noncontact infrared thermometer to monitor wounds and surrounding tissue, clinicians can identify signs of deep inflammation, infection, or trauma that may be invisible on the surface. “Infrared skin thermometry: An underutilized cost-effective tool for routine wound care practice and patient high-risk diabetic foot self-monitoring,” published in Advances in Wound Care, found wounds with an elevated temperature measured with infrared thermometry were eight times more likely to be diagnosed with deep infection. A temperature elevation over the same spot on the other foot in a patient with diabetes without a foot ulcer may indicate an acute Charcot foot. In addition, limb ischemia results in lower regional, local, and side-to-side variability in temperatures. Using an infrared thermometer, clinicians can identify unequal vascular supply by measuring temperatures proximal and distal to the wound. Commercially available, inexpensive, noncontact infrared thermometers can detect localized increases in skin surface temperature comparable to scientific grade instruments.

Noncontact infrared thermometry also can be used to assess the skin for pressure ulcers, such as deep-tissue injury, dark skin tones, and circulatory status around the wound. I believe all wound care practitioners should have a noncontact infrared skin thermometer on their tool belt. For examples of these thermometers, visit

Product buzz

Debrisoft® is a ground-breaking active debridement system from Loh­mann & Rauscher that mechanically debrides and cleans wounds by rapidly removing debris, necrotic material, slough, exudate, and hyperkeratotic tissue. The dressing is made of soft, angled polyester fibers that loosen debris while protecting intact granulation tissue and epithelial cells. To use, moisten with tap water or saline solution. Then, using light pressure and a circular motion, gently rub the wound or skin with the soft, fleecy side of the dressing. You can use Debrisoft each time you change the wound dressing.

A similar product, DebriMitt™ from Crawford Healthcare, is designed as a single-use mitt with a finger pouch. It gently removes nonviable tissue, hyper­keratotic skin, and debris and can disrupt biofilms in the wound base.

A natural approach to wound debridement can be achieved with the new BioMonde BioBag®, which contains disinfected larvae of Lucilia sericata (maggots) in a sealed sterile polyester net bag. The bag is placed directly onto the wound bed; larvae remain sealed within the dressing for the full 4-day treatment. The BioBag allows larvae to pass secretions through the pores of the polyester containment net, dissolving and physically removing devitalized tissue and bacteria from the wound without removing healthy and viable tissue. All wound-cleaning benefits of larval therapy remain in the BioBag without fear of larvae wandering from the treatment area.

Helix3 CM™ and Helix3 CP™ are new collagen wound dressings from Amerx. Helix3 CM is a bioactive collagen matrix dressing composed of 100% type 1 bovine native collagen formulated in a highly absorptive porous collagen sheet. Helix3 CP is 100% type 1 bovine nonhydrolyzed collagen powder. Because these products aren’t hydrolyzed, they contain 10 times more nondenatured, native triple-helix structured collagen than similar products.

For the latest bedding fabrics that reduce shear and friction, see New bedding fabrics.

Note: Watch for part 2 of the Buzz Report in the March-April issue.

Selected references

Brienza D, Antokal S, Herbe L, et al. Friction-induced skin injuries: Are they pressure ulcers? An updated NPUAP white paper. J Wound Ostomy Continence Nurs. 2015;42(1):62-4

Brienza D, Deppisch M, Gillespie C. Do lift slings significantly change the efficacy of therapeutic support surfaces? A National Pressure Ulcer Advisory Panel White Paper. March 2015.

Call E, Deppisch M, Jordan R, et al. Hand check method: Is it an effective method to monitor for bottoming out? A National Pressure Ulcer Advisory Panel Position Statement. June 2015.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler, ed. Perth, Australia: Cambridge Media; 2014.

Palese A, Luisa S, Ilenia P, et al; PARI-ETLD Group. What is the healing time of Stage II pressure ulcers? Findings from a secondary analysis. Adv Skin Wound Care. 2015;28(2):69-75.

Penne JR, Goodman BM, Chen IA. Sickle cell disease & wound care: lower extremity ulcers in “crisis.” Today’s Wound Clinic. 2015;9(3).

Qaseem A, Humphrey LL, Forciea MA, et al; Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162(5):370-9.

Qaseem A, Mir TP, Starkey M, et al; Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162(5):359-69.

Sibbald RG, Mufti A, Armstrong DG. Infrared skin thermometry: an underutilized cost-effective tool for routine wound care practice and patient high-risk diabetic foot self-monitoring. Adv Skin Wound Care. 2015;28(1):37-44.

Snyder RJ, Frykberg RG, Rogers LC, et al. The management of diabetic foot ulcers through optimal off-loading: building consensus guidelines and practical recommendations to improve outcomes. J Am Podiatr Med Assoc. 2014;104(6):555-67.

Online Resources


Donna Sardina is editor-in-chief of Wound Care Advisor and cofounder of the Wound Care Education Institute in Plainfield, Illinois.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Clincal Notes

Value of systematic reviews and meta-analyses in wound care

Systematic reviews and meta-analyses—literature-based recommendations for evaluating strengths, weaknesses, and clinical value,” in Ostomy Wound Management, discusses evidence-based practice and how systematic reviews (SRs) and meta-analyses (MAs) can help improve management of wound care patients.

The authors of the article explain evidence-based practice and provide useful definitions for key terms. They then provide a list of eight questions to use when evaluating SRs and practical tips such as how to search for SR and MA studies. The article finishes with a list of eight inter­ventions supported by the most evidence: hydro­colloidal dressings, honey, biosynthetic dressings, iodine complexes, silver compounds, hydrogels, foam dressings, and negative pressure wound therapy.

Inflammatory markers and diabetic foot osteomyelitis

Procalcitonin (PCT) is higher in patients with osteomyelitis than those without, according to a study of 35 patients with infected foot ulcers published in International Wound Journal.

The authors of “The value of inflammatory markers to diagnose and monitor diabetic foot osteomyelitis” also measured erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-8 (IL-8), and monocyte chemotactic protein-1 (MCP-1) at baseline and after 3 and 6 weeks of standard therapy. They found that CRP, ESR, PCT, and IL-6 levels decreased significantly in patients with

osteomyelitis after starting therapy, while MCP-1 increased. These findings indicate the markers might be helpful in monitoring response to therapy.

Proposed treatment algorithm for patients with sickle cell disease and leg ulcers

The authors of “A treatment algorithm to identify therapeutic approaches for leg ulcers in patients with sickle cell disease,” published in International Wound Journal, note that sickle cell ulcers, a common complication of sickle cell disease, are slow to heal and often recur. The article reviews treatment options and presents a proposed treatment algorithm.

Mechanism of action for maggot therapy

Maggot debridement therapy can promote healing in patients with diabetic foot wounds, according to “Maggot debridement therapy promotes diabetic foot wound healing by up-regulating endothelial cell activity.”

The authors of the study, published in Journal of Diabetes and Its Complications, report that maggot excretions/secretions promote healing by “up-regulating endo­thelial cell activity.” In vitro, maggot excretions/secretions increased human umbilical vein endothelial cell proliferation, improved tube formation, and increased expression of vascular endothelial growth factor receptor 2 in a dose-dependent manner. CD34 and CD68 levels were increased in treated wounds.

People with diabetes and PAD at greater risk for impaired mobility

Diabetes is associated with increased risks of low lean mass and slow gait speed when peripheral artery disease is present,” published in Journal of Diabetes and Its Complications, notes that low lean mass and mobility impairment were not seen in people who had either diabetes or peripheral artery disease (PAD) alone, only when both were present.

The study included 4,769 participants 40 years or older from the National Health and Nutrition Examination Survey 1999–2004.

Systematic review of diabetic foot offloading

Treatment of the diabetic foot by offloading: a systematic review” reports that total contact casts are the “most effective” devices for ulcer healing. However, the authors of the study in Journal of Wound Care note that contact casts “are not without complications and their impact on cost, compliance, and quality of life is not well understood.” The review included 15 studies.

Fleet enema may be sufficient prep for DLI surgery

A fleet enema alone may be sufficient for preoperative bowel prep in patients under­going anterior resections followed by a diverting loop ileostomy (DLI), according to “Colonic transit: what is the impact of a diverting loop ileostomy?”

The study in ANZ Journal of Surgery included 10 patients with a mean age of 57 years who were undergoing low anterior resection or ultra-low anterior resection for treatment of rectal cancer.

CDP with surgery treatment option for lower-extremity lymphedema

The combination of complex decongestive physical therapy (CDP) perioperatively and reduction surgery is an option for some patients with elephantiastic lymphedema of the lower extremity, according to a study in Obesity Surgery.

An integrative therapeutic concept for surgical treatment of severe cases of lymphedema of the lower extremity” included 26 patients who underwent CDP and surgery and 30 patients who received medial thigh lift due to post-bariatric or aesthetic issues.

Clinician Resources

Start the New Year off right by checking out these resources.

Pressure ulcer prevention education

Access the following education resources from Wounds International:

The webinar “Real-world solutions for pressure ulcer prevention: Optimising the role of support surfaces” includes:

• an overview of the issue of pressure ulcers

• what to consider when choosing a support surface

• how to operationalize support surfaces in the clinical setting.

The program “Advances in pressure ulcer prevention and treatment made easy” highlights the guidance on prevention and treatment strategies for pressure ulcer care, with a focus on the role of silicone-foam wound dressings.

CAUTI toolkit

The Agency for Healthcare Research and Quality has released a toolkit for reducing catheter-associated urinary tract infections (CAUTI) in patients who are hospitalized. The toolkit consists of three modules—implementation, sustainability, and resources—that a hospital can use to teach team members how to apply concepts from the Comprehensive Unit-based Safety Program (CUSP) to prevent CAUTI. Each module contains:

• guides

• tools

• archived webinars.

The 4-year project to develop the toolkit brought together subject matter experts and participating hospitals across the United States.

Ostomy patient resources

Here are two resources for patients:

• The Ostomy Society’s website aboutstoma provides a wealth of resources for patients, including links to videos on how to change an ostomy bag, how to stop stoma leaks, and how to measure stoma size.

• The Memorial Sloan Kettering Cancer Center provides “A guide for patients with an ileostomy or colostomy,” which includes types of ostomies, care of an ostomy, body image issues, nutrition, medication, exercise, odor control, sexual activity, work, and travel. It also has a list of frequently asked questions.

Multi-drug-resistant gram-negative bacteria

Wound infections are too often resistant to antibiotics, which makes prevention of infection and early intervention if infection occurs essential. A new resource comes from European colleagues in the form of the article “Prevention and control of multi-drug-resistant Gram-negative bacteria: Recommendations from a Joint Working Party,” published in the Journal of Hospital Infection. Gram-negative bacteria are often difficult to treat and can slow wound healing.

The article includes recommendations for screening, diagnosis, and infection control precautions, such as hand hygiene, single-room accommodation, and environmental screening and cleaning. One recommendation is, “Screening for rectal and wound carriage of carbapenemase-producing Enterobacteriaceae should be undertaken in patients at risk.”

STDs guidelines from CDC

The Centers for Disease Control and Prevention (CDC) has updated its guidelines for the treatment of sexually transmitted diseases (STDs). The guidelines discuss:

• alternative treatment regimens for Neisseria gonorrhoeae

• the use of nucleic acid amplification tests for the diagnosis of trichomoniasis

• alternative treatment options for genital warts

• the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications

• updated HPV vaccine recommendations and counseling messages

• the management of persons who are transgender

• annual testing for hepatitis C in persons with HIV infection

• updated recommendations for diagnostic evaluation of urethritis

• retesting to detect repeat infection.

Clinicians can download the 2015 STD treatment guide app, which combines information from the treatment guidelines and MMWR updates. The app features a streamlined interface so providers can access treatment and diagnostic information easily.

Time to select a support surface


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

Having the proper support surface for beds and wheelchairs is imperative in preventing pressure ulcers. “Pressure” ulcers are named that for a reason—pressure is the primary cause of interruption of blood flow to the tissue. Unfortunately, guidelines for support surface selection tend to make recommendations for the type of surface to use after a pressure ulcer has developed. Another factor that complicates matters is the development of deep-tissue injuries. These injuries start at the bone level, which means that often, tissue damage is extensive before we see visible signs and realize that the support surface we chose might not have been effective enough.

Being proactive in preventing pressure ulcers requires that a pressure redistribution surface is provided for the bed and wheelchair when the patient is admitted. Even when you decide to apply a support surface early, choosing the specific surface can be difficult.

Choosing a support surface

What makes support surface selection so challenging is that we are all different in body weight, size, distribution of weight, and sensitivity to pressure, humidity, and temperature. What might be cool and comfortable (and prevent a pressure ulcer) for one patient might be too firm and hot for another. Of course, it’s not possible to have every type of support surface in stock. Clinicians and administrators should consider the following characteristics when working with manufacturers to determine the options to provide. The products that best fit the following areas should be considered:

  • Microclimate: Does the product diffuse heat and prevent humidity?
  • Immersion: What is the immersion capability? Immersion is the ability to “sink” into a support surface. The more a patient can sink into the surface without bottoming out (there should be at least 1″ of space between the buttock and the bed frame), the less likely there will be pressure points.
  • Envelopment: What is the envelopment degree of the surface? Envelopment is the ability of the support surface to conform to body contours. The more the surface can conform to body contours, the more effective it will be in preventing pressure.
  • Shear and friction: Does the cover of the support surface help reduce shear and friction?

Another important question is, “For up to what stage ulcer is the mattress recommended?”

Following up

Your responsibility doesn’t end with the initial application of the support surface on admission. You need to re-evaluate the choice of support surface every time you conduct a risk assessment of skin integrity and when any of the following occurs:

  • decline in mobility status
  • decline in activity level. This factor is often overlooked in patients who are independent in their mobility. Even though they are independent, they may choose to sit for prolonged periods or prefer to stay in the same positon.
  • acute illness or injury that may render patients bedbound or decrease their activity level
  • change in weight; weight loss may accentuate a bony prominence or weight gain can affect the ability to move.
  • development of a pressure ulcer.

Taking prompt action

Support surfaces can be expensive, but selecting the right support surface early and changing it as needed is more cost effective in the long run if pressure ulcers are prevented or a current pressure ulcer heals more quickly. You also need to consider that to prove a pressure ulcer was unavoidable, the care setting needs to show that interventions were in place before its development. Choosing—and documenting—appropriate support surfaces will help provide that proof.

For more information on support surface selection, refer to the National Pressure Ulcer Advisory Panel’s “Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline.” You can order the guidelines online and download a copy of the Quick Reference Guide. Another resource is the evidence-based support surface algorithm available from the Wound, Ostomy and Continence Nurses Society.

Donna Sardina is editor-in-chief for Wound Care Advisor.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Cutaneous candidiasis


By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS

Each issue, Apple Bites brings you a tool you can apply in your daily practice. Here’s an overview of cutaneous candi­diasis.

Cutaneous candidiasis is an infection of the skin caused by the yeast Candida albicans or other Candida species. Here’s a snapshot of this condition.


Yeast fungi, which include the Candida species, are normal flora found throughout the human GI tract. These fungi thrive in a warm, moist environment, so certain conditions, such as poor hygiene, tight clothing, moist skin under surgical or wound dressings, high humidity, and constantly moist skin can result in overgrowth. When the overgrowth occurs on skin, it’s called cutaneous candidiasis. Other conditions that can contribute to cutaneous candidiasis include compromised immunity, antibiotics, stress, and diabetes.


  • Location—most commonly found in intertriginous areas, such as in the axillae, groin, body folds, gluteal folds, digital web spaces, and glans penis, as well as beneath the breasts
  • Appearance—in people with light skin tones: bright- to dull-red central area with peripheral red vesicles (satellite lesions); in people with dark skin tones: darker than surrounding skin, color may vary from dark-red to purple, purple-blue, violet, or eggplant
  • Distribution—consolidated or patchy
  • Shape—diffuse differential areas; small round erythematous papules, pustules, plaques, and/or satellite lesions
  • Depth—partial thickness; superficial epidermal infection
  • Wound bed—pink or beefy red; associated crusting or scaling with cheesy white exudate
  • Margins—Diffuse and irregular edges; satellite lesions (outside the advancing edge of candidiasis) are the most important diagnostic feature
  • Key diagnostic indicator—itching and/or burning.


The first strategy is to remove moisture:

  • Place absorptive fabric in skin folds.
  • Teach the patient and caregiver(s) meticulous skin care.
  • Change linen and gowns as frequently as needed to keep dry.
  • Minimize friction and shear to the skin when cleansing, and use a pH-based, skin-friendly cleanser. No-rinse cleans­ers are particularly useful.
  • Dry the skin well, especially in the skin folds.

At the first sign of redness, itching, or discomfort, apply an over-the-counter (OTC) or prescription antifungal powder or a silver powder/cream to the area daily per package instructions. Examples include:

  • Nystatin
  • Clotrimazole (Lotrimin, OTC)
  • Miconazole (Micatin, OTC)
  • Econazole (Spectazole)
  • Ketoconazole (Nizoral)
  • Oxiconazole (Oxistat).

If, after 10 to 14 days of treatment with an antifungal product, the rash is not resolving, consider switching to another preparation because Candida resistance can occur.

Nancy Morgan, cofounder of the Wound Care Education Institute, combines her expertise as a Certified Wound Care Nurse with an extensive background in wound care education and program development as a nurse entrepreneur.

Information in Apple Bites is courtesy of the Wound Care Education Institute (WCEI), © 2015.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Clinical Notes



Modified Braden risk score proposed

A study in Ostomy Wound Management states the risk classification of patients using Braden Scale scores should comprise three (rather than five) levels: high risk, with a total score ≤11; moderate risk, with a total score of 12 to 16; and mild risk, with a total score ≥17.

The retrospective analysis of consecutively admitted patients at risk for pressure ulcer to an acute-care facility included 2,625 patients, with an age range from 1 month to 98 years; 3.1% developed a pressure ulcer.

The authors of “A retrospective analysis of pressure ulcer incidence and modified Braden Scale score risk classifications” conclude that the modified Braden Scale “may be more convenient and feasible in clinical practice.”

CN_DialysisAmputations and foot-related hospitalization in dialysis patients

Amputations and foot-related hospitalisations disproportionately affect dialysis patients,” even though the incidence of foot ulcers is the same in dialysis patients and patients with an ulcer history.

The study in International Wound Journal included 150 consecutive patients with diabetes who were on dialysis and 150 patients with a history of foot ulceration. Each patient was followed for 30 months.

CN_FootPlantar shear plays important role in foot ulcers

Considering both plantar shear and pressure, as opposed to pressure alone, is more effective in preventing foot ulcers, according to a study in Diabetes Care.

Peak plantar shear and pressure and foot ulcer locations: A call to revisit ulceration pathomechanics” notes that pressure is a poor predictor of foot ulcer in patients with diabetes, and pressure-reducing therapeutic footwear has minimal effect in preventing recurrent ulceration.

The authors write that their findings indicate that plantar shear has a “clinically significant role in ulceration” and that ulcers at different sites may have different pathologies. They also call for more research on plantar shear.

CN_amputationLower extremity amputation in patients with diabetes

A longitudinal study in Diabetes Care reports that people with diabetes who have undergone lower-extremity amputation “are more likely to die at any given point in time” compared to those who have not experienced amputation.

Diabetes, lower-extremity amputation, and death” notes that complications from diabetes account for only some of the variation.

CN_CPRAHA releases new CPR guidelines

The American Heart Association has published the “2015 Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)” in the journal Circulation. The guidelines recommend chest compressions at a rate of 100 to 120 per minute and to a depth of at least 2 inches (avoiding depths greater than 2.4 inches). Other recommendations include having clinicians perform steps simultaneously to reduce the time to the first chest compression.

Bystanders should use mobile phones to immediately call 911, placing the phones on speaker, so the dispatcher can offer assistance. Untrained bystanders should provide Hands-Only CPR, and bystanders who are trained in CPR should add breaths in a 30:2 compressions-to-breath ratio.

CN_diabetesDiabetes increases risk of fracture

Type 1 diabetes is associated with an increased risk of fracture across the life span: A population-based cohort study using The Health Improvement Network (THIN)” included patients with and without diabetes, who were matched on parameters such as age and sex.

The risk of fracture was lowest in males and females younger than 20 years and highest in men ages 60 to 69, according to the study, which was published in Diabetes Care. Lower extremity fractures accounted for a higher proportion of incident fractures in participants with diabetes compared to those without. Secondary analyses for incident hip fractures identified the highest hazard ratio of 5.64 in men ages 60 to 69 and the highest hazard ratio of 5.63 in women ages 30 to 39.

CN_ostomyNurses play important role in quality of life for ostomy patients

Analysing the role of support wear, clothing and accessories in maintaining ostomates’ quality of life,” published in Gastrointestinal Nursing, notes that nurses with expertise in stoma care can help patients with ostomies achieve optimal quality of life by using their expertise to guide patients in making decisions that will help them return to the activities, sports, hobbies, and lifestyle they enjoyed before surgery.

Liposuction may be helpful for lymphedema

Complete reduction of arm lymphoma following breast cancer—A prospective twenty-one years’ study” concludes that liposuction is effective for treating chronic, nonpitting leg lymphedema in patients who don’t respond to conservative treatment.

The study, published in Plastic and Reconstructive Surgery, included 146 women, with a mean age of 63 and a mean duration of arm swelling of 9 years. It notes that reduced volume is maintained through constant use of compression garments.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.