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Skin substitutes: Understanding product differences

Skin substitutes (also called tissuebased products and dermal replacements) are a boon to chronic wound management when traditional therapies have failed. When selecting skin substitutes for their formularies, wound care professionals have many product options—and many decisions to make.

Repair of skin defects has been a pressing concern for centuries. As early as the 15th century BC, Egyptian physicians chronicled procedures and herbal treatments to heal wounds, including xenografts (skin from another species). The practice of applying allografts (human cadaver skin) to wounds was first documented in 1503. In 1871, autologous skin grafting (skin harvested from the the person with the wound) was tried. Next came epithelial- cell seeding, which involves scraping off the superficial epithelium of healthy skin and transplanting the cells onto the wound.

Today, skin grafting and seeding techniques are used successfully for treating wounds. Autologous grafts are the optimal choice for wound coverage. But availability of skin for harvesting may be limited, particularly in cases of large burns. Also, autograft procedures are invasive and painful.

Allografts and xenografts (for instance, porcine or bovine grafts) may be used as temporary skin replacements. Typically, though, these are later covered by an autograft. Also, they have significant clinical limitations, including immune rejection with allogeneic grafts (grafts from donors who are genetically different from the recipient but of the same species), as well as pain, scarring, slow healing, and infection.

Bioengineered skin substitutes

Bioengineered skin substitutes were created to eliminate certain problems with skin grafts. They’re used to treat non-healing wounds and for soft-tissue grafts in patients with life-threatening full-thickness (third-degree) or deep partialthickness (second-degree) burns, surgical wounds, diabetic foot  ulcers, venous ulcers, and certain other conditions, including epidermolysis bullosa. (See Skin substitutes for chronic wounds.)

Bioengineered skin substitutes contain live human cells that are seeded onto a matrix and provided with the proteins and growth factors needed to grow and multiply into the desired tissue. Various biosynthetic and tissue-engineered human skin equivalents are manufactured under an array of trade names and marketed for various purposes. Because these products are procured, produced, manufactured, or processed in different ways, they can’t be evaluated as equivalent.

Bioengineered skin substitutes fall into five classifications:

cultured epithelial autografts

human skin allografts derived from donated human cadaver tissue

allogenic matrices derived from human neonatal fibroblasts

composite matrices derived from human keratinocytes, fibroblasts, and bovine or porcine collagen

acellular matrices derived from porcine or bovine collagen.

Some skin substitutes also possess unique regenerative properties. For instance, an allograft made of amniotic membrane and umbilical cord (NEOX®, made by Amniox Medical) exhibits the same biology responsible for propagating fetal regenerative and scarless wound healing. When transplanted into the adult wound environment, these placental tissues modulate inflammation and promote healing.

In a 2016 study of 32 diabetic foot ulcers by Raphael, an average of 1.68 NEOX applications resulted in a healing rate of 87.5%. A 2016 study by Caputo et al found that an amniotic membrane/umbilical cord allograft proved effective in treating complex diabetic foot ulcers with osteomyelitis; patients had a 78.8% healing rate after an average of 1.2 applications. In contrast, a 2002 study by Margolis et al found that only 32% of diabetic foot ulcers healed within 20 weeks of standard-of-care therapy (debridement, dressings, and topical ointment).

Choosing skin substitutes

Efficacy of skin substitutes varies widely in terms of the number of applications needed to close a wound, healing rates, and healing times. Dehydrated amniotic skin substitutes are convenient to store and use, but are less potent than cryopreserved amniotic/umbilical cord skin substitutes, which better preserve the structure and key biological signaling of fetal tissues to quickly promote revascularization in the adult wound bed. Choosing the skin substitute to match the desired clinical outcome is crucial. In addition, Medicare coverage varies considerably by region. (See How Medicare reimburses for skin substitutes.)

Ease of use and storage

Some skin substitutes require more maintenance than others, potentially leading to product waste if storage conditions aren’t  optimal. For example, tissue-based products containing live cells have stringent shipping and application requirements; they’re shipped on dry ice and the patient must receive the graft within hours after the product arrives at the wound center. During an ice storm in Dallas, a truck delivering a tissuebased skin substitute for one of our patients had to wait out the storm on the side of the road; the patient cancelled his appointment due to impassable roads. By the time the patient rescheduled and the truck arrived with the skin substitute, the product was no longer usable and had to be thrown out.

In contrast, a skin substitute that remains stable in a wound center’s refrigeration unit is available when the patient needs it, so treatment can start sooner than with a product that has a narrow window for use. For instance, NEOX can be refrigerated safely at temperatures ranging from -112° to 39° F (-80° to 3.8° C) for up to 2 years without structural or functional compromise. If the product isn’t opened, it can be exposed to room temperatures of 68° to 77° F (20° to 25° C) for up to 6 hours and safely returned to cold storage. NEOX is the only cryopreserved amniotic membrane product that doesn’t need to be stored in a deep freezer.

Also, skin substitutes that require extensive preparation consume precious staff resources. One product, for example, needs to be washed in water at a temperature not exceeding 43° F (6.1 °C) before it can be applied to a patient’s wound. This requires an extraordinary effort for personnel in a busy wound clinic. Skin substitutes that can be exposed to room temperature before use are much more convenient and eliminate the need for special equipment, such as thawing tubs.

Disadvantages of skin substitutes

As an advanced tissue treatment modality, skin substitutes are more expensive than conventional wound dressings and may have more complex storage and preparation requirements. To prevent waste, clinicians should choose a product that can be stocked in a range of sizes. Some substitutes are available only in small or very large sizes, which don’t conform to most wounds; this means the wound center ends up paying for the excess product it must throw away.

Also consider how many times a skin substitute will need to be placed on a patient’s wound before it closes. One that needs to be applied only twice is more cost effective than a less expensive one that requires multiple applications. n

Myra Varnado is director of Clinical Wound and Ostomy Services for Corstrata, a national telemedicine company in Savannah, Georgia. Since 2000, she has been a member of the Wound Guidelines Task Force for the Wound, Ostomy and Continence Nurses Society (WOCN). Varnado is a primary author of WOCN’s guideline for management of wounds in patients with lower-extremity neuropathic disease. She is also a speaker and consultant for Amniox Medical, Inc., which markets the NEOX line of products.

Selected references

Amin N, Doupis J. Diabetic foot disease: from the evaluation of the “foot at risk” to the novel diabetic ulcer treatment modalities. World J Diabetes. 2016;7(7):153-64.

Calota DR, Nitescu C, Florescu IP, et al. Surgical management of extensive burns treatment using allografts. J Med Life. 2012;5(4):486-90.

Caputo WJ, Vaquero C, Monterosa, A et al. A retrospective study of cryopreserved umbilical cord as an adjunctive therapy to promote the healing of chronic, complex foot ulcers with underlying osteomyelitis. Wound Repair Regen. 2016;24(5):885-93.

Cooke M, Tan EK, Mandrycky C, et al. Comparison of cryopreserved amniotic membrane and umbilical cord tissue with dehydrated amniotic membrane/ chorion tissue. J Wound Care. 2014;23(10):465-74, 476.

Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society® Core Curriculum: Wound Management. Philadelphia, PA: Wound, Ostomy and Continence Nurses Society; 2015.

Halim AS, Khoo TL, Mohd, et al. Biologic and synthetic skin substitutes: an overview. Indian J Plast Surg. 2010;43(Suppl):S23-8.

Hill-Rom. 2016 International Pressure Ulcer Prevalence (IPUP) Survey. 2016.

Margolis DJ, Allen-Taylor L, Hoffstad O, et al. Diabetic neuropathic foot ulcers. Diabetes Care. 2002; 25(10):1835-9.

Nathoo R, Howe N, Cohen G. Skin substitutes: an overview of the key players in wound management. J Clin Aesthet Dermatol. 2014;7(10):44-8.

National Pressure Ulcer Advisory Panel. NPUAP Pressure Injury Stages. 2016.

Raphael A. A single-centre, retrospective study of cryopreserved umbilical cord/amniotic membrane tissue for the treatment of diabetic foot ulcers. Wound Care. 2016;25(Suppl 7):S10-7.

Lymphedema and lipedema: What every wound care clinician should know

Imagine you have a health condition that affects your life every day. Then imagine being told nothing can be done about it; you’ll just have to live with it. Or worse yet, your physician tells you the problem is “you’re just fat.”

Many people with lymphedema or lipedema have no idea their condition has a name or that many other people suffer from the same thing. Although lymphedema and lipedema can’t be cured, proper management and resources can help patients cope. This article improves your grasp of these conditions, describes how to recognize and manage them, and explains how to support your patients.

To understand lymphedema and lipedema, first you need to understand how the lymphatic system functions. It makes lymph, then moves it from tissues to the bloodstream. It also plays a major role in the immune system, aiding immune defense. In addition, it helps maintain normal fluid balance by promoting fluid movement from the interstitial tissues back to the venous circulation. (See Lymphatic system: Four major functions.)

If the lymphatic system is impaired from a primary (hereditary or congenital) condition or a secondary problem, lymphedema can result. In this chronic, potentially progressive, and incurable condition, protein-rich fluid accumulates in the interstitial tissues.

Lymphedema basics

Lymphedema occurs in four stages.

Stage 0. During this stage (also called the subclinical or latency stage), transport capacity of the lymphatic system decreases but remains sufficient to manage normal lymphatic loads. Signs and symptomsaren’t evident and can be measured only by sensitive instruments, such as bioimpedance spectroscopy and optoelectronic volumetry. Without such instruments to quantify volume changes, diagnosis may rest on subjective complaints.

In this stage, limited functional reserve of the lymphatic system leads to a fragile balance between subnormal transport capacity and lymphatic loads. Added stress on the lymphatic system (as from extended heat or cold exposure, injury, or infection) may cause progression to stage 1.

Providing appropriate patient information and education, especially after surgery, can dramatically reduce the risk that lymphedema will progress to a more serious stage.

Stage 1. Considered the spontaneously reversible stage, stage 1 is marked by softtissue pliability without fibrotic changes. Pitting can be induced easily. In early stage 1, limb swelling may recede over – night. With proper management, the patient can expect the extremity to decrease to a normal size compared to that of the uninvolved limb. Otherwise, lymphedema is likely to progress to stage 2.

Stage 1 lymphedema may be hard to distinguish from edemas from other causes. Clinicians must rely on the patient history and monitor for swelling resolution with conventional management, such as compression and elevation, or note if swelling persists despite these standard interventions.

Stage 2. Sometimes called the spontaneously irreversible stage, stage 2 is identified mainly from tissue proliferation and subsequent fibrosis (called lymphostatic fibrosis). The fluid component can be removed spontaneously, but removal of the increased tissue proliferation (initially irreversible) takes more time. Tissue proliferation stems from long-standing accumulation of protein-rich fluid; over time, the tissue hardens and pitting is hard to induce. In many cases, swelling volume increases, exacerbating the already compromised local immune defense.

Consequently, infections (particularly cellulitis) are common; these, in turn, increase the volume of the affected area. Proper treatment can reduce volume.

With proper care (complete decongestive therapy [CDT]), lymphedema can stabilize during stage 2. But patients with chronic or recurrent infections are likely to progress to stage 3.

Stage 3. Also called lymphostatic elephantiasis, this stage is marked by further fluid volume increases and progression of tissue changes. Lymphostatic fibrosis becomes firmer and other skin alterations may occur, including papillomas, cysts, fistulas, hyperkeratosis, fungal infections, and ulcers. Pitting may be present. Natural skinfolds deepen (especially those of the dorsum of the wrist or ankle) and, in many cases, cellulitis recurs.

If lymphedema management starts during this stage, reduction can still occur. Even in extreme cases, with proper care and patient adherence to treatment, lymphostatic elephantiasis can be reduced so the leg is a normal or near-normal size.

Assessment and diagnosis

A thorough physical examination is the gold standard for diagnosing lymphedema. A complete patient history, body-systems review, inspection, and palpation can help determine if edema is lymphedema.

Clinically, the only test with proven reliability and validity in diagnosing lymphedema is the Stemmer sign. Fibrotic changes associated with lymphedema can lead to thickened skin over the proximal phalanges of the toes or fingers. If you can’t tent or pinch the skin on the involved extremity, lymphedema is present (a positive Stemmer sign). However, a negative finding (soft, pliable tissue) doesn’t rule out  lymphedema because the condition may be in an early stage, before tissue proliferation and fibrosis have set in.


Although incurable, lymphedema can be managed successfully through CDT. This approach involves proper identification of lymphedema, manual lymph drainage, skin and nail care, patient education, compression, and exercise.

CDT has two phases:

Phase I, the intensive phase, continues until the extremity has decongested or reached a plateau. The clinician provides treatments and educates the patient about all aspects of CDT to prepare him or her for phase II. Phase I can last several weeks to several months depending on lymphedema severity.

Phase II, the maintenance phase, begins once the extremity has decongested or plateaued. This phase still focuses on CDT, but now the patient, not the clinician, is responsible for all care. The goal is to reduce limb size while enabling the patient to become self-sufficient in managing lymphedema. Although CDT can bring significant improvements in limb size, skin quality, and function, patients must remember that phase II continues lifelong. Be sure to provide education about ongoing self-management strategies.

Lipedema: The disease they call “fat”

Lipedema is a painful disorder of fat deposition. Pathologic deposition of fatty tissue (usually below the waist) leads to progressive leg enlargement. Like lymphedema, lipedema is incurable but manageable. Unless managed properly, lipedema can reduce mobility, interfere with activities of daily living, and lead to secondary lymphedema. (See Lipedema stages.)

Lipedema commonly is misdiagnosed as lymphedema. However, lymphedema involves protein-rich fluid, whereas lip edema is a genetically mediated fat disorder. Because lipedema resists diet and exercise, it can lead to psychosocial complications. Lipedema occurs almost exclusively in women; typically, onset occurs between puberty and age 30. One unpublished epidemiologic study puts lip edema incidence in females at 11%. Some patients have a combination of lipedema and lymphedema. (See Viewing lipolymphedema.)

Assessment and diagnosis

As with lymphedema, lipedema diagnosis rests on clinical presentation. Lipedema characteristics include bilateral and symmetrical involvement, absence of pitting (because lipedema isn’t a fluid disorder), soft and pliable skin, and filling of the retromalleolar sulcus (called the fat pad sign.)

Key signs and symptoms include:

• feeling of heaviness in the legs (aching dysesthesia)

• easy bruising

• sensitivity to touch (called “painful fat syndrome”)

• orthostatic edema

• oatmeal-like changes to skin texture.

Nearly half of lipedema patients are overweight or obese, but many appear of normal weight from the waist up. Essentially, the upper and lower extremities don’t match. The lower extremities typically show fatty deposits extending from the iliac crest to the ankles, sparing the feet. (See Lipedema patterns.)


Lipedema is best  managed through weight control, as additional weight gain through adipose tissue tends to deposit in the legs. For patients with concomitant lymphedema (lipolymphedema), modified CDT helps reduce and manage lymphatic compromise. To address excess fat deposition, newer “wet” liposuction techniques have proven beneficial. These techniques gently detach adipose cells from the tissue, helping to preserve connective tissue and lymphatic vessels.

Know what to look for

In both lymphedema and lipedema, early identification and proper diagnosis are key. (See Differentiating lymphedema and lipedema.) A thorough history and physical exam will likely lead to an accurate diagnosis, if clinicians know what to look for. Proper diagnosis and treatment can prevent expensive and ineffective interventions, which can negatively affect both the patient’s condition and psychological well being.

Heather Hettrick is an associate professor at Nova Southeastern University, Department of Physical Therapy in Fort Lauderdale, Florida.

Selected references

Fat Disorders Research Society. Lipedema description.

Fife CE, Maus EA, Carter MJ. Lipedema: a frequently misdiagnosed and misunderstood fatty deposition syndrome. Adv Skin Wound Care. 2010;23(2):81-92

Herbst KL. Rare adipose disorders (RADS) masquerading as obesity. Acta Pharmacol Sin. 2012;33(2):155-72.

Lipedema Project.

National Lymphedema Network. Position papers.

Schmeller W, Hueppe M, Meier-Vollrath I. Tumescent liposuction in lipoedema yields good long-term results. Br J Dermatol. 2012;166(1):161-8.

Zuther J. A closer look at lipedema and the effects on the lymphatic system. December 13, 2012. lymphedemablog.com/2012/12/13/a-closer-look-at-lipedema-and-the-effects-on-the-lymphatic-system/

Zuther J. Stages of lymphedema. October 3, 2012.

Clinician Resources

Wound patient’s bill of rights

The Association for Advancement of Wound Care has developed the “Wound Care Patient’s Bill of Rights.” The 10 points include the right to:

know what wound treatment options are available to you

know the benefits, risks, and side effects of your wound care treatments

participate in the development of your treatment plan with your wound care team

have your pain adequately controlled.

The bill of rights is available in both English and Spanish.

Infection prevention brochure

Win the Battle Against Infection,” from the Association for Advancement of Wound Care, is an ideal tool for enlisting patients in the effort to prevent infection. The bro – chure, which can be downloaded as a PDF at no charge, answers questions such as:

What is a wound infection?

What does a wound infection look and feel like?

Is my wound infected?

The brochure also provides:

strategies for preventing infection. Handwashing is well covered, with step-by-step instructions.

instructions on when to contact the healthcare provider, for example, “if you have uncontrolled bleeding from your wound.”

Healthy feet

The Canadian Association of Wound Care devotes a section of its website to “Diabetes, healthy feet, and you.”

One particularly valuable section is Your personal foot care plan,” which includes two forms that can be downloaded:

Steps for healthy feet checklist

Your personal plan for change.

Patients who access the information online can follow easy instructions to enlarge the text—helpful for those with impaired vision.

Preventing falls at home

Clinicians who work with older patients in the home setting may want to pass along resources to prevent falls from the Centers for Disease Control and Prevention. These include:

“What you can do to prevent falls,” available in English, Spanish, and Chinese

“Check for safety,” which patients can use to identify and eliminate fall hazards in their home.

Medication guides

Patients can download PDFs of medication guides from the Food and Drug Administration website.

The guides are written in patient-friendly language and contain tips that can help patients avoid serious adverse events.

Practicing emotional intelligence may help reduce lateral violence

It’s been a stressful day at work—nothing new. One confused patient pulled off her ostomy bag, you’re having difficulties applying negative-pressure wound therapy on another, and a third patient’s family is

angry with you. We all experience stressful days, but unfortunately, sometimes we take our stress out on each other. Too often, this ineffective way of identifying and managing stress leads nurses to engage in lateral violence.

Lateral violence is identified and described by the American Nurses Association as acts between colleagues that include covert or overt aggression. These acts of displaced stress can create a tense work environment and psychological anguish, and may even lead some clinicians to quit their jobs or abandon their profession all together. The unnecessary outcomes of lateral violence require that we, as professionals, proactively seek out meaningful methods to identify and reduce its formation and occurrence. The first step in this endeavor is to examine and develop our emotional intelligence (EI).

What is EI?

EI is the ability to understand and control our own emotions while reading and adjusting to the emotions of others. The behaviors and traits of people who have high EI levels are also those of people who are less likely to engage in lateral violence. There are other benefits, too. For example, a study conducted with ICU nurses demonstrated that EI education increased nurses’ general health.

Improving EI skills

A study by Sharif and colleagues reported that EI can be taught, meaning we all have the potential to increase our self-awareness, self-regulation, and empathy. Strengthening these aspects of EI can help us to not only understand ourselves, but also how our emotions impact our colleagues.

The first step is to educate ourselves about EI. Next, we must adapt our daily culture to incorporate EI into our practice. Clinicians are, after all, nothing if not adaptable. We have gone from paper charting to electronic charting, from wet-to- dry dressings to better wound care options, and from provider-centered interventions to patient-centered, evidence-based practice.

This adaptation requires the use of three tools: purposeful reflection, improvisation, and empathy.

Purposeful reflection

Self-awareness occurs when we engage in purposeful reflection, viewing a situation from multiple angles with the intent to learn and improve decision making. Take a moment to think about a recent situation when an interaction or conversation did not go well. What started it? What were you feeling at the time? Did you have a long day at work? Did you expect this person to say something you didn’t want to hear? Did someone approach you and demand an immediate conversation?

Now remove yourself from that moment and think of yourself as another person looking in. If you removed the emotions, what was that conversation truly about? Was fear involved? Were you put in a situation that should have been handled at another time? Reflecting purposefully on the situation enables you to recognize the irrational responses.

Purposeful reflection also enables you to identify negative patterns, called triggers. Learning to recognize triggers may prevent unfavorable situations or reactions. Purposeful reflection, when done consistently, will aid in reducing negative energy, cut short the conflict, and possibly prevent tense situations. Once you make purposeful reflection a habit, you can then use improvisation to process conflicts on the spot and provide thoughtful feedback.

Improvisational skills

Applying improvisation skills can help us to control our emotions and can teach us to notice the difference between reactive words and thoughtful words. Here are the steps of improvisation in a situation:

1. Be present in the conversation. This can be achieved by counting to 10 before speaking. Counting to 10 releases the limbic system of the body from the flight or fight emotion, so we can be more thoughtful.

2. Listen to the other person in the situation.

3. Eliminate bias and establish an objective or overall goal for the situation. For example, in nursing we may need to stop thinking how the situation affects us and think about how it affects the patient.

4. Be encouraging even if you don’t agree with someone. Try to find a positive spin on another person’s view before sharing your own opinions.

5. Seek to provide the necessary feedback that will allow the other person to walk away knowing they were heard, whether or not an agreement was made.

Once you’ve honed the tools of purposeful reflection and improvisation, you can develop a stronger sense of empathy.


Empathy, the process of walking in another’s shoes, moves us away from focusing on ourselves and towards thinking about the needs of others. It is a fundamental aspect of social interaction. As nurses, we consistently do this with our patients, but rarely do it with our coworkers. If the previous shift’s staff caused a problem that you want to discuss with them, you must protect yourself from letting your emotions become reactive and ask yourself, “Why am I so angry?” Empathy begins with listening. Begin to discuss the situation with the nurse from the last shift by asking an open-ended question. For example say, “How was your night?” Then listen: Your coworker may share that he or she had a significant problem on the shift. Follow through with the conversation to better understand why this coworker was unable to complete a task or complete a task correctly. Do not listen to solve a problem or to think about how this affects you, but rather listen with an open mind as it may present an opportunity to learn or an opening to pose clarifying questions.

An agent of change

By developing and sharing the tools of EI—purposeful reflection, improvisation, and empathy—you can be an agent of change. Being a leader has many challenges, but when others see how calmly you manage yourself, aggressive coworkers, and tense situations, they will be inspired.

Tara Slagle is a course mentor for Western Governor’s University in Salt Lake City, Utah, and a clinical educator at Hanover Hospital in Hanover, Pennsylvania.

Selected references

American Nurses Association. Bullying and workplace violence. 2015.

Caldwell L, Grobbel C. The importance of reflective practice in nursing. Int J Caring Sci. 2013;6(3):319-26.

Martos M, Lopez-Zafra E, Pulido-Martos M, et al. Are emotional intelligent workers also more empathic? Scand J Psychol. 2013;54(5):407-14.

Sharif F, Rezaie S, Keshavarzi S, et al. Teaching emotional intelligence to intensive care unit nurses and their general health: a randomized clinical trial. Int J Occup Environ Med. 2013;4(3):141-8.

Understanding NPUAP’s updates to pressure ulcer terminology and staging

On April 13, 2016, the National Pressure Ulcer Advisory Panel (NPUAP) announced changes in pressure ulcer terminology and staging definitions. Providers can adapt NPUAP’s changes for their clinical practice and documentation, but it’s important to note that, as of press time, the Centers for Medicare & Medicaid Services (CMS) has not adopted the changes. This means that providers can’t use NPUAP’s updates when completing CMS assessment forms, such as the Minimum Data Set (MDS) or Outcome and Assessment Information Set (OASIS). Instead, they must code the CMS assessment forms according to current CMS instructions and definitions. In addition, there is no ICD-10 code for pressure injury.

In a nutshell

Here are the key overall changes made by NPUAP:

The term “pressure injury” replaces “pressure ulcers.”

Arabic numbers replace Roman numerals in the names of the stages.

The term “suspected” has been removed from the Deep Tissue Injury diagnostic label.

Additional pressure injury definitions were added for medical device related pressure injury and mucosal membrane pressure injury.

The staging system definitions were updated. The NPUAP updated terminology and staging system definitions are listed below.

Pressure injury

A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue.

Stage 1 pressure injury: Non-blanchable erythema of intact skin

Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Stage 2 pressure injury: Partial-thickness skin loss with exposed dermis

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an in tact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical-adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

Stage 3 pressure injury: Full-thickness skin loss

Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury.

Stage 4 pressure injury: Full-thickness skin and tissue loss

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is anunstageable pressure injury.

Unstageable pressure injury: Obscured full-thickness skin and tissue loss

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed.

Deep tissue pressure injury: Persistent non-blanchable deep red, maroon, or purple discoloration

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage 3, or stage 4). Do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic, or dermatologic conditions.

More definitions

Below are additional pressure injury definitions.

Medical-device related pressure injury:

This describes an etiology. Medical-device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant  pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

Mucosal membrane pressure injury:

Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue, these injuries cannot be staged.

Next steps

Providers should carefully consider how these changes will affect their clinical and reimbursement systems. It’s important to tell staff what definitions and terminology the organization will use for clinical practice, documentation, and completing CMS-mandated assessment forms.

Access free resource: staging illustrations from the NPUAP website.

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

Selected reference

National Pressure Ulcer Advisory Panel. National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. April 13, 1016.

Preparing the wound bed: Basic strategies, novel methods

The goal of wound-bed preparation is to create a stable, well-vascularized environment that aids healing of chronic wounds. Without proper preparation, even the most expensive wound-care products and devices are unlikely to produce positive outcomes.

To best prepare the wound bed, you need to understand wound healing physiology and wound care basics, as well as how to evaluate the patient’s overall health and manage wounds that don’t respond to treatment. (See Normal wound healing.)

Basic wound care: DIME

To choose the right method of wound-bed preparation for a particular wound, first assess your patient’s condition, wound history, physical wound characteristics, and availability of resources. Local wound-bed preparation factors can be summarized by the acronym DIME—Debridement, Infection or Inflammation, Moisture balance, and Epithelial advancement. These four components address the various pathophysiologic abnormalities underlying chronic wounds.

D: Debridement

Nonviable tissue must be debrided because cell debris impairs healing. Research and clinical evidence show that debriding necrotic or fibrous tissue accelerates wound healing. (See Types of debridement.)

I: Infection or inflammation

Bacterial load directly impacts wound-bed preparation. Assess and treat the patient’s wound for superficial or serious infection, persistent inflammation, extensive colonization, and cellulitis. With infection or inflammation, wound healing stalls because the extracellular matrix and growth factors degrade more rapidly than they synthesize, impeding progression toward the proliferative phase and ultimately affecting re-epithelialization. Managing the bacterial load with local or systemic therapy is crucial to wound-bed preparation.

M: Moisture balance

Appropriate moisture promotes the action of growth factors and cytokines and aids migration of cells, including fibroblasts and keratinocytes. However, attaining a moisture balance is challenging. Excessive moisture can damage the wound bed and surrounding skin, leading to maceration and skin breakdown. Inadequate moisture, on the other hand, can impede cellular activities and promote eschar, resulting in poor wound healing.

Be sure to evaluate the patient’s nutritional status, cardiac and peripheral vascular status, and renal function. Check for risk factors that can cause moisture imbalance. Then identify an appropriate treatment plan. To increase compliance, explain planned interventions to patients and their caregivers. The typical plan includes medical wound management strategies, such as manual lymph drainage, compression devices and garments, absorptive dressings, and negative pressure wound therapy.

E: Epithelial advancement

Cellular dysfunction and biochemical imbalance can stall wound-bed progression by impeding epidermal cell and keratinocyte migration. Migration of epidermal cells and keratinocytes indicates the wound bed is adequately prepared. Wound contraction is another key sign of an adequately prepared wound bed.

Assessing the patient’s overall health

Remember—you must treat the patient before you can treat the wound. Especially with difficult wounds, multiple comorbidities can delay or interrupt re-epithelialization. Adequate nutrition and smoking cessation are especially important. (See How smoking and poor nutrition impair wound healing.)

Checking for wound-specific problems

Assess the patient for two wound-specific problems—biofilms and abnormal matrix.

Biofilms delay wound healing by creating a host-pathogen environment that promotes cohabitation of many bacterial species and anaerobes. These bacteria promote their own survival within the wound environment. Elderly patients and those with complex diseases, diabetic foot ulcers, venous leg ulcers, or pressure ulcers may develop extensive bacterial populations. That’s why restoring bacterial balance is important in managing chronic wounds. Techniques for managing biofilms effectively include use of topical agents or systemic antibiotics and regular maintenance debridement.

Abnormal matrix can develop in chronic wounds containing proteases that digest fibronectin and growth factors in the fibrin clot, causing a degraded matrix that no longer supports re-epithelialization or formation of granulation tissue.

Managing wounds unresponsive to treatment

Cells in chronic wounds become unresponsive, unable to divide or respond to such messengers as cytokines and growth factors. This results in phenotypic dysregulation. For successful wound-bed preparation, options may include bioengineered skin-cell therapy, stem-cell therapies, and platelet-rich plasma (PRP) for cutaneous wounds.

Bioengineered skin-cell therapy

Bioengineering treatments have provided viable therapeutic options, especially in managing chronic or difficult-to-heal wounds. Bioengineered skin and soft-tissue substitutes can be acellular or cellular.

Acellular products contain a matrix or scaffold composed of such materials as collagen, hyaluronic acid, and fibronectin. These products differ in various ways, including:

species source (human, bovine, or porcine)

tissue source (such as dermis, pericardium, or intestinal mucosa)

additives (for instance, antibiotics or surfactants)

hydration (wet or freeze-dried)

required preparation (multiple rinses or rehydration).

Cellular products contain living cells, such as fibroblasts and keratinocytes within the matrix. Cells within the matrix may be autologous, allogeneic, or derived from other species (such as sheep or pigs). Skin substitutes also may be composed of dermal cells, epidermal cells, or a combination and may provide growth factors to stimulate healing. Topical growth factors are used as an adjuvant treatment to such therapies as debridement, off-loading, frequent dressing changes, and compression of wounds caused by vascular insufficiency

Stem-cell therapy

Use of stem cells in tissue regeneration has significant potential in cutaneous wound-bed preparation. Stem cells act in several ways to aid wound repair; in chronic wounds, they  could serve as an additional tool for therapeutic augmentation. This combined mode of repair and regeneration probably explains why cell therapies are more effective than simpler alternatives, such as direct growth-factor therapy treatment.


Multiple studies since the 1990s have shown promising results for PRP. For instance, researchers found PRP gel accelerates bone regeneration and studies confirmed the presence of specific platelet-derived growth factor receptors (PDGFs) in bone tissue. Research has uncovered strong evidence that these therapies are effective.

The PRP gel aids molecular and cellular induction of normal wound-healing responses, similar to platelet activation. In addition, PRP contains several growth factors and other cytokines that stimulate healing of bone and soft tissues. Autologous PRP is an advanced wound therapy used for hard-to-heal acute and chronic wounds.

Growth factors such as topical PDGF can help correct matrix abnormalities of growth factors. Also, studies have found that accelerated wound healing follows topical application of epidermal growth factor derived from the patient’s own cultured keratino cytes, delivered in a fluid compress.

A systematic approach

When preparing the patient’s wound bed and managing the wound, use a systematic approach that helps remove barriers to healing. Proper preparation helps ensure optimal patient outcomes.

Kulbir Dhillon is a nurse practitioner and wound care specialist with VA HBPC in Sacramento, California.

Selected references

Falanga V. Wound bed preparation: science applied to practice. In: Wound Bed Preparation in PracticeEWMA Position Document. London: Medical Education Partnership Ltd;2004;2-5.

Fitzgerald RH, Armstrong DG. Palliative advanced wound care. Vein Mag. 2009;2(2):44-6.

Harris RJ. The nursing practice of conservative sharp wound debridement: promotion, education and proficiency. Wound Care Canada. 2009;7(1):22-30.

Hess CT. Checklist for factors affecting wound healing. Adv Skin Wound Care. 2011;24(4):192.

Knox KR, Datiashvili RO, Granick MS. Surgical wound bed preparation of chronic and acute wounds. Clin Plast Surg. 2007;34(4):633-41.

Laplaud AL, Blaizot X, Gaillard C, et al. Wound debridement: comparative reliability of three methods for measuring fibrin percentage in chronic wounds. Wound Repair Regen. 2010;18(1):13-20.

Ligresti C, Bo F. Wound bed preparation of difficult wounds: an evolution of the principles of TIME. Int Wound J. 2007;4(1):21-9.

Mustoe TA, O’Shaughnessy K, Kloeters O. Chronic wound pathogenesis and current treatment strategies: a unifying hypothesis. Plast Reconstr Surg. 2006;117(7 Suppl):35S-41S.

Opletalová K, Blaizot X, Mourgeon B, et al. Maggot therapy for wound debridement: a randomized multicenter trial. Arch Dermatol. 2012;148(4):432-8.

Panuncialman J, Falanga V. The science of wound bed preparation. Surg Clin North Am. 2009;89(3):611-26.

Paul AG, Ahmad NW, Lee HL, et al. Maggot debridement therapy with Lucilia cuprina: a comparison with conventional debridement in diabetic foot ulcers. Int Wound J. 2009;6(1):39-46.

Payne WG, Salas RE, Ko F, et al. Enzymatic debriding agents are safe in wounds with high bacterial bioburdens and stimulate healing. Eplasty. 2008;7;8:e17.

Sardina D. Wound bed preparation. In: Skin and Wound Management Course Workbook. Lake Geneva, WI: Wound Care Education Institute; August 2010;5:42-58.

Sibbald RG, Goodman L, Woo KY, et al. Special considerations in wound bed preparation 2011: an update. Adv Skin Wound Care. 2011;24(9):415-36.

Sibbald RG, Orsted HL, Schultz GS, et al. Preparing the wound bed 2003: focus on infection and inflammation. Ostomy Wound Manage. 2003;49(11):23-51.

Wolcott RD, Rumbaugh KP, James G. Biofilm maturity studies indicate sharp debridement opens a time-dependent therapeutic window. J Wound Care. 2010;19(8):320-8.

Who can perform sharp wound debridement?

Nurses and therapists often wonder if their license permits them to perform sharp wound debridement. Scope of practice varies significantly from state to state, so it’s imperative to check your state for specific guidance, but we can address some of the challenges clinicians face in deciding whether they can perform this valuable service for patients.

Sharp debridement vs. other forms

In general, clinicians can perform wound debridement using mechanical, enzymatic, chemical, biological, and autolytic means as long as their scope of practice includes wound care. These noninvasive forms of debridement aren’t highly technical, so they don’t require a specific skill set.

In contrast, sharp debridement is an invasive procedure and requires the ability to use scalpels, sharp curettes, and scissors safely and effectively. This type of debridement is divided into two types — surgical and conservative. Surgical sharp debridement refers to debriding “into” viable tissue, while conservative sharp debridement refers to “up to” viable tissue.

Scope of practice

In all states, surgical and conservative debridement fall under the scope of practice for physicians, nurse practitioners, and physician assistants. Physical therapists, physical therapy assistants, occupational therapists, certified occupational therapy assistants, and nurses (both registered nurses and licensed practical/vocational nurses) are allowed to perform conservative sharp debridement in some, but not all, states.

What if you are licensed in a state that doesn’t address if you can perform sharp debridement? In this situation, you should use a decision tree or algorithm to determine whether you can proceed. Some questions to ask are:

Did my wound care training prepare me for debridement and am I competent to provide this service? Remember that in addition to the skill, you need to know how to manage the patient’s pain and bleeding.

Will I be providing this service under the supervision of a prescribing clinician who has expertise in debridement?

Does my facility allow me to perform this procedure? (See Sharp debridement policies and procedures.)

The answers will help you make the best decision for you and your patient.

For more information or examples of policies, email the authors at cutabove@sharpdebridement.com. You can also download a sample policy

Bill Richlen is the owner of Infinitus, LLC, in Santa Claus, Indiana. Denise Richlen is an area manager for Paragon Rehabilitation.

Note: This article is intended to provide general information. For specific legal questions, contact an attorney.

Balancing the wheels of life

Have you ever ridden a bicycle with a wobbly wheel? The ride isn’t smooth, and you notice every bump in the road. As you focus on your discomfort, you may be distracted from the beautiful vistas you’re riding past.

Think of the bicycle as your overall health, which carries you through life. For most of us, learning how to ride a bike begins in childhood as we learn to control the wheels. But with more wear and tear on the bike, the once-pleasant ride becomes uncomfortable and sometimes out of balance.

As clinicians, we need not just to practice riding our own bicycles gracefully, but also to care for our patients’ worn and hurt bikes. Only by being balanced yourself can you truly help another. Living a balanced, healthy life means finding joy in the journey. Unfortunately, our mortal existence comes with bumps in the road. In our fast-paced society that requires us to juggle family, professional, and other demands, many of us seem compelled to ride faster. But this may not be effective or productive—and it can lead to distress.

The wheel as metaphor

One way to find a balance is to examine the wheels that carry you through life. Each wheel has many spokes; think of the section within each spoke as one of the areas of life that together make up your whole well-being. One section represents your physical health and the others your spiritual, mental, social, environmental, financial, recreational, and emotional health.

Now imagine the center of each spoke is a zero and the outer rim is a 10; from the center to the rim, the numbers increase. How would you rank yourself in each area of life, with 0 representing the lowest ranking and 10 the highest? Put a dot on the number that represents how strong you think you are in each area of your life. Giving each section a numeric value helps you identify problems so you can move toward a plan for improvement. For most people, the numbers will vary from section to section, because most of us feel stronger in some areas of life than in others.

Next, connect the dots around your wheel to see how bumpy the wheel is. If you assigned a 4 to some parts of your life but gave others a 2 or an 8, the connected dots would create an irregular wheel. When you look at your wheel as a whole, you’re examining how bumpy or out of balance  your life may be. With this wheel, would your ride through life be smooth or bumpy? Using this tool can help you identify why your ride seems out of balance and can pinpoint which areas need improvement.

Using SOAP to clean your bike

Clinicians often use the acronyms SOAP and SOAPIER to guide the nursing or patient care process.

SO stands for subjective and objective data—the process of collecting important information about a potential or real problem.

A stands for assessment, the second step. Being able to label a problem helps you recognize the reality of your situation.

With that information, you can create a plan, represented by P, to address the problem.

The additional steps of intervention, valuation, and reevaluation (the IER of SOAPIER) can guide you through the cyclic nature of the process.

Improving the numbers on your wheel

Similarly, we can keep ourselves in balance by using the patient care process on our wheels—and by extension, ourselves. During the assessment step, examine the ratings you gave to each wheel section to gauge the status of each area of your life. Then ask yourself the following questions:

What would it take for me to move from a 4 to a 5, or from a 6 to a 7, in this area?

What one action could I take today to improve this rating?

Am I willing to do this?

What are the barriers to improving my rating in this area?

What resources do I have or need to have to improve the rating in this area?

Joy in the journey

By using the SOAP process on your own wheels that carry you through life, you can make your ride less jarring. When we’re in balance, our ride through life is much smoother and we can enjoy the journey more. When you’re balanced and stable, you can run aside the wobbly bikes of struggling patients—and use the bicycle analogy to help them identify imbalances in their own health and lives.

Holistic practice helps individuals find meaning and balance in their lives. Health is more than just absence of disease. It refers to our emotional, physical, spiritual, social, and environmental well-being. A problem in any one area can affect the whole.

Striving for balance in life is a constant challenge. The terrain changes with the seasons and demands of life. Sometimes just keeping perspective on the road ahead helps you realize that despite the hills and valleys, your wheels are in balance and you just need to keep pedaling. By applying the patient care process to ourselves, we can adjust our wheels and better enjoy the ride. Savor the journey.

A certified nurse educator and certified diabetes educator, Tracey Long is also on the faculty of Nevada State College in Las Vegas.

Selected references

American Nurses Association. The Nursing Process.

Julliard K, Klimenko E, Jacob MS. Definitions of health among healthcare providers. Nurs Sci Q. 2006; 19(3):265-71.

Kimsey-House H, Kimsey-House K, Sandahl P, Whitworth L. Co-Active Coaching: Changing Business Transforming Lives. 3rd ed. Boston, MA: Nicholas Brealey America; 2011.

Luck S. Wellness coaching in integrative health care: a holistic nursing perspective. Integrat Practit.

Instill instead: Negative pressure wound therapy with instillation for complex wounds

Negative pressure wound therapy (NPWT) uses negative pressure to draw wound edges together, remove edema and infectious material, and promote perfusion and granulation tissue development. The tissue stretch and compression created by negative pressure during NPWT promotes tissue perfusion and granulation tissue development through angiogenesis, cellular proliferation, fibroblast migration, increased production of wound healing proteins, and reduction of wound area. NPWT has been used to improve healing in a variety of wounds, including traumatic injuries, surgical wounds, pressure ulcers, diabetic foot ulcers, and venous stasis ulcers.

NPWT has now evolved to include automated instillation with dwell time (NPWTi-d, V.A.C. VERAFLO™ Therapy,KCI, an ACELITY Company, San Antonio, TX) that provides wounds with the benefits of both NPWT and wound irrigation. Wound irrigation is an effective, commonly used method to remove debris and infectious material as a means to promote wound healing. This article provides an overview of NPWTi-d.

Support for NPWTi-d

NPWTi-d has been used to treat many different wound types, including traumatic injuries, dehisced surgical wounds, pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and burns. Studies report that NPWTi-d, compared to NPWT alone, decreases the number of surgical debridements, length of hospital stay, and length of treatment. These studies also report improved granulation tissue production and filling of undermined cavities. One study detailed the use of NPWTi-d as adjunctive treatment for bioburden management.

When to use (and not use)

NPWTi-d is primarily indicated for wound cleansing or to promote granulation tissue formation. (See Wound characteristics and NPWTi-d therapy goals.) NPWTi-d is contraindicated for patients with:

• a wound malignancy

• untreated osteomyelitis

• nonenteric and unexplored fistula

• necrotic tissue with eschar.

The treatment also shouldn’t be used with Octenisept® (Schülke and Mayr GmBH, Norderstedt, Germany), hydrogen peroxide, or alcohol-based solutions, or to deliver fluid into the thoracic or abdominal cavity because of the risk to alter core body temperature and cause fluid retention within the cavity. In addition, each wound should be thoroughly explored for intactness before starting NPWTi-d to avoid instilling topical solutions into adjacent body cavities.

Clinical considerations

Several wound irrigation solutions have been recommended for use with NPWTid. (See Instillation therapy settings). Common wound cleansers include normal saline, quarter strength (0.125%) or 0.0125% (one-tenth the concentration of quarter strength due to cytotoxicity) Dakin’s solution, super-oxidized water with neutral pH (Microcyn®, Oculus Innovative Sciences, Petaluma, CA), 0.5% sliver nitrate, and 0.01% polyhexanide (Prontosan® Wound Irrigation Solution, B. Braun Medical, Bethlehem, PA).

Concerns have been raised in Europe regarding polyhexamethylene biguanide (PHMB), a component of 0.01% polyhexanide. It was classified as a cancer-causing agent in concentrations of 1.0% or higher. However, 0.01% polyhexanide contains PHMB in extremely low concentrations (0.1%) diluted with betaine and purified water, so the carcinogenic classification does not apply.

Here are tips to ensure patients receive the optimal benefit from NPWTi-d:

• Become familiar with how to operate the pump. Getting used to the format may require a learning curve.

• Understand that NPWTi-d foam has higher tensile strength than traditional black NPWT foam to facilitate its easier removal from the wound bed and undermined cavities. It’s also less hydro – phobic, which helps to evenly distribute the wound irrigation solutions.

• For very large wounds, traditional black foam may be used in addition to the NPWTi-d foam to fill large wound cavities.  If an additional drape is needed, a traditional drape may be used; however, the NPWTi-d drape is specifically designed to provide enhanced moisture-resistant adhesion along the wound edges to minimize irrigation solution leakage.

• In large wounds, it’s important to keep a running tally of the number of foams used. This will ensure their complete removal during dressing changes and when treatment has been completed.

• Periwound skin is fragile, so take care to protect it before treatment is started. Foam dressings should not come into contact with intact skin. Application of skin preparation products, an additional drape, hydrocolloid dressings, or transparent film over the periwound skin is recommended.

• Know that NPWTi-d can be used with bridging techniques if needed. Use careful attention to ensure the wound cavity is not overfilled, as additional irrigation solution will be required.

• Ensure a good seal because leaks could alter the amount of instillation volume and the negative pressure delivered to the wound and lead to a leak alarm. Apply gentle traction to skin creases and folds to obtain a flat surface for optimal drape adhesion. Apply the drape carefully, avoiding creases or puckering of the drape even in areas where they may overlap. Drape wrinkles may create small, unidentifiable passages for air to enter along the skin or in sections where the drape is overlapped into the foam as the negative pressure is initiated, which could cause a leak alarm. Applying a thin strip of additional drape along the existing edges or a silicone-based skin prep on the overlapped sections of drape may help achieve a good seal.

• Confirm that both the NPWTi-d cassette and canister are fully engaged and latched. Inappropriate placement or latching of the cassette and canister will cause errors in treatment application.

• Check that the NPWTi-d cassette tubing is not kinked, crimped, or blocked and that all clamps are open. This will allow the instillation fluid to be delivered easily into the wound bed.

• Remember that NPWTi-d canisters usually fill more quickly when combining wound drainage with the instilled solutions, so have extra canisters on hand to alleviate this problem. The unit will alarm when the canister is full.

• As the wound improves and the wound dimensions decrease, reduce the amount of solution instilled accordingly. Overfilling the wound may lead to a compromised seal and solution leakage.

• If possible, have an extra bag of prescribed irrigation solution on hand. Solutions other than normal saline will come from the pharmacy. Use quarter strength (0.125%) Dakin’s solution to minimize cytotoxicity. The pump will alarm when the solution bag is empty.

• Remember that you do not need to prime the line when spiking a new solution bag.

• Become familiar with the settings. The home screen on the unit will display the current NPWTi-d phase (Instill, Soak, or NPWT) with a timer indicating time remaining in that particular phase.

• Be aware of any discrepancy between the amount of prescribed solution instilled into the wound and the amount of solution returning into the drainage canister. Decreased or no return of solution may indicate transmission into an internal cavity. If this is the case, immediately stop instillation and notify the prescribing clinician.

• Understand that there is a learning curve with using NPWTi-d. Estimating the amount of solution to be instilled will vary. I have noticed a slight predisposition to overfilling. As such, I have taken 20% off the suggested instillation volume and continue to have success.

See Case study of NPWTi-d for an example of how this treatment can benefit patients.

An optimal patient experience

NPWTi-d helps remove infectious materials and promotes a wound-healing environment by combining the wound management benefits of NPWT and wound irrigation. Obtaining a complete drape seal, achieving appropriate attachment of canisters and cassettes, maintaining an open instillation solution line, and monitoring levels of fluid instilled and returned can contribute to a more comfortable patient treatment experience.

Ron Rock is the nurse manager and clinical nurse specialist for the WOC nursing team in the Digestive Disease Surgical Institute of the Cleveland Clinic in Cleveland, Ohio. R. Rock is a consultant for KCI, an ACELITY Company. The author thanks Julie M. Robertson, PhD (ACELITY) for assistance in the preparation and editing of this manuscript.

Selected references

Back DA, Scheuermann-Poley C, Willy C. Recommendations on negative pressure wound therapy with instillation and antimicrobial solutions – when, where and how to use: what does the evidence show? Int Wound J. 2013;10(1):32-42.

Gabriel A, Kahn KM. New advances in instillation therapy in wounds at risk for compromised healing. Surg Technol Int. 2014;24:75-81.

Gupta S, Gabriel A, Lantis J, et al. Clinical recommendations and practical guide for negative pressure wound therapy with instillation. Int Wound J. 2016;13(2):159-74.

Huang C, Leavitt T, Bayer LR, et al. Effect of negative pressure wound therapy on wound healing. Curr Probl Surg. 2014;51(7):301-31.

Kim PJ, Attinger CE, Steinberg JS, et al. Negativepressure wound therapy with instillation: international consensus guidelines. Plast Reconstr Surg. 2013;132(6):1569-79.

Assessing footwear in patients with diabetes

Inappropriate footwear is the most common source of trauma in patients with diabetes. Frequent and proper assessment of appropriate footwear is essential for protecting the diabetic foot from ulceration.

Here is a step-by-step process for evaluating footwear. Be sure to evaluate footwear with the patient walking, standing, and sitting.

Observe wear patterns for areas of high pressure or abnormalities

Check the inside of shoe, upper area, and soles.

Check that pressure under the sole of the shoe is even, so no one part wears out excessively.

Assess wear. Normal wear should occur at the lateral heel and medial central forefoot; there also may be slight curvature on the undersurface of the sole at the toe area.

Inspect inside of the shoes

Observe and feel for wrinkled lining, protruding rough seams, and foreign objects.

Observe for drainage on the insole or socks.

Check that soles are sufficiently thick to prevent puncture wounds.

Ensure that shoes have supportive, cushioned soles, with nonslip liners to absorb shock and reduce pressure under the feet.

Observe for correct fit

Check for sizing. In general, there should be about a thumbnail (approximately ½ to ¾ inch) distance between the end of your longest toe and the tip of the shoe.

Check heel-to-ball length:

Measure the distance from the patient’s heel to the first and fifth metatarsal heads.

Bend the shoe to determine toe break and repeat the measurement on the other shoe.

The two measurements should be close to the same.

Check width. The sides of the shoe should not compress the sides of the foot, with the shoe fitting snugly but not tightly. The widest part of foot should be in the widest part of shoe. The correct width allows the toes to rest flat on the insole without being compressed.

Verify that there is no rubbing of the feet or slipping in the shoe and that the heel cup fits snugly.

Be sure the shoe follows the natural outline of the foot.

Observe for a secure fastening mechanism, which should be adjustable with laces, Velcro, or buckles.

Observe that socks are being worn with shoes to reduce friction

Check that socks meet the following criteria:

Socks are nonconstricting with no tight band around ankle or calf.

Socks with prominent seams are worn turned inside-out.

Socks are made of absorbent materials, such as cotton.

Lighter-colored or white socks are worn when there is an open wound to help alert wearers with compromised sensation to a draining wound.

Check that socks meet individual patient needs:

Patients with a partial foot require a sock that will conform to the shape without distal prominent seams or excess material at the distal end.

For active patients, socks can be obtained with silicone over high-stress areas to prevent shear for full or partial feet.

Inspect shoes to determine if they meet the characteristics for the ideal diabetic foot shoe

The shoe is foot-shaped and has a soft heel counter to keep the foot in place.

The shoe upper is made of leather or other breathable material.

The leather over the forefoot is as soft as possible.

The inside lining of the shoes is smooth and free from seams and/or wrinkles.

• The shoe has a heel height that is not excessive (under 5 cm).

Note: A number of studies have shown that wearing athletic shoes can reduce plantar pressure and lead to fewer calluses.

The simplest intervention for a patient who is at risk for ulceration would be a good-fitting, well-cushioned pair of athletic shoes if the patient’s foot fits well in the upper area.

Provide patient education

Patient education about the importance of appropriate footwear choices is critical for the prevention of diabetic foot ulceration and possible amputation. In addition to the points already discussed, patients should be advised to:

change their shoes twice daily

ensure shoes are in a good state of repair

check shoes for foreign objects before putting them on.

Provide patients with guidance on how to buy new shoes. (See Tips for buying shoes for patients with diabetes.) 

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), © 2016.

Selected reference

Cavanagh PR, Ulbrecht JS. The biomechanics of the foot in diabetes mellitus. In Levin ME, O’Neil LW, Bowker JH, et al, eds. The Diabetic Foot. 7th ed. Philadelphia: Mosby Elsevier; 2008.