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Clinician Resources

Check out the following resources, all designed to help you in your clinical practice.

Human trafficking resources

Victims of human trafficking often suffer tremendous physical and psychological damage. Clinicians play an important role in identifying potential victims so they can obtain help.

Here are some resources to learn more about human trafficking.

Addressing human trafficking in the health care setting” is an online course that includes a downloadable quick-reference guide that can be saved and easily accessed from a mobile device to assist providers with essential information in the healthcare setting.

The National Human Trafficking Resource Center provides an online course for healthcare professionals on how to identify human trafficking victims. You also can access tools such as a short summary of what to look for on examination.

Experts recommend posting the phone number for the National Human Trafficking Resource Center in a prominent location: (888) 373-7888. The hotline is staffed 24 hours a day, 7 days a week, and help is available in more than 200 languages.

Resources from NPUAP

The National Pressure Ulcer Advisory Panel (NPUAP) website includes links to resources, including:

Do lift slings significantly change the efficacy of therapeutic support surfaces?

The Role of Nutrition for Pressure Ulcer Management” (from the NPUAP, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance).

Patient/caregiver education brochure

The European Pressure Ulcer Advisory Panel’s website includes a brochure for patients and caregivers that describes the “RISE” strategy for preventing pressure ulcers—Reposition, Inspect, Skin care, and Eat well. The brochure defines pressure ulcer, describes who is at risk, and reviews the elements of the RISE strategy, providing caregiver tips for each one.

Online course on ostomy care

Nursing care of the person with an ostomy,” an online education course from Hollister, includes types of ostomies, pouching systems, pouching basics, ostomy accessories, problem solving, and patient education and resources.

New guidelines for use of antiretroviral agents in HIV

The recently updated “Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents,” developed by a panel convened by the U.S. Department of Health and Human Services, are based on two large randomized clinical trials.

A summary of key changes is available online and includes information on when to start antiviral therapy (ART):

ART is recommended for all HIV-infected individuals, regardless of CD4 cell count, to reduce the morbidity and mortality associated with HIV infection.

ART is also recommended for HIV-infected individuals to prevent HIV transmission.

Nutritional considerations in patients with pressure ulcers

Optimizing nutritional status is a key strategy both in preventing and managing pressure ulcers. In patients across all care settings, compromised nutrition— as from poor intake, undesired weight loss, and malnutrition—increases the risk of pressure ulcers. It contributes to altered immune function, impaired collagen synthesis, and decreased tensile strength. In many cases, malnutrition also contributes to wound chronicity and increases the risk for delayed and impaired wound healing. In patients with chronic wounds, such as pressure ulcers, a chronic inflammatory state can induce catabolic metabolism, malnutrition, and dehydration.

Adequate nutrition, on the other hand, promotes wound healing in patients with pressure ulcers. Wound healing occurs in three distinct but overlapping phases—inflammatory, proliferative, and remodeling. Each phase is time limited and marked by distinct physiologic events, with specific key nutrients playing a crucial role during that phase. (See Understanding wound-healing phases.)

Pressure-ulcer management must include a comprehensive nutritional care plan based on the latest practice guidelines. This article describes the four essential elements that help you address the nutritional needs of patients with pressure ulcers:

performing a nutrition screening for potential nutrition deficits

identifying malnutrition

addressing the patient’s macronutrient and fluid needs

determining appropriate micronutrient supplementation. (See Nutritional therapy recommendations for pressure-ulcer management.)

Element 1: Nutrition screening

The goal of nutrition screening is to identify patients who need a more in-depth nutritional assessment and a comprehensive nutritional plan based on identified nutritional risk factors. On admission to a healthcare facility, the patient should undergo a complete nutrition screening, including assessment of pressure ulcer risk using a tool such as the Braden Scale. In the hospital setting, the nurse generally completes this initial screening.

Several validated screening tools can be used in various settings, including the Nutrition Risk Classification, Malnutrition Universal Screening Tool, and Nutrition Risk Screening 2002. Screening parameters include malnutrition risk factors, such as:

unintentional weight loss

changes in appetite or food and fluid intake

poor dental health

chewing and swallowing difficulties

poor self-feeding ability

GI signs and symptoms.

If the screening determines the patient is at nutritional risk, a registered dietitian (RD) conducts a timely and complete nutrition assessment. The RD determines the patient’s nutritional status and develops a comprehensive nutritional care plan in consultation with interdisciplinary team members, including the physician or a mid level practitioner, a registered nurse, and when appropriate, a speech pathologist, occupational therapist, or dentist. The RD also provides the expertise to ensure that the plan of care is based on standard nutritional guidelines from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and the Academy of Nutrition and Dietetics. This plan must be individualized to reflect the patient’s comorbidities and malnutrition level. Then the RD implements the plan to address nutritional deficits and monitors macro- and micronutrient interventions until the patient’s nutritional status has been optimized.

Element 2: Malnutrition identification

Adult malnutrition (undernutrition) results from inadequate calories, protein, or other nutrients needed for tissue maintenance and repair. At least two of the following conditions indicate the patient has malnutrition:

insufficient energy intake

weight loss

muscle mass loss

subcutaneous fat loss

localized or generalized fluid accumulation that may mask weight loss

diminished functional status, as measured by handgrip strength.

The extent of these conditions determines if malnutrition is severe. Based on symptom duration and inflammation presence, malnutrition is classified further as acute, chronic, or social/environmental. Severe malnutrition of acute or chronic illness is associated with pressure ulcer development with increased severity, delayed healing, and chronicity. (See Clinical features of severe malnutrition.)

Be aware that using serum inflammatory biomarkers (such as albumin and prealbumin) to diagnose malnutrition isn’t recommended. These values can be affected by inflammation, renal function, hydration status, and other factors (such as comorbidities and illness severity) and may not accurately reflect the patient’s nutritional status.

Element 3: Macronutrient requirements and hydration

Calories, protein, fat, and fluids each play a specific role in supporting wound healing.


Patients with pressure ulcers require sufficient calorie and protein intake to support anabolism, nitrogen retention, collagen formation, and angiogenesis—all of which are fundamental for wound healing. The 2014 National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel/Pan Pacific Pressure Injury Alliance (NPUAP/EPUAP/PPPIA) Nutrition Guidelines recommend providing 30 to 35 calories/kg/day to adults who have, or are at risk for, pressure ulcers and malnutrition. The guidelines suggest adjusting energy intake based on weight change, underweight, and obesity.

Dietary carbohydrates and fat are the preferred energy sources because they spare protein for collagen production and cell structure. According to dietary reference intakes, adults should get 45% to 65% of calories from carbohydrates and 20% to 35% from fat. No recommendations exist for carbohydrate intake based on pressure ulcer stage; however, hyperglycemia is linked to impaired leukocyte production, which impedes wound healing and increases susceptibility to infection. In patients with diabetes mellitus or glucocorticoid-induced hyperglycemia, the interdisciplinary team should maximize blood glucose control through medication adjustment and carbohydrate restriction as needed.

Similarly, no recommendation exists for fat intake specific to patients with pressure ulcers. A dense energy source, fat provides essential fatty acids and carries fat-soluble vitamins. Nonetheless, its role in wound healing hasn’t been established. Protein is needed for cell growth and structure, collagen production, fibroblast proliferation, and synthesis of enzymes involved in wound healing. Pressure-ulcer healing requires adequate protein; increased protein intake is associated with improved wound healing rates. NPUAP/EPUAP/PPPIA guidelines recommend providing 1.25 to 1.5 g/kg/day of protein for adults who have, or are at risk, for pressure ulcers and malnutrition. Patients with stage III/IV pressure ulcers or multiple wounds may need 1.5 to 2 g/kg/day. Those with a protein intake as high as 2g/kg/day must be monitored for changes in renal function and hydration status.

Current guidelines for patients with pressure ulcers recommend supplements of specific amino acids, such as arginine, along with high protein supplementation in patients with stage III/IV pressure ulcers or multiple pressure ulcers whose nutritional needs can’t be met with traditional high-calorie and protein supplements. According to A.S.P.E.N, recommendations for arginine and glutamine supplementation are lacking.


To prevent or treat pressure ulcers, patients require adequate hydration. Sufficient fluid intake maintains skin turgor and delivery of oxygen and nutrients to both healthy and healing tissues. Current fluid intake recommendations are 30 mL/kg/day or 1 to 1.5 mL per calories consumed. The interdisciplinary team must monitor the patient’s hydration status carefully because high protein intake, fluid losses from draining wounds, elevated temperature, diaphoresis, vomiting, and diarrhea may increase fluid requirements.

Element 4: Micronutrient requirements

Micronutrients are vitamins, minerals, and trace elements that the body requires for cell metabolism in small but critical amounts. Standard multivitamin supplements with minerals are recommended for patients with pressure ulcers and inadequate oral or enteral intake. In particular, vitamins C and A and zinc play important roles in wound healing.

Vitamin C is crucial for collagen formation, angiogenesis, and fibroblast formation; it also acts on neutrophil activity. Patients with stage I or II pressure ulcers should receive 100 to 200 mg/day in vitamin C supplementation; those with stage III or IV ulcers should receive 1,000 to 2,000 mg/day.

Vitamin A stimulates the inflammatory phase of wound healing, maintains integrity of mucosal and epithelial surfaces, increases collagen formation, and inhibits detrimental effects of glucocorticoid therapy, diabetes, radiation, and chemotherapy. Patients with vitamin A deficiencies and pressure ulcers of any stage should receive 10,000 to 50,000 units/day for 10 days. Patients receiving glucocorticoids should receive 10,000 to 15,000 units/day for 1 week prophylactically to counter immunosuppression.

Zinc promotes cell replication and growth and aids protein and collagen synthesis. Supplements are recommended only for patients with zinc deficiency, which commonly accompanies malnutrition,

malabsorption, diarrhea, and hypermetabolic states. For patients with zinc deficiency, supplementation at the recommended dose of 220 mg zinc sulfate twice daily for 10 to 14 days can enhance wound healing.

Strategies to improve nutritional intake

For patients with pressure ulcers who can’t achieve an adequate dietary intake, NPUAP/EPUAP/PPPIA guidelines recommend these additional strategies to improve overall nutritional status:

• Liberalize dietary restrictions if those restrictions lead to inadequate nutritional intake.

• Offer high-calorie, high-protein oral supplements between meals.

• Consider providing enteral or parenteral nutrition support to patients who can’t achieve a satisfactory oral nutritional intake.

When considering whether to implement these strategies, keep in mind the patient’s comorbidities and overall care goals.

A comprehensive nutritional plan based on the latest clinical practice guidelines can improve outcomes for patients who have pressure ulcers or are at risk for developing them. All healthcare team members are responsible for optimizing nutrition for these patients. The RD is central to developing and refining a successful nutritional plan. As frontline caregivers, nurses are in a unique position to identify nutritional deficiencies, evaluate pressure-ulcer healing, and communicate assessment findings to the medical team and RD.

The authors work at Englewood Hospital and Medical Center, in Englewood, New Jersey. Jill Cox is an advanced practice nurse and WOC nurse; Sophia Zigouras is a clinical dietitian. Dr. Cox is also an assistant professor of nursing at Rutgers University in Newark.

Selected references

Bergstrom N, Braden BJ, Laguzza A, et al. The Braden scale for predicting pressure sore risk. Nurs Res. 1987;36(4):205-10.

Doughty DB, Sparks-DeFriese B. Wound healing physiology. In: Bryant R, Nix D, eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier; 2012.

Iizaka S, Okuwa M, Sugama J, et al. The impact of malnutrition and nutrition-related factors on the development and severity of pressure ulcers in older patients receiving home care. Clin Nutr. 2010; 29(1):47-53.

Institute of Medicine. Panel on Macronutrients, Panel on the Definition of Dietary Fiber, Subcommittee on Upper Reference Levels of Nutrients, Subcommittee on Interpretation and Uses of Dietary Reference Intakes, and the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids. Washington, DC: National Academies Press; 2005.

Kondrup J, Allison SP, Elia M, et al. ESPEN guidelines for nutrition screening 2002. Clin Nutr. 2003;22(4):415-21.

Kovacevich DS, Boney AR, Braunschweig CL, et al. Nutrition risk classification; a reproducible and valid tool for nurses. Nutr Clin Pract. 1997;12(1):20-5.

Lee SK, Posthauer ME, Dorner B, et al. Pressure ulcer healing with a concentrated, fortified, collagen protein hydrolysate supplement: a randomized controlled trial. Adv Skin Wound Care. 2006:19(2):92-6.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Haesler E (ed.). Perth, Australia: Cambridge Media; 2014.

Patel V, Romano M, Corkins MR, et al; American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Nutrition screening and assessment in hospitalized patients: a survey of current practice in the United States. Nutr Clin Prac. 2014;29(4):483-90.

Posthauer ME, Banks M, Dorner B, et al. The role of nutrition for pressure ulcer management: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance White Paper. Adv Skin Wound Care. 2015;28(4):175-88.

Stechmiller JK. Understanding the role of nutrition and wound healing. Nutr Clin Pract. 2010;25(1): 61-8.

Stechmiller JK. Wound healing. In: Mueller C, ed. A.S.P.E.N. Adult Nutrition Support Core Curriculum. 2nd ed. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2012: 348-63.

Stotts N. Nutritional assessment and support. In: Bryant R, Nix D, eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St Louis, MO: Elsevier; 2012

Todorovic V, Russell C, Elia M. The MUST explanatory booklet: A Guide to the “Malnutrition Universal Screening Tool” (“MUST”) for Adults.

White JV, Guenter P, Jensen G, Malone A, Schofield M; Academy Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force; A.S.P.E.N. Board of Directors. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36(3):275-83.

How to apply silver nitrate

Topical application of silver nitrate is often used in wound care to help remove and debride hypergranulation tissue or calloused rolled edges in wounds or ulcerations. It’s also an effective agent to cauterize bleeding in wounds. Silver nitrate is a highly caustic material, so it must be used with caution to prevent damage to healthy tissues.

Application method

Silver nitrate applicators are firm wooden sticks with 75% silver nitrate and 25% potassium nitrate embedded on the tip. Moistening the tip sparks a chemical reaction that burns organic matter (skin), coagulates tissue, and destroys bacteria.


Silver nitrate is very caustic to skin and clothing. Wear protective equipment as needed.

Excess silver nitrate can be neutralized with 0.9% or stronger saline and then washed away with water.

Because silver nitrate is a corrosive substance, apply it only to tissue to be treated. Take care to confine the silver nitrate to the desired area by using a suitable barrier, such as petroleum jelly. Prevent any excess from oozing by covering the application area as necessary.

Silver nitrate directly reduces fibroblast proliferation, so it is not recommended for prolonged or excessive use.

Some patients report pain or burning during treatment with silver nitrate. Consider the need for medication before the procedure, including use of topical anesthetic, to reduce discomfort.


1. Wash your hands and put on gloves.

2. Remove the wound dressing, following dressing-removal procedure.

3. Wash your hands and put on new gloves.

4. Clean the wound with sterile normal saline solution according to wound cleansing procedure.

5. Remove your gloves, wash your hands, and put on new gloves.

6. Confine the area to be treated by encircling it with petroleum jelly or equivalent.

7. Cover the wound base tissue with moistened normal saline gauze to protect it from any spillage. It is important not to allow drips of silver nitrate to settle on any surface, as they will stain and burn.

8. Slightly moisten the caustic tip of the silver nitrate applicator stick by dipping (tip only) in distilled or deionized water.

9. To apply to tissue, rub and rotate the tip of the applicator along the tissue to be debrided. Two minutes of contact time is typically sufficient, keeping in mind that the degree of caustic action depends on the quantity of silver nitrate applied, which in turn is governed by the length of time the moistened tip is left in contact with the tissue. Do not touch any other part of the body, clothing, or furnishings with the tip. Depending on the size of the area to be debrided, more than one applicator may be needed.

10.Monitor the patient closely for response to the procedure, including pain and discomfort. STOP the procedure if the patient complains of pain.

11. Use damp saline gauze to gently clean the treated area after application. Pat dry to avoid trauma to surrounding tissue. Do not rub or apply friction to treated area.

12. Remove gloves and put on new ones.

13. Apply any other prescribed treatment to the wound base as ordered.

Length of treatment

Frequency of application varies based on wound needs. If silver nitrate is being used for hypergranulation, apply it once daily for up to 5 days or until resolution of hypergranulation. In the case of rolled edges/epibole, treatment varies from daily to 3 times a week until the problem is resolved.

Use with care

Silver nitrate can be an effective tool in treating wounds, but, as with many treatments, it must be used with care to obtain the best results for patients. ?

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.

Selected references

Crawley-Coha T. A practical guide for the management of pediatric gastrostomy tubes based on 14 years of experience. J Wound Ostomy Continence Nurs. 2004;31(4):193-200.

Garten AJ. Keys to diagnosing and addressing hypergranulation tissue. Podiatry Today Blog. 2015.

Stephen-Haynes J, Hampton S. Achieving effective outcomes in patients with over-granulation. Wound Care Alliance UK. 2010.

No more skin tears


Imagine watching your skin tear, bleed, and turn purple. Imagine, too, the pain and disfigurement you’d feel.

What if you had to live through this experience repeatedly? That’s what many elderly people go through, suffering with skin tears through no fault of their own. Some go on to develop complications.

A skin tear is a traumatic wound caused by shear, friction, or blunt-force trauma that results in a partial- or full-thickness injury. Skin tears are painful because the precipitating injury commonly involves the dermis, which is rich with nerve endings.

Skin tears that lead to complications can exact a toll not just on patients but also on healthcare facilities, whose reputations may suffer if the public believes staff are delivering a poor quality of care. A reported 1.5 million skin tears occur in institutionalized adults each year. And that doesn’t include tears that occur at home. The problem isn’t going away any time soon.

So what makes skin tears such a frequent occurrence? Who’s at greatest risk? How can we better prevent and treat them?


With age, our skin undergoes specific, well-documented changes. The epidermis and dermis are joined together by a wavelike basement membrane that prevents sliding. In aging skin, this junction flattens, allowing the skin to slip back and forth. This decreases the surface area between the layers, in turn reducing nutrient transfer and resistance to shearing forces.

Aging also slows epidermal turnover, wound repair, and collagen deposition; impairs vascularity; and causes thinning of the dermal and subcutaneous layers. These changes work in tandem to make the skin much more susceptible to the shearing and friction forces that result in skin tears.


Common causes of skin tears include:

• applying or removing stockings, particularly over tibial areas and ankles

• removing tape or dressings too often, which can strip the epidermis

• improper patient handling

• handling by caregivers who are wearing jewelry or have long fingernails

• blunt-force trauma, as from a patient fall or wheelchair injury.

In some cases, the cause of a skin tear can’t be identified—for example, in patients with cognitive impairment who can’t communicate what happened to cause the injury.

Risk factors

Patients who depend on caregiver assistance for activities of daily living are at risk for skin tears. Assistance with bathing, dressing, positioning, and transferring involves significant caregiver handling. Research from across many settings shows that roughly 70% to 80% of skin tears occur on the hands and arms, and most happen during peak activity hours (from 6 to 11 AM and from 3 to 9 PM).

Very young patients with immature skin also are at risk. The dermis doesn’t develop fully until after birth; even at full-term, it has reached only 60% of its adult thickness. In neonates, skin tears commonly are linked to device trauma or adhesive use. In many cases, they occur on the head, face, and extremities.

Additional at-risk groups include critically ill patients with multiple risk factors and older adults who ambulate independently, especially those with an unsteady gait. Among these older adults, skin tears are common on the lower extremities. (See Additional risk factors for skin tears.)

Risk assessment tool

You can use a risk assessment tool to help identify patients at risk and guide implementation of a prevention protocol. Called the Skin Integrity Risk Assessment Tool by White, Karam, and Colwell, it’s the only tool designed specifically to assess skin integrity risk. Although the instrument is somewhat dated and not used widely in clinical settings, clinicians who’ve adopted it report it helps reduce skin-tear incidence through early identification and immediate targeted prevention. (Click here for more information.)


The Payne-Martin Classification system provides a common language for assessing and classifying skin tears, promoting better communication among clinicians and helping to guide treatment. Developed in 1990 and updated in 1993, it has three primary classifications based on degree of severity. Besides helping clinicians differentiate full-thickness from partialthickness tears, it addresses the skin flap (if present). For images of skin tears classified by the Payne-Martin system, click here.

In addition to identifying the skin-tear classification, also check for and document the following:

• anatomic location and duration of the tear

• dimensions of the tear (length, width, and depth)

• wound bed characteristics and percentage of viable vs. nonviable tissue

• exudate type and amount

• presence of bleeding or hematoma

• periwound skin color and condition; note edema, maceration, and induration

• wound-edge approximation and condition (open vs. closed)

• degree of flap necrosis

• integrity of surrounding skin

• signs and symptoms of infection

• associated pain.


Preventing skin tears requires a multifaceted approach, described below. Although not all skin tears are preventable, take all necessary steps to minimize risk. Remember— skin tears are a negative patient outcome. If your healthcare facility has a high skin-tear incidence, some people may suspect the facility is not doing everything it can to decrease tears or that its caregivers are too rough when providing direct patient care.

Provide an optimal environment

To minimize skin tears, start by providing a safe environment. Remove scatter rugs and unclutter walkways. Pad bedrails, wheelchairs, and sharp furniture corners. Provide support for the patient’s dependent limbs and ensure adequate lighting.

Keep room temperature on the cool side, as heat tends to dry the skin. Elderly patients commonly are sensitive to cold, so this isn’t always realistic—but you can add moisture to the air by using a humidifier.

Follow bathing guidelines

Too-frequent bathing dries the skin, making it more vulnerable to tearing. The following recommendations help minimize tears.

• Decrease bathing frequency.

• Advise patients to take shorter showers with warm to tepid (not hot) water to help the skin resist tearing.

• Use pH-balanced cleaning products that contain emollients and don’t require rinsing. Know that although a bar of soap is inexpensive and removes soil, it also alters the skin’s physical and chemical make-up and makes it more vulnerable to tears.

• Pat the patient’s skin dry instead of rubbing it.

• Moisturize the patient’s skin after bathing while it’s still damp. This traps moisture and keeps skin hydrated. The skin’s top layer, the stratum corneum, requires at least 10% moisture to maintain its integrity.

• Encourage proper fluid intake to help patients stay hydrated.

Handle patients gently

Learn about the proper way to touch patients to decrease skin trauma risk. Using a practiced, deliberate, gentle touch makes all the difference.

Also, use low-friction repositioning sheets and equipment to decrease skin trauma caused by repositioning. Avoid wearing jewelry, because it can cause skin trauma, and keep your fingernails short.

Dress patients properly

Patient clothing plays a role in preventing skin tears. Dress at-risk patients in long sleeves, long pants, and knee-high socks to protect the skin below these garments. You can use athletic shin guards as protective devices on patients who are willing to wear them. Specialized products, such as the DermaSaverArm Tube, Dermatuff® Protection Socks and Leg Protectors, and Posey® SkinSleevesProtectors, also help safeguard the skin. If the budget is tight, you can use tube socks to protect the patient’s arms; just cut off the toe section and slip the socks on over your patient’s hands.


Despite all of our efforts, skin tears do occur. How we treat them can make a big difference in our patient’s pain level, how quickly tears resolve, and whether complications arise. Although we lack gold-standard or clinical practice guidelines to identify the ideal treatment regimen, many approaches can work well. Choose the one that best fits your individual patient.

Management goals include:

• stopping the bleeding

• reapproximating the edges of the skin flap to maintain integrity without stretching

• providing moisture and protection for the wound

• protecting periwound skin

• minimizing pain and discomfort

• preventing infection.

Also, if possible, try to determine the cause of the skin tear and remove it to help prevent recurrence.

Methods of treating skin tears include skin glue, skin-closure strips, and dressings. (See Applying skin-closure strips.)

Skin glue

A specially formulated liquid topical bandage, skin glue creates a clear film that dries in 15 to 30 seconds. It doesn’t require secondary dressings and allows for routine inspection. Examples of skin glues include Dermabond®, Surgiseal®, and Octylseal.


The best standard dressing for a skin tear depends on the type of tear, amount of exudate, skin fragility, and other patient factors. In general, hydrocolloids or traditional transparent film dressings aren’t recommended, as they may cause skin stripping and injure the healing tear if not removed properly.

To manage a skin-tear dressing, mark the outer dressing with an arrow to indicate the preferred direction of removal; document this to help prevent disturbing the healing wound. Ideally, this step should be included in your facility’s policy and procedures to help ensure it’s done every time.

When using a dressing over your patient’s skin tear, remember these important points:

• Calcium alginates may help control bleeding and exudate.

• Soft silicone or silicone-impregnated dressings promote flap security and aid nontraumatic removal.

• Foam or hydrofiber dressings aid exudate management.

• Hydrogel dressings promote pain relief and a moist wound bed.

• Petroleum-based protective ointments and gauze also may be used.

• Antimicrobial dressings aid infection control.

• If the wound is infected or contaminated, observe it daily.

• Avoid tape whenever possible, because  it may tear the skin on removal. To prevent this, use an adhesive remover.

• Alternative ways to secure the dressing include gauze netting, stockinette, cohesive bandages, TubiFastbandages, and other specialty products, such as TAPElessdressings. Be sure to follow the manufacturer’s instructions for proper application to protect patients from harm stemming from circulatory compromise.

Education is key

We need more research on skin tears to improve management. Education is the key to preventing skin tears. All caregivers should be well versed in prevention and management strategies and should teach patients about them.

Gail R. Hebert is a clinical instructor with the Wound Care Education Institute in Plainfield, Illinois.

Selected references

Ayello EA, Sibbald RG. Preventing pressure ulcers and skin tears. In: Boltz M, Capezuti E, Fulmer T, et al, eds. Evidence-Based Geriatric Nursing Protocols for Best Practice. 4th ed. New York: Springer; 2012; 298-323.

LeBlanc K, Baranoski S; Skin Tear Consensus Panel Members. Skin tears: state of the science: Consensus statements for the prevention, prediction, assessment and treatment of skin tears. Adv Skin Wound Care. 2011;24(9):2-15.

LeBlanc K, Christensen D, Orsted HL, et al. Best practice recommendations for the prevention and treatment of skin tears. Wound Care Canada. 2008; 6(1):14-30.

Pennsylvania Patient Safety Authority. Patient Safety Advisory. Skin Tears: The Clinical Challenge. 2006.

White MW, Karam S, Cowell B. Skin tears in frail elders: a practical approach to prevention. Geriatr Nurs. 1994;15(2):95-9.

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.

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.