Tag Archives: pressure ulcer

Pressure Injury Prevention: Managing Shear and Friction

Let us start off this post with a typical scenario. You walk into any facility or institution and you see a patient slouched in their wheelchair, with no wheelchair cushion. You notice part of their brief hanging out of the top of their pants, so you assume the patient may be incontinent. So let’s think about this for a minute. We most likely have friction, shear, and moisture going on with this patient.

This scenario is the perfect recipe for a pressure injury. So what can we do to help this patient and prevent a pressure injury from developing? We must first identify the cause, and then remove the cause. The cause in this example is shearing, friction, moisture, and pressure. We will remove the pressure injury causes with interventions such as using a 4 inch viscoelastic wheelchair cushion, Dycem® non-slip matting to keep the patient in place, and offloading the patient every hour while up in wheelchair.

The NPUAP pressure injury definition states that the ability of soft tissue to tolerate shear and pressure may also be affected by the factors of microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue. We still do not know whether shear damages muscle more than fat, the relationship between external and internal shear, or the affect of postural changes (frequency of speed or changes have on shear force).

Identifying signs of shearing and friction

Many times you may identify signs of shearing stresses within a wound that presents an irregular shape and undermining. There may even be evidence of excoriation and blistering on areas in contact with support surfaces. Friction usually, but not always, accompanies shear. Friction is the force of rubbing two surfaces against one another. Shear is a gravity force pushing down on the patient’s body with resistance between the patient and the chair or bed.

What can we do to reduce friction and shearing in managing our patients?

  1. Pad and protect vulnerable areas (transparent, hydrocolloid, composite, foam dressings) as per facility protocol.
  2. Use heel or elbow protectors for hospice/palliative patients.
  3. Educate caregivers and nursing staff about how to identify key factors for pressure injuries.
  4. Ensure that support surfaces provide for individual’s particular needs: pressure redistribution, shear reduction, and or microclimate control.
  5. Utilize positioning devices in wheelchairs or chairs to reduce shearing.
  6. Establish a risk assessment per facility protocol.
  7. Use draw sheets to pull up, transfer and position your patient. DO NOT DRAG.

via Wound Source

Accuracy of the Ankle-brachial Index in the Assessment of Arterial Perfusion of Heel Pressure Injuries

Abstract: Background. The evaluation and treatment of heel pressure injuries are a significant and expensive sequela of the aging population. Although the workup of patients with lower extremity tissue loss usually involves an assessment of the arterial blood flow by means of noninvasive vascular testing, the results may be misleading in patients with heel pressure injuries when the ankle-brachial index (ABI) does not provide direct information about perfusion of the rearfoot. The objective of this retrospective, observational investigation was to determine if noninvasive vascular testing provides accurate and reliable results in patients with heel pressure injuries.

Materials and Methods. A retrospective chart review of 67 consecutive inpatients with 75 heel decubitus ulcerations was performed. Results. At least 1 noncompressible ankle artery was observed in 35 (46.67%) of the 75 feet. When at least 1 compressible vessel was present, allowing for calculation of an ABI (n = 49 feet), it was based on the posterior tibial artery in 23 (46.94%) feet and on the anterior tibial artery in 26 (53.06%) feet. In total, of the 75 feet with heel pressure injuries that underwent noninvasive vascular testing, a compressible posterior tibial artery allowing for calculation of an ABI as a direct measure of heel perfusion was observed in only 23 (30.67%) feet. Conclusions. The results of this study suggest noninvasive vascular testing may be inaccurate and unreliable in the majority of patients with heel pressure injuries.

 The evaluation and treatment of pressure injuries are a significant and expensive sequela of the aging population.1-6 Specific to the lower extremity, this is particularly true in people who are nonambulatory, those who are bedridden for any period of time, and in the presence of certain comorbidities including diabetes mellitus and peripheral arterial disease.7-11 Part of the initial clinical workup of any patient with lower extremity tissue loss usually involves an assessment of the arterial blood flow by means of noninvasive vascular testing (ankle-brachial index [ABI] and pulse volume recording).12-15 Although these are primarily screening tests for peripheral arterial disease, abnormalities should prompt a formal vascular evaluation, potentially including angiography.
Read more at Wounds Research

Clinical Notes—May/June 2016

Moldable skin barrier effective for elderly patients with ostomy

A study in Gastroenterology Nursing reports that compared to a conventional skin barrier, a moldable skin barrier significantly improves self-care satisfaction scores in elderly patients who have a stoma. The moldable skin barrier also caused less irritant dermatitis and the costs for leakage-proof cream were lower.

The application of a moldable skin barrier in the self-care of elderly ostomy patients” included 104 patients ages 65 to 79 who had a colostomy because of colorectal cancer.

Risk factors for severe hypoglycemia in older adults with diabetes identified

Risk factors associated with severe hypoglycemia in older adults with Type 1 diabetes” include glucose variability and greater lack of awareness of hypoglycemia.

Participants in the case-control, multi-center study, published in Diabetes Care, were age 60 or older and had a history of diabetes dating back 20 years or more.

Thermal imaging via smartphone helps detect inflammation

Early detection of inflammation in wounds promotes early treatment, and clinicians may have an additional assessment tool available to them. A recent study published in the Journal of Wound Care concludes the FLIR ONE, a thermography device that connects to a smartphone, can be successfully used to assess subclinical inflammation in patients with pressure ulcers and diabetic foot in clinical settings.

Use of smartphone attached mobile thermography assessing subclinical inflammation: A pilot study” included 16 thermal images from eight patients and found good criterion-related validity and inter-rater reliability when the FLIR ONE results were compared to those from a handheld device. The findings may open the door to more thermal imaging assessment at the bedside.

Role of skin substitutes in treatment of diabetic foot ulcers analyzed

Systematic review and meta-analysis of skin substitutes in the treatment of diabetic foot ulcers,” published in Wound Repair and Regeneration, concludes that skin substitutes “can, in addition to standard care, increase the likelihood of achieving complete ulcer closure compared with standard care alone in the treatment of diabetic foot ulcer.”

The authors caution, however, that long-term effectiveness, including limb salvage and recurrence, is not known, and cost-effectiveness is not clear. The review included 17 randomized clinical trials, with a total of 1,655 patients.

Tap water safe alternative for wound cleaning

“Tap water is a safe alternative to sterile normal saline for wound cleansing in a community setting,” concludes a study in the Journal of Wound, Ostomy and Continence Nursing.

Tap water versus sterile normal saline in wound swabbing: A double-blind randomized controlled trial” studied 22 people with 30 wounds. Half were in the tap water group and half in the sterile normal saline group. Researchers found no differences in the proportion of wound infection and healing between the two groups.

Review of skin grafting in patients with chronic leg ulcers

Autologous split-thickness skin grafting remains the gold standard in terms of safety and efficacy for chronic leg ulcers, according to a review article in International Wound Journal.

Skin grafting for the treatment of chronic leg ulcers—a systematic review in evidencebased medicine” also found that skin grafts are more successful in patients who have chronic venous leg ulcers, compared to other types. The researchers noted that skin tissue engineering is “rapidly expanding” and holds promise for better outcomes when treating patients with long-lasting chronic wounds.

C difficile may be risk factor for pouch failure after reconstruction

Patients with a history of preoperative Clostridium difficile colitis may be at higher risk for pouch failure after ileal pouchanal anastomosis reconstruction following total proctocolectomy for ulcerative colitis, according to a study in Inflammatory Bowel Disease.

The authors of “Clostridium difficile infection in ulcerative colitis: Can alteration of  the gut-associated microbiome contribute to pouch failure?” defined pouch failure as permanent ostomy diversion or pouch excision. Of 417 patients in the study, 28 (6.7%) developed pouch failure.

Lymphedema education lacking

Researchers of a study in the Journal of Cancer Education report that only 19.9% of 180 women with lymphedema after breast cancer surgery reported they had received education or information about the condition postoperatively.

The importance of awareness and education in patients with breast cancer-related lymphedema” also reports that, “The degree and duration of lymphedema were lower in patients who had been informed or educated about lymphedema as compared to the patients who had not been informed or educated, but the difference was not statistically significant.”

Color charts help improve pressure ulcer risk assessment

Use of Munsell color charts to measure skin tone objectively in nursing home residents at risk for pressure ulcer development,” published in the Journal of Advanced Nursingconcludes that the color charts provide a “more objective measurement of skin tone than demographic categories.”

The researchers state that use of the charts can improve pressure ulcer risk assessment when current clinical guidelines are less effective.

Clinician Resources

PDF-iconThe resources below will help you address issues in your practice.


NPUAP position statement on hand check for bottoming out

Use of the hand check to determine “bottoming out” of support systems should be limited to static air overlay mattresses, according to a position statement from the National Pressure Ulcer Advisory Panel (NPUAP).

“Hand check method: Is it an effective method to monitor for bottoming out” adds that the hand check method is “inappropriate” for replacement mattresses and integrated bed systems and calls for additional research for a bedside method to determine when a support surface has bottomed out.

Summary of pressure ulcer treatment guidelines from ACPCR_wound

The National Guideline Clearinghouse, part of the Agency for Healthcare Research and Quality, has published a summary of “Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians” (ACP).

The full guidelines can be found in the March 3 issue of the Annals of Internal Medicine.

CR_WomanNIOSH education on nurses’ work hours

The National Institute for Occupational Safety and Health (NIOSH) has published “NIOSH training program for nurses on shift work and long work hours.” Part 1 of the program discusses the risks associated with these work hours related to fatigue, and Part 2 is designed to increase knowledge about personal behaviors and workplace systems to reduce the risks.

Continuing education credit is available for the course.

Implementing guidelines in an organization

Struggling to implement practice guidelines where you work? Check out “Implementing guidelines in your organization: What questions should you be asking?” an expert commentary in the National Guideline Clearinghouse, part of the Agency for Healthcare Research and Quality.

Case study: Working under a time crunch in a short-stay facility


By Janet Wolfson, PT, CWS, CLT-LANA

After landing my dream job as the wound care coordinator at an inpatient rehabilitation facility (IRF), I found myself trying to determine how much healing could be achieved for our more challenging patients, given the constraints of reimbursement and what can be done in the typical 10 to 14 days of a patient stay.

Here’s an example of how I worked with our team to help one of these challenging patients.

Mr. B arrives

Mr. B was a Medicare patient admitted to the IRF after months of hospitalization for bilateral diabetic foot ulcers (DFUs) on the plantar surfaces, diabetic neuropathy, bilateral lower extremity lymphedema elephantiasis, gangrene, bilateral fungal infection with thick fungal scale and callus from the toes to the upper calves, end-stage renal disease (ESRD), heart failure (HF), coronary artery disease, a stage IV pressure ulcer in the sacral area, acquired polymyopathy, and methicillin-resistant Staphylococcus aureus (MRSA).

If I had high-tech ultrasonic debriders, skin substitutes, growth factors, and 4 hours to dedicate to Mr. B each day, I knew I could have a significant impact. But a reality check focused me to think about what I could do in a few short weeks to accelerate the healing journey of this man: What were realistic short-term goals?

Closure of his complicated wounds couldn’t be the goal, so I decided that I could reduce or remove necrotic tissue or biofilm from his DFUs; disinfect and bluntly remove the thick scale and callus on his lower legs and feet that was composed of fungus, dead tissue, and other debris; prevent worsening of the pressure ulcer; and increase granulation tissue and epithelialization in his wounds.

Edema was present bilaterally, but with HF, MRSA, ESRD, and only 3 weeks before Mr. B’s expected discharge, I knew I wasn’t going to be able to significantly address this. After reflecting on previous successful regimens used for similar patients and consulting colleagues who are experts in wound care and lymphedema, I embarked on a plan that included patient education on lymphedema, pressure relief, diabetic foot care, and skin care. I optimized Mr. B’s treatment by reviewing wound products available in our facility and adding more as needed, promoting good communication among staff stakeholders, and reaching out to the community for discharge planning.

Stakeholders step up

I knew that I alone couldn’t provide everything this patient needed. I identified and sought to involve many members of our facility’s wound team to maximize the benefit of Mr. B’s rehab stay. Each of us had an important contribution to make.

As a certified wound and lymphedema specialist, I was the cornerstone to optimize Mr. B’s wound and lymphedema care. My credentials and experience enabled me to determine the cause of his pressure ulcer and DFUs, stage them, and know the phase of wound healing for each. I removed necrotic and nonviable tissue through a series of sharp debridement of his DFUs and blunt debridement via tongue blade on the leg scales. Mr. B’s wounds progressed from the inflammatory towards the proliferative phase, which increased the healing rate.

Our physicians and pharmacists addressed Mr. B’s MRSA with I.V. antibiotics. The nephrologist and internist advised me that because of Mr. B’s ESRD and HF, he wasn’t a candidate for leg compression. The dietitian maximized Mr. B’s nutritional wound support within his disease-related dietary restrictions. The nursing staff tracked his blood glucose level and delivered medications to support wound healing; they also provided dressing changes.

All staff, from certified nursing assistants to therapists, promoted pressure relief and provided direct hygiene and skin care while teaching Mr. B so he could eventually take over his own care. The dialysis nurse positioned Mr. B on a low-air-loss mattress for pressure relief during dialysis.

The RN admission assessment had provided me with Braden scores and a body mass index so that I could order the proper durable medical equipment (DME) needed to relieve Mr. B’s pressure areas. Our purchasing clerk provided the support surfaces and the appropriate bandage supplies. Timely ordering and delivery of supplies that were being used faster than normal ensured Mr. B received the treatment he needed. Access to the manufacturer’s catalog allowed me to request wound cleansers, antimicrobial dressings, and high-absorbency foams to enhance Mr. B’s treatment and decrease frequency of changes. Off-loading shoes allowed Mr. B. to improve his mobility while protecting his plantar ulcers.

Ready for discharge

After a bit over 3 weeks, Mr. B was ready for discharge. The short-term goals of removing necrotic tissue, reducing bioburden, and increasing granulation had been met. (See Wound improvement.) Because complicated wounds can take much longer to heal than a short inpatient stay allows, knowledge of local resources to keep Mr. B on a healing continuum was vital.

Wound Improvements

Mr. B left our IRF knowing his expectations for wound healing and ongoing care. Printed instructions and predischarge teaching were part of this. Communicating his needs to case managers helped ensure he was put in touch with community resources. Community partners included family members, nongovernment organizations for DME funding, diabetic educators, podiatrists, wound centers, hyperbaric technicians, lymphedema therapists, infectious disease physicians, home care agencies, and support groups.

Making a difference

Because the Centers for Medicare & Medicaid Services constricts reimbursement and incentivizes quality care, facilities maximizing patient benefits while being cost effective will have the edge in the marketplace, particularly in the case of patients like Mr. B. Now is the time for each IRF facility to assess its wound care product inventory, reflect on the facility’s team for provision of wound care, and expand its network in the community. Tracking readmissions within 30 days back to the acute referral source enables a facility to monitor prog­ress. These actions can help ensure the facility can maximize patient outcomes and be a leader in the community.

Janet Wolfson is a wound care coordinator at HealthSouth Ocala in Florida.

Selected references

Centers for Medicare & Medicaid Services. Bundled payments for care improvement (BPCI) initiative. http://innovation.cms.gov/initiatives/bundled-payments/

Scarborough P. Understanding your wound care team: defining unidisciplinary, multidisciplinary, interdisciplinary, and transdisciplinary team models. Wound Source. 2013.

White-Chu EF, Reddy M. Wound care in short-term rehabilitation facilities and long-term care: special needs for a special population. Skinmed. 2012 Mar-Apr; 10(2):75-81.

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.

Tips on staging pressure ulcers


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

Pressure ulcers have been a health concern for a long time—since at least 5,000 years ago, when evidence of a pressure ulcer was found on an ancient Egyptian mummy. But not until 1975 did the staging classification system we’re familiar with begin. This system was designed to make things easier by creating a universal way to describe and communicate the various levels of tissue destruction.

In my travels and work as a wound care educator, the questions I’m asked most frequently relate to pressure ulcer staging. How can this be, given that the staging system was supposed to make it easier for us? Most wound care clinicians who live and breathe wound care 24/7 (the experts) can probably stage a pressure ulcer in their sleep. But the staging struggles of nonexpert clinicians make staging the wound experts’ problem. In many facilities across the country, staging is so challenging that some wound care experts have forbidden anyone else in their facility to document a pressure ulcer’s stage in the medical record. As desirable as this may sound to some of us, I don’t think this approach is practical. One person can’t be everywhere at once.

To stage a pressure ulcer accurately, you need to understand the anatomy and physiology of tissue destruction and be able to interpret what you see. I don’t have all the answers to the staging problem, but I have identified a few issues clinicians find most confusing—differentiating stage II and stage III pressure ulcers, suspected deep tissue injury, and restaging and downstaging. Here are a few tips that may help.

  • Stage II pressure ulcers are pink and partial thickness, without necrotic tissue (yellow or black). Tissue destruction is seen through the epidermis and into, but not through, the dermis. (See Stages of pressure ulcers.) In contrast, stage III pressure ulcers involve tissue destruction through the dermis and into the subcutaneous tissue. Of course, there’s no dotted black line showing where epidermis and dermis end, so we have to rely on our knowledge of anatomy: The epidermis is thinnest on the eyelids (0.05 mm) and thickest on the palms and soles (1.5 mm). The dermis is thinnest on the eyelids (0.3 mm) and thickest on the back (3.0 mm). By comparison, a single sheet of copy paper is 0.1 mm thick, while a U.S. penny is 1.5 mm thick.


  • A deep tissue injury is a localized area of intact, discolored skin (purple or maroon) or a blood-filled blister. Intact is the key word. Once the skin opens, the wound must be reclassified as unstageable, stage III, or stage IV. Deep tissue injury implies tissue damage at the subcutaneous level or deeper, so it can’t possibly be a stage II wound.
  • Reverse or downstaging doesn’t accurately characterize what’s occurring in the ulcer. Stage III and IV pressure ulcers heal by filling in with granulation (scar) tissue—not new dermis and subcutaneous tissue. Therefore, the staging system definitions can be used only one way—as the wound progresses—and not in reverse, as the wound heals. A stage IV pressure ulcer can’t become a stage III, stage II, or subsequently stage I ulcer. When a stage IV ulcer is healing or healed, it should be classified as a healing or healed stage IV pressure ulcer—not a stage I or stage 0 pressure ulcer.
  • Progression (worsening) of tissue destruction follows an upward scale of the staging system—from least to worst: stage I, stage II, stage III, and stage IV (the deepest level of tissue destruction). Unstageable and suspected deep tissue injuries are categories, not stages. Based on their definitions, they would be equal to or greater than a stage III ulcer. In other words, they can’t be recategorized as stage I or II ulcers.
  • The staging system isn’t perfect and still has many gray areas, but for now this is the internationally accepted tool we need to use. When staging gets confusing or falls into a gray area, I find it’s best not to overthink things. Instead, go back and reread the basic definitions. For answers to other staging questions, check out the article “FAQs for pressure ulcer staging”.

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


Wound Care Advisor

Cofounder, Wound Care Education Institute

Plainfield, Illinois

Selected references

National Pressure Ulcer Advisory Panel. The Facts about Reverse Staging in 2000: The NPUAP Position Statement. http://iwa.joerns.com/docs/HTML/education/documents/Facts_about_Reverse_Staging_in_2000.pdf

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. Osborne Park, Western Australia: Cambridge Media; 2014.

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.

More from The Buzz Report: A wound care clinician’s best friend


 By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMSPDF-icon


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, and 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.

In the January issue, I discussed some of the updates from my 2014 Buzz Report, and now I’d like to share more, with appropriate updates since the September WOW conference.

Necrotizing fasciitis

Necrotizing fasciitis, also called the “flesh-eating disease,” is a progressive,rapidly spreading inflammatory infection located in deep fascia with necrosis of the subcutaneous tissues. Early diagnosis and treatment of necrotizing fasciitis are critical to saving the life of the patient.

Summarized in an article by Edlich and colleagues published in Medscape, two studies found the following:

• Of 27 patients studied, 20 died, for an overall mortality rate of 73%; 11 of the patients whose treatment was delayed for more than 12 hours died.

• The average time from admission to operation was 90 hours in nonsurvivors of necrotizing soft-tissue infections, compared to 25 hours in survivors.

To promote prompt diagnosis and treatment, the National Necrotizing Fasciitis Foundation launched a program that connects patients and their families from all over the United States and other countries with John Crew, MD, FACS, vascular surgeon and medical director for the Advanced Wound Care Center at Seton Medical Center in Daly City, California.

Crew consults with physicians (at no fee) about his groundbreaking treatment of necrotizing fasciitis, which earned him a nomination for the prestigious Lister Legacy Prize in early 2014. Crew’s treatment plan includes the use of Neutro -Phase® in combination with negative pressure wound therapy. His treatment approach has saved patients’ limbs—and lives.

If you have a patient with necrotizing fasciitis, contact Crew, who is available 24/7, at 908-422-7744. For more information, visit the National Necrotizing Fasciitis Foundation.

Bedside assessment

It’s always hard to choose which published articles to focus on, but three caught my eye as being particularly useful for bedside assessment.

Burn care

Burn care is its own specialty within wound care, but some injuries don’t require a specialist burn unit. The article Best practice guidelines: Effective skin and wound management in non-complex burns,” published in Wounds International, is an excellent resource for clinicians.

The article focuses on hands-on and relevant clinical information for evaluation and management of noncomplex burn injuries that are appropriate for treatment in locations outside specialist burns units, with steps for the immediate emergency management of all burns. The article also highlights the importance of correctly and expediently identifying complex wounds that indicate the patient must be transferred rapidly for specialist care, and discusses ongoing management of newly healed burn wounds as well as postdischarge rehabilitation.

Nutritional needs

Good nutrition includes not only adequate macronutrients, such as protein, carbohydrate, and fat, but also micronutrients—vitamins and minerals—for wound healing. Several micronutrient deficiencies can be identified through a simple skin assessment.

The article “Learning the oral and cutaneous signs of micronutrient deficiencies,” published in the Journal of Wound, Ostomy & Continence Nursing, notes that the hallmark symptom of vitamin B deficiency is glossitis, a reddish tongue with a smooth surface. B12 deficiency is characterized by hypertrophic papillae scattered across the villous surface of the tongue, and signs of B3 deficiency include dermatitis (pellagra), which is characterized by a crepe-paper appearance with wrinkles in the skin and flat surfaces between the wrinkles.

Vitamin C deficiency can manifest as purpura, skin tears, and “plastic-wrap” skin, in which the dermis is so thin that blood vessels can easily be seen beneath a transparent epidermis.

When cutaneous symptoms of vitamin deficiency appear, serum studies should be obtained to confirm the deficiency so prompt treatment can begin.

International ostomy guidelines

The new World Council of Enterostomal Therapists (WCET) International Ostomy Guidelines are evidence-based practice guidelines that are internationally focused rather than country specific. The guidelines can be applied in all countries or care settings, whether resource challenged or resource abundant. The WCET guidelines include cultural, religious, and ethnic considerations for ostomy patients that are international in perspective. You can purchase the full version (64 pages) of the guidelines with the evidence tables, or download a free summary.

New products

Here are several new products from 2014 that you should know about. Granulotion® Medicated Lotion. This over-the-counter lotion is designed to help support the healing of excessive granulation tissue. Granulotion was developed by a nurse practitioner, Christopher R. Speaker, APN, FNP-BC, who was frustrated with steroids and silver nitrate as the only treatment options for hypergranulation tissue. The product is nontoxic and nonsteroidal, with ingredients that provide anti-itch benefits, antimicrobial properties, skin barrier for protection, and the ability to shrink granulation tissue that develops at gastrostomy, jejunostomy, tracheostomy, ileostomy, and colostomy sites.

SenSura® Mio ostomy appliance. This appliance fits to individual body contours and maintains a secure seal over abdomens uneven from scarring, skin folds, hernias, and other problems. SenSura Mio has a soft, elastic, hydrocolloid adhesive barrier that shapes and follows body contours when ostomates bend and stretch. The pouch is made from water-resistant textile material that gives the pouch the feel of clothing and is a neutral gray designed to stay unnoticed under all colors of clothing.

RightSpot™ pH Indicator. This small, noninvasive, in vitro diagnostic device is used to verify gastric acidity to avoid misplacement of nasogastric feeding and percutaneous endoscopic gastrostomy tubes. The RightSpot indicator strip is placed on the tube and gastric fluid is aspirated; as the aspirate saturates the strip, the strip changes color according to the level of pH in the aspirate. The color of the indicator strip is compared to a color chart on the device. A pH below 4.5 indicates gastric acidity.

Hydrofera Blue® Ready Foam. This antibacterial dressing is made of polyurethane foam, methylene blue, and gentian violet. It can be used on a variety of wounds and also under compression bandages or a total contact cast. It has broad-spectrum antibacterial activity and can be left in place for up to 7 days. This new version of Hydrofera Blue doesn’t require hydration before application or a secondary dressing.

Perfect Choice Next Generation NO STINGOstomy Barrier Paste. Designed to help extendwear time, this no-sting skin barrier and filler paste has easy-on, easy-off application and removal.

NOTraum Silicone Foam Dressing. This absorbent foam dressing has a silicone border, which means no trauma for the wound and supporting skin upon removal. The dressing adheres easily and securely to dry, intact skin. It keeps the wound bed moist, but doesn’t adhere to the wound bed, thereby preventing trauma.

Staytex™ tubular dressings. This tubular stretch bandage secures and maintains primary wound dressings to the affected site. The unique weave of the Staytex tube keeps the dressing in place, yet is comfortable and free of latex. It’s available in precut lengths or rolls that can be cut to fit, and is washable and reusable.

Stay tuned

I’m already gathering the latest and greatest for the 2015 Buzz Report, so look for a new edition of The Buzz Report in 2016!

Selected references

Edlich RF, Gubler, KD, Long WB III, et al. Necrotizing fasciitis. Medscape. http://emedicine.medscape.com/article/2051157-overview

International best practice guidelines: Effective skin and wound management of non-complex burns. Wounds International. www.woundsinternational.com/pdf/content_11308.pdf

Kaminski MV Jr, Drinane JJ. Learning the oral and cutaneous signs of micronutrient deficiencies. J Wound Ostomy Continence Nurs. 2014 Mar-Apr;41(2):127-35.

McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determinants of mortality for necrotizing softtissue infections. Ann Surg. May 1995;221(5):558-63; discussion 563-5.

Rouse TM, Malangoni MA, Schulte WJ. Necrotizing fasciitis: a preventable disaster. Surgery. Oct 1982; 92(4):765-70.

Zulkowski K, Ayello EA, Stelton S, eds. WCET International Ostomy Guideline. Perth, Australia: World Council of Enterostomal Therapists; 2014.

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

The Buzz Report: A wound care clinician’s best friend

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

In 2014, more than 8,000 new articles related to wound healing were added to the PubMed online database and hundreds of new patents for topical wound formulations were filed. Staying up-to-date with the latest and greatest findings and products can be challenging. We all lead busy lives, and our demanding work schedules and home responsibilities can thwart our best intentions. Although we know it’s our responsibility to stay abreast of changes in our field, we may feel overwhelmed trying 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, and 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 2014 Buzz Report, with appropriate updates since the September WOW conference.

Pressure ulcer prevention and treatment

2014 was an active year in the area of pressure ulcer prevention. The latest practice guideline on pressure ulcers, released last September, was a joint collaboration of the National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. The intent of the guideline, titled “Clinical Practice Guideline for Pressure Ulcer Prevention and Treatment,” was to advance international consensus on pressure ulcer prevention and management. This document is a must-read for all clinicians practicing wound care today.

Also, NPUAP updated its Registered Nurse Competency-Based Curriculum: Pressure Ulcer Prevention. The curriculum now includes major competencies, content objectives, content topics, suggestions for varied teaching methods, and references.

Are some pressure ulcers unavoidable? This continues to be a hot topic. At a February 2014 multidisciplinary conference hosted by NPUAP, participants reached a consensus on these key points:

  • Some pressure ulcers are unavoidable.
  • Patients at increased risk for developing unavoidable ulcers are those with malnutrition and multiple comorbidities, those with extensive body edema, and those who must keep the head of the bed elevated more than 30 degrees for medical reasons. It’s in every wound clinician’s best interest to stay abreast of NPUAP’s position on unavoidable pressure ulcers. The report was published in the Journal of Wound, Ostomy and Continence Nursing.


According to the 2014 National Diabetes Statistics Report, more than 21 million people in the United States have diabetes, and an estimated 8 million of them are undiagnosed. Diabetes raises the risk of cardiovascular disease because of common concurrent conditions, such as hypertension, obesity, abnormal cholesterol and triglyceride levels, and poorly controlled glucose levels. Help your patients reduce their risk by referring them to the free “Diabetes and Coronary Artery Disease ‘Make the Link’ Toolkit” from the American Diabetes Association.

Compression therapy

Do you use compression therapy to treat patients with venous ulcers? I reviewed three documents on this topic. (See the selected references at the end of this article.) The most compelling was a study published in JAMA Dermatology titled “Delivery of Compression Therapy for Venous Leg Ulcers.” It found more than half the nurses who applied either inelastic or elastic bandages obtained sub-bandage pressures below the 30 mm Hg required for therapeutic compression. The authors concluded that training programs focused on practical bandaging skills are needed to improve management of venous leg ulcers.

Wound care and infection

Infected wounds pose a challenge for even the most seasoned practitioners, who may have difficulty determining the recommended course of action. The Infectious Diseases Society of America published an updated guideline, “Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014.” It covers both diagnosis and ongoing management recommendations for a wide variety of infections, ranging from minor to life-threatening. Although practice varies, clinicians should use evidence-based
interventions to identify and manage wound infections; failing to do so could lead to death.

Resources and new products

Need more resources? See Clinician Resources on page 35 for valuable links. Also, check out new products that might be useful for your patients (See New products in wound care.)

The world of wound care is always changing and evolving. We all need to develop a plan for staying current so we’re not using outdated modalities. I’m already gathering the latest and greatest for the 2015 Buzz Report. One thing is certain—there’s never a lack of issues to review when it comes to wound care.

Selected references

Principles of compression in venous disease: a practitioner’s guide to treatment and prevention of venous leg ulcers. Wounds International, 2013. www.woundsinternational.com/pdf/content_10802.pdf. Accessed December 10, 2014.

Zarchi K, Jemec GB. Delivery of compression therapy for venous leg ulcers. JAMA Dermatol. 2014;150(7):730-6.

Zenilman J, Valle MF, Malas MB, et al. Chronic Venous Ulcers: A Comparative Effectiveness Review of Treatment Modalities. Comparative Effectiveness
Review No. 127. Prepared by Johns Hopkins Evidence-Based Practice Center. AHRQ Publication No. 13(14)-EHC121-EF. Rockville, MD: Agency for Healthcare Research & Quality; December 2013. www.effectivehealthcare.ahrq.gov/ehc/products/
. Accessed December 10, 2014.

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.

An easy tool for tracking pressure ulcer data

By David L. Johnson, NHA, RAC-CT

As a senior quality improvement specialist with IPRO, the Quality Improvement Organization for New York State over the past 11 years, I’ve been tasked with helping skilled nursing facilities (SNFs) embrace the process of continuous quality improvement. A necessary component of this effort has been to collect, understand, and analyze timely and accurate data. This article discusses a free tool I developed to help SNFs track their data related to pressure ulcers and focus their quality improvement efforts for the greatest impact.

The beginning

Since 2002, the quality initiatives administered by CMS have included the prevention and treatment of pressure ulcers as a focus topic for SNFs across the country. The challenge has been to guide identified facilities to collect their own data, in real time, and drill down into that data to identify trends and opportunities for improvement.

In 2002, I decided to develop a tracking tool to help SNFs with the timely collection of their pressure ulcer data. The tool had to be in a format that could be easily used by most providers, including those with basic computer equipment and operating skills. The purpose of this tracking tool was not to replace the necessary clinical documentation of the pressure ulcers, but to offer a focused document with pertinent statistical information for all cases of pressure ulcers in the SNFs at any point in time.

The current Monthly Pressure Ulcer Tracking Form is in its fifth generation. First developed in an Excel 2003 format, the original tracking tool was very functional, but basic. However, Excel 2007 enabled me to add functionality that launched the originally developed tool into a format offering not only a detailed summary and graphs for the entire SNF but also instant access to individual summaries and related graphs for up to 15 separate user-defined locations. For example, those designated locations could be as general as individual units or as detailed as specific care assignments.

How it works

The current version of the Monthly Pressure Ulcer Tracking Form offers the convenience of an Excel spreadsheet to instantly summarize and graph your pressure ulcer data by such categories as site, origin, stage, age of wound (auto-calculated), days to heal (auto-calculated), and weekly response to treatment. The tracking form also summarizes all wounds that are new for the month, by both site and stage and by whether they developed in-house or were present on admission. (See Sample data calculation and graph for all acquired in-house pressure ulcers by stage.)

All of the printed summaries and graphs are clearly identified by their user-defined facility location. Users can quickly identify the data source with the opportunity to easily detect both adverse trends and their own program successes.

Built-in macros for the tracking form walk the user through everything from adding a new case to an end-of-month routine that conveniently saves the data in the current monthly file. The macros then remove the information for all healed or discharged pressure ulcer cases before carrying over all of the data on existing pressure ulcers for the start of a new month of tracking.

All wounds are entered only once, and the weekly status update is as simple as a single letter code for “new,” “improved,” “same,” “worsened,” or “healed.” The data format was intentionally built to allow these factual entries to be clerically entered after collection and assessment by the appropriate professional.

The user is guided through the data entry process with helpful hints in cell drop-down menus as well as embedded data validation rules to restrict what is entered, thereby offering a summary and analysis true to the expectations and spirit of the tracking form.

Efficient data collection in real time is invaluable to wound care teams, offering them the potential to immediately identify adverse trends or celebrate small successes in their wound care program. Take, for example, a calculated increase in facility-acquired stage 2 pressure ulcers. Is there a common site? Is the increase isolated to one designated location or unit? Are there opportunities for focused education efforts, such as early identification or proper prevention practices? The ability to drill down into your data will allow you to focus your limited resources in the areas of identified documented need. (See Sample data calculation and graph for all healed pressure ulcers by site.)

In another example, the data analysis offered instantaneously through this tracking form can easily compare data among designated units within your facility. Is there a unit experiencing better healing times? Has there been a unit experiencing no facility-acquired pressure ulcers? What does that tell you about its prevention practices? How can those practices be spread?

A free resource

In summary, the timely collection, analysis, and attention to your facility’s pressure ulcer data can be invaluable in your internal quality improvement efforts.

These tracking forms are available for download free of charge at nursing
under “Clinical Topics, Pressure Ulcer Clinical Tools and Resources.” You can download a tracking tool with sample data (for demonstration and training purposes), a master blank file for immediate facility implementation, and a multipage PDF desk-side instructional booklet. The instructional booklet offers simple, clear instruction with actual screen prints to help guide the user through the tracking tool functionality. The original tracking tool written in Excel 2003 is still available for those providers with Excel versions earlier than 2007. However, the functionality of the latest generation, which is available to anyone with Excel 2007 or newer, is far superior and highly recommended.

For additional information, please e-mail me at david.johnson@hcqis.org.

Note: This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM7.2-14-24.

David L. Johnson is a senior quality improvement specialist with IPRO, the Quality Innovation Network-Quality Improvement Organization for New York State.

Disclaimer: The views expressed in this article are those of the author and do not necessarily represent the views of, and should not be attributed to, Wound Care Advisor. 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.