Tag Archives: pressure ulcers

Caring for Wounds eBook Series: Pressure Injuries

This e-book is sponsored by Angelini Pharma, Inc.

angelini pharma ebookPatient care teams rely on the wound care nurse alone to implement a pressure injury prevention program; however, a successful program requires involvement from the entire care team and is a 24/7 endeavor.

Learn how your healthcare team can provide better patient care, topics include:

  • Prevention Programs: Where to Begin
  • It Takes a Team
  • Establish a System
  • Empowering Your Patients
  • Prevention Education
  • Pressure Injuries

Clinical Notes, September 2016

Electrical stimulation and pressure ulcer healing in SCI patients

A systematic review of eight clinical trials of 517 patients with spinal cord injury (SCI) and at least one pressure ulcer indicates that electrical stimulation increases the healing rate of pressure ulcers. Wounds with electrodes overlaying the wound bed seem to have faster pressureulcer healing than wounds with electrodes placed on intact skin around the ulcer.

A quantitative, pooled analysis and systematic review of controlled trials on the impact of electrical stimulation settings and placement on pressure ulcer healing rates in persons with spinal cord injuries,” published in Ostomy Wound Managementstates that the overall quality of the studies was “moderate” and that future trials “are warranted.”

Effect of antiseptics on maggot viability

The short-term application of wound antiseptics on wound beds does not impair the viability of maggots, according to a study in International Wound Journal.

Viability of Lucilia sericata maggots after exposure to wound antiseptics” reports that the maggots can survive up to 1 hour of exposure to antiseptics, such as octenidine, povidone-iodine, or polyhexanide.

Global impact of diabetes underestimated

The prevalence of global diabetes has been seriously underestimated by at least 25%, according to a study published in Nature Reviews Endocrinology.

Diabetes mellitus statistics on prevalence and mortality: facts and fallacies” indicates that there may be more than 100 million people with diabetes globally than previously thought.

Axillary evaluation and lymphedema

A retrospective cohort study in Epidemiology reports that women with ductal carcinoma in situ who receive an axillary evaluation have higher rates of lymphedema, without breast cancer-specific or overall survival benefit.

Axillary evaluation and lymphedema in women with ductal carcinoma in situ” included 10,504 women.

Topical insulin and pressure ulcers

A randomized, controlled trial to assess the effect of topical insulin versus normal saline in pressure ulcer healing” concludes that topical insulin is safe and effective in reducing the size of pressure ulcers compared to normal saline-soaked gauze.

Participants of the study, published in Ostomy Wound Management, received either normal saline dressing gauze or insulin dressing twice daily for 7 days. The insulin was sprayed over the wound surface with an insulin syringe, allowed to dry for 15 minutes, and then covered with sterile gauze.

Sexual function and ostomy

Sexual function and health-related quality of life in long-term rectal cancer survivors” reports that long-term sexual dysfunction is common in patients who have undergone surgery for rectal cancer, with more problems seen in patients who have a permanent ostomy.

The study, published in the Journal of Sexual Medicine, included 181 patients with an ostomy and 394 patients with anastomosis.

Effect of venous leg ulcers on body image

Many patients with venous leg ulcers have low self-esteem and negative feelings about their bodies, according to a prospective study published in Advances in Skin & Wound Care.

The impact of venous leg ulcers on body image and self-esteem” included 59 participants. The mean score on the Rosenberg Self-esteem Scale was 22.66, indicating low self-esteem.

Understanding NPUAP’s updates to pressure ulcer terminology and staging

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

In a nutshell

Here are the key overall changes made by NPUAP:

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

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

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

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

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

Pressure injury

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

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

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

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

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

Stage 3 pressure injury: Full-thickness skin loss

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

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

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

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

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

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

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

More definitions

Below are additional pressure injury definitions.

Medical-device related pressure injury:

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

Mucosal membrane pressure injury:

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

Next steps

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

Access free resource: staging illustrations from the NPUAP website.

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

Selected reference

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

Clinical Notes

Management of biofilm recommendations

The Journal of Wound Care has published Recommendations for the management of biofilm: a consensus document,” developed through the Italian Nursing Wound Healing Society.

The panel that created the document identified 10 interventions strongly recommended for clinical practice; however, panel members noted that, “there is a paucity of reliable, well-conducted clinical trials which have produced clear evidence related to the effects of biofilm presence.”

Statins reduce CVD risk in patients with diabetes

Statins reduce the risk of cardiovascular disease (CVD) and death in patients with type 1 diabetes without a history of CVD, according to a study published in Diabetes Care.

Association between use of lipid-lowering therapy and cardiovascular diseases and death in individuals with type 1 diabetes” included more than 24,000 individuals from the Swedish National Diabetes Register who were followed for a mean of 6 years.

International diabetes organizations support bariatric surgery

Metabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by international diabetes organizations,” published in Diabetes Care, supports including metabolic (bariatric) surgery as a treatment option for people with type 2 diabetes who are obese. The statement notes when metabolic surgery is recommended and when it should be considered.

The 2nd Diabetes Surgery Summit was convened in collaboration with leading diabetes organizations to develop the guidelines. The multidisciplinary group included 48 international clinicians and scholars from leading diabetes associations; 75% were not surgeons. Draft conclusions were presented and opened to public comment. Following comment, they were amended.

Medicare-VHA dual use associated with poorer chronic wound healing

Veterans with chronic wounds who are enrolled in Medicare and access care through Medicare and the Veterans Health Affairs (VHA) experience poorer healing of chronic wounds, according to a study in Wound Repair and Regeneration.

Medicare-VHA dual use is associated with poorer chronic wound healing” was a retrospective study that followed 227 Medicare-enrolled individuals who used the VHA and who had a chronic lower limb wound. Individuals were followed until the wound was healed or up to 1 year.

“Dual use was associated with a significantly lower hazard of wound healing compared to VHA-exclusive use,” the study authors note. The risks of amputation or death were higher for dual users.

Sacral dressing may help prevent ulcers in ICU patients

Prophylactic sacral dressing for pressure ulcer prevention in high-risk patients,” published in the American Journal of Critical Care, reports that the dressing reduced the number of sacral pressure ulcers in three ICUs by 3.4 to 7.6 per 1,000 patient days depending on the unit.

Data were collected for 7 months and compared to 7 months before the dressings were used, and patients were identified as high risk by using an evidencebased tool. The study authors note that heightened awareness by the care team and increased education also are key in preventing pressure ulcers.

Scale has limited ability to predict pressure ulcers

A study that evaluated the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) during acute care and inpatient rehabilitation following spinal cord injury (SCI) found that the scale could predict pressure ulcers occurring within 2 to 3 days after it was administered in acute care, but didn’t predict ulcer development over a longer term within acute or inpatient rehabilitation.

Predictive validity of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) in acute care and inpatient rehabilitation in individuals with traumatic spinal cord injury,” published in NeuroRehabilitation, used retrospective analysis to determine the findings.

Braden Q and Glamorgan scales compared in children

The Journal of Tissue Viability has published A comparison of the performance of the Braden Q and the Glamorgan paediatric pressure ulcer risk assessment scales in general and intensive care paediatric and neonatal units,” which found that both work  well in these settings.

The study authors note, however, that the Braden Q may be better at predicting risk in general pediatric units. More than 500 pediatric admissions were included in the study.

Axillary reverse mapping may reduce lymphedema

Researchers report that using axillary reverse mapping during surgery to help identify lymph nodes and vessels reduces the risk of lymphedema in patients undergoing sentinel lymph node biopsy and/or axillary node dissection.

A total of 654 patients participated in Does axillary reverse mapping prevent lymphedema after lymphadenectomy?,” published in Annals of Surgery.

Muslims and QOL after ostomy surgery

Muslims who undergo ostomy surgery experience significant reductions in health-related quality of life (QOL) — greater reductions than seen in non-Muslim patients, according to a study in Journal of Wound Care and Ostomy.

Quality of life after ostomy surgery in Muslim patients: a systematic review of the literature and suggestions for clinical practice” notes that factors associated with the difference include “psychological factors, social isolation, underreporting of complications, and sexual dysfunction leading to breakdown of marital relations as well as diminished religious practices.”

Chronic venous insufficiency consensus statement

Circulation has published “Investigation of chronic venous insufficiency: a consensus statement,” which “provides an up-to-date account of the various methods available for the investigation of chronic venous insufficiency of the lower limbs (CVI), with an outline of their history, usefulness, and limitations.”

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.

Clinical Notes

Self-management ostomy program improves HRQOL

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

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

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

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

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

Keratin-based products effective for burn treatment

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

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

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

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

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

Incontinence of older persons affects QOL of their caregivers

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

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

Trauma patients vulnerable to device-related pressure ulcers

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

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

Intensive therapy for patients with diabetes reduces CV complications

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

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

Buzz Report: Latest trends, part 2

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

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

Product buzz

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

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

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

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

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

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

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

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

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

Resource buzz

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

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

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

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

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

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

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


Empowering patients to play an active role in pressure ulcer prevention

Developing a pressure ulcer can cause the patient pain, lead to social isolation, result in reduced mobility, and can even be fatal. According to the Agency for Healthcare Research and Quality, estimated costs for each pressure ulcer range from $37,800 to $70,000, and the total annual cost of pressure ulcers in the United States is an estimated $11 billion.

Nurses understand their role in preventing pressure ulcers, but what role do patients play in the prevention plan? Nurses need to empower the patient to be an active member in health promotion activities and participate in prevention measures. In this article, I highlight the importance of incorporating pressure ulcer prevention into patient education for high-risk patients as a way to empower patients. Empowered patients can help improve outcomes and reduce overall costs of this hospital-acquired complication.

Patient engagement

A basic element of empowerment is engagement. Nurses must practice a patient-centered approach to healthcare delivery that embraces and supports the belief that patients are, or can become, competent to make informed decisions. Engaged patients tend to function better, experience fewer symptoms, and are less likely to experience an adverse event compared to those who aren’t engaged.

As a practicing nurse, you would think that engaging patients in their care would lie at the core of the culture of our healthcare system; unfortunately, that is not always the case. For example, sometimes we forget to explain to patients why we are asking them to perform health promotion activities. If we instruct patients to follow a direction without explaining the meaning behind it, they may be less likely to actively participate in the activities.

Helping patients understand the reason behind an activity, instead of making it seem like we are ordering them to do it, can help performance and adherence levels. With our expertise and close proximity to patients, we are able to take a leading role in engaging them in their care.

The value of teach-back

High-risk patients must be informed about pressure ulcers, including prevention and complications. Arming patients with knowledge makes them feel empowered to actively participate in their health promotion. Unfortunately, studies reported by Dewalt and colleagues note that 40% to 80% of information taught to patients is forgotten immediately. The teach-back method is one way to reduce those percentages.

In the teach-back method, patients teach the information taught to them back to the nurse. This can be done through discussion or demonstration, depending on the topic. (See More about teach-back.) When information is correctly taught back, it confirms that the patient understands the content. Using the teach-back method in combination with daily reinforcement from nursing staff can help to solidify the knowledge learned and encourage implementation of health practices.

Integrating into care

Latimer, Chaboyer, and Gillespie reported that after conducting interviews regarding pressure ulcer education, patients had varying knowledge of pressure injuries and only a few reported receiving education from healthcare providers about risk factors and strategies to prevent pressure ulcers.

To ensure pressure ulcer prevention education occurs when needed, it’s helpful for this education to be part of the standard of care for high-risk patients. Making these education sessions mandatory and using the teach-back method to confirm understanding can help patient adherence to suggested prevention interventions. As nurses, we are empowering our patients by effectively supplying them with information they need to make good choices and be active in promoting their health.

Clinicians should document that education was provided and its level of effectiveness. Evidence of effectiveness includes patient involvement in prevention measures, such as actively turning themselves. Proper documentation by nursing staff shows the effect of education on patients’ participation in their own health promotion activities. Although education may take time, the time spent outweighs the complications of this debilitating condition. After all, it is far easier to prevent a complication than it is to treat one and regain a patient’s health.

Promoting engagement

A pressure ulcer often results in patient pain and suffering, poor patient outcomes, decreased quality of life, and increased costs for both patients and their providers. The integration of pressure ulcer prevention into required patient education using the teach-back method empowers and engages patients, fostering their active participation in their own health promotion. Healthcare providers and patients can work together as a team to prevent the many costs of pressure


Hannah Miller is a clinical learning lab specialist at Chamberlain College of Nursing in Cleveland, Ohio.

Selected references

Agency for Healthcare Research and Quality. Pressure ulcer treatment strategies: Comparative effectiveness. Comp Eff Rev. 2013;90. effectivehealthcare.ahrq.gov/ehc/products/308/1492/Pressure-ulcer-treatment-executive-130508.pdf.

DeWalt DA, Callahan LF, Hawk VH, et al. Health literacy universal precautions toolkit. AHRQ. 2010.

Gillespie BM, Chaboyer W, Sykes M, et al. Development and pilot testing of a patient-participatory pressure ulcer prevention care bundle. J Nurs Care Qual. 2014;29(1):74-82.

Latimer S, Chaboyer W, Gillespie BM. Pressure injury prevention: do patients have a role? Qld Nurse. 2012;31(4):33.

Sherman RO, Hilton N. The patient engagement imperative. Am Nurse Today. 2014;9(2).


Online Resources

A. http://www.teachbacktraining.org/

B. http://www.nchealthliteracy.org/toolkit/tool5.pdf

C. https://www.youtube.com/watch?v=cGtTZ_vxjyA

Restorative nursing programs help prevent pressure ulcers

Immobility affects all our body systems, including our skin. According to the National Pressure Ulcer Advisory Panel, many contributing factors are associated with the formation of a pressure ulcer, with impaired mobility leading the list.

So what can clinicians do to prevent harm caused by immobility? One often-overlooked strategy is a restorative nursing program. (See About restorative nursing.)

Moving up the time line

Most patients who score poorly for mobility and/or activity impairments on the Braden Scale for Predicting Pressure Ulcer Risk are referred to physical therapy, but too often a restorative nursing program

isn’t started until patients are ready to be discharged from therapy. However, the more active we can keep patients, the less likely they will have prolonged periods of time in the same position, thus preventing pressure ulcer formation. If your patients are spending most of their time sitting in wheelchairs and/or in their beds, consider tapping into a restorative nursing program, which should run parallel to therapy.

Benefits of restorative nursing

Implementing a restorative nursing program can significantly benefit your patients. For example, restorative nurses can promote early mobility by assessing patients’ ability to turn and reposition themselves in bed, go from a lying to sitting position, and shift their weight in the wheelchair, including reverse push-ups.

Restorative nurses also can provide strength-training exercises as part of range-of-motion programs. These exercises can help patients develop the muscles they need for mobility and self-positioning. A strength-training program can be tailored to any position (supine, sitting, or standing) so it’s individualized for the patient’s needs. Many clinicians think patients who are of advanced age or deconditioned aren’t eligible for strength-training programs, but studies show that these patients still benefit. Essentially it is never too late.

Connecting patients with a restorative nursing program

To start a restorative nursing program, first discuss its benefits with the patient and ensure he or she is willing to participate. Next, work with therapists to identify the appropriate exercises that restorative nurses and nursing aides will perform with the patient. Physician clearance is recommended.

Remember that the program can be enhanced with interactive activities such as obstacle courses, video games, gardening, dance classes, tai chi, and bowling to keep your patients mobile.

Be proactive

The more active and mobile your patients are—and the earlier they begin activity—the less likely they will develop a pressure ulcer. You might want to have a policy in your care setting that automatically triggers a restorative nursing program for residents who score poorly for mobility and/or activity on the Braden Scale. The program may be just what the patient needs to protect him or her from harm.

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


Selected references

Edsberg LE, Langemo D, Baharestani MM, et al. Unavoidable pressure injury: state of the science and consensus outcomes. J Wound Ostomy Continence Nurs. 2014;41(4):313-34.

Minnesota Department of Health. What are restorative nursing programs? August 2014.


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

Online Resource

A. https://www.youtube.com/watch?v=lCRRiEkUtOk

Clinician Resources


End your year by checking out these resources for your practice.



Sentinel event alert for falls

As part of its sentinel event alert “Preventing falls and fall-related injuries in health care facilities,” The Joint Commission has assembled information and multiple resources, including:

  • analysis of contributing factors for falls
  • evidence-based suggestions for improvement
  • Joint Commission requirements relevant to falls
  • links to toolkits and protocols
  • an infographic on preventing falls.

Falls with serious injury are consistently among the top 10 sentinel events reported to The Joint Commission Sentinel Event Database.


Position statements for NPUAP

The National Pressure Ulcer Advisory Panel publishes several position statements of interest to wound care clinicians, including:

  • Hand check method: Is it an effective method to monitor for bottoming out?
  • Pressure ulcers with exposed cartilage are stage IV pressure ulcers
  • Staging pressure ulcers
  • Mucosal pressure ulcers
  • Reverse staging.

The statements recap a topic or delineate NPUAP’s opinion on a specific issue.


Patient safety primer on high reliability

The Agency for Healthcare Research and Quality has released a Patient Safety Primer on high reliability. High-reliability organizations operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures.

The primer describes characteristics of high reliability and links to resources that can help organizations foster an environment conducive to high reliability.


Civility resources

The American Nurses Association offers resources on incivility, bullying, and workplace violence, including:

  • two infographics: “Bullying prevention strategies for nurses” and “Civility best practices for nurses”
  • the position statement “Incivility, Bullying, and Workplace Violence”
  • links to other resources, such as a National Institute for Occupational Safety and Health training program on occupational violence.

Guideline synthesis on prevention of pressure ulcers

Access a comparison of two guidelines for the prevention of pressure ulcers. The comparison was done by the National Guideline Clearinghouse, part of the Agency for Healthcare Research and Quality.

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.