Tag Archives: skin care

Providing skin care for bariatric patients


By Gail R. Hebert, MS, RN CWCN, DWC, WCC, OMS

How would you react if you heard a 600-lb patient was being admitted to your unit? Some healthcare professionals would feel anxious—perhaps because they’ve heard bariatric patients are challenging to care for, or they feel unprepared to provide their care.

With the obesity epidemic showing no signs of abating, you’re likely to encounter bariatric patients at some point. How can you care for them with the dignity and respect they deserve? If we expect to conduct “business as usual” on our units, we’ll be caught off guard without the tools and knowledge we need to make the experience a positive one for the patient, family, and staff. This article reviews how to prepare for and manage one of the most challenging aspects of caring for bariatric patients—providing skin care.

Skinfolds: A special focus of care

Bariatrics is the branch of health care that specializes in treating people with obesity and associated conditions. Defined as a body mass index (BMI) over 30, obesity reflects how a person’s weight relates to height. Bariatric patients have an excessively large size, with excess adipose tissue under the skin and throughout the body.

Skinfolds may develop in various locations—including behind the neck; under the arms, breasts, and abdomen; between the inner thighs; and under the pannus (an overlapping tissue flap formed from the abdomen that extends downward like an apron). Complications commonly arise in skinfolds and include intertriginous dermatitis, candidiasis, and pressure ulcers. (See Understanding skinfold complications in bariatric patients.)

Understanding skinfold

OBESE: An apt mnemonic

Use the word OBESE as a mnemonic tool to help you remember key clinical issues in bariatric skin management.

O: Observe for atypical pressure ulcer development.

B: Be knowledgeable about common skin conditions.

E: Eliminate moisture on skin and in skinfolds.

S: Be sensitive to the patient’s emotional distress.

E: Use equipment to protect the skin and for safe patient handling.

Observe for atypical pressure ulcer development.

Bariatric patients are at higher risk for pressure ulcers, as their extra padding doesn’t necessarily protect them from the forces of pressure and shear. Although the data supporting higher risk for this population aren’t cut and dried, most expert clinicians believe the risk is higher, so be sure everyone knows that fat pads don’t provide protection.

Also, bariatric patients commonly are malnourished and less mobile than others, making it hard for them to avoid excess pressure on the skin. Many have multiple comorbidities, such as diabetes, that further increase their pressure ulcer risk. We lack a risk assessment instrument specifically designed for this population, so we must use our clinical skills and experience to anticipate risk.

In this population, pressure ulcers can develop in atypical and unique locations—hips, lower back, buttocks, in skinfolds, and in areas with medical devices, such as tubes. Also, foreign objects, such as medicine cups and TV remote controls, can get lost in the bed and lead to pressure areas. Bariatric patients require frequent turning and repositioning to help prevent breakdown from pressure and shear forces.

Be knowledgeable about common skin conditions.

Intertriginous dermatitis is an inflammatory skin condition commonly seen in the skinfolds of bariatric patients. It results from the weight of skin, which creates skin-on-skin contact coupled with friction forces and trapped moisture from perspiration. Dermatitis most often occurs in skinfolds behind the neck, under the arms and breasts, under the abdomen or pannus, on the side, and on the inner thigh.

Intertriginous dermatitis is partial thickness and typically presents in a mirror-image pattern on each side of the skinfold. Initially, the involved area of the skin shows mild redness, which may progress to more intense inflammation with erosion, oozing, drainage, maceration, and crusting. Associated findings include pain, itching, burning, and odor. As clinicians, we should anticipate this problem and not wait for intertriginous dermatitis to develop. To help prevent and intervene for intertriginous dermatitis, read “Eliminate moisture on skin and in skinfolds” below. (For information on other common skin conditions in bariatric patients, see Candidiasis, acanthosis nigricans, and chafing.)

Candidiasis, acanthosis nigricans, and chafing

Eliminate moisture on skin and in skinfolds.

Many barriers to healthy skin in bariatric patients can be eliminated by reducing moisture on the skin, avoiding skin-to-

skin contact, minimizing heat build-up on these tissues, and keeping the skin clean. Using absorbent materials can accomplish these goals. For instance, Interdry AG® Textile (from Coloplast, Inc.) is impregnated with ionic silver, which provides broad-spectrum antibacterial and antifungal action for up to 5 days. It’s designed to wick away moisture and reduce skin-to-skin friction.

Clean the patient’s skin frequently with a pH-balanced cleanser, using gentle strokes to avoiding harming fragile tissues. Avoid scrubbing. Handheld showers and no-rinse cleansers can simplify this pro­cess. Advise patients to wear loose-fitting clothing made of absorbent fibers.

Be sensitive to the patient’s emotional distress.

Everyone involved in caring for bariatric patients should receive sensitivity training to increase their awareness and compassion. Many of us hold an unconscious negative view of these patients, which can manifest in our interactions with them. Bariatric patients have reported many incidents of unprofessional treatment by staff who are otherwise excellent caregivers but lack empathy and understanding.

To make matters worse, bariatric patients frequently suffer from depression, altered self-esteem, and social isolation. Take care not to demonstrate prejudice through your actions and words, or to show reluctance to render care due to fear of injury, inadequate equipment, inadequate staffing, or a misunderstanding of obesity.

Be aware of possible obesity bias. View: “Weight bias in healthcare,” from Yale Rudd Center.

Use equipment to protect the skin and for safe patient handling.

Equipment must be the proper size and construction to prevent rubbing and creating pressure points against the skin (for example, from the side panels of a too-small wheelchair). Reposition patients frequently to prevent skin breakdown; also, reposition any tubes and tube fixation devices. Use support surfaces of the appropriate weight limit to prevent bottoming out. With skin moisture a common concern, most bariatric patients should use a low-air-loss mattress.

Transferring and moving patients presents a hazard to both staff and patients. Ideally, healthcare facilities should have the proper equipment on hand and ready for use when the patient reaches the unit. The best way to ensure the right type and amount of equipment is to work with companies that specialize in safe patient-handling programs. They can conduct a needs analysis and provide evidence-based recommendations that can be reviewed before equipment purchase or rental. Although facility administrators may believe they lack the budget for equipment purchase, I would advise them they don’t have the budget not to purchase it. A single lawsuit or injury claim by a patient or a workers compensation claim by staff can cost considerably more than the investment in proper patient-handling equipment.

Meeting the challenge

Specialized knowledge of common conditions and appropriate treatments can help us meet the challenge of caring for ba­ri­atric patients’ skin. That knowledge must be coupled with planning activities to address such issues as required staff, devices, and lifting and repositioning equipment. Accomplishing these goals long before you hear of a 600-lb patient on the way to your floor will greatly enhance the chance of a successful outcome.

Selected references

Beitz JM. Providing quality skin and wound care for the bariatric patient: an overview of clinical challenges. Ostomy Wound Manage. 2014;60(1):12-21.

Black JM, Gray M, Bliss DZ, et al. MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2011;38(4):359-70.

Blackett A, Gallagher S, Dugan S, et al. Caring for persons with bariatric health care issues: a primer for the WOC nurse. J Wound Ostomy Continence Nurs. 2011;38(2):133-8.

Bryant RA. Types of skin damage and differential diagnosis. In: Bryant RA, Nix DP. Acute & Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Mosby; 2012;83-105.

Corbyn C, Rush A. Challenges of wound management in bariatric patients. Wounds UK. 2010;6(4):62-71.

Cuddigan JE, Baranoski S. Wounds in special populations: bariatrics. In: Baranoski S, Ayella EA, eds. Wound Care Essentials: Practice Principles. 3rd ed. Ambler, PA: Lippincott, Williams & Wilkins; 2012;542-51.

Doughty D. Differential assessment of trunk wounds: pressure ulceration versus incontinence associated dermatitis versus intertriginous dermatitis. Ostomy Wound Manage. 2012;58(4):20-2.

Doughty D, Junkin J, Kurz P, et al. Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges. J Wound Ostomy Continence Nurs. 2012;39(3):303-15.

Clark L, Black JM. Keeping the bariatric patient’s skin intact. Bariatric Times. May 17, 2011. bariatrictimes.com/keeping-the-bariatric-patient%E2%80%99s-skin-intact/

Miller JH. Acanthosis nigricans. Medscape. July 15, 2010; updated September 26, 2014. emedicine.medscape.com/article/1102488-overview

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.

Sardina D. Skin and Wound Management Course Workbook. Lake Geneva, WI: Wound Care Education Institute; April 2011.

Swezey L. Top 5 ways to prevent skin breakdown in bariatric patients. April 2, 2014. woundsource.com/blog/top-5-ways-prevent-skin-breakdown-bariatric-patients.

Zulkowski K. Diagnosing and treating moisture-associated skin damage. Adv Skin Wound Care. 2012; 25(5):231-6.

Gail R. Hebert is a clinical instructor with 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.

Is your therapy department on board with your wound care team?


By Cheryl Robillard, PT, WCC, CLT, DWC

Patients in your clinical practice who develop wounds should prompt a call for “all hands on deck” to manage the situation, but some personnel may be missing the boat. Physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs) should be on board your wound care ship so patients can receive care they need. But unfortunately, sometimes they aren’t.

Several reasons can account for the lack of therapy involvement in some facilities. They include a knowledge deficit of what PTs, OTs, and SLPs can do to help heal wounds, or misinformation such as the myth that therapy can’t get involved until a wound has been present for 30 days. Another reason may be lack of therapist’s knowledge or desire to treat wounds and their complications. Lastly, it could be a “turf” issue when several members of the team could perform a similar intervention.

Let’s take a closer look at some of these areas.

Therapy services

An understanding of the services therapists can provide helps you know when to make referrals.

Cognition assessment

SLPs are experts in assessing a patient’s cognition. The assessment includes learning ability, so they can help the team determine effective strategies for teaching.

Consider the nonadherent patient with diabetes who has a foot wound. Diabetes is a risk factor for cognitive impairment, but how many of your patients with diabetes have been tested for this impairment so they—and you—know how to compensate?

Another problem is that patients with mild cognitive impairment can often “talk the talk, but not walk the walk”: They may say they understand but not truly “get it.” This is especially true with written information. Too much money has been wasted on literature given to patients who might be able to read it but don’t comprehend the information or can’t make the connection between the information and what specifically they need to do.

You can use a simple screening test such as the SLUMS (St. Louis University Mental Status exam) or the MoCA (Montreal Cognitive Assessment) for an initial assessment and refer patients to an SLP if the results are positive.


SLPs and OTs, working closely with dietitians, can assess and treat swallowing and feeding issues that can impair the ability of patients to receive the nutrition they need for wound healing. SLPs and OTs also can educate staff and patients in good oral care to help prevent such complications as pneumonia that can derail healing.

Skin care

General skin care isn’t only the function of nursing—OTs and PTs can help. Ensuring that patients and caregivers have the knowledge and capability to inspect, cleanse, and moisturize the skin should be part of a complete activities-of-daily-living program, a specialty of OTs.

Urinary and bowel continence management, which is within the scope of practice for PTs and OTs, can make a significant difference in avoiding contamination of truncal wounds.

Pressure reduction and off-loading is another reason for referral to PTs and OTs. Splinting and contracture management can prevent some wounds and help in healing others. PTs can assess sensation and examine footwear, then teach patients and make recommendations to prevent excessive pressure. They also can provide specialty shoes or total contact casts. Decisions about pressure redistribution in seating systems and beds should involve PTs or OTs.

Edema management

Edema management, which may include manual lymphatic drainage, compression, and exercise, is a good reason to refer patients to PTs and OTs. Although some of these methods require additional training beyond entry-level education, therapists should be able to provide them.

Psychosocial issues

OTs also address psychosocial issues pertinent to wound healing. For example, a patient confined to bed or home for extended periods of time may experience social isolation, learned helplessness, and depression. A patient with a vascular wound who is at risk for amputation may experience extreme stress. Or a patient may not be able to return to his or her previous profession because of wound issues. OTs are trained to provide psychotherapeutic interventions aimed at improving and maintaining the highest quality of life.


Debridement of nonviable tissue, including both necrotic tissue and epiboly, is part of clinical practice for PTs and specially trained OTs. These therapists can use scalpels, forceps, curettes, and scissors for conservative sharp debridement. Sterile instruments are used in a clean environment to remove only nonviable tissue. This differs from surgical debridement, which is completed by physicians in a sterile surgical environment and may also include removal of viable tissue to effectively create a new wound. Debridement may also be nonspecific, such as using pulsed lavage, a high-pressure saline jet with suction.

Please note that all of the interventions discussed so far may be provided when needed, regardless of the length of time a wound has been present.

Biophysical agents

Biophysical agents, also commonly known as modalities, use various forms of energy to facilitate healing by decreasing inflammation, increasing circulation, decreasing edema, decreasing pain, and removing or softening necrotic tissue. PTs and specially trained OTs can provide these modalities. Each modality has specific contraindications and may have payer-specific limitations on provision. (See Types of biophysical agents.)

Types of biophysical agents

Bringing therapists onboard

Now that you know what therapists should be able to do for your wound patients, what if your clinicians aren’t trained in some of these areas? Discuss the problem with the department manager because there are many continuing education courses available, as well as the Wound Care Education Institute certification program.

An excellent way to increase involvement of therapists in wound care is to have them participate in wound rounds with nurses. This is a great way for you to share your knowledge with them, allow them to see various wounds and wound dressings, and have them determine with you what wounds might need the therapy interventions discussed in this article.

Mowing down turf issues

Eliminating turf issues begins with knowing each discipline’s scope of practice. You also may need to take financial issues into consideration. Depending on your setting, if the PT can debride and be separately reimbursed, freeing up nurses to focus on other medical issues, wouldn’t that be the most expedient course?

Another potential problem may be coordination of services. For example, although applying a dressing is not a billable therapy service, does it make sense to have a therapist undress the wound for a modality then leave the wound uncovered until a nurse has time to apply the dressing?

Resolving turf issues requires a collaborative spirit from all team members to negotiate what makes the most sense in your setting and determine what would be best for the patient’s healing.

Setting sail

Having therapists as active members of your wound care team will ensure you’re providing the best state-of-the-art care for patients’ wounds. Knowing what the different therapies can do will help you determine which wounds require a therapist’s direct involvement. Lastly, navigating barriers to getting your therapists on board your wound care ship will help you reach top speed in sailing to healing!

Selected references

Cheng G, Huang C, Deng H, Wang H. Diabetes as a risk factor for dementia and mild cognitive impairment: A meta analysis of longitudinal studies. Intern Med J. 2012;42(5):484-91.

McCrimmon RJ, Ryan CM, Frier BM. Diabetes 2: diabetes and cognitive dysfunction. Lancet. 2012;379:


Marseglia A, Xu W, Rizzuto D, et al. Cognitive functioning among patients with diabetic foot. J Diabetes Complications. 2014;28(6):863-868.

Nasreddine ZS, Phillips NA, Bedirian V, et al The Montreal Cognitive Assessment, MoCa: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695-9.

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

Tariq SH, Tumosa N, Chibnall JT, et al. Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder—a pilot study. Am J Geriatr Psychiatry. 2006;14(11):900-10.

Whitmer RA. Type 2 diabetes and risk of cognitive impairment and dementia. Curr Neurol Neurosci Rep. 2007;7(5):373-80.

Cheryl Robillard is a clinical specialist for Aegis Therapies in Milwaukee, Wisconsin.


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.

A Saudi rehabilitation facility fights pressure ulcers

By Joanne Aspiras Jovero, BSEd, BSN, RN; Hussam Al-Nusair, MSc Critical Care, ANP, RN; and Marilou Manarang, BSN, RN

A common problem in long-term care facilities, pressure ulcers are linked to prolonged hospitalization, pain, social isolation, sepsis, and death. This article explains how a Middle East rehabilitation facility battles pressure ulcers with the latest evidence-based practices, continual staff education, and policy and procedure updates. Sultan Bin Abdulaziz Humanitarian City (SBAHC) in Riyadh, Saudi Arabia, uses an interdisciplinary approach to address pressure-ulcer prevention and management. This article describes the programs, strategies, and preventive measures that have reduced pressure-ulcer incidence.

Committed to excellence

With 409 beds, SBAHC is the largest rehabilitation facility in the Middle East; it treats both inpatients and outpatients. Therapeutic, supportive, and educational services are designed to restore patients’ health and function after acute illness and promote their safe return to the home and community. SBAHC admits adult and pediatric patients who have suffered brain injuries, spinal-cord injuries (SCIs), stroke, and limb loss. The facility also offers other services (such as prosthetics, orthotics, and wound care) at clinics that operate 5 days a week.

SBAHC launched its wound care service in late 2007, with the mission of becoming a center for wound care excellence. To prevent and manage pressure ulcers, it uses guidelines from the National Pressure Ulcer Advisory Panel (NPUAP) (www.npuap.org) and the European National Pressure Ulcer Panel. From the onset, the SBAHC administration has fully supported efforts to eradicate pressure ulcers. It has a well-defined process, studied thoroughly and approved by an interdisciplinary team, for identifying, preventing, and managing pressure ulcers.

Initial evaluation

Before admission, patients are screened with special attention to their rehabilitation potential. (Patients who need acute medical care are transferred to an acute-care facility.) Those admitted with community-acquired pressure ulcers are distinguished from those with hospital-acquired pressure ulcers (HAPUs). Within 2 to 6 hours of admission, all patients undergo a comprehensive, front-to-back and head-to-toe skin assessment to check for wounds. Within 24 hours, a pressure ulcer or other wound must be documented; pressure ulcers found later than 24 hours after admission are considered HAPUs.

Also on admission, patients undergo a risk assessment using the Braden scale, a standardized assessment tool for evaluating pressure-ulcer risk. Early identification of at-risk patients is crucial for early implementation of preventive measures and to establish a baseline for later comparison, as when patients sustain new wounds in the facility. The Braden score corresponds to a prevention protocol that varies with the patient’s risk level. A change in the patient’s condition calls for reevaluation with the Braden scale. All direct-care staff are involved in the process and take an active role in the protocol. Pressure ulcers of all stages are referred to the wound care specialist, who in turn may refer the patient to the consultant surgeon, if needed.

Pink clover status

A communication process alerts all SBAHC care providers that a patient has developed a pressure ulcer or is at increased risk. A rotating pink clover icon (chosen to symbolize that healthy skin is pink and that the patient requires repositioning and checking of the skin) is activated for patients with Braden scores of 18 or below. This alert icon appears across the patient’s name and medical-record number in the electronic system, signaling caregivers to use caution because certain types of care or other activities may cause or exacerbate existing pressure ulcers in at-risk patients.

Campaign to lower HAPU rates

The alarming rate of pressure ulcers impelled the SBAHC wound care team to
review and revise existing preventive measures, develop new policies and procedures (which are reviewed annually and revised every 3 years or as necessary), and fine-tune its prevention and management protocols. HAPU incidence became an internal quality indicator. In 2012, an initiative was implemented to reduce HAPU incidence to less than 1% of the monthly total average census. The project had three goals:

  • to educate at least 80% of all direct-care staff (including nursing, medical, and rehabilitation staff) on pressure-ulcer identification and prevention
  • to reduce pressure-ulcer incidence in patients with SCIs to less than 27% of the total incidence (monthly report trends and data from other hospitals worldwide indicate most pressure ulcers occur in SCI patients)
  • to reduce the number of pressure ulcers in patients permitted to go on therapeutic-leave pass to 50% or fewer monthly, within 1 year.

The HAPU prevention team took on the challenge of lowering the incidence. At monthly meetings, staff receive updates on issues related to pressure ulcers. The team addresses these issues, identifies factors that contribute to pressure ulcers, discusses updated evidence-based practices in areas that may need improvement, and provides input on implementation with team members’ consensus.

By the end of 2012, about 82% of direct-care staff had received education. From 2011 to 2012, pressure-ulcer incidence in SCI patients dropped significantly to 18.6%. Also that year, no pressure ulcers were reported in patients who had therapeutic-leave passes. Overall, the project has achieved its goals. Average HAPU incidence for 2012 was 1.8%. Incidence for 2013 was 1.05%—a 41.6% decrease.

Because a lower HAPU incidence reflects a facility’s high standards of care, these initiatives have placed SBAHC’s quality of care in the spotlight. In published data, HAPU rates in long-term care facilities range from 2.2% to 23.9%. At SBAHC, the goal is a rate below 1%.

Pressure-ulcer surveys

Monthly HAPU incidence reports are compiled for monitoring and reference. The
facility also conducts a quarterly point-prevalence survey. The survey measures the proportion of individuals in a defined population who have a pressure ulcer at a given time, such as a particular date.

For the second year, a hospital-wide prevalence survey was conducted simultaneously in all in-patient units, with a thorough skin check of all patients admitted on a designated day. Total prevalence included all patients with preexisting pressure ulcers and those with HAPUs. (However, not all patients could participate. Some were in therapy sessions or undergoing procedures outside the unit; others simply refused to be assessed.) Inter-rater reliability testing using kappa statistics has been adopted and results are submitted quarterly, with the goal of comparing reliability of pressure-ulcer identification by the nursing and medical staff to that of SBAHC wound care specialists.

Staff training and testing

As part of our continual staff education on pressure ulcers, all newly hired direct-care staff receive initial training and competency testing in wound care procedures. Topics include frequency of skin inspections and reinspection in patients at risk for pressure ulcers, use and implementation of pressure-ulcer prevention plans and protocols, identification of pressure-ulcer stages based on NPUAP guidelines, and completion of the comprehensive wound-assessment tool. Annual competency checks are done for staff who have been with SBAHC for more than 1 year to ensure their current practice is evidence-based and doesn’t deviate from standards. Nursing staff (including nurses’ aides) re­ceive weekly wound care education sessions, with greater emphasis on pressure-ulcer prevention and identification. Physicians and rehabilitation staff are educated in separate sessions. The goal is to ensure that at least 80% of all direct-care staff receive education aimed at reducing or eliminating pressure ulcers.

Expanding the wound care service

Currently, the wound care unit at SBAHC has four beds and admits patients with stage 3 or 4 pressure ulcers or unstageable ulcers who have rehabilitation potential. The goal is to treat patients capable of sustaining an optimal functioning level after their debilitating pressure ulcers heal. Later, the service will expand to up to 11 beds, with patient stays of at least 6 weeks.

The first patient admitted to the service had a stage 4 pressure ulcer on the right trochanter; after 1 month of wound management, he was discharged with the ulcer healed and was able to participate in intensive rehabilitation sessions. Other patients have been admitted with multiple and more severe pressure ulcers; their wounds have improved significantly. (See Photos tell the story.)

Some patients’ wounds aren’t totally healed at discharge because of expired fund­ing, noncompliance with management, or refusal to cooperate. They are advised to return to the wound care clinic to ensure continuity of care. SBAHC plans to implement benchmarking to compare its performance against that of other facilities and help gauge the success of its pressure-ulcer practices.

100 Days campaign

Around the same time SBAHC opened its wound care unit, the hospital launched the “100 Days—100% HAPU Free” Campaign. The goal was to reach zero HAPUs in all hospital units for 100 days and to empower all healthcare providers in all disciplines to use effective pressure-ulcer prevention strategies. This campaign was the first of its kind in the Middle East. Spearheaded by the SBAHC wound care team, the campaign spotlights our facility as a role model for evidence-based, innovative wound care.

The authors work at Sultan Bin Abdulaziz Humanitarian City in Riyadh, Saudi Arabia. Joanne Aspiras Jovero is a wound and stoma care specialist and educator. Hussam Al-Nusair is director of nursing. Marilou Manarang is a senior wound and stoma care specialist and educator.

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.

Guidelines for safe negative-pressure wound therapy

By Ron Rock MSN, RN, ACNS-BC

Since its introduction almost 20 years ago, negative-pressure wound therapy (NPWT) has become a leading technology in the care and management of acute, chronic, dehisced, traumatic wounds; pressure ulcers; diabetic ulcers; orthopedic trauma; skin flaps; and grafts. NPWT applies controlled suction to a wound using a suction pump that delivers intermittent, continuous, or variable negative pressure evenly through a wound filler (foam or gauze). Drainage tubing adheres to an occlusive transparent dressing; drainage is removed through the tubing into a collection canister. NWPT increases local vascularity and oxygenation of the wound bed and reduces edema by removing wound fluid, exudate, and bacteria.

Every day, countless healthcare providers apply NPWT devices during patient care. More than 25 FDA Class II approved NPWT devices are available commercially. If used safely in conjunction with a comprehensive wound treatment program, NPWT supports wound healing. But improper use may cause harm to patients. (See Risk factors and contraindications for NPWT.)

Lawsuits involving NPWT are increasing. The chance of error rises when inexperienced caregivers use NPWT. Simply applying an NPWT dressing without critically thinking your way through the process or understanding contraindications for and potential complications of NPWT may put your patients at risk and increase your exposure to litigation.

Proper patient selection, appropriate dressing material, correct device settings, frequent patient monitoring, and closely managed care help minimize risks. So before you flip the switch to initiate NPWT, read on to learn how you can use NPWT safely.

Understand the equipment and its use

Consult your facility’s NPWT protocols, policies, and procedures. If your facility lacks these, consult the device manufacturer’s guidelines and review NPWT indications, contraindications, and how to recognize and manage potential complications. Ideally, facilities should establish training programs to evaluate clinicians’ skills. Enhanced training should include comprehension of training materials, troubleshooting, and correct operation of the device, as shown by return demonstration of the specific NPWT device used in the facility.

Assess the patient thoroughly

The prescribing provider is responsible for ensuring patients are assessed thoroughly to confirm they’re appropriate NPWT candidates. Aspects to consider include comorbidities, contraindicated wound types, high-risk conditions, bleeding disorders, nutritional status, medications that prolong bleeding, and relevant laboratory values. The pain management plan also should be evaluated and addressed.

Assess the order

Before NPWT begins, make sure you have a proper written order. The order should specify:

  • wound filling material (foam or gauze dressing and any wound adjunct, such as a protective nonadherent, petrolatum, or silver dressing)
  • negative pressure setting (from -20 to-200 mm Hg)
  • therapy setting (continuous, intermittent, or variable)
  • frequency of dressing changes.

Follow all parts of the order as prescribed. Otherwise, you may be held responsible if a complication arises—for example, if you apply a nonadherent dressing when none is ordered and this dressing becomes retained, requiring surgery for removal; or if you set a default pressure when none is ordered and the patient suffers severe bleeding or fistula formation as a result.

Assess the wound

If you know what your patient’s wound needs, you can take proactive measures. What is the wound “telling” you? With adept assessment, you can become a “wound whisperer”—a clinician who understands wound-healing dynamics and can interpret what the wound is “saying.” This allows you to see the wound as a whole rather than just maintaining it as a “hole.”

  • If the wound tells you it’s too wet, take steps to absorb fluid or consider increasing negative pressure, as ordered.
  • If it’s telling you it’s dry, consider decreasing negative pressure, as ordered. If the wound bed remains dry, you might want to take a NPWT “time out”. Apply a moisture dressing for several days and assess the patient’s hydration status before restarting NPWT.
  • If the wound says it’s moist, maintain the negative pressure.
  • If it tells you it’s infected, treat the infection.
  • If it tells you it’s dirty, debride it.
  • If it says it’s malnourished, feed it.

The DIM approach

To establish a baseline evaluation, develop a systematic approach for assessing
the wound before NPWT. This will help optimize wound-bed preparation, enhance NPWT efficacy, and prevent delayed wound healing. (See Assessing with DIM.)

Take a time-out
Before you apply the NPWT dressing, be a STARStop, Think, Act, and Review your action. This time-out allows you to critically think your way through the application process and consider potential consequences of your actions.

Ongoing patient assessment and monitoring

Follow these guidelines to help ensure safe and effective NPWT:

  • Follow the device manufacturer’s instructions and your facility’s NPWT protocol, policy, and procedures.
  • Identify and eliminate factors that can impede wound healing (poor nutritional status, limited oxygen supply, poor circulation, diabetes, smoking, obesity, foreign bodies, infection, and low blood counts).
  • Evaluate the patient’s nutritional status to ensure protein stores are adequate for healing.
  • Assess and manage the patient’s pain accordingly.
  • Protect the periwound from direct contact with foam or gauze.
  • Prevent stretching or pulling of the transparent drape to secure the seal and avoid shear trauma to surrounding tissue.
  • Prevent stripping of fragile skin by minimizing shear forces from repetitive or forceful removal of transparent drapes.
  • Use protective barriers, such as multiple layers of nonadherent or petrolatum gauze, to protect sutured blood vessels or organs near areas being treated with NPWT.
  • Don’t overpack the wound too tightly with foam. Compressing the foam prevents negative pressure from reaching the wound bed, causing exudate to accumulate.
  • Position drainage tubing to avoid bony prominences, skinfolds, creases, and weight-bearing surfaces. Otherwise, a drainage tubing related pressure wound may develop.
  • Bridge posterior wounds to the lateral or anterior surface to minimize drainage tubing related pressure wounds to the surrounding tissue.
  • Count and document all pieces of foam, gauze, or adjunctive materials on the outer dressing and in the medical record, to help prevent retention of materials in the wound.
  • Ensure the foam is collapsed and the NPWT device is maintaining the prescribed therapy and pressure at the time of initial patient assessment and when rounding.
  • Address and resolve alarm issues. If you can’t resolve these issues and the device needs to be turned off, don’t let it stay off more than 2 hours. While the device is off, apply a moist-to-dry dressing.
  • With a heavily colonized or infected wound, consider changing the dressing every 12 to 24 hours.
  • Monitor the patient frequently for signs and symptoms of complications.

Evaluate patient comprehension of teaching

A proactive approach to education can ease the patient’s anxiety about NPWT. Unfamiliar sounds and alarms may heighten anxiety and cause unwarranted concerns, so inform patients in advance that the device may make noise and cause some discomfort. An educated and empowered patient can participate actively in treatment. Improved communication may enhance outcomes and help identify errors in technique before they cause complications.

Be prepared to answer patients’ questions, which may include:

  • Am I using the device correctly?
  • How long will I have to use it?
  • What serious complications could occur?
  • What should I do if a complication occurs? Whom should I contact?
  • How do I recognize bleeding?
  • How do I recognize a serious infection?
  • How do I tell if the wound’s condition is worsening?
  • Do I need to stop taking aspirin or other medicines that affect my bleeding system or platelet function? What are the possible risks of stopping or avoiding these medicines?
  • Can you give me written patient instructions or tell me where I can find them?

View: Patient Education


To avoid patient harm and potential litigation, be a STAR and a wound whisperer. If you’re in doubt about potential complications of NPWT or how to assess and monitor patients, stop the therapy and seek expert guidance. “Listen” to the wound and assess your patient. This may take a little time, but remember—monitoring NPWT, the wound, and the patient is an ongoing process. You can’t rush it. Sometimes, to go fast, you need to go slowly.

Access more information about NPWT.

Selected references
Agency for Healthcare Research and Quality. Technology Assessment: Negative Pressure Wound Therapy Devices. Original: May 26, 2009; corrected November 12, 2009. Available online at: www.ahrq.gov/research/findings/ta/negative-pressure-wound-
f. Accessed January 30, 2014.

Daeschlein G. Antimicrobial and antiseptic strategies in wound management. Int Wound J. 2013; 10(Suppl 1):9-14.

Food and Drug Administration. Guidance for Industry and FDA Staff—Class II Special Controls Guidance Document: Non-powered Suction Apparatus Device Intended for Negative Pressure Wound Therapy. November 10, 2010. Available at: www.fda.gov/MedicalDevices/DeviceRegulationand
. Accessed January 30, 2014.

Food and Drug Administration. FDA Preliminary Public Health Notification: Serious Complications Associated with Negative Pressure Wound Therapy Systems. November 13, 2009. Available at: www
. Accessed January 30, 2014.

FDA Safety Communication: UPDATE on Serious Complications Associated with Negative Pressure Wound Therapy Systems. February 24, 2011. Available at: /www.fda.gov/MedicalDevices/Safety/
. Accessed January 30, 2014.

Fife CE, Yankowsky KW, Ayello EA, et al. Legal issues in the care of pressure ulcer patients: key concepts for healthcare providers—a consensus
paper from the International Expert Wound Care Advisory Panel©. Adv Skin Wound Care. 2010;23(11):493-507.

Improving the Safety of Negative-Pressure Wound Therapy. Pa Patient Saf Advis. 2011;8(1):18-25. Available at: http://patientsafetyauthority.org/
. Accessed January 29, 2014.

Krasner D. Why is litigation related to negative pressure wound therapy (NPWT) on the rise? Wound Source. Posted November 11, 2010. Available at: www.woundsource.com/article/why-litigation-related-negative-pressure-wound-therapy-npwt-rise. Accessed January 30, 2014.

Lansdown AB. A pharmacological and toxicological profile of silver as an antimicrobial agent in medical devices. Adv Pharmacol Sci. 2010; Article ID 910686. Available at: www.hindawi.com/journals/aps/2010/910686/

Lipsky BA, Hoey C. Topical antimicrobial therapy for treating chronic wounds. Clin Infect Dis. 2009;49(10):1541-9.

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

Sibbald RG, Woo KY, Ayello EA. Clinical Practice Report Card: A Survey of Wound Care Practices in the U.S.A. Ostomy Wound Manage. April 2009 Suppl:12-22.

Ron Rock is the nurse manager and clinical nurse specialist for the WOC nursing team in the Digestive Disease Institute of the Cleveland Clinic in Cleveland, Ohio.

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

Clinician Resources


Take a few minutes to check out this potpourri of resources.

International Ostomy Association

The International Ostomy Association is an association of regional ostomy associations that is committed to improving the lives of ostomates. Resources on the association’s website include:

  • a variety of discussion groups
  • information for patients
  • list of helpful links.

The site also provides contact information for the regional associations.

Substance use disorder in nursing

Substance use disorder (SUD) can have a profound effect not only on patients but also on the nursing profession. “What You Need to Know About Substance Use Disorder in Nursing,” a brochure from the National Council of State Boards of Nursing, discusses SUD, including how to recognize the warning signs and what to do to get a colleague help.

Enhancing patient and family engagement

The Agency for Healthcare Research and Quality has released the “Guide to Patient and Family Engagement in Hospital Quality and Safety,” an evidence-based resource to help hospitals work as partners with patients and families to improve quality and safety. The guide includes the following:

  • Strategy 1: Working With Patients and Families as Advisors shows how hospitals can work with patients and family members as advisors at the organizational level.
  • Strategy 2: Communicating to Improve Quality helps improve communication among patients, family members, clinicians, and hospital staff from the point of admission.
  • Strategy 3: Nurse Bedside Shift Report supports the safe handoff of care between nurses by involving the patient and family in the change-of-shift report.
  • Strategy 4: IDEAL Discharge Planning helps reduce preventable readmissions by engaging patients and family members in the transition from hospital to home.

Download the entire guide.

Lymphedema Treatment Act

The Lymphedema Treatment Act (HR 3877) is intended to improve coverage for the treatment of lymphedema from any cause. You can visit the Act’s website to learn how to contact your members of Congress about the Act and join your state’s advocacy team. Consider these six easy ways to increase awareness:

  • Distribute information cards.
  • Distribute or post fact sheets.
  • Like the Act’s Facebook page.
  • Follow the act on Twitter and re-tweet tweets.
  • Include information on your website or blog.
  • Use a tell-a-friend form to quickly tell up to 10 people at a time about the website.

You can also access an update on the Act on the National Lymphedema Network’s website.

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.

Medicare reimbursement for hyperbaric oxygen therapy

By Carrie Carls, BSN, RN, CWOCN, CHRN, and Sherry Clayton, RHIA

In an atmosphere of changing reimbursement, it’s important to understand indications and utilization guidelines for healthcare services. Otherwise, facilities won’t receive appropriate reimbursement for provided services. This article focuses on Medicare reimbursement for hyperbaric oxygen therapy (HBOT). (See What is hyperbaric oxygen therapy?)

Indications and documentation requirements

The Centers for Medicare & Medicaid Services (CMS) National Coverage Determination for HBOT lists covered conditions for HBOT, as do the individual Medicare Administrative Contractor’s (MAC) Local Coverage Determination policies and/or articles. (See Conditions for which CMS approves use of HBOT.) Providers should thoroughly review the indications and utilization guidelines to ensure coverage criteria are met for each clinical condition.

It’s important that the documentation in the patient’s medical record supports the medical necessity for HBOT. Reimbursement hinges on documenting all services performed. For example, diabetic wounds of the lower extremity will first require the assessment of the patient’s vascular status with correction of any problems found, optimization of nutritional status and glucose control, removal of nonviable tissue, appropriate offloading of the ulcer, treatment and resolution of infection, and maintenance of a clean, moist wound bed.

HBOT is indicated if all of the above have been done and the ulcer doesn’t show measurable signs of healing after 30 days of standard wound care.

Provider requirements

For HBOT to be reimbursed, a facility must ensure the provider supervising the treatment meets CMS requirements. Physicians who supervise HBOT should be certified in Undersea and Hyperbaric Medicine or must have completed a 40-hour, in-person training program by an approved entity. In addition, if HBOT is performed off-site from a hospital campus or in a physician’s office, Advanced Cardiac Life Support training and certification of the supervising physician are required.

CMS also requires appropriate direct physician supervision for coverage, meaning that the physician must be present on the premises and immediately available to furnish assistance and direction throughout the performance of the procedure.

Billing and coding

In a hospital outpatient setting, the correct code is C1300, hyperbaric oxygen under pressure, full body chamber, per 30-minute interval. Physician supervision of HBOT is reported with CPT code 99183, physician attendance and supervision of hyperbaric oxygen therapy, per session. It’s important to note that the physician supervision code should be reported in a unit of 1, and the hospital outpatient procedure code of C1300 will be in multiple units, typically 4 units.

Prepay probes

Providers may be asked to submit medical documentation for specific claims identified by the MAC prior to payment (“prepay probes”). These Additional Development Requests require a response within 30 days and generally involve 20 to 40 claims per provider. Such requests occur in both inpatient and outpatient settings, and some MACs are starting to use prepay probes in skilled nursing facilities as well.

After review of the documentation, providers receive notification of the results. Further reviews are based on the provider error rate calculated.

Skilled nursing facility, inpatients, critical access hospitals

In a skilled nursing facility, HBOT is part of the facility Prospective Payment System (PPS) payment in Medicare part A stays. For hospital inpatients, HBOT is reported under revenue code 940. For critical access hospitals, a reasonable cost-based system is used.

Ensuring reimbursement

To ensure reimbursement of HBOT, check CMS policies and articles for indications, utilization guidelines, and provider requirements. In addition, ensure that documentation clearly supports the need for HBOT and follows the billing and coding requirements.

Both authors work at Passavant Area Hospital in Jacksonville, Illinois. Carrie Carls is the nursing director of advanced wound healing and hyperbaric medicine and Sherry Clayton is the director of managed care and revenue integrity.

Selected references
Centers for Medicare & Medicaid Services. Hyperbaric oxygen therapy (HBO) supplemental article (A52118). http://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52118. Accessed February 19, 2014.

Centers for Medicare & Medicaid Services. National coverage decision for hyperbaric oxygen therapy (20.29). Publication No. 100-3. http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx. Accessed February 19, 2014.

Clarke D. Economics of hyperbaric medicine. In: Kindwall E, Whelan H, eds. Hyperbaric Medicine Practice. 3rd ed. Flagstaff, AZ: Best Publishing Company; 2008;275-288.

Gesell L. Hyperbaric Oxygen Therapy Indications. 12th ed. Durham, NC: Undersea and Hyperbaric Medical Society; 2008.

Kranke P, Bennett MH, Roecki-Wiedmann I, Debus S. Hyperbaric oxygen for chronic wounds. Cochrane Database Syst Rev. http://www.ncbi.nlm.nih.gov/pubmed/22513920. Updated 2012. Accessed February 19, 2014.

National Government Services. Article for hyperbaric oxygen (HBO) therapy—medical policy (A52174). http://www.ngsmedicare.com. Accessed February 19, 2014.

National Government Services. Part B medical review: the medical review process. http://www.ngsmedicare.com. Accessed February 19, 2014.

Schaum K. Hyperbaric oxygen therapy reimbursement reminders for a successful 2010. Today’s Wound Clinic. 2010;4:9-14.

Tuner T. The coming audit storm. Today’s Wound Clinic. 2012;6:18-20, 38.

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.

Achieving a work-life balance

By Julie Boertje, MS, RN, LMFT, QMRP, and Liz Ferron, MSW, LICSW

Almost everyone agrees that achieving a work-life balance is a good thing. Without it, we risk long-term negative effects on our physical and mental health, our relationships, and our work performance. But many clinicians have a hard time achieving this balance due to job demands, erratic work schedules, or the inability to say no when someone asks for help.

The challenges of stress and burnout

Stress and job burnout can cause, contribute to, or result from a poor work-life balance. They disrupt our normal patterns, behaviors, and feelings.

Of course, no one can escape stress altogether. Sometimes stress is a good thing, but we need to be able to identify when it’s a problem. For many clinicians, stress springs from the desire to provide good service and care in all parts of their lives. This desire can create stress, especially when barriers exist to achieving it.

Barriers to balancing work and life

Some barriers are external and outside one’s control. These may include everything from inadequate staffing levels to changes in practice expectations due to healthcare reform. Generational differences among healthcare providers also may pose an external barrier. Clinicians from different generations have different training, expectations, and skill sets. This can lead to new paradigms, changes, conflict, and other challenges.

Other stressors are more personal and internal—and within one’s control. Most clinicians try to stay hopeful and promote realistic hope in their patients, but this can be exhausting. What’s more, time, age, and life stage can change a person, altering his or her goals, priorities, and perhaps bedside manner. This can create a gap between the goal of on-the-job perfection and the realities of daily life. Guilt and frustration can result.

How to help yourself

First, come to terms with some fundamentals. Acceptance is a good starting point for combating stress. Start by acknowledging the things you can’t change. Then develop better coping strategies so you can address your feelings about these things and help remove them as barriers to finding a work-life balance.

  • Embrace your perfectionism, but be alert to when it’s tormenting you or others. When it comes to patient safety, perfection is a necessity. But because we’re human, we sometimes make mistakes. We need to be able to learn from them and move on, or the result can be crippling. When patient safety isn’t at risk, try to do the best you can; you simply don’t have the time to dwell on entering information in a chart perfectly. Give it a once-over to make sure it’s accurate, then move on.
  • Develop empathy for others, rather than judging them. Judging others and finding they don’t meet your expectations adds unnecessary stress. Instead, ask questions and seek to understand their point of view.
  • Take a “time out” when possible if things get overwhelming. Do some deep breathing or brief meditation. This helps ground you so you’re better able to focus, concentrate, and stay calm.

Moving toward a better balance

Once you’ve set ground rules for yourself, achieving a better work-life balance can help clear away other stressors. Don’t take shortcuts here: Either you make work-life balance a priority or you don’t. If you decide to make it a priority, recognize you don’t need to change everything at once. Just making a few changes can lead to better-than-expected results.

More effective time management

For most clinicians, practicing better time management is a challenge because we have so many demands we may perceive as conflicting. Here are ways to manage your time more effectively:

  • Sit down with your spouse or partner to discuss and negotiate relationship expectations.
  • Align your priorities and values between home and work.
  • Look for areas where you should set limits and boundaries on your time—both at home and at work—and stick to them.
  • Set limits with patients while still conveying empathy and instilling their confidence in your care.
  • Seek mentors who model good time management, and ask for their advice and guidance.
  • Work on self-acceptance for the person you are today. Acknowledge that you’re doing your best, and keep boundaries by trusting and allowing others to do their job.

Stronger relationships

Relationship problems can be a great drain on your time and emotional energy. Here are some ways to strengthen your relationships both at work and at home.

  • Engage in necessary conversations regarding conflict. Addressing conflict and moving beyond it can make an enormous difference in your feelings and perceptions.
  • Set regular times to get together with family and friends, and stick to those plans. Find time for regularly scheduled family meetings and meals together. Everyone may have to give a little to make this happen, but it will be worth it.
  • Give people the benefit of a doubt and avoid jumping to conclusions. Work on identifying obstacles to trust.
  • Be open to reasonable feedback.
  • Ask for help and delegate responsibilities and duties when possible.

Better self-care

Make yourself a priority by practicing good self-care. To build “down” time into your schedule, take restorative breaks throughout the day. Enroll in a yoga, Pilates, or mindfulness meditation class or other activity that helps reduce stress. Read fiction, write in a journal, or meditate.

Take time to reflect on the positive parts of your day and life. Doing this before bedtime can promote a good night’s sleep. Speaking of sleep, make it a priority. If you can’t get a full night’s sleep, take short naps.

Identify more ways to integrate exercise into your day. Exercise is the cheapest antidepressant around. Go for a 10-minute walk outside the clinic or hospital. Purchase exercise equipment for your home, or use onsite facilities if they’re available. Get a partner for workouts, running, or other activities.

Improve your nutrition by sitting down to breakfast, taking a break for lunch, bringing healthy snacks to work, and being there for family dinners.

Take care of yourself mentally and emotionally. Acknowledge losses and give yourself permission to grieve.

Identify workplace and personal challenges that create stress, and develop an action plan for addressing or coping with them. Set realistic goals for stress management and update them as needed, either alone or with a coach, therapist, friend, or partner.

One step at a time

Perhaps you agree with our advice, but think your life is too overwhelming and demanding to put our recommendations into practice. If so, keep in mind that just wishing and hoping things will get better won’t make it happen. You may end up wishing and hoping for the rest of your life.

So take it one small step at a time. Never underestimate the power of small changes. Start by making one small change that takes just a few minutes. After the first week, evaluate the results of this change. You may find they’re good enough to inspire you to make further changes.

Finally, don’t go it alone. Look for and request support in areas that seem the most challenging. Consider your organization’s employee assistance program (EAP), a life coach, a peer coach, family or marital counseling, and individual counseling. The investment you make in yourself will help you become a better clinician, increase your satisfaction, and have a positive effect that carries over into all areas of your life.

The authors work at Midwest EAP Solutions in St. Cloud, Minnesota. Julie Boertje is a nurse peer coach. Liz Ferron is a senior EAP consultant.

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

Clinical Notes

Low BMD common after ostomy

Low bone mineral density (BMD) is common in patients with inflammatory bowel disease who have a stoma placed, according to “Frequency, risk factors, and adverse sequelae of bone loss in patients with ostomy for inflammatory bowel diseases,” published in Inflammatory Bowel Diseases.

A total of 126 patients participated in the study, with most (120) undergoing an ileostomy. Fragility fractures occurred five times more often in ostomy patients who had a low BMD compared with those who had a normal BMD. Low BMD was also associated with a low body mass index.

Prevalence of CKD higher in African Americans and Hispanics with diabetes

African Americans and Hispanics with diabetes have a higher prevalence of early chronic kidney disease (CKD), accord­ing to a study in Diabetes Care. The study also found early CKD was significantly associated with higher urinary albumin excretion and/or C-reactive protein.

Association of race/ethnicity, inflammation, and albuminuria in patients with diabetes and early chronic kidney disease” analyzed data from 2,310 patients with diabetes in the National Health and Nutrition Examination Survey (1999-2008) who were age 20 or older and had a fasting plasma glucose of 126 mg/dL or higher.

Severe hypoglycemia associated with cognitive decline

Severe hypoglycemia and cognitive decline in older people with type 2 diabetes: the Edinburgh Type 2 Diabetes Study,” published in Diabetes Care, found that severe hypoglycemia in older adults with type 2 diabetes was associated with poorer cognitive ability and faster decline in ability.

The researchers assessed cognitive function in 831 adults age 60 to 75 who had type 2 diabetes, then repeated the assessment after 4 years. Hypoglycemia at baseline and at the follow-up was associated with cognitive decline, with greater decline at the 4-year mark.

HBOT benefits patients with diabetic foot ulcers

The most common benefits of hyperbaric oxygen therapy (HBOT) in patients who have diabetes and foot ulcers are reduced amputation rates and improved healing, according to a literature review published in International Wound Journal.

Diabetic foot ulcers treated with hyperbaric oxygen therapy: a review of the literature” included 10 prospective and 7 retrospective studies that evaluated use of HBOT in patients with diabetic foot ulcers. The few studies that analyzed long-term outcomes found that the wounds were likely to remain intact in the future.

Most of the studies had methodological flaws and small sample sizes, so the authors recommend more “robust” research.

Pain in chronic leg wounds common

A study published by Acta Dermato-Venereologica reports that 82% of 49 patients with a chronic leg wound experienced wound-related pain, and 42% said their analgesia was insufficient for pain relief.

Of the patients who participated in the “Association of pain level, health and wound status in patients with chronic leg ulcers” study, up to 69% had leg ulcerations caused by vascular disease. Patients with a pain level equal to or greater than 5 on the visual analogue scale had a lower health status than those with lower pain scores.

HbA1c variability predictor for mortality in patients with diabetes

Variability in HbA1c is a predictor of mortality, especially noncancer mortality, in patients with type 2 diabetes, according to a study in the Journal of Diabetes and Its Complications. Prediction was independent of mean HbA1c.

Association between HbA1c variability and mortality in patients with type 2 diabetes” studied 754 patients who were first seen between 1995 and 1996, had been followed for at least 2 years, and had four or more HbA1c values. Through June 2012, 63 patients died. The researchers also found that mean HbA1c, but not HbA1c variability, predicted mortality from cancer.

Acetaminophen risk

The U.S. Food and Drug Administration (FDA) warns that acetaminophen can cause three rare but serious skin reactions. Clinicians should instruct patients to stop taking acetaminophen immediately if a rash or other skin reaction occurs and promptly seek medical attention.

Stevens-Johnson Syndrome and toxic epidermal necrolysis usually require hospitalization and can cause death. Patients with these conditions usually experience flu-like symptoms followed by rash, blistering, and extensive damage to the surfaces of the skin. Recovery can take weeks or months, and possible complications include scarring, changes in skin pigmentation, blindness, and damage to internal organs. Acute generalized exanthematous pustulosis usually resolves within 2 weeks of stopping the medication.

Revascularization less costly than primary amputation

Revascularization costs less and provides more health benefits than wound care alone or primary amputation, according to a study in the Annals of Vascular Surgery.

Cost-effectiveness of revascularization for limb preservation in patients with marginal functional status” used a model to simulate clinical outcomes, health utilities, and costs over a 10-year period. The researchers found that the total 10-year costs of endovascular or surgical revascularization were lower than the costs of local wound care or primary amputation. Revascularization health benefits included more years of ambulatory ability, limb salvage, or quality-adjusted life years.

Effect of ostomy on sexual function

Gastrointestinal ostomies and sexual outcomes: a comparison of colorectal cancer patients by ostomy status” found that a current or past ostomy increases the likelihood of a negative impact on sexual function compared with patients who never had an ostomy.

A total of 141 patients participated in the study (18 with a past ostomy, 25 with a current ostomy, and 98 with no ostomy), published in Supportive Care in Cancer. The researchers conclude, “Colorectal cancer treatment puts patients at risk for sexual difficulties and some difficulties may be more pronounced for patients with ostomies as part of their treatment.” They recommend clinical information and support.

Editor’s note: Patient information on sexuality is available from United Ostomy Associations of America, Inc.

RLNR increases lymphedema risk

Regional lymph node radiation (RLNR) significantly increases the risk of lymphedema compared with breast/chest wall radiation alone, according to a study in International Journal of Radiation Oncology*Biology* Physics.

The impact of radiation therapy on the risk of lymphedema after treatment for breast cancer: a prospective cohort study” included 1,476 patients with breast cancer. Treating each breast individually, 1,099 of 1,501 patients received radiation therapy, and researchers used a Perometer® to obtain preoperative and postoperative arm volume measurements.

The researchers recommend that clinicians “weigh the potential benefit of RLNR for control of disease against the increased risk of lymphedema.”

Prophylactic dressings may help prevent pressure ulcers

A systematic review published in International Wound Journal found that the use of a dressing as part of prevention may help reduce the incidence of pressure ulcers associated with medical devices, especially in intensive care unit patients who are immobile.

Systematic review of the use of prophylactic dressings in the prevention of pressure ulcers” reviewed 21 studies, including one randomized clinical trial. The researchers note that the evidence doesn’t suggest that one dressing type is more effective than another.

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.

Becoming a wound care diplomat

By Bill Richlen, PT, WCC, CWS, DWC, and Denise Stetter, PT, WCC, DCCT

The Rolling Stones may have said it best when they sang, “You can’t always get what you want,” a sentiment that also applies to wound care. A common frustration among certified wound care clinicians is working with other clinicians who have limited current wound care education and knowledge. This situation worsens when these clinicians are making treatment recommendations or writing treatment orders not based on current wound-healing principles or standards of care.
Frequently, these same clinicians seem uninterested in listening to what you say and aren’t receptive to treatment suggestions. This is where your skills of diplomacy will make all the difference. Rarely is it a simple matter of sharing your expertise to change a person’s mind. Lack of training and knowledge of current best practices may be part of the reason for resistance. “We’ve always done it that way” or “The rep told me” are common statements you might hear. Other factors include ego, self-image, politics, and the need to be in control. Sadly, human nature gets in the way more often than we think.

Practicing our diplomacy skills will help us bridge the gap between resistance and openness to learning. Here’s what makes a good diplomat.

Communication skills

The words you choose and your tone can make a huge difference in how the information you give is received. Avoid using “you” in your statements because this generally makes the other person feel defensive. Instead use “I” or “we” statements beginning with “I think” or “I feel.” For example, “Dr. Smith, I see that the treatment for Jane Doe is currently wet to dry b.i.d. When we assessed the wound today, we noted she had a fair amount of drainage and some slough. I think that an absorptive dressing like an alginate would handle the drainage better and help promote debridement of the slough. It might be a better choice for Jane. Would you consider trying that for a couple of weeks and see what happens?”

When discussing opposing viewpoints, work to get agreement on smaller or more general issues before addressing the main concern: “Can we agree that using current evidence-based practice is what’s best for Mrs. Jones?”


Be prepared to defend your position with evidence-based practices and, if necessary, provide resources to support your position. When clinicians refuse to listen or acknowledge facts, it can be a sign that their position is more about ego and power than what’s right for the patient.

Use open-ended questions to help create dialogue and the sharing of ideas. Questions such as, “Do you have experience with this product? What were your results?” or “This product may not be on your formulary, but if I got a sample, would you consider trying it?” put you on a collegial level with the clinician. It becomes a collaboration rather than a power struggle. When interacting with clinicians who aren’t certified in wound care, it’s not a good idea to play your “certification” trump card. This strategy only makes you appear arrogant, causing the perception that you think you’re superior to the other person, putting your colleague on the defensive and seriously compromising the potential for further debate and reaching a solution.

Emotional control

We’re all passionate about caring for our patients, so it’s easy to take criticism and conflict personally. When emotions run high, logical thinking is impaired. We can lose grasp of our objectivity and say things we may regret, potentially undermining our integrity and damaging lines of communication. Consider scripting communication points or responses to help maintain professionalism. Use such phrases as “Have you considered…”, “I know we both have the patient’s best interest at heart…” or, when making a request, finishing with “…does that seem reasonable?”

Ability to compromise

Compromise doesn’t mean compromising on principles or standards of care. However, we may not get the exact treatment we want. It’s the old saying, “You aim for the eagle, you bag the pheasant, and you don’t eat crow.” We need to be creative and think outside the box to offer treatment options that will promote healing as best as possible and ultimately win the approval of the person with whom we are compromising. Sometimes we just have to accept the lesser of two evils. Our willingness to compromise can set the stage for future dialogue and less conflict.


Become an ambassador for wound care. Be the same person in public as you are in private. Always promote best practice and not personal gain. It’s no surprise that news travels fast, especially bad news. If people figure out that you’re manipulative, dishonest, or egotistical, it won’t be long before your reputation will precede you and you’ll lose the confidence of your colleagues. Perception is reality in the minds of others. How are you representing wound care clinicians?

Sincere appreciation

Kill them with kindness. Drawing battle lines and creating conflict over differing opinions doesn’t help our patients. We can catch more flies with honey than vinegar. But no one wants to hear insincere flattery or thank-you’s. Take the time to tell others how much you appreciate their cooperation.

In the end, we need to remember that the patient has to be our focus. Our own personal issues need to be put aside. It’s not ever about winning; it’s about doing what’s best for the patient.

As the Rolling Stones sang, “You can’t always get what you want, but if you try sometimes, well you might find, you get what you need.”

Bill Richlen is CEO of Infinitus, LLC in Ferdinand, Indiana. Denise Stetter is area manager for southern Indiana for Paragon Rehabilitation in Louisville, Kentucky.

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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.

How to assess wound exudate

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

Each issue, Apple Bites brings you a tool you can apply in your daily practice.

Exudate (drainage), a liquid produced by the body in response to tissue damage, is present in wounds as they heal. It consists of fluid that has leaked out of blood vessels and closely resembles blood plasma. Exudate can result also from conditions that cause edema, such as inflammation, immobility, limb dependence, and venous and lymphatic insufficiency.

Accurate assessment of exudate is important throughout the healing process because the color, consistency, odor, and amount change as a result of various physiologic processes and underlying complications.

Consistent terminology is crucial to ensure accurate communication among clinicians. Here are terms you should keep in mind when observing the wound and documenting your findings.


  • Serous—thin, clear, watery plasma, seen in partial-thickness wounds and venous ulcera­tion. A mod­er­ate to heavy amount may indicate heavy bio-burden or chronicity from a subclinical infection. Serous exudate in the acute inflammatory stage is normal.
  • Sangui­neous—bloody drain­age (fresh bleeding) seen in deep partial-thickness and full-thickness wounds during angiogenesis. A small amount is normal in the acute inflammatory stage.
  • Serosangui­neous—thin, watery, pale red to pink plasma with red blood cells. Small amounts may be seen in the acute inflammatory or acute proliferative healing phases.
  • Purulent—thick, opaque drainage that is tan, yellow, green, or brown. Purulent exudate is never normal and is often associated with infection or high bacteria levels.


  • None—Wound tissues are dry.
  • Scant—Wound tissues are moist, but there is no measurable drainage.
  • Small/minimal—Wound tissues are very moist or wet; the drainage covers less than 25% of the dressing.
  • Moderate—Wound tissues are wet; the drainage involves more than 25% to 75% of the dressing.
  • Large or copious—Wound tissues are filled with fluid that involves more than 75% of the dressing.


  • Low viscosity—thin, runny
  • High viscosity—thick or sticky; doesn’t flow easily


  • No odor noted
  • Strong, foul, pungent, fecal, musty, or sweet

Use the following terms to describe the condition of primary and secondary wound dressings:

  • Dry—The primary dressing is unmarked by exudate; the dressing may adhere to the wound.
  • Moist—Small amounts of exudate are visible when the dressing is removed; the primary dressing may be lightly marked.
  • Saturated—The primary dressing is wet and strikethrough occurs.
  • Leaking—The dressings are saturated, and exudate is leaking from primary and secondary dressings onto the patient’s clothes.

A useful resource to help you with your assessment is the Bates-Jensen Wound Assessment Tool.

Selected references

Bates-Jensen Wound Assessment Tool. http://www


Pressure_ulcer_prevention/puBWAT.pdf. Accessed March 3, 1214.

Romanelli M, Vowden K, Weir D. Exudate management made easy. Wounds International. 2010;1(2). http://www.woundsinternational.com/made-easys/exudate-management-made-easy. Accessed March 3, 2014.

World Union of Wound Healing Societies. Principles of Best Practice: Wound Exudate and the Role of Dressings. London: MEP Ltd; 2007. http://www.woundsinternational.com/clinical-guidelines/wound-

exudate-and-the-role-of-dressings-a-consensus-document/page-1. Accessed March 3, 2014.

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

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