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With medial sclerosis (eg, diabetes, renal disease, atherosclerosis), distal arteries may become noncompressible, invalidating the ABI, in which case toe pressure measurements and waveform analysis should be employed. Vowden, K. and P. Vowden, Debridement made easy. Risk management – is there a chance you could do more harm than good, is there training you can do to improve your skills, and again, is there someone who can assist you? 2006;42 Suppl 2:S82-S89. Lydia has an extensive knowledge of wound care and diagnoses that affect wound healing, and a passion to heal patients. This image shows the progression from normal inflammation (where the wound is contaminated with opportunistic and transient pathogens) to systemic infection. Davis, S.C., et al., Microscopic and physiologic evidence for biofilm-associated wound colonization in vivo. Cultures are obtained to direct antibiotic selection. J Vasc Surg. The importance of adequate and repetitive debridement of necrotic tissue in chronic wounds cannot be overemphasized. The FDA approved becaplermin in 1998 for treatment of diabetic foot ulcers that extend into the subcutaneous tissue that have adequate blood supply. Discuss with the treating team the need for a diagnosis and plan for compression. Wound care assessment acronym help dddreeesssss. Ostomy/Wound Management, 2008. Topical antimicrobials are indicated. Angel DE, Lloyd P, Carville K, Santamaria N. The clinical efficacy of two semi-quantitative wound-swabbing techniques in identifying the causative organism(s) in infected cutaneous wounds. The dehisced surgical wound requires a thorough assessment of cavities or structures involved, as well as presence of foreign bodies, infection and/or necrotic tissue. Wounds may not progress beyond the inflammatory phase if the lack of oxygen reduces leukocyte-killing capacity. The micronutrient vitamins C, A, E, K, zinc, and copper all have a role in wound healing. Delayed wound healing requires additional nursing and medical resources, higher costs of consumables in wound care, and potentially higher costs of hospital lengths of stay to treat complications(37). Is the pain going to come back? The presence of non-viable tissue and debris (foreign bodies/old dressing product/sutures)(6): Debridement is the act of removing devitalized tissues from the wound bed. It can be used for excisional debridement and/or maintenance debridement over several sessions. Scientific evidence should be translated for current practice. While some of the pitfalls of wound photography are mentioned in another module, I think that it is safe to say that with the accuracy and non-contact nature of taking the photo(4), the minimal expense required, the tech-savvy nature of nurses and speed of measurement, this type of wound measurement will increase in clinical use. An example of a combination dressing is the Aquacel Surgical, which has a hydrofibre interface and a hydrocolloid adhesive backing. A mod­er­ate to heavy amount may indicate heavy bio-burden or chronicity from a subclinical infection. Management of exudate and infection. Kalani M, Jorneskog G, Naderi N, Lind F, Brismar K. Hyperbaric oxygen (HBO) therapy in treatment of diabetic foot ulcers. Can be used for pre-debridement, when there is a small amount of non-viable tissue. ePlasty, 2011. 45. 43. These and other common types of chronic wounds will require accurate and concise diagnosis and appropriate treatment as part of holistic care(2). These recommendations are very broad and AWMA does not provide specifics on how this should be done. The importance of wearing the offloading device must repeatedly be stressed to patients; individuals who wear their prescribed footwear at least 60% of the time have 50% greater ulcer free intervals compared to less compliant patients.5 Wearing the offloading devices outside of the home but not while at home is also associated with increased rate of breakdown and ulcer recurrence.6   Pressure ulcers, which represent an enormous ongoing health care problem, are painful, costly, and in many cases, preventable. J Plast Reconstr Aesthet Surg. 3. Advances In Wound Care: The Journal For Prevention And Healing, 1997. Moffatt, C., et al., Psychosocial factors and delayed healing, in Position Document: Hard-to-heal wounds: a holistic approach, European Wound Management Association, Editor 2008, MEP Ltd: London. 2010;23(1):34-38. Padula WV, Wald HM, Makic MB. Cochrane Database Syst Rev. This is especially true in the case of edema management, wound offloading, and diabetic blood sugar control. And if a wound does not show improvement within 2-4 weeks of optimum care, do a full patient re-assessment and consider further collaboration with others. Borgquist O, Anesater E, Hedstrom E,Lee CK, Ingemansson R, Malmsjo M. Measurements of wound edge microvascular blood flow during negative pressure wound therapy using thermodiffusion and transcutaneous and invasive laser Doppler velocimetry. In some areas you may be limited in your options. Journal of Wound, Ostomy & Continence Nursing, 2013. 32. Inernational consensus, Making the case for cost effective wound management. We have no diagnosis so we don’t know why. Any bleeding must be completely controlled prior to applying the device.44,47,51,52, The standard application pressure for most wounds is -125 mm Hg in a continuous mode with an effective range between -40 and -150 mm Hg. 2008;16(1):37-44. 2012;11:CD000265. Hyperbaric oxygen therapy is not a substitute for potential revascularization but can be added if tissue hypoxia persists. It will be grounded in research and evidence, and fast to use for clinicians of all knowledge levels(42-45). British Journal Of Nursing (Mark Allen Publishing), 1998. For example, in a wound with bone on view, it is reasonable to recommend imaging for osteomyelitis. 31. 2013;159(10):718. A number of specialized photographic devices are on the market today. 23(11): p. 12. Slough and eschar are not viable, they do not have a blood supply to support healing and they are not alive. Implement Sci. So, continuing on from above, we now need to assess regional symptoms that will need to be managed to improve wound healing. Once you have collected your history, done your examination, completed any other investigations and determined the wound diagnosis, you will be ready to put together your comprehensive wound care plan. Annals Of The Royal College Of Surgeons Of England, 1980. 73. 59. Best Practice Statement: Optimising wound care. Gray, D., et al., Applied wound management, in Applied wound management supplement, D. Gray, Editor 2004, Wounds-UK: Aberdeen. 2010, CRC Press: Boca Raton, Fla. p. 151-186. 2005;41(5):837-843. In cases of chronic wounds, a risk-benefit analysis should be performed to determine whether medication adjustment would be advisable, if only temporarily, to help the wound heal. You can read this review in full on my website (http:// woundcareresource.com/downloads/litreview-wat.pdf). Wound Repair Regen. Debridement is not always the preferred option for all wounds. Larvae of the green bottle fly are used to remove necrotic and devitalised tissue from the wound. Wounds UK, 3(2), 25-46 . Anderson, I., Debridement methods in wound care. There are in-vitro studies (controlled environment, in a lab/not on a live subject) that indicate Staphylococcus aureus can create a biofilm within 2-3 hours and other studies on pig models that have established biofilms within 48 hours(15, 16). Debridement: Term. This is a quick method and works best with regularly shaped, small to medium sized wounds like the one in the photo on the right(3, 4). 19. Affiliations: Steven S. Gale, MD, FACS and Fedor Lurie, MD, PhD are from Jobst Vascular Institute, Toledo, OH. 51. 5. Therefore, the use of Veraflo™ Cleanse Choice as well as Veraflo™ instill therapy was used as treatment methods in this patient. These are alive and doing well. Raffetto JD. Reston, VA: NPUAP; 2001. STONES: Term. Position the patient in a comfortable position keeping mind that positioning, body curvature, or tapering of the limbs will impact on the accuracy of the various techniques(3). Robson MC. However, when HBOT is used as adjunctive therapy in cases of soft tissue infection, impaired healing from osteomyelitis and persistent non limb-threatening ischemia, wound healing outcomes are improved.40, Hyperbaric oxygen therapy is an approved, safe medical procedure and has been proven to enhance healing of difficult wounds when used as part of a multidisciplinary wound care approach. • moisture balance • status of the edge of the wound 4. Dressings that conserve moisture (stop if from evaporating away and/or handle a small amount of exudate) include films and hydrocolloids. Weed T, Ratliff C, Drake DB. Adv Skin Wound Care. 29. 3. Int Wound J. Mobilization of the obese patient and prevention of injury. The foot is usually cool, often pale, and pulseless. By creating communities where different bacteria inhabit niche micro-habitats best suited for their survival, and where the bacteria cooperate to meet their collective metabolic requirements, the biofilm is more likely to succeed. 43. J Vasc Surg. British Journal of Nursing, 2004. Moisture imbalance must be corrected for healing to progress. Reyzelman A, Crews RT, Moore JC, et al. Critical Colonization Stage—Climax Community or “Biofilm”. Surrogate endpoints for the treatment of venous leg ulcers. 74. Microcirculation and healing. 19(3): p. 309-315. Must be performed in the operating theatre by a surgeon, podiatrist or specialist nurses following training. Long-term follow-up. Wound Bed Preparation. NERDS acronym is helpful to assess these type of wounds. Treadwell T. Skin substitutes in the diabetic and venous stasis ulcer. 2006;14(3):371-374. 39. Conversely, where skilled clinicians use a standardized framework which clearly guides Nurses from assessment through to implementing and monitoring wound care plans that correctly address the factors impacting on wound healing, healing times are reduced, patient suffering is reduced and the overall economic burden is reduced(36-38). There is potential for aerosol spread and it is associated with higher costs. This means that once the hardier species have started to establish a biofilm the more sensitive species will have a safe place to attach and grow. Benbow, M., Fungating malignant wounds and their management. 26. Acute infection most common sx (5) ... epidermal flap covers dermis to within 1mm of wound margin. World Union of Wound Healing Societies. From a microbiological point of view it is the critical mass of bacteria that has formed a viable colony but has not yet obtained high enough numbers to invade surrounding tissues (cause infection). 56. It’s important to choose the proper dressing based on wound drainage or dryness. Environmental factors – things like lighting, posture, PPE and risk for contamination of the environment or further contamination of the wound. Advances in Wound Care, 1997. Devices deliver ultrasound either in direct contact with the wound bed or via an atomised solution (mist). 30. immune compromised - will not show typical signs of infection, do you watch for other signs or use a topical antimicrobial prophylactically? The diabetic foot ulcer is one of the most common and devastating complications of diabetes and is associated with considerable morbidity and mortality. It allows us clinicians to identify and breakdown local barriers to wound healing. 2011;64 Suppl:S1-16. 2000;115(2):225-233. 34. ter Riet G, Kessels AG, Knipschild PG. 4. Ferrell, B.A., The Sessing Scale for measurement of pressure ulcer healing. 4. 52. This patient is likely to re-present to hospital time and time again with the same symptoms, or worse. Assessing the wound for clinical signs and symptoms of inflammation and infection is an important part of preparing the wound bed for healing. Niezgoda JA, Van Gils CC, Frykberg RG, Hodde JP. Continuous and aggressive maintenance debridement reduces the necrotic burden, microbial bioburden, excessive exudate, and biofilm. Hydration is important, especially with fluid loss from draining wounds, and patients without cardiac or renal insufficiency require 30 ml/kg/day or more of fluids. Fletcher, J., Wound assessment and the TIME framework. Biofilms and chronic infections. The treating team will be managing the fluid overload, but the condition will impact on any plans for compression: compression shifts the fluid from the legs back into circulation, which will exacerbate the fluid overload problem. Choosing the proper absorbent dressing can control the exudate and help prevent breakdown of new collagen scaffolding and neovasculature in the proliferative phase.13 Wounds that are too dry, on the other hand, also are disadvantaged since new cells will die if they dessicate. Effectiveness of an extracellular matrix graft (OASIS Wound Matrix) in the treatment of chronic leg ulcers: a randomized clinical trial. working around surgical sites – applying a VAC around ex-fix pins, expect delay – higher protein and caloric intake is required for wound healing, Not mobile – pressure related tissue damage, poor calf muscle pump, Poor housing or income – poor environmental controls can impact on healing. Being able to quickly, easily and accurately record the progress of a wound through these images has been incredibly helpful, increasing objectivity in temporal assessment. Mental health issues such as depression can affect treatment compliance and should be identified and addressed. 44. Mary Cheney, RN, NP-C and Matthew M. Wilkin, DPM, ACFAS are from ProMedica Wound Care, Toledo, OH. Pink is for epithelial, red for granulating, yellow for slough and black for eschar. Wound infection: a failure of wound healing caused by an imbalance of bacteria. A phase III randomized placebo-controlled double-blind study. The modern care environment is one where nurses find they have more responsibilities, less time and high staff turnover rates; all of which are barriers to ensuring consistent use of a WAT(38, 45, 49). Proc Natl Acad Sci U S A. Lundberg C. Inflammatory reaction and collagen accumulation in an experimental model of open wounds in the rat. This year that procedure looks cheaper for both John and the hospital! The first cell-containing product was developed and reported in 1979 by Bell, Ivarsson, and Merrill,54 following Rheinwald and Green’s process of sustaining living cells in tissue culture a few years before.55 These cell-containing products are beneficial because they 1) act as a biologic dressing; 2) provide healthy, responsive cells as opposed to the senescent, nonresponsive cells commonly seen in chronic wounds; 3) act as a “smart material” responding to the wound environment providing the necessary growth factors at the time needed to stimulate healing; 4) operate as a source for growth factors commonly known to be missing in chronic wounds; 5) act as a template for developing new blood vessels and granulation tissue; and, 6) in the presence of keratinocytes, act as a source for antibacterial peptides (defensins) that suppress bacteria on the wound.56. Topical negative pressure therapy can also be considered if there is a wound deficit (depth) that also needs to be managed. Patients with significant PAD often complain of calf cramping when walking short distances (intermittent claudication) or pain in their foot or toes. Tissue Eng. Defective extracellular matrix reorganization by chronic wound fibroblasts is associated with alterations in TIMP-1, TIMP-2, and MMP-2 activity. 62. 51. Negative pressure wound therapy (NPWT), which involves applying subatmospheric pressure to the wound site, was first described in 1997. BMJ. Ziyadeh N, Fife D, Walker AM, Wilkinson GS, Seeger JD. The recommendations presented in this paper provide practitioners with a methodical approach to optimize wound … Scand J Plast Reconstr Surg. More evidence-based wound care recommendations are appearing and educational opportunities abound. 7(8): p. 481-486. 71. 2009;49(4):1013-1020. Advances in Skin & Wound Care, 2005. 23. The act of debriding the wound bed not only improves the tissue in the wound bed but it also has a positive impact on inflammation (restores functional extracellular matrix proteins), moisture (reduces exudate) and edges (encourages migration) – the other three components of TIME. The SilhouetteStar is a camera which uses laser technology to measure wound depth and digital planimetry (where the user traces the wound edge in the photo) to measure area. Burns. 45. 2006;42 Suppl 2:S65-S71. Stechmiller J, Cowan L, Schultz G. The role of doxycycline as a matrix metalloproteinase inhibitor for the treatment of chronic wounds. Pressure ulcers in America: prevalence, incidence, and implications for the future. They expand this spread from colonization to infection into 6 stages: Cleaning, debriding and appropriate use of antimicrobial dressings all help to reduce bioburden and reduce the establishment of a biofilm. McDonald LC. If planning to debride, conduct measurements after debriding. If patients understand the value of the DOMINATE components with respect to their wounds and receive constant reminders, compliance and healing rates should increase. Adv Skin Wound Care. 54. Capable of removing most if not all devitalised tissue from the wound bed. Chronic Wound Care: A Problem-Based Learning Approach. 37. Chronic wounds are a significant health problem worldwide. Edema is a common, major component of venous and lymphatic insufficiency affecting all phases of wound healing and often associated with leg ulcers. This can often be achieved with diabetic ulcers. Chronic Wound Infection and Antimicrobial Use. Ann Plast Surg. Dr. Alisa Savetamal Presents the Health Economics of Allograft VS, Two Methods of NPWT for Wound Management and Patient Satisfaction, Dr. Blome-Eberwein Presents BTM Extreme: Three years experience at Lehigh Valley, Dr. Wagstaff Presents 5 Years of NovoSorb BTM Surgical Cases. Offloading the boney prominences prone to pressure is the mainstay of prevention and treatment. However, the digital age is encroaching on wound care. Since 1970 we have known that a standardized method for measuring wound healing is needed(34). Wounds UK, 2008. National Pressure Ulcer Advisory Panel. Also suitable for wounds where other forms of debridement are inappropriate. Grey, J.E., S. Enoch, and K. Harding, ABC of Wound Healing: Wound Assessment. 2005, MEP Ltd: London. Learn vocabulary, terms, and more with flashcards, games, and other study tools. From a clinical perspective, this is where the wound is sufficiently colonized to exert it’s effects on the wound and prevent healing. MacNeil S. What role does the extracellular matrix serve in skin grafting and wound healing? 26(Spring 2009): p. 5-6. Wound appearance+Rx acronym: Definition. As time goes on the adhesion forces become stronger and the bacteria start to produce extracellular substances to make the area more suitable, thus starting the development of the biofilm. The Unna boot (ie, short-stretch gauze impregnated with calamine lotion, zinc oxide, and gelatin) with an outer layer of a self-adherent dressing is often a good first choice. Advances in Skin & Wound Care, 2006. Sheehan P, Jones P, Caselli A, Giurini JM, Veves A. 77. With adequate renal function, the protein requirement increases to 1.25-1.50 grams/kg/day for synthesis of collagen, antibodies, and enzymes. Also, even when using the SilhouetteStar, undermining is not detected and, again, will need to be measured manually with a sterile probe. Offloading also allows epithelialization and remodeling to progress undisturbed by pressure, especially if said pressure is accompanied by a rubbing effect that can break down new tissue. Journal of Community Nursing, 2009. Chronic wound exudates contain high levels of matrix metalloproteinases (eg, collagenases, elastases), inflammatory cells, and other wound healing inhibitory factors. In a person who is immunocompromised or has a reduced immune response for another reason (such as in the feet of people with diabetes) there may be no local sign that infection is present; the first signs could be rigors or pain at regional lymph nodes(21, 22). Debridement converts a chronic or stalled wound to one that is acute by removing nonviable tissue that can stimulate excessive inflammation and bacterial growth. 53. Serous—thin, clear, watery plasma, seen in partial-thickness wounds and venous ulcera­tion. The internet provides us with a wealth of wound management information, some excellent (Wounds International, World Wide Wounds) and some which are, well let’s say, not peer reviewed… Within our healthcare settings the majority of our WATs are still paper-based and we continue to measure with disposable rulers. Ann Surg. Wounds UK, 2011. Journal Of Clinical Microbiology, 2009. 16(8): p. 462-4. Percival, S.L. 2004;42(7):2879-2883. Cook H, Davies KJ, Harding KG, Thomas DW. Finlayson, K., H. Edwards, and M. Courtney, Relationships between preventive activities, psychosocial factors and recurrence of venous leg ulcers: a prospective study. These caloric needs may be met with carbohydrates, proteins, and fats. 66. Varicose veins, ankle flair, haemosiderin staining, Manage moisture, prevent periwound maceration, Long duration of ulcer (6 years) and ‘lumpy’ tissue in part of the wound base. When classic diagnostic features are present, such as swollen feet, squared swollen toes, and dorsal foot pitting, the diagnosis can be clinical. New Rochelle, NY: Mary Ann Liebert, Inc Publications; 2012:412-418. Now we will go into ALOT more detail about each of these. Ayello, Increased bacterial burden and infection: the story of NERDS and STONES. Therefore, in the picture on the right you would describe the undermining as being Xcm extending from 6 O’clock to 9 O’clock. 32(2): p. 10-30. This is where we start to get our hands on the patient. It has been established that maintenance debridement is necessary and effective in achieving healing of chronic wounds.4   One precautionary note is in dealing with wounds due to pyoderma gangrenosum, which is often associated with rheumatoid arthritis and ulcerative colitis. Jones, and D.G. Simple periwound skin protection can be obtained by using barrier wipes, creams or sprays(11). 1998;21(5):822-827. Definition of a cavity wound. However the ruler measurement itself has been proven to consistently over-estimate the wound size(53). Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Chantelau E, Haage P. An audit of cushioned diabetic footwear: relation to patient compliance. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Wound Repair Regen. Using various splints, boots, customized shoes, and casts can eliminate this type of pressure. J Plast Reconstr Aesthet Surg. You can unscramble WEUNNOSDR (DENNORSUW) into 413 words. 2011;54(6 Suppl):83S-90S. 4 Suppl. The major causes of these ulcers are repetitive trauma, often from pressure with loss of protective sensation due to neuropathy. Tweet. The FDA has approved both products for the treatment of diabetic foot ulcers, and only the second for the treatment of venous leg ulcers. Table copied from Debridement Made Easy(12). Poor oxygenation – how much oxygen is making it to the skin? Lydia developed her outlook from classes, hands on experience, research and doctors’ influence. M Adv Skin & Wound Care 2008; 21: 531–540. Biochemical analysis of wound fluid from nonhealing and healing chronic leg ulcers. In legs with signs of arterial or venous disease, it is reasonable to recommend an ABPI. 2007;335(7610):83. However, this is just a guide and not a diagnosis. Availability issues due to higher costs and requirement for specialist equipment. Signs and symptoms of infection are present. No analgesia is required normally. It is well known that control of bioburden is an important aspect of wound management.17 Chronic wounds can become contaminated and/or colonized with either bacteria and/or fungi.18 However, when the microorganisms become invasive, critical colonization can result and, if left untreated, wound infection may develop. This material provides an efficient growth medium for microorganisms and contributes to the development and maintenance of the biofilm. The use of adhesives can cause damage from their frequent removal or may trigger an allergic response. 2009;30(8):1482-1491. 18. 20(24): p. 65-72. 40. A wound is defined as a loss of continuity of the skin or mucous membrane with associated tissue loss, which involves the epidermal layer of the skin. If a wound is too wet or too dry, the new cells do not thrive and healing is impaired. Cook, L., Wound assessment: exploring competency and current practice. The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. I State-of-the-art treatment of chronic leg ulcers: A randomized controlled trial comparing vacuum-assisted closure (V.A.C.) Chronic wounds tend to have more anaerobes than acute wounds and these may not be identified on routine swabs unless specific culture techniques are utilized. J Vasc Surg. This does not result in total debridement of all non-viable tissue and can be undertaken in conjunction with other therapies (eg autolysis). While all the review articles agreed that comprehensive wound assessment is needed, such a comprehensive tool as outlined by AWMA would not be practical, and would not be used by Nurses. Int Wound J. There are some dressings which will allow the exudate to pass through to a secondary dressings so that the primary dressing does not have to get changed as often as the cheaper secondary dressing but still provide the benefits of the longer wear time for the primary dressing (examples are mepilex transfer, aquacel, tulle gras, and silicone interface dressings). Newer methods are more selective, faster and relatively pain-free. Adv Skin Wound Care 2006;19:447–63. Therefore, it makes sense to prioritize patient education regarding the DOMINATE concept. Clinical settings that may increase the diagnostic yield include chronic inflammation from wound sinus, burn scars, radiation, immunosuppression, known systemic malignancy (especially lymphoma or leukemia since skin infiltrates can ulcerate), and change in ulcer appearance.15,16 A full-thickness punch biopsy that includes the wound bed, subcutaneous, and surrounding tissue, with the patient under local anesthesia, is adequate. Trends in antimicrobial resistance in health care-associated pathogens and effect on treatment. Arterial insufficiency, peripheral arterial disease (PAD), and atherosclerosis can be a significant impediment to wound healing since tissue oxygenation is essential for wounds to heal. 47. 2004;22(2):42-48. Chronic Wounds •Leg ulcers •Pressure ulcers •Diabetic foot ulcers •Malignant wounds Healing is delayed by intrinsic/extrinsic ... NERDS and STONES. Bacteria are present on the wound surface (contaminated). For the wound bed that is friable, has an odd or pearly texture, especially where the patient has a history of skin cancers, it is reasonable to recommend a biopsy. Diabetes Care. Arguably, the greater number of assessment items means the greater the ability to detect variation(47) but also the more time consuming to administer and therefore more costly(48). Liesse Iyamba, J.M., et al., Study of the formation of a biofilm by clinical strains of Staphylococcus aureus. The important thing to remember is that we need to know what it is to be able to create the most appropriate care plan. by The WoundSource Editors. 2011;19(2):134-148. Rapid detection of antimicrobial-resistant organism carriage: an unmet clinical need. Argenta LC, Morykwas MJ. Barber, S., A clinically relevant wound assessment method to monitor healing progression. Excision or wider resection of non-viable tissue, including the removal of healthy tissue from the wound margins, until a healthy bleeding wound bed is achieved. Cullen Gill E, Moore Z. Reported granulation tissue discolouration has included yellow, green, or blue when bacteria such as Pseudomonas aeruginosa, Streptococci, and Bacteroides fragilis have been cultured. High amounts of exudate need either much more frequent changes of simpler dressings (such as combine) or use of high absorbency dressings such as Zetuvit or Drymax. Ronfard V, Williams T. Developments in cell-based therapy for wounds. 3D cameras and the software to run them, digital planimetry devices and their consumables, all have high costs and take time to learn. If a scab is present proteases have to break down and clear a path for the keratinocytes to burrow underneath the scab. Moore ZE, Webster J. Dressings and topical agents for preventing pressure ulcers. Do we have enough information to understand the underlying problem (diagnosis) and create a comprehensive management plan, or do we need more? 35. 14. Inflammation in chronic venous ulcers. Wald H, Richard A, Dickson VV, Capezuti E. Chief nursing officers’ perspectives on Medicare’s hospital-acquired conditions non-payment policy: implications for policy design and implementation. Sibbald, R.G., K. Woo, and E.A. 50. Chronic and acute wounds are also assessed differently because in acute wounds we have the window of the first 48 hours where we have an expectation of what the ‘normal’ wound healing will look like. If the biofilm is not disturbed with appropriate wound bed preparation techniques, appropriate dressing management and the use of topical antimicrobials the colony will continue to produce invading bacteria which can lead to bacteria getting into the bloodstream (bacteremia) leading to sepsis or septicemia (multiplication of bacteria in the blood and toxin production), potential organ failure, and in extreme cases, death.

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