Taking the PressureOut of Ulcer Management

Taking the
of Ulcer Management
Heather Hettrick PT, PhD, CWS, FACCWS,
Vice President Academic Affairs and
American Medical Technologies
The information presented in this presentation constitutes an
introduction to a topic that has been prepared and provided for
educational and informational Purposes only. It is for the attendees
general knowledge and is not a substitute for legal or medical
Legal and or medical advice requires appropriate licensure, expert
consultation and an in-depth knowledge of your situation. Although
every effort has been made to provide accurate information herein,
laws and precedents are always changing and will vary from state to
state and jurisdiction to jurisdiction.
As such, the material provided herein is not comprehensive for all
legal and medical developments and may inadvertently contain
errors or omissions. This review, we hope, will give a starting point
for thinking about the way you practice wound care in that you
begin to understand the need for thorough knowledge and careful
documentation about the care of the residents. American Medical
Technologies shall not be held liable for any situation that may
result directly or indirectly from use or misuse of this information.
Content Overview
• Anatomy and physiology of the skin and
associated systems relating to the development of
pressure ulcers
• Definition of pressure ulcer
• Risk factors for the development of pressure
• Comprehensive nursing assessment to identify
risk factors for pressure ulcer development
• Importance of early identification of risk factors for
pressure ulcer development
• Development and implementation of interventions
to prevent the development of pressure ulcers
A&P Review of the Skin
In a 150- pound person, the skin is comprised of
18 square feet and weighs about 12 pounds.
In 1 square inch the skin contains:
• 65 hairs
• 100 sebaceous glands
• 78 yards of nerves
• 650 sweat glands
• 19 yards of blood vessels
• 9,500,000 cells
• 1,300 nerve endings
• 20,000 sensory cells
• 32,000,000 bacteria
A&P Review of the Skin
• Skin is the largest organ of the body
– The skin has three functional layers
• Epidermis
• Dermis
• Hypodermis or subcutaneous layer
A&P: Layers of the Skin
• Epidermis
– Five layers of cells (superficial to deep)
– Functional components:
• Made up of tough, flattened cells of the protein keratin
• Cells provide barrier to injury, contaminants, light, retain water
• Keratinocytes secrete protein keratin
• Melanocytes produce melanin (pigment)
• Basal and prickle cells regenerate epidermis, produce Vit D
• Langerhans cells are a component of the immune system
Epidermis: Stratum Corneum
Protective layer
Highlighted in green
Outermost layer with
cells that are
desquamated and turn
over every 30 days
Comprised of 15-20
layers of nonnucleated keratinized
From: trc.ucdavis.edu/.../ skin/epi0/epi4.html
Epidermis: Stratum Lucidum
• Transparent layer
found mainly in the
soles and palms
(i.e. thick
• Transitional layer
that is 1-5 layers
From: trc.ucdavis.edu/.../ skin/epi0/epi4.html
Epidermis: Stratum
• Granular layer that is
1-5 cells thick
• Forms a waterproof
barrier that functions
to prevent fluid loss
• Synthesizes
keratonyaline which
is the precursor to
From: trc.ucdavis.edu/.../ skin/epi0/epi4.html
Epidermis: Stratum Spinosum
This is the prickle cell layer
This layer contains
desmosomes which
terminate in spiny
projections which hold the
cells together and help
protect the skin from
Langerhan’s cells also
provide antigens to Tlymphocytes (immune
From: trc.ucdavis.edu/.../ skin/epi0/epi4.html
Epidermis: Stratum Germanitivum
• Single cell layer
• Provides germinal
cells necessary for
the regeneration of
the epidermis
• Contains
melanocytes which
are responsible for
the pigment of the
From: trc.ucdavis.edu/.../ skin/epi0/epi4.html
Basement Membrane
• The epidermal-dermal junction- where cells
reside that are responsible for mitotic growth
and epidermal regeneration
occurs approximately every 30 days
• Fibronectin is the major protein in the basement
– It is an adhesive glycoprotein (the glue that holds it
• Layers are lamina lucida and lamina densa
• Rete pegs (epidermal) attach with the dermal
papillae to support the epithelium and dermis
Layers of the Skin
• The epidermis has an irregular shape, resembling
downward, finger-like projections called rete ridges or
rete pegs (see next slide).
– The significance of this anatomical structure is that the dermis
has upward projections.
– The upward and downward projections fit together, very much
like a waffle iron. These protuberances connect, anchoring the
epidermis to the dermis.
– This bond also helps to prevent the epidermis from sliding back
and forth across the dermis with normal movement and skin
• In healthy young skin, the 2 layers of skin move as one. This is not the case
in elderly skin (skin over the age of 60!)
• This is why shear and friction can cause skin tears in the elderly.
Layers of the Skin
Note the dark pink fingerlike projections. These are the rete pegs.
Layers of the Skin
• As the skin ages, the rete ridges begin to flatten between the
dermal-epidermal junction.
– Such epidermal/dermal flattening typically appears by the
sixth decade.
– With this anchoring now diminished, there is an increased
potential for the epidermis to detach from the dermis,
leading to tearing of the uppermost layers of the skin,
especially in the older adult population.
• This leads to skin tears, bruising or ecchymosis, and an
increased susceptibility to damage from pressure,
friction and shear.
From: Advances in Skin & Wound Care: Volume 20(6)June 2007pp 315-321, Preventing and Treating Skin Tears
Layers of the Skin
• Dermis
– Two layers of irregular connective tissue
• Papillary layer- anchors dermis to epidermis
• Reticular layer- contains dense, deep accessory organs
– Functional components of the dermis:
• hair follicles
• nerve endings (pain, heat, cold, touch, pressure)
• lymph vessels (remove excess fluid, store protein)
• capillaries (supply nutrients and O2, remove water and
• collagen (bulk, strength, support)
• elastin and reticulin (extensibility, integrity)
• sweat glands
• sebaceous glands (sebum, controls pH, antibacterial and
antifungal effects)
Layers of the Skin
• Subcutaneous tissue
– Functional components:
• adipose or fat
• connective and elastic tissue
– insulate, support, cushion
and store energy
Adipose tissue
Functions of the Skin
• Dynamic organ continuously engaged in biological and
biochemical activity
– Protection
– Temperature regulation
– Fat and water storage
– Vitamin D synthesis
– Excretion of waste
– Cosmesis
– Touch/sensation
Trauma and damage to the skin can lead to functional impairments
Aging Skin:
• Over the lifespan, skin becomes drier, less
elastic, less perfused vulnerable to
damage from pressure, friction, shear,
moisture, malnutrition, etc.
Aging Skin:
Gerontodermatological Changes
• Skin aging is a complex process
– Most major changes occur in the dermis
• Two independent aging processes
– Normal aging slow, irreversible degeneration of
– Extrinsic aging AKA photoaging due to exposure of
the elements (primarily UV irradiation)
Photos: www.dermnet.com
Aging Skin:
Gerontodermatological Changes
• Combination of normal aging and
photoaging results in altered wound
healing processes
– Progressive loss of skin function
– Increased vulnerability to the environment
– Decreased homeostatic ability
Healing is delayed but is as effective as that of younger adults
Aging Skin:
Gerontodermatological Changes
• Replicative senescence
– Epithelial and fatty layers thinner
– Collagen and elastic fibers shrink 1% per year
– Sweat glands decrease in number and size
– Skin vascularity decreases
– Vessel walls thin
– Ateriosclerotic changes occur in small and
large vessels
Aging Skin:
Gerontodermatological Changes
• With these changes
Oxygen-carbon dioxide exchange decreases
Tissue turnover slows
Increase occurrence of ecchymosis
Inflammatory response decreases
Tissue regeneration is slower which can delay healing and
make tissue more susceptible to infection
All these factors can ultimately lead to skin breakdown
and impair or delay healing!
Now What?
Knowing the basic anatomy and physiology
of the skin and understanding changes
associated with aging skin…
What can we do to help reduce the risk of
injury or trauma (especially pressure,
friction and shear)?
Identify Threats To Skin Integrity
Pressure, friction, shear
Malnutrition, dehydration
Cognition impairments
Medications (topical and systemic)
Comorbidities and other health complications
Assess appropriateness of support surfaces (bed, chair)
Exogenous, endogenous, iatrogenic factors
These threats are more pronounced in older
individuals…the majority of long-term-care residents
Skin Assessment
Understanding changes associated with
Identifying threats to the skin
Recognizing residents comorbidities
and overall health status
All create a picture of the individuals skin health and
risk of breakdown
Skin Assessment
• Thorough skin
assessment is paramount
• Prevention is key
– Address all modifiable risk
• Early intervention is
To Prevent and Reduce These… Pressure
Pressure Ulcer Definition
“A pressure ulcer is
localized injury to the
skin and/or underlying
tissue usually over a
bony prominence, as a
result of pressure, or
pressure in combination
with shear and/or
friction.” (NPUAP)
Diagrams from: www.dick-ford.com
Pressure Ulcer Considerations
The amount and duration
of pressure and the
severity of shearing forces
influence pressure ulcer,
herein PrU, formation
These forces combine
causing a distortion of the
capillary network, limiting
blood flow
Additional compounding
factors: nutritional
deficiencies, immobility,
decreased immunity, and
excessive moisture
Shear force
Diagrams from: www.dick-ford.com
Friction and Shear Force
Mechanical force exerted on the
skin when moved against any
May result in a skin abrasion
A distortion of the tissue caused by
two opposing parallel or
horizontal forces
Friction + Gravity = Shear
Shear has its greatest effect on the
deep tissues of the body
Pressure Ulcers
• Anatomical sites at risk
greater trochanter
ischial tuberosities
medial/lateral malleoli
knee (all aspects)
olecranon process
toes (tight sheets)
thoracic vertabrae
areas exposed to tubes, lines and/or
external devices (casts, splints, etc)
Residents at Risk for Pressure
mental impairment
altered cognition
corticosteroid history
diminished pain awareness
poor circulation
drugs that impair wound
bed rest/chronic immobility
intrinsic/extrinsic/ iatrogenic
multisystem trauma
significant obesity or
co-morbid conditions
resident refusal
previous PrU history*
altered blood pressure**
So what do you do?
Difference Between Skin
Assessment and PrU Risk
Skin Assessment Goal
• PrU Risk Assessment
– Gather info to describe
the current health of
the skin
– Detect variations from
normal (erythema,
rashes, lesions,
dryness, etc)
– Identify age-related or
changes (thinning,
decreased elasticity,
trophic changes, etc)
– Gather info about
specific factors, such
as immobility, poor
nutrition, etc that place
a resident at risk for
developing a PrU
Risk Assessment
• The implementation and
consistent use of a risk
assessment tool can reduce
the incidence of pressure
ulcers by ~60%*
• Utilized upon admission,
weekly thereafter for four
weeks, quarterly, and at
Prevention and Risk Factors
Risk assessment is not
just a number!
Risk assessment identifies specific factors that place a resident at
risk for the development of a PrU
Each risk factor must be addressed in the care plan with
appropriate interventions
Identify, remove, modify, and/or stabilize risk factors
Risk Assessment
• Prevention and early
intervention of at-risk
residents is essential
• Requires thorough
history & systems
• Observation and
palpation of resident’s
– Palpation is particularly
important for residents
with noncausian skin
Tissue Tolerance
• Definition:
– The ability of the skin and its supporting structures to endure the
effects of pressure without adverse effects
• Every person's tissue tolerance is different
• Some residents may tolerate an hour in the wheelchair without
breakdown and others may not
• Skin inspection for tolerance
– Inspect for any skin discoloration (note darker skin tones my not
show any change in color)
– Assess sensation (pain and itching)
– Palpate for any changes in temperature (warm or cold) or
consistency (firm or boggy)
Tissue Tolerance
• Note that after pressure is relieved from any area of
the body a hyperemia (redness) response will appear
from the blood flow going back to that area (again note
darker skin tones may not present with this)
• If this response doesn't resolve right away, check
again within 45 minutes to an hour (due to the changes
associated with aging skin, it takes them longer to reperfuse)
– If it is still discolored and nonblanching, then it is a Stage I
• This process will allow you to determine if the turning
intervals are adequate for the individual resident
• CMS considers a PrU to
be a sentinel event in a
resident of a long-termcare facility who had been
assessed as being at low
risk for a PrU
• According to CMS, the
only residents who are at
high risk (automatically)
are those who have
impaired transfer or bed
mobility, are comatose, or
malnourished; any other
resident is at low risk until
assessed as otherwise.
Identify and document all risk factors
Identify pre-existing signs of skin trauma
Assess and document pain
Include the Resident Assessment Instrument (RAI)
Identify the resident with:
– multi-system organ failure
– end-of-life condition
– refusal of care and treatment
• Address all factors that have been identified as having
an impact on the development, treatment and/or healing
of pressure ulcers
VA Incidence Reports
• 22 VAC 40-72-100 A- Incident Reports
– Q: would a PrU be considered a “major
incident that has negatively affected or that
threatens the life, health, safety or welfare of
a resident” that has to be reported?
– A: YES
• Stage II, III, & IV PrU must be reported whenever
identified on or after admission to a facility
VA Incidence Reports
• 22 VAC 40-72-100 A- Incident Reports
– The acceptable description of the incident as required
at 22 VAC 40-72-100.c.7 will include but is not limited
Location of the wound(s)
Measurements and appropriate stage
Exudate description (amount, color, consistency)
Presence of odor (after cleansing)
– Actions and outcomes…c.9-10 will depend upon the
extent of the clinical intervention but at a minimum will
• Nurse and/or physician contacts
• Treatment orders
• Preventive measures undertaken
Clinical Presentation of
Pressure Ulcers
Red flag!
– Blanchable erythema
• Variations in skin
• Edema and
increased tissue
• If pressure relieved,
skin can return to
normal in 24 hours.
If not, damage
NPUAP: February 2007
• “The National Pressure Ulcer Advisory Panel has
redefined the definition of a pressure ulcer and the
stages of pressure ulcers, including the original 4
stages and adding 2 stages on deep tissue injury
and unstageable pressure ulcers.”
• NPUAP Pressure Ulcer definition:
– “A pressure ulcer is localized injury to the skin
and/or underlying tissue usually over a bony
prominence, as a result of pressure, or pressure
in combination with shear and/or friction.”
– “A number of contributing or confounding factors
are also associated with pressure ulcers; the
significance of these factors is yet to be
Clinical Presentation of
Pressure Ulcers
• Stage I
– Intact skin with nonblanchable redness of a
localized area usually
over a bony prominence.
Darkly pigmented skin
may not have visible
blanching; its color may
differ from the
surrounding area.
– The area may be painful,
firm, soft, warmer or
cooler as compared to
adjacent tissue. May be
difficult to detect in
individuals with dark skin
tones. May indicate “at
risk” persons (a heralding
sign of risk).
Clinical Presentation of
Pressure Ulcers
• Stage II
– Partial thickness loss of
dermis presenting as a
shallow open ulcer with a red
pink wound bed, without
slough. May also present as
an intact or open/ruptured
serum-filled blister.
– Presents as a shiny or dry
shallow ulcer without slough
or bruising.* This stage
should not be used to
describe skin tears, tape
burns, perineal dermatitis,
maceration or excoriation.
• *Bruising indicates
suspected deep tissue
Clinical Presentation of
Pressure Ulcers
• Stage III
– Full thickness tissue loss.
Subcutaneous fat may be
visible but bone, tendon or
muscle are not exposed.
Slough may be present but
does not obscure the depth
of tissue loss. May include
undermining and tunneling.
– The depth of a stage III
pressure ulcer varies by
anatomical location. The
bridge of the nose, ear,
occiput and malleolus do not
have subcutaneous tissue
and these ulcers can be
shallow. In contrast, areas of
significant adiposity can
develop extremely deep
stage III pressure ulcers.
Bone/tendon is not visible or
directly palpable.
Clinical Presentation of
Pressure Ulcers
• Stage IV
– Full thickness tissue loss with
exposed bone, tendon or
muscle. Slough or eschar
may be present on some
parts of the wound bed.
Often include undermining
and tunneling.
– The depth of a stage IV
pressure ulcer varies by
anatomical location. The
bridge of the nose, ear,
occiput and malleolus do not
have subcutaneous tissue
and these ulcers can be
shallow. Stage IV ulcers can
extend into muscle and/or
supporting structures (fascia,
tendon, joint capsule) making
osteomyelitis possible.
Exposed bone/tendon is
visible or directly palpable.
Clinical Presentation of
Pressure Ulcers
• Unstageable
– Full thickness tissue loss
in which the base of the
ulcer is covered by slough
(yellow, tan, gray, green
or brown) and/or eschar
(tan, brown or black) in
the wound bed.
– Until enough slough
and/or eschar is removed
to expose the base of the
wound, the true depth,
and therefore stage,
cannot be determined.
Stable (dry, adherent,
intact without erythema or
fluctuance) eschar on the
heels serves as “the
body’s natural (biological)
cover” and should not be
Suspected Deep Tissue Injury
Purple or maroon localized
area of discolored intact skin
or blood-filled blister due to
damage of underlying soft
tissue from pressure and/or
shear. The area may be
preceded by tissue that is
painful, firm, mushy, boggy,
warmer or cooler as
compared to adjacent tissue.
DTI may be difficult to detect
in individuals with dark skin
tones. Evolution may include
a thin blister over a dark
wound bed. The wound may
further evolve and become
covered by thin eschar.
Evolution may be rapid
exposing additional layers of
tissue even with optimal
Suspected Deep Tissue Injury
Tissue injury that appears as
dark discoloration, deep
bruising, hematoma
Borders are irregular and not
well demarcated
Typically acute formation
– Long OR times
– Falls
– Splints
– Single episode of
Damage to deeper structures
has already occurred
Skin may still be intact
because of its higher
resistance to hypoxia
Heralding sign of an
impending stage III or IV
Clinical Presentation of
Pressure Ulcers
• Other PrU characteristics
– Wound exudate varies in amount
– PrU usually round and well defined, shape may be irregular
depending upon pressure causing agent (catheter) and
location (butterfly shape common at sacrum)
– Periwound usually dry unless clinical signs of infection
– Pain is variable
– To facilitate healing, must eliminate mechanical trauma forces
(pressure, friction, shear)
CMS: Avoidable Pressure
• Resident developed a pressure ulcer and
the facility DID NOT DO one or more of
the following:
– Evaluate the resident’s clinical condition and
pressure ulcer risk factors
– Define and implement interventions that are
consistent with resident needs, goals, and
recognized standards of practice
– Monitor and evaluate the impact of the
– Revise the interventions if appropriate
CMS: Unavoidable Pressure
• Resident developed a pressure ulcer even
though the facility:
– Evaluated the resident’s clinical condition and risk
– Defined and implemented interventions that are
consistent with resident needs, goals, and
recognized standards of practice
– Monitored and evaluated the impact of the
– Revised interventions as appropriate
Documentation Issues
• Until the MDS is revised, reverse staging must be used
for completion of the RAI
– For example, if upon observation a healing Stage III
ulcer has the appearance of a Stage II ulcer, it should
be coded as a Stage II ulcer on the MDS
– Correct staging and descriptions should be in the
wound care/nursing notes
• Healing Stage III ulcer recorded as Stage II on the
• A PrU should progress toward healing in 2-4 weeks. If
not, the reason for continuing the current treatment must
be documented.
F314 & Documentation
• The F314 addresses the minimum
requirements for documentation for a
resident with a PrU
– Protocol for assessment
– Mandated daily monitoring
– Mandated weekly or dressing change
Protocol for Assessment
• Differentiate type of ulcer (pressure related versus
non-pressure related)
• Determine stage (if pressure) or depth of tissue
involvement for non-pressure related ulcers (partial or
• Describe and monitor the ulcer’s characteristics
• Monitor the progress toward healing and potential
• Determine if infection is present
• Assess, treat, and monitor pain
• Monitor dressings and interventions
Mandated Daily Monitoring
• Evaluation of ulcer if no dressing is present
• Evaluation of the status of the dressing, if present
– Is it intact? Is there drainage? Is it leaking?
• Status of the peri-ulcer area
– Area around the ulcer that can be observed without
removing the dressing
• Presence of possible complications
– Increased redness, swelling, drainage…
• Whether pain, if present, is being adequately controlled
Mandated Weekly or Dressing
Change Monitoring
• Size, depth, and the presence, location and extent of
undermining or tunneling/sinus tract
• Exudate if present: type, color, amount, odor
• Pain if present: nature and frequency
• Wound bed: color and type of tissue
– Evidence of healing or necrosis?
• Description of wound edges and periwound
– Rolled edges, erythema, induration, maceration?
PrU Intervention Considerations
• Interventions should be selected based upon
the clinical presentation of the wound as well
as that of the resident
• You should be able to justify your
interventions (provide rationale) and
demonstrate that they are based upon the
standard of care and current clinical practice
guidelines (see last few slides)
• You should also modify/change your
interventions as needed, and be able to
explain why you did so
Dressing and Treatment Caveats
Thomas, JAMDA Oct 2006
• Stage III, IV ulcers should be covered
• Determination of the need for a dressing for a Stage I, II
ulcer is based upon individual practitioner’s clinical
judgment and facility protocols based upon current
clinical standards of practice
• Current literature does not indicate significant
advantages of any single specific product
• Current literature suggests that PrU dressing protocols
may use clean technique rather than sterile
• Appropriate sterile technique may be needed for those
wounds that have recently been surgically debrided or
Debridement Caveats
Thomas, JAMDA Oct 2006
• Variety of methods available
– Mechanical, sharp, surgical, enzymatic, autolytic
• Must be appropriate for the resident and clinical wound
• Stable, dry, intact, and adherent eschar on the foot/heal
should not be debrided unless signs/symptoms of local
infection or instability
• Wet-to-dry dressings (a form of debridement) or irrigations
may be appropriate in limited circumstances, but repeated
use may damage healthy granulation tissue and may lead to
excessive bleeding and increased pain
• A facility should be able to show that its treatment protocols
are based upon current standards of practice and are in
accord with the facility’s policies and procedures as
developed with the medical director’s review and approval
Summary of PrU Prevention
Turn and/or reposition non-ambulatory Rotates the sites of pressure and
residents every 2 hrs at minimum.
allows blood flow to return to an area
Reposition immobile residents every 1 where blood flow had been restricted.
hour while up in chair.
Teach and encourage residents to
weight shift every 15 minutes,
assisting as necessary while up in
Assist or provide resident with devices
to maintain mobility.
Lift resident off bed; do not drag when
moving. Use a lift sheet to help when
moving or turning a resident. Protect
heels and elbows with clothing or
Prevents pressure points from
developing and allows blood flow to
return. Helps prevent pressure ulcers
from developing on the lower portion
the buttocks.
residents’ risk for
development of a pressure ulcer or
Minimizes shear and friction that can
tear the skin and damage the
capillaries supplying blood to the skin.
Summary of PrU Prevention
Elevate heels by placing a pillow
lengthwise under the residents’ calves
Decreases pressure on the heels and
may decrease shear and friction
Place resident on proper pressure
redistribution mattress and cushion for
Reduces effects of pressure
Avoid use of excessive linens or
padding under resident while in bed
Too many layers of linen between
resident and pressure redistribution
mattress will decrease the
of the mattress
Identify any redness
of skin or skin
Inspect residents skin during
positioning, bathing, changing clothes,
providing ADLs, etc.
Apply pH balanced lotion to skin at
bath time and PRN
breakdown so appropriate treatment
or prevention measures can be
Keeps skin soft, supply and
Summary of PrU Prevention
Apply barrier ointment to the skin of an Helps protect skin from excessive
incontinent resident
Report frequent incontinence to
ensure that appropriate methods of
containment or treatment will be
promptly implemented
Decreases the change of
complications from incontinence
Encourage resident to eat a healthy
balanced diet and to maintain healthy
fluid intake. Encourage resident to
eat/drink prescribed nutritional
Helps maintain and/or improve
nutritional and hydration status which
is necessary for healing skin and to
support wound healing
Keep bed linens and clothing clean
and wrinkle free
Helps prevent shear, friction, and
possible moisture against skin
Summary of PrU Prevention
Use positioning devices (pillow, foam
wedges) to maintain 30 degree lateral
position and separation of bony
Minimized pressure, shear and friction,
which can tear the skin and damage
the capillaries supplying blood to the
Maintain head of bed at the lowest
Minimizes exposure to shearing, which
degree of elevation consistent with
occurs with head of bed elevation
medical conditions and other
restrictions; elevate knee gatch on bed
to prevent sliding while head of bed is
• Awareness is the first step in prevention!
• Implement care that is consistent with best
practice and the standard of care
• Prevention and early intervention are
critical so be proactive with skin
assessment and risk assessment
• Implement interventions in the plan of care
that are specific to the resident and his/her
clinical condition(s)
Resources on Standards of
• AHRQ Guidelines
– ahrq.gov/clinic/cpgonline.htm
• AMDA Guidelines
– amda.com/cmedirect/pressureulcers/index.cfm
– npuap.org/PDF/treatment_curriculum.pdf
• WOCN Guidelines
– Guideline.gov/summary/summary.aspx?ss=15&doc_id=3860&nbr=3071
CMS RAI User’s Manual: cms.hhs.gov/medicaid/mds20/man_form.asp
Proud Champion of
From: Moues, Heule, Legerstee, Hovius. Five Millenia of Wound Care Products- What Is
new? A Literature Review. Ost Wound Mgmnt 2009;55(3):16-32.
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