Skin and Wound Care

1

Skin and Wound Care
Negative Pressure Wound Therapy Section 6 of 7 RN
and LPN Self-learning Module

DMC Adv Wound Care and Specialty Bed Committee

2
Acknowledgements

• Original authors 1997
• Maria Teresa Palleschi, CNS-BC, CCRN
• JoAnn Maklebust, MSN, APRN-BC, AOCN, FAAN
• Kristin Szczepaniak, MSN, RN, CS, CWOCN
• Karen Smith, MSN, RN, CRRN
• The authors would like to acknowledge the efforts
  of the 1997 Critical Care Wounds Work Group in
  providing the basis for this self-learning
  module. We thank the following members for their
  expertise and dedication to the effort in
  formulating these recommendations and the ongoing
  work required to communicate wound care advances
  to our DMC staff
• Cloria Farris RN
• Evelyn Lee, BSN, RN, CETN, CRNI
• Mary Sieggreen MSN, RN, CS, CNP
• Patricia Clark MSN, RN, CS, CCRN
• Bernice Huck, RN, CETN
• James Tyburski, MD
• Michael Buscuito, MD
• In 2000 the authors acknowledge the following
  staff for assisting with reviewing and revising
  this learning module
• Mary Gerlach MSN, RN, CWOCN, CS
• Carole Bauer BSN, RN, OCN, CWOCN

3

Purposes and Objectives

• Purposes
• To communicate DMC standards and policies in skin
  and wound care practice.
• To provide a study module and source of
  reference.
• To prepare RN and LPN orientees for clinical
  validation of skin and wound care.
• Directions
• All staff are responsible to read the content of
  these modules and pass the tests.
• If you are unable to finish reviewing the content
  of this course in one sitting, click the Bookmark
  option found on the left-hand side of the screen,
  and the system will mark the slide you are
  currently viewing. When you are able to return
  to the course, click on the title of the course
  and you will have button choices to either
• Review the Course Material which will take you to
  the beginning of the course OR
• Jump to My Bookmark which will take you to where
  you left off on your previous review of this
  module.
• Objectives
• By completing this module, the RN and LPN
  will
• 1. Recognize the professional responsibility of
  licensed health care providers.
• RNs will utilize the knowledge to make clinical
  decisions and enter EMR orders based on DMC
  evidenced based flowcharts found in Tier 2 Skin
  and Wound Policies.
• 2. Review basic skin and wound care concepts.

4
Negative Pressure Wound Therapy
2 PC 5218

• DEFINITION
• Negative pressure wound therapy (NPWT) provides
  an occlusive controlled sub-atmospheric pressure
  (negative pressure) suction dressing that
  promotes moist wound healing.
• Controlled sub-atmospheric pressure improves
  tissue perfusion, stimulates granulation tissue,
  reduces edema and excessive wound fluid, reduces
  overall wound size, helps increase the rate of
  granulation tissue formation and epithelial
  migration.
• Some indications for use include pressure ulcers,
  venous ulcers, diabetic foot ulcers, dehisced
  surgical incisions, partial thickness burns,
  grafts, split thickness skin grafts, traumatic
  wounds, fasciotomy, myocutaneous flaps, and
  temporary closure for abdominal compartment
  syndrome (V.A.C. ACS).
• The decision to initiate or discontinue NPWT is
  done collaboratively between the physician and
  the APN / CWOCN. The APN / CWOCN is consulted to
  evaluate appropriateness of NPWT. The APN /
  CWOCN must approve NPWT using following
  manufacturers criteria / guidelines. If the
  patient meets criteria, the APN / CWOCN initiates
  the rental process.
• A. A pain management plan is in place.
• B. A nutrition management plan is in place.
• C. NPWT remains in place for 22 hours per day.
  The sponge cannot be left in place without
  suction for more than 2 hours per day.
• D. A pressure-redistribution surface is in place
  for patients with pressure ulcers.
• E. Plan of care, including goals, is documented
  in the Progress Notes.

5
Negative Pressure Wound Therapy

• Additional considerations which influence
  patient eligibility for NPWT
• Other wound care treatment has failed.
• Wound free of necrotic tissue
• Nutrition management plan in place
• Patients with bone or soft tissue infection have
  concurrent antibiotic treatment
• Circulation to the wound is adequate to heal.
• Patients are encouraged not to smoke
• Patients with the following may not be candidates
  for NPWT or therapy
• is contraindicated
• Exposed arteries or veins
• Malignancy in the wound bed.
• Active bleeding or coagulopathic patients
• Untreated osteomyelitis
• Hospice or comfort care measures only patients.
• Two types of NPWT units are available.
  InfoV.A.C. Model (500ml canister)
  in Acute Care Hospitals and KCI ActiVAC Model
  (300ml canister) for portable therapy at
  home and at RIM.
• InfoV.A.C. dressings are supplied in different
  types of sponges.

6
Negative Pressure Wound Therapy

• Info V.A.C. dressings are connected to the
  V.A.C. suction unit only and not to other
  sources of suction.
• Dressing changes are done by the APN / CWOCN with
  the staff nurse every 48 - 96 hours. Staff nurses
  may patch leaks with extra InfoV.A.C. film
  dressing or transparent film (Tegaderm) as
  needed.
• V.A.C. Abdominal Compartment Syndrome (ACS)
  dressing changes are only done by the physician
  due to exposed bowel and complexity.
• In the event that the VAC ACS stops functioning,
  contact the surgeon immediately. Do not remove
  the dressing.
• Sternal wounds with myocardial / pulmonary
  parychmal exposure are done under full barrier
  precautions.
• InfoV.A.C. dressings and VAC canisters are
  ordered in CIS and are charged to the unit, not
  the patient.
• If the patient is to continue NPWT as an
  outpatient, the paperwork for home care
  eligibility is initiated as soon as possible by
  discharge planner / CMS.
• If a home VAC is not available for placement in
  the hospital, NPWT is discontinued prior to
  patient discharge and replaced with a
  continuously moist dressing.
• NPWT is discontinued for patients being
  transferred to long term care facilities and
  replaced with a continuously moist dressing.
  Therapy is restarted at the new facility.
• Do not send rental units or supplies home with
  the patient.

7
Negative Pressure Wound Therapy

• Checking For Leaks In The Dressing
• Locate the source of the air leak, by listening
  for whistling for air and pressing down on the
  drape. Patch leaks with V.A.C. drape or
  transparent film (Tegaderm).
• If the dressing is leaking fluid, dry the area,
  prep the skin and drape surrounding the dressing
  thoroughly with adhesive skin prep /spray. Patch
  with film drape until dressing collapses.
• Checking for Leaks after canister change
• Remove canister and reseat the canister
• If machine continues to alarm low pressure and
  leak is not from dressing, obtain canister tubing
  cap from CPD to check if canister is leaking.
  Reseat canister. If unit continues to leak,
  change canister
• In the event that the NPWT stops functioning and
  the RN cannot solve the problem
• The APN / CWOCN / Wound Care Specialist or
  physician group who placed the dressing is
  contacted.
• The sponge dressing is removed within 2 hours of
  malfunction and replaced with a moist saline
  gauze dressing.
• Patients are at risk for toxic shock syndrome if
  the sponge is left in place and not attached to
  suction.
• If the patient leaves the unit for a procedure,
  the NPWT is sent with the patient and therapy
  continues. Do not clamp tubing and send patient
  to any test or procedure without the V.A.C.
  suction unit.
• To Replace The Drainage Collection Canister
• The InfoVAC machine alarms when the canister is
  full.
• Replace the canister when full or minimally once
  a week.
• Document canister content on intake and output
  record when canister is changed

8

Definitions

• DEFINITIONS
• The following definitions apply to the Skin and
  Wound Care Flow Charts
• A
• Abscess a circumscribed collection of pus that
  forms in tissue as a result of acute or chronic
  localized infection. It is associated with
  tissue destruction and frequently swelling.
• Acute wounds those likely to heal in the
  expected time frame, with no local or general
  factor delaying healing. Includes burns,
  split-skin donor grafts, skin graft donor site,
  sacrococcygeal cysts, bites, frostbites, deep
  dermabrasions, and postoperative-guided tissue
  regeneration.
• B
• Bariatric Term applying to care, prevention,
  control and treatment of obesity.
• Basic Wound Care RN identifies and orders
  treatment plan based on DMC Skin and Wound Care
  Flowcharts.
• Blister elevated fluid filled lesions caused by
  pressure, frictions, and viral, fungal, or
  bacterial infections. A blister greater than 1
  cm in diameter is a bulla and blisters less than
  1 cm is a vesicle.
• Bottoming Out determined by the caregiver
  placing an outstretched hand (palm up) under a
  mattress overlay, below the part of the body at
  risk for ulcer formation. If the caregiver can
  feel less than one inch of support material
  between the caregivers hand and the patients
  body at this site, the patient has bottomed
  out. Reinflation of the mattress overlay is
  required.
• C
• Cellulitis inflammation of cellular or
  connective tissue. Inflammation may be
  diminished or absent in immunosuppressed
  individuals.
• Chronic wounds those expected to take more than
  4 to 6 weeks to heal because of 1 or more factors
  delaying healing, including venous leg ulcers,
  pressure ulcers, diabetic foot ulcers, extended
  burns, and amputation wounds.
• Colonized presence of bacteria that causes no
  local or systemic signs or symptoms.
• Community Acquired Pressure Ulcer Any pressure
  ulcer that is identified on admission and
  documented in the Adult or Pediatric Admission
  Assessment as being present on admission (POA).
• Contaminated containing bacteria, other
  microorganisms, or foreign material. Term
  usually refers to bacterial contamination.
  Wounds with bacterial counts of 105 or fewer
  organisms per gram of tissue are generally
  considered contaminated those with higher counts
  are generally considered infected.
• Cytotoxic Agents solutions with destructive
  action on all cells, including healthy ones. May
  be used by APN / CWOCN to cleanse wounds for
  defined periods of time. Examples of cytotoxic
  agents include Betadine, Dakins Peroxide, and
  CaraKlenz.
• D
• Debridement, autolytic disintegration or
  liquefaction of tissue or cells self-digestion
  of necrotic tissue.

5
9
Definitions

• D
• Denuded Loss of superficial skin / epidermis.
• Drainage wound exudate, fluid that may contain
  serum, cellular debris, bacteria, leukocytes,
  pus, or blood.
• Dressings, primary dressings placed directly on
  the wound bed.
• Dressings, secondary dressings used to cover
  primary dressing.
• Dressings, alginate primary dressing. A
  non-woven highly absorptive dressing manufactured
  from seaweed. Absorbs serous fluid or exudate in
  moderately to heavily exudative wounds to form a
  hydrophilic gel that conforms to the shape of the
  wound. May be used for hemorrhagic wounds. Non
  adhesive, nonocclusive primary dressing.
  Promotes granulation, epithelization, and
  autolysis.
• Dressings, foam primary or secondary dressing.
  Low adherence sponge-like polymer dressing that
  may or may not be adherent to wound bed or
  periwound tissue e.g., Mepilex. Indicated for
  moderately to heavily exudative wounds with or
  without a clean granular wound bed, capable of
  holding exudate away from the wound bed. Not
  indicated for wounds with slough or eschar. Foam
  and low-adherence dressings are used in wounds
  for granulation and epithelialization stages as
  well as over fragile skin.
• Dressings, continuously moist saline primary
  dressing. A dressing technique in which gauze
  moistened with normal saline is applied to the
  wound bed. The dressing is changed often enough
  to keep the wound bed moist and is remoistened
  when the dressing is removed. The goal is to
  maintain a continuously moist wound environment.
  Indicated for dry wounds or those with slough
  that require autolytic therapy.
• Dressings, gauze primary or secondary dressing.
  a woven or non-woven cotton or synthetic fabric
  dressing that is absorptive and permeable to
  water, water vapor, and oxygen. May be
  impregnated with petrolatum, antiseptics, or
  other agents. Indicated for surgical and
  draining wounds.
• Dressings, hydrocolloid primary dressing. Two
  kinds of wafer, thick and thin. Wafers contain
  hydroactive/absorptive particles that interact
  with wound exudate to form a gelatinous mass.
  Moldable adhesive wafers are made of carbohydrate
  with a semiocclusive film layer backing e.g.,
  DuoDerm.
• Thick wafers are applied over areas with exudate
  while thin wafers are used over sites with
  minimal or no exudate.
• Thin wafers may conform to sites easier than
  thick wafers. Contraindicated where anaerobic
  infection is suspected.
• Dressing is not removed upon external soiling.
  Removing any intact product that adheres to skin
  strips the epidermis, causes damage and increases
  the risk for breakdown.
• Cover hydrocolloid with a transparent film to
  decrease friction from repositioning patient or
  if dressing is at risk for soiling.
• May be used for intact skin that requires
  protection against friction.
• Hydrocydrocolloid and low-adherence dressings are
  for wounds in the epithelialization stage.
• Used to cover a wound entirely, leaving
  approximately a 1.5 inch border around the wound
  margins.
• Does not require a secondary dressing

10
Definitions

• D
• Dressings, hydrogel or hydrogel impregnated
  gauze primary dressing. A water-based
  non-adherent dressing primarily designed to
  hydrate the wound, may absorb small amount of
  exudate e.g., Skintegrity. Indicated for dry to
  minimally exudative wounds with or without clean
  granular wound base. Donates moisture to the
  wound and is used to facilitate autolysis. May
  be used to provide moisture to wound bed without
  macerating surrounding tissue. Requires a
  secondary dressing.
• Dressings Primary dressing placed directly on
  the wound bed.
• Dressings Secondary dressing used to cover
  primary dressing.
• Dressings, silver Useful for colonized wounds or
  those at risk of infection and decreases wounds
  bacterial load. good for up to 5 - 7 days.
• Alginate e.g., Aquacel Ag - Highly absorbent
  interacts with wound exudate and forms a soft gel
  to maintain moist environment. May be used in
  dry wounds covered with saline moistened gauze as
  secondary dressing to maintain moisture
• Foam e.g., Mepilex Ag - Used for colonized wounds
  or those at risk of infection and decreases
  wounds bacterial load. Used in exudating
  colonized wounds
• Textile e.g., InterDry Ag - Used for Intertrigo
  and other skin to skin surfaces with rash. May
  remain in place for 5 days.
• Dressings, transparent primary or secondary
  dressing. A clear, adherent non-absorptive
  dressing that is permeable to oxygen and water
  vapor e.g., Tegaderm. Creates a moist
  environment that assists in promoting autolysis
  of devitalized tissue. Protects against
  friction. Allows for visualization of wounds.
  Indicated for superficial, partial-thickness
  wounds, with small amount of slough to enhance
  autolytic debridement. Used in wounds with little
  or no exudate
• Dressings, wet-to-dry a debridement technique in
  which gauze moistened with normal saline is
  applied to the wound and removed once the gauze
  becomes dry and adheres to the wound bed.
  Indicated for debridement of necrotic tissue
  from the wound as the dressing is removed,
  however method is not selective and removes
  healthy tissue as well. Other methods of
  debridement are considered more effective. Wet
  to dry dressing orders that are changed at a
  frequency that does not allow drying are
  considered continuously moist dressings.
• Dressing, xeroform primary dressing. Impregnated
  gauze with petrolatum and 3 bismuth. Indicated
  for skin donor sites and other areas to protect
  from contamination while allowing fluid to pass
  to secondary dressing.

11
Definitions

• E
• Enzymes protein catalyst that induces chemical
  changes in cells to digest specific tissue.
  Indicated for partial and full thickness wounds
  with eschar or necrotic tissue. Gauze is used as
  a secondary dressing, e.g.., Santyl and
  polysporin.
• Epithelialization regeneration of epidermis
  across a wounds surface.
• Erythema Blanchable (Reactive Hyperemia)
  reddened area of skin that turns white or pale
  when pressure is applied with a fingertip and
  then demonstrates immediate
  capillary refill. Blanchable erythema over a
  pressure site is usually due to a
  normal reactive hyperemic response.
• Erythema Non-blanchable redness that persists
  when fingertip pressure is applied.
  Non-blanchable erythema over a pressure site is a
  sign of a Stage I pressure ulcer.
• Excoriation loss of epidermis linear or
  hollowed-out crusted area dermis is exposed
  Examples  Abrasion scratch. Not the same as
  denuded of skin.
• Exudate any fluid that has been extruded from a
  tissue or its capillaries, more specifically
  because of injury or inflammation. It is
  characteristically high in protein and white
  blood cells but varies according to individual
  health and healing stages.
• G
• Gangrene Gangrene is ischemic tissue that
  initially appears pale, then blue gray, followed
  by purple, and finally black. Pain occurs at
  the line of demarcation between dead and
  viable tissue. Consists of 3 types Dry, Wet,
  and Gas
• Dry gangrene is tissue with decreased perfusion
  and cellular respiration. Tissue becomes dark
  and loses fluid. Area becomes shriveled /
  mummified. Not considered harmful and is not
  painful. Area requires protection, kept dry,
  avoid maceration. Alcohol pads may be used
  between gangrenous toes to dry tissue out.
• Wet gangrene is dead moist tissue that is a
  medium for bacterial growth. Area requires
  protection, kept dry, do not use a wet to dry
  dressing. Monitor for erythema and signs of
  infection in adjacent tissue.
• Gas gangrene is tissue infected with an anaerobic
  organism e.g., clostridium. Systemic antibiotics
  are required and tissue must be removed by
  physician in the OR. Keep moist tissue moist and
  dry tissue dry. Monitor adjacent tissue for
  signs of infection progressing
• Granulation Tissue pink/red, moist tissue that
  contains new blood vessels, collagen,
  fibroblasts, and inflammatory cells, which fills
  an open, previously deep wound when it starts to
  heal.
• H
• Hospital acquired condition (HAC) condition
  that occurs during current hospitalization.
  Formerly known as nosocomial. Ulcers without
  assessment documentation in the patient medical
  record within 24 hours of admission are
  classified as hospital acquired even though they
  were present on admission (POA). Acceptable
  documentation of ulcer assessment for hospital
  acquired conditions / pressure ulcers includes a
  detailed description within any assessment record
  e.g., EMR Adult Ongoing Assessment, Progress
  Note, HP or consultative form.

12
Definitions

• I
• Incontinence-related dermatitis an inflammation
  of the skin in the genital, buttock, or upper leg
  areas that is often associated with changes in
  the skin barrier. Presents as redness, a rash,
  or vesiculation, with symptoms such as pain or
  itching. Associated with fecal or urinary
  incontinence.
• Infection overgrowth of microorganisms causing
  clinical signs/ symptoms of infection
• warmth, edema, redness, and pain.
• Induration an abnormal hardening of the tissue
  surrounding wound margins, detected by
  palpation. It occurs following reactive
  hyperemia or chronic venous congestion.
• J
• K
• L
• M
• Maceration excessive tissue softening by wetting
  or soaking (waterlogged).
• N
• Negative pressure wound therapy (NPWT) provides
  an occlusive controlled sub-atmospheric pressure
  (negative pressure) suction dressing that
  promotes moist wound healing. Controlled
  sub-atmospheric pressure improves tissue
  perfusion, stimulates granulation tissue, reduces
  edema and excessive wound fluid, and reduces
  overall wound size. Some indications for use
  include pressure ulcers, venous ulcers, diabetic
  foot ulcers, dehisced surgical incisions, partial
  thickness burns, grafts, split thickness skin
  grafts, traumatic wounds, fasciotomy,
  myocutaneous flaps, and temporary closure for
  abdominal compartment syndrome (V.A.C. ACS).
• No Touch Technique Dressing change technique
  where only the outer layer of dressing is touched
  with clean gloves. The dressing surface against
  the wound bed is never touched.
• O

13
Definitions

• P
• Pressure Ulcer Staging One of the most commonly
  used systems to classify pressure ulcers. This
  staging system was developed by the National
  Pressure Ulcer Advisory Panel (NPUAP) and is
  recommended by the AHCPR Guidelines for pressure
  ulcers.
• Stage I Intact skin with non-blanchable 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. Stage I may be difficult to detect in
  individuals with dark skin tones. May indicate
  "at risk" persons (a heralding sign of risk).
  Treatment Do not cover, assess frequently for
  progression.
• 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. Treatment Hydrogel / hydrogel
  impregnated gauze, or foam / Mepilex dependent on
  location.
• 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 stage III 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.
  Treatment Hydrogel / hydrogel impregnated gauze
  or continuously moist dressings.
• 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
  (e.g., fascia, tendon or joint capsule) making
  osteomyelitis possible. Exposed bone/tendon is
  visible or directly palpable. Treatment Hydrogel
  / hydrogel impregnated gauze, continuously moist
  dressings.
• 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 removed. Treatment contact APN / CWOCN for
  enzymatic agent for areas outside of the heels.
• 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. Bruising indicates suspected deep tissue
  injury. These lesions may herald the subsequent
  development of a Stage 3 or Stage 4 Pressure
  Ulcer even with optimal management. Treatment
  protect, reposition off area at all times,
  contact APN CWOCN, assess frequently for
  deterioration.
• Although useful during initial assessment, the
  staging classification system cannot be used to
• monitor progress over time. Pressure ulcer
  staging is not reversible. Ulcers do not heal in
  
• reverse order from a higher number to a lower
  number and are not be described s such e.g.,
• the ulcer was a Stage II but now looks like a
  Stage I). Wounds with slough or eschar cannot
• be staged. The full extent or wound depth is
  hidden by slough or eschar.

14
Definitions

• P
• Present on Admission (POA) Any alteration in
  tissue integrity that is identified on admission
  is defined as community-acquired and documented
  in the Adult Admission History as present on
  admission (POA).
• Acceptable documentation of ulcer assessment for
  community acquired conditions / pressure ulcers
  includes a detailed description within any
  assessment record e.g., EMR Adult Admission
  History, Progress Note, HP or consultative form.
  
• Protective barrier film Clear liquid that seals
  and protects the skin from mechanical injury
  e.g., AllKare wipes (contains alcohol), Medical
  Adhesive Spray (alcohol free). Some contain
  alcohol and require vigorous fanning after
  application to avoid burning on contact.
• Pustule Elevated superficial filled with
  purulent fluid.
• Purulent forming or containing pus.
• Q
• R
• Rash term applied to any eruption of the skin.
  Usually shade of red.
• Shear friction plus pressure causing muscle to
  slide across bone and obstructing blood flow
  e.g., sitting with head of the bed (HOB) at gt 30?
  angle.
• Skin Sealant clear liquid that seals and
  protects the skin.
• Tissue Biopsy use of a sharp instrument to
  obtain a sample of skin, muscle, or bone.

15
Bibliography

• Ayello, E.A. Braden, B.J. (2001). Why is
  pressure ulcer risk assessment so important?
  Nursing 2001 31(11) 75-79.
• Ayello, E.A Lyder, C. (2007) Protecting
  patients from harm preventing pressure ulcers.
  Nursing 2007 Lippincott, Williams Wilkins New
  York. 36-40
• Baharestani,M. (2007). An Ovedrview of neonatal
  and pediatric wound care knowledge and
  considerations. OstomyWoundManagement 53(6)
  34-55.
• Baranoski, S Ayello,E. (2003) Wound Care
  Essentials Practice Principles Lippincott,
  Williams WilkinsNew York
• Bates-Jensen BM, Ovington LG. (2007). Management
  of exudate and infection. In Sussman C,
  Bates-Jensen BM,(Eds.), Wound Care A
  Collaborative Practice Manual for Health
  Professionals. 3rd ed. Baltimore, MD Lippincott
  Williams Wilkins.
•  
• Bergstrom N, Bennett MA, Carlson CE, et al.
  (1994) Treatment of Pressure Ulcers. Clinical
  Practice Guideline, No. 15. Rockville MD U.S.
  Department of Health and Human Services. Public
  Health Service, Agency for Health Care Policy
  and Research. AHCPR Pub. No. 95-0652.
• Bergstrom N, Braden B, Kemp M, Champagne M , Ruby
  E (1998). Predicting pressure ulcer risk a
  multisite study of the predictive validity of the
  Braden Scale. Nursing Research 47 (5) 261-9.
• Bergstrom N, Braden B, Laguzza A, Holman V (1987)
  The Braden Scale for Predicting Pressure Sore
  Risk. Nursing Research, 36, 205-210.

16

Bibliography

• Kinetic Concepts Inc. (2007). V.A.C. therapy
  clinical guidelines A reference for
  clinicians.San Antonio,Texas.
• Kinetic Concepts Inc.(2006) Info V.A.C. User
  manual. San Antonio, Texas
• Krasner, DL Rodeheaver, GT Sibbald, RG. (eds).
  (2001). Chronic wound care a clinical source
  book for healthcare professionals (3rd ed.).
  Wayne, PA HMP Communications.
• Maklebust, J. Sieggreen, M. (2001). Pressure
  ulcers guidelines for prevention and management,
  (3rd ed.). Springhouse PA Springhouse
  Corporation.
• Maklebust, J. (2005). Pressure ulcers The great
  insult. In M. Lorusso (Ed.), Nursing Clinics of
  North America,40(2) (365-89).Pennsylvania W.B.
  Saunders.
• Maklebust, J.,Sieggreen, M., Sidor, D., Gerlach,
  M., Bauer, C., Anderson, C. (2005)
  Computer-based testing of the Braden Scale for
  Predicting Pressure Sore Risk. Ostomy Wound
  Management, 51(4) 40-42,44,46.
• Panel for the Prediction and Prevention of
  Pressure Ulcers in Adults (1992). Pressure
  Ulcers in Adults Prediction and Prevention.
  Clinical Practice Guideline, No. 3. AHCPR
  Publication No. 92-0047. Rockville, MD Agency
  for Health Care Policy and Research, Public
  Health Service, US Department of Health and Human
  Services.
• Sussman, C. Bates-Jensen, B. (2007). Wound
  care a collaborative practice manual for
  healthcare professionals. 3rd ed. Baltimore,MD
  Lippincott Williams Wilkins.
• Van Rijswijk, L., Braden, B.J. (1999). Pressure
  ulcer patient and wound asssessment an AHCPR
  clinical practice guideline update. Ostomy Wound
  Management, 45 (1A Suppl) 56s-67s.