Wound Ca re AD VISOR Practical issues in wound , skin , and ostomy management Official journal of ®

Maggot therapy

Treating wounds in intimate areas Wound care in the home Staff education

July/August 2014 • Volume 3 • Number 4 ww w.WoundCareAdvisor.com

A Publication Advancing Safe Skin throughout the Care Continuum.

Through our unique combination of people, process and technology, Hill-Rom can help you achieve positive safe skin outcomes for you and your patients in hospitals, long-term care facilities and in the home.

For additional information, please contact us at 800-445-3730 or visit www.hill-rom.com.

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Zinc Number US-PA-0414-0134 staff Group Publisher Gregory P. Osborne Publisher Tyra London Editor-in-Chief Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS editor-in-chief Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS Managing Editor Co-Founder, Wound Care Education Institute Cynthia Saver, RN, MS Lake Geneva, WI Editor Kathy E. Goldberg editorial advisory Board Copy Editor Nenette L. Brown, RN, PHN, MSN/FNP, WCC Karen C. Comerford Wound Care Program Coordinator Sheriff’s Medical Services Division Art Director San Diego, CA David Beverage Debra Clair, PhD, APN, RN, WOCN, WCC, DWC Production Manager Wound Care Provider Rachel Bargeron Alliance Community Hospital Alliance, OH Account Managers Susan Schmidt Kulbir Dhillon, NP, WCC Wound Care Specialist Renee Artuso Skilled Wound Care Sacramento, CA PuBlished By Fred Berg HealthCom Media Vice President, Marketing/Business Development 259 Veterans Lane, Doylestown, PA 18901 National Alliance of Wound Care and Ostomy Telephone: 215/489 -7000 Glendale, WI Facsimile: 215/230-6931 Catherine Jackson, RN, MSN, WCC Clinical Nurse Manager Chief Executive Officer Inpatient and Outpatient Wound Care Gregory P. Osborne MacNeal Hospital Executive Vice President, Sales Berwyn, IL Bill Mulderry Jeffrey Jensen, DPM, FACFAS Dean and Professor of Podiatric Medicine & Surgery Web Producer Barry University School of Podiatric Medicine Winston Powell Miami Shores, FL Business Manager Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, WCC Connie Dougherty Director of Clinical Education RecoverCare, LLC Wound Care Advisor (ISSN 2168-4421) is published by Louisville, KY HealthCom Media, 259 Veterans Lane, Doylestown, PA Jeff Kingery, RN 18901. Printed in the USA. Copyright © 2014 by Health - Vice President of Professional Development Com Media. All rights reserved. No part of this publica - RestorixHealth tion may be reproduced, stored, or transmitted in any Tarrytown NY form or by any means, electronic or mechanical, includ - ing photocopy, recording, or any information storage Jeri Lundgren, RN, BSN, PHN, CWS, CWCN and retrieval system, without permission in writing from Vice President of Clinical Consulting the copyright holder. Send communication to Health - Joerns Com Media, 259 Veterans Lane, Doyles town, PA 18901. Charlotte, NC The opinions expressed in the editorial and advertis - Courtney Lyder, ND, GNP, FAAN ing material in this issue are those of the authors Dean and Professor and advertisers and do not necessarily reflect the UCLA School of Nursing opinions or recommendations of the National Al - Los Angeles ® liance of Wound Care and Ostomy ; the Editorial Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS Advisory Board members; or the Publisher, Editors, Co-Founder, Wound Care Education Institute and the staff of Wound Care Advisor . Plainfield, IL Steve Norton, CDT, CLT-LANA Editorial Mission: Wound Care Advisor provides Co-founder, Lymphedema & Wound Care Education, LLC multidisciplinary wound care professionals with President, Lymphedema Products, LLC practical, evidence-based information on the Matawan, NJ clinical management of wounds. As the official journal of the National Alliance of Wound Care Bill Richlen, PT, WCC, CWS, DWC and Ostomy ®, we are dedicated to delivering Owner succinct insights and information that our read - Infinitus, LLC ers can immediately apply in practice and use Chippewa Falls, WI to advance their professional growth. Lu Ann Reed, RN, MSN, CRRN, RNC, LNHA, WCC Adjunct Clinical Instructor Wound Care Advisor is written by skin and wound University of Cincinnati care experts and presented in a reader-friendly elec - Cincinnati, OH tronic format. Clinical content is peer reviewed. Stanley A. Rynkiewicz III, RN, MSN, WCC, DWC, CCS The publication attempts to select authors who are Administrator knowledgeable in their fields; however, it does not Deer Meadows Home Health and Support Services, LLC warrant the expertise of any author, nor is it responsi - BHP Services ble for any statements made by any author. Certain Philadelphia, PA statements about the use, dosage, efficacy, and charac - Cheryl Robillard, PT, WCC, CLT teristic of some drugs mentioned here reflect the opin - Clinical Specialist ions or investigational experience of the author. Any Aegis Therapies procedures, medications, or other courses of diagnosis Milwaukee WI or treatment discussed or suggested by authors should not be used by clinicians without evaluations of their Donald A. Wollheim, MD, WCC, DWC, FAPWCA patients’ conditions and possible contraindications or Owner and Clinician, IMPLEXUS Wound Care Service, LLC Watertown, WI danger in use, review of any applicable manufacturer’s prescribing information, and comparison with the rec - Instructor, Wound Care Education Institute ommendations of other authorities. Plainfield, IL

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 1 CLICK HERE CLICK HERE TO REGISTER TO DOWNLOAD ONLINE BROCHURE National Conference

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WWW.WOUNDSEMINAR.COM July/August 2014 • Volume 3 • Number 4 CONTENTS ww w.WoundCareAdvisor.com

FEATURES 12 Using maggots in wound care: Part 1 By Ronald A. Sherman, MD; Sharon Mendez, RN, CWS; and Catherine McMillan, BA Learn about this simple, effective, low-risk, low-cost wound debridement technique.

32 You want to touch me where ? By Debra Clair, PhD, APRN, WOCN, WCC, DWC page 12 Using intimate touch in wound care

DEPARTMENTS 4 From the Editor Device–related pressure ulcers: Avoidable or not? 5 Clinical Notes

8 Best Practices Creating an effective care plan Education vital for successful wound management in the home page 28

20 Apple Bites What you need to know about transparent film dressings

22 Business Consult Creating effective education programs on a shoestring budget Confronting conflict with higher-ups How to love and care for yourself unconditionally

36 Clinician Resources 38 NAWCO News page 32

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 3 From the EDITOR

Device–related pressure ulcers: Avoidable or not?

medical device–related pressure ul - • Remove or move the device daily to as - cer (MDRPU) is defined as a local - sess skin. A ized injury to the skin or underlying • Avoid placing the device over the site of tissue resulting from sustained pressure a previous or existing pressure ulcer. caused by a medical device, such as a • Educate staff on the correct use of de - brace; splint; cast; respiratory mask or tub - vices and prevention of skin breakdown. ing; tracheostomy tube, collar, or strap; • Be aware of edema under the device feeding tube; or a negative-pressure wound and the potential for skin breakdown. therapy device. The golden rule of pressure • Confirm that the device isn’t placed di - ulcer treatment is to identify the cause of rectly under a patient who’s bedridden pressure and remove it. Unfortunately, many or immobile. of the medical devices are needed to sustain the patient’s life, so they can’t be removed. Of course, even when caregivers focus But does that mean MDRPUs aren’t on prevention, mistakes can happen. Un - avoidable? Yes—and no. Some aren’t fortunately, mistakes are a part of life. But avoidable, but not as many as you might that doesn’t mean we can’t learn from our think. Many result not from the device it - mistakes to better protect our patients. self but from poor device positioning or se - When a mistake occurs, determine what curement. Some result from simple failure happened, correct it, and take steps to pre - to check under the tubing or device. These vent it from happening again. That’s our causes are avoidable. Preventive practices job as clinicians and as patient advocates. include frequently evaluating device posi - tioning and securement. Also, if possible, loosen the device at least once per shift to check for skin problems. Donna Sardina, RN, MHA, WCC, CWCMS, The National Pressure Ulcer Advisory Pan - DWC, OMS el has created four “Best Practices for Pre - Editor-in-Chief vention of Medical Device–Related Pressure Wound Care Advisor Ulcers” posters, which can be downloaded Cofounder, Wound Care Education Institute for free. Besides a general poster, you’ll find Plainfield, Illinois posters for the specialties of critical care, pe - diatrics, and long-term care. Each poster fea - Selected references tures photos of MDRPU-related injuries and Black JM, Cuddigan JE, Walko MA, Didier LA, Lan - prevention strategies such as: der MJ, Kelpe MR. Medical device related pressure ulcers in hospitalized patients. Int Wound J . • Choose the correctly sized medical de - 2010;7(5):358–65. vice for the individual. Fletcher J. Device related pressure ulcers made easy. • Cushion and protect the skin with dress - Wounds UK . 2012;8(2). www.woundsinternational ings in high-risk areas. .com/pdf/content_10472.pdf. Accessed June 23, 2014.

4 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor Clinical NOTES

cin), a new antibacterial drug used to treat adults with skin infections. Dalvance is indicated for the treatment of acute bacterial skin and skin-structure infections caused by certain bacteria, such as Staphylococcus aureus (including methicillin-susceptible and methicillin- resistant strains) and Streptococcus pyogenes . The drug is administered I.V., and the Aspirin inhibits wound healing most common adverse effects are nausea, headache, and diarrhea. A study in the Journal of Experimental Med - Dalvance is the first drug designated as icine describes how aspirin inhibits wound a Qualified Infectious Disease Product healing and paves the way for the develop - (QIDP) to receive FDA approval. Under ment of new drugs to promote healing. the Generating Antibiotic Incentives Now The authors of “ 12-hydroxyheptadeca - title of the FDA Safety and Innovation Act, trienoic (12-HHT) acid promotes epidermal wound Dalvance was granted QIDP designation healing by accelerating keratinocyte migration via because it’s an antibacterial or antifungal the BLT2 receptor ” report that aspirin re - human drug intended to treat serious or duced 12-HHT production, which resulted life-threatening infections. in delayed wound closure in mice. How - ever, a synthetic leukotriene B4 receptor 2 (BLT2) agonist increased the speed of wound closure in cultured cells and in di - abetic mice. The study suggests that BLT2 agonists may accelerate wound healing, particularly for intractable wounds such as diabetic ulcers. NPWT has positive effects for high-risk surgical incisions

“Value of incisional negative pressure wound therapy (NPWT) in orthopaedic surgery,” a review article in International Wound Journal , reports that application of NPWT on high-risk closed surgical incisions after total ankle replacement or calcaneal frac - FDA approves new drug for skin ture repair prevents hematoma and infections wound dehiscence. NPWT also decreased swelling, pain, and healing time. The U.S. Food and Drug Administration Other effects of NPWT included de - (FDA) has approved Dalvance (dalbavan - creased infection and wound-healing

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 5 problems after acetabular fracture repair, and reduced incidence of postoperative seroma and improved wound healing after total hip arthroplasty. The authors conclude that incisional NPWT “can help to reduce risk of delayed wound healing and infection after severe trauma and orthopaedic interventions.” 4,250 patients who underwent ostomy cre - ation surgery. The unadjusted morbidity and mortality rates were 43.9% and 10.7%. Risk-adjusted morbidity rates varied significantly among the 34 hospitals participating in the Michi - gan Surgical Quality Collaborative, ranging from 31.2% to 60.8%.

Treatment with insulin and metformin increases mortality risk

Patients with diabetes who take insulin and metformin, versus insulin and a sul - fonylurea, are at increased risk for non- fatal cardiovascular outcomes, such as Proactive program may reduce stroke, and mortality, according to a study lymphedema risk in JAMA . The authors of “ Association between inten - According to a study in the Annals of Sur - sification of metformin treatment with insulin vs gical Oncology , a proactive education and sulfonylureas and cardiovascular events and all- behavioral program focused on self-care cause mortality among patients with diabetes ” strategies may reduce the risk of lymphe - studied 178,341 patients. Among these pa - dema in breast cancer survivors. The tients, 2,948 added insulin and 39,990 strategies promote lymph flow and opti - added a sulfonylurea; the mean follow-up mize body mass index (BMI). after the change in therapy was 14 months. “Proactive approach to lymphedema risk reduc - tion: A prospective study ” included 140 pa - Complication rates after ostomy tients who participated in The Optimal surgery are high Lymph Flow program; 134 completed the study. Most patients (97%) had improved “Complication rates of ostomy surgery are high their preoperative limb volume and BMI and vary significantly between hospitals ,” in at the end of the study, which was 12 Diseases of the Colon & Rectum , included months after cancer surgery. Four patients

6 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor had measureable lymphedema; in two of ducted a review of articles obtained from them, limb volume returned to the preop - multiple databases. erative level without compression therapy but with the maintenance of the exercises Stoma reversal techniques to promote daily lymph flow. studied

“Circular closure is associated with the lowest rate of surgical site infection following stoma re - versal: A systematic review and multiple treatment meta-analysis ,” in Colorectal Disease , includ - SCHD effective for pressure ulcers ed 15 studies for a total of 2,921 cases of stoma reversal. However, the study’s au - Silver-containing hydrofibre dressing thors noted that, overall, the quality of the (SCHD; Aquacel ® Ag) is a safe, effective, studies was poor, so that it wasn’t possible and easy-to-apply treatment for pressure to reach any definite conclusions. ulcers and may eliminate the need for antibiotic therapy, according to a study in Wound Medicine . The authors of “ Effective management of pressure ulcers using Hydrofibre technology with silver ions ” studied 20 patients with pres - sure ulcers who were treated with SCHD for 1 week. Wound bioburden decreased Pressure ulcers reduce QOL in by 80% over the treatment period, with patients with SCI 60% of wounds showing no bacterial bur - den at the end of the study. A study in the Journal of Wound Care re - ports that pressure ulcers have a negative effect on the health-related quality of life (QOL) and self-esteem of patients with traumatic spinal cord injury (SCI). “Quality of life and self-esteem in patients with paraplegia and pressure ulcers: A controlled, cross-sectional study ” included 120 patients evenly distributed between those with Study notes strategies for wound pressure ulcers and those without. The re - pruritus searchers used the generic Medical Out - comes Study 36-Item Short Form Health Methods such as habit reversal, sugges - Survey (SF-36) questionnaire and the tions, relaxation, massage, and itch-coping Rosenberg Self-Esteem/UNIFESP-EPM programs have the potential to reduce Scale to assess patients. Patients with SCI itching, according to “ Psychological manage - who had pressure ulcers had significantly ment of wound pruritus ,” a study in the Jour - lower scores on both scales compared to nal of Wound Care . The researchers con - those with no pressure ulcers. n

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 7 Best PRACTICES

Creating an the interventions to the identified risk factors is key, but given the multitude of effective care possible interventions, this can seem overwhelming. One solution is to devel - plan op a suggestion sheet of potential inter - ventions for common risk factors. For ex - By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN ample, for the risk factor of immobility, potential interventions might include: he development of a care plan related • pressure redistribution surface for the Tto skin integrity can be challenging for bed and wheelchair any clinician. It takes a strong understand - • heel floats/heel-lift devices ing of skin integrity risk factors and knowl - • turning and repositioning edge of how to modify, stabilize, and program eliminate those risk factors. This article • grab bars on the bed to provides tips for the care-planning process. promote mobility • referral to physical Establish goals therapy . A skin integrity care plan starts with a comprehensive risk assessment and skin inspection. (For more information, refer to What is a comprehensive risk assessment? in the May/June 2014 issue of Wound Care Advisor .) Once the risk assessment is complete, all identified risk factors or skin concerns should be brought forward to the plan of care. Now it’s time to determine the goal. Ensure the goal is measurable; for exam - ple, “The skin will remain intact during the patient’s stay” or “The pressure ulcer on the coccyx will show signs of healing, such as a decrease in dimension size and filling in of the wound base in 2 weeks.” You also want to ensure the goal is re - alistic. For example, you don’t want to state that an arterial wound with no cir - culation will heal in 3 months. Instead, your goal may be that the arterial wound will remain stable.

Select interventions After you establish the goal, you’re ready to develop the interventions. Correlating

8 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor It’s important to understand the root Make care planning cause of risk factors to help determine less intimidating the appropriate intervention. For exam - Overall, the care-planning ple, if the patient doesn’t want to turn process can become less and reposition because of pain (a risk intimidating if you use a factor that’s known to potentially reduce comprehensive risk tool mobility), you would first need to pro - with a suggestion sheet of goals and in - vide pain relief. terventions to consider. Also, it’s impera - Some risk factors, such as elimination tive to ensure all interventions listed on problems secondary to urinary inconti - the care plan that need to be implement - nence or nutrition deficit because of loss ed by the nursing assistant are clearly of taste, will require their own interven - communicated and documented on the tions. In this case, list the risk factor under nursing assistant assignment sheet. n skin integrity; then, under interventions, state “See elimination problem” or “See Jeri Lundgren is vice president of clinical con - nutritional problem.” This will eliminate sulting at Joerns in Charlotte, North Carolina. the risk of having conflicting interventions She has been specializing in wound prevention listed under two care-plan problems. and management since 1990.

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Wound Care Advisor • Ju ly/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com   9 Begin by asking caregivers how they learn best. For example, some want to see the wound care done and then review writ - ten information, while others prefer the re - verse. Set teaching times so that all those who will be delivering care can be present. Focus on the triad of wound care: nutri - tion, technique, and infection control. Teaching the basics of these three items will improve wound care outcomes and patient care.

1—Nutrition Be sure to include the patient in discus - sions related to the first corner of the tri - angle: nutrition. Patients with wounds, es - Education vital pecially wounds with heavy drainage, need appropriate nutrition such as addi - for successful tional protein to facilitate healing. Strate - wound gies to increase protein intake include: • Give the patient supplements such as management Boost ®, Ensure ®, or Carnation ® Instant in the home Breakfast. • Add a spoonful of peanut butter to a By Judy Bearden, MSN/ED, RN chocolate-flavored Boost to increase protein and enhance flavor. hanges in healthcare policy and reim - • Add frozen fruit and a small amount of Cbursement are pushing treatment yogurt to a very cold drink supplement from the hospital to the community. This to make it similar to a smoothie and shift is likely to result in a higher number enhance taste. of complex wounds being treated in the • Add protein powder to foods. home, which can create stress for patients • Encourage high-quality proteins, such as and families. Education plays a key role in peanut butter, nuts, seeds, or cheese, reducing this stress. This article focuses on and avoid junk food that fills but doesn’t education for family members or friends provide much nutritional value who are caregivers for the patient. Patients with dietary restrictions be - The basics cause of conditions such as diabetes and Keep in mind that caregivers don’t need renal conditions and patients who have to have the same depth of knowledge as difficulty swallowing require a special diet clinicians. It’s best to stick to the basics, plan. Patients who have wounds should evaluate care on a regular basis, and also try to eat six small meals instead of make adjustments as needed. three large meals.

10 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor 2—Technique A small amount of yellow tissue may be The next corner of the triangle is teaching slough if it wipes away easily; clinicians wound care. Simple or complex wounds and caregivers should note the amount both require the same steps to complete a and watch for increases. Black inside a dressing change. Provide these steps to wound is dead tissue and should be re - the caregiver to facilitate dressing moved only by a professional; simply note changes. the size of the black area. • Step one: Gather the supplies needed, including a garbage bag for soiled Drainage dressings. Place the supplies away from Any increase in drainage indicates prob - the bed, but within reach. lems. Ask caregivers to note how many lay - • Step two: Wash your hands, put on ers of bandages the drainage soaks through gloves, and position the patient so you and how many times a day the dressing can best see the wound. needs to be changed. Drainage color • Step three: Remove old dressings and should also be noted because a change in put them in your garbage bag; wipe any drainage away from the wound. • Step four: Change gloves, using alcohol to clean your hands between the glove Focus on the triad changes, and open the new dressing supplies. Clean the wound as ordered by of wound care: the physician or nurse practitioner. Meas - ure the wounds, reapply the dressing, nutrition, technique, and cover with a 4" x 4" or abdominal pad and tape in place. Then help the and infection control . patient into a more comfortable position.

3—Infection control color of the drainage is significant. For in - The last step in the triangle is to teach care - stance, drainage that changes from clear to givers how to recognize a “good” (healthy) yellow or green indicates infection. wound and one that is going “bad” (be - coming infected). Remember that the sim - Odor pler the directions, the better. Tell caregivers Most wounds have some type of an odor; to watch for color, drainage, and odor. caregivers should note how far away they are when they smell the odor and under Color what conditions; for example, an arm’s The inside of the wound should be beefy length away, after positioning the patient, red, but redness outside the wound bed or when the old dressing is removed. is a sign of infection. Frequently in home Wound smells can be compared to a rusty care, clinicians use a permanent marker smell like blood; a smell almost like a to mark the line of redness outside of the dead animal, which indicates dying flesh; wound to see if it’s getting larger; you or a musty smell, which indicates the might want to suggest this to the caregiver. (continued on page 19)

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 11 Using maggots in wound care: Part 1 Learn about this simple, effective, low-risk, low-cost wound debridement technique. By Ronald A. Sherman, MD; Sharon Mendez, RN, CWS; and Catherine McMillan, BA

aggot therapy is the con - trolled, therapeutic applica - tion of maggots to a wound. MSimple to use, it provides rapid, precise, safe, and powerful debride - ment. Many wound care professionals don’t provide maggot therapy (also called wound myiasis) because they lack train - ing. But having maggot therapy technolo - gy available for patients adds to your ca - pabilities as a wound care provider. Knowledge of maggot biology and life history helps wound care practitioners op - timize therapy and anticipate or prevent problems. Educating patients and col - leagues about maggot therapy can reduce stress and simplify your life as a wound care professional, whether you’re a novice or an experienced maggot therapist. In this two-part series (the second part will appear in the November/December issue), the authors share their combined experience of more than 2,000 treatments to help you start and manage a maggot therapy service as part of a comprehen - sive wound care program. stealthily without disturbing the host. (See Maggots as healers From fly to maggot .) The wound-healing benefits of maggots Myiasis refers to fly larvae living on a (fly larvae) have been documented for live vertebrate host. Larvae deposition in centuries. Wound care therapists have preexisting wounds isn’t always invasive. been placing maggots on wounds deliber - In fact, it may bring improvements in ately for at least 100 years—but flies have overall wound condition. been depositing their larvae on wounds for at least 500 million years. That’s plenty History and current status of time for maggots to perfect their ability One of the first clinicians to study and to dissolve necrotic tissue rapidly and optimize maggot therapy was William

12 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor Baer, MD, chief of orthopedic surgery at Johns Hopkins Hospital in Baltimore, From fly to maggot Maryland. After the 1931 publication of Baer’s work, more than 1,000 surgeons Understanding the natural history of flies and maggots allows clinicians to use and control ther - incorporated maggot debridement therapy apeutic maggots successfully. The fly’s life cycle (MDT) into their practice; more than 90% has four stages: egg, larva, pupa, and adult. Me - reported being very satisfied with their dicinal maggots are chosen from among the few experience. But by the mid-1940s, maggot fly species that feed exclusively on dead tissue therapy had nearly disappeared, at least (preferentially animal tissue). in part due to the rise of antibiotics and In the wild, adult flies are attracted to dead ani - mals, with female flies depositing their eggs on the the corresponding decrease in soft-tissue carcass. Sometimes, flies mistake the necrotic and bone infections. wound of a live animal for a suitable food source By the late 1980s, the prevalence of an - and lay their eggs there (called wound myiasis). At tibiotic-resistant bacteria combined with room temperature, the eggs hatch in less than a day the ability to keep patients with neurolog - (sometimes within a few hours). The newly emerged ic and cardiovascular impairments alive wormlike larvae, called maggots at this point, se - crete digestive enzymes into the environment and brought a resurgence in problematic soft- imbibe liquefied necrotic tissue. Lacking teeth, they tissue wounds. The time was right to in - don’t bite. They feed for 2 to 5 days (depending on vite medicinal maggots back into hospitals the species, temperature, and the abundance of and clinics. food), after which they leave the host and wander Recent clinical trials irrefutably demon - off to find a concealed, protected spot to pupate. strate the efficacy and safety of MDT. In Within the motionless puparium (the hardened lar - val skin that encloses the pupa), they transform into fact, the pressing question for today’s full-grown adult flies in fewer than 3 weeks (again, wound care professionals isn’t “Does mag - depending on species and temperature). got therapy work?” but “How can I and This illustration shows the typical blowfly life my patients take advantage of this simple, cycle stages—egg, larva, pupa, and adult. effective, low-risk, low-cost technology?” (See Maggot mechanisms of action .) Whether using manufactured maggot- specific dressings or creating custom dress - ings at the bedside, clinicians have applied medicinal maggots to just about every ex - ternal bodily surface imaginable except the eyes—from tiny wounds of nonhealing toe amputations to huge traumatic and burn injuries on the torso, extremities, and face; from fungating breast wounds to necrotic glans penis and resected Fournier’s gan - grene of the perineal, genital, or perianal regions. Maggot dressings have even been applied to joints with infected hardware, the pleural cavity (via a persistently drain - ing thoracotomy), and the necrotic peri - toneum of an open abdomen. Almost any wound with nonviable soft tissue that’s the harder it may be to confine the mag - open to the outside is a potential candi - gots. One caveat: Soft white, yellow, or tan date for maggot therapy, although the larg - slough is easy for newborn larvae to han - er and more complicated the topography, dle, whereas black dry eschar takes longer

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 13 for the maggots to dissolve. Therefore, we Maggot mechanisms of action always remove the eschar (through sharp debridement) or soften it before applying Medicinal maggots are capable of three actions on maggots. A simple autolytic dressing or, a wound: better yet, a wound gel under a hydrocol - • debriding (dissolving necrotic tissue and debris) • disinfecting (killing microbes in the area) loid or thin film can be used to soften the • stimulating the healing process. eschar for a day or two while waiting for the maggots to arrive. Like the phases of the healing process, these ac - tions commonly overlap and contribute to each other. Maggots’ physical movements on the Therapeutic controls wound bed and the biochemical properties of their Clinicians control or optimize myiasis so excretions and secretions produce these actions. it’s most advantageous to the patient. Ways to control maggot therapy include: • selecting species (usually Phaenicia [Lu - cilia] sericata ) and strains proven to be safe and effective • culturing contamination-free flies in lab - oratories • disinfecting the maggots to remove microbes • using quality-control assays to ensure the A 61-year-old diabetic man was hospitalized for I.V. maggots are truly germ-free and larvae antibiotic therapy and twice-weekly surgical debride - meet safety and regulatory standards. ment of a wound on his right big toe. After 3 weeks of hospitalization without improvement (left photo), maggot therapy was initiated. Three weeks of mag - Therapeutic controls continue at the got therapy led to a decreased callus, decreased bedside, as special dressings are used to depth, and a smaller, clean, healthy wound bed filled maintain maggots on the wound during with granulation tissue (right photo). treatment. The three photos at right show a stage 3 Indications and contraindications sacral pressure ulcer The Food and Drug Administration (FDA) with extensive under - has approved medicinal maggots for de - mining before maggot therapy (top photo), 4 bridement of nonhealing necrotic skin and weeks later (middle soft-tissue wounds. Commonly, such photo), and when near - wounds include pressure ulcers, venous ly healed (bottom pho - stasis ulcers, diabetic foot ulcers, and non - to). After maggot thera - healing traumatic or postsurgical wounds. py, the wound was Maggot therapy also has been used suc - smaller and the base was filling in with cessfully in burns, in hospice care, and in healthy granulation tis - debriding necrotic, fungating tumors. sue. Because healing Sometimes, maggot therapy is used in con - slowed and slough de - junction with other modalities, such as sys - veloped again, maggot temic antibiotics, hyperbaric oxygen, and therapy resumed for surgical debridement (for example, in os - maintenance debride - ment until closure. teomyelitis or necrotizing fasciitis).

Photos courtesy of the BioTherapeutics, Education & Research (BTER) Foundation. Understanding maggot dressings Because medicinal maggots feed only on

14 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor necrotic tissue, they leave the wound After evaluating and educating the pa - when satiated or when all the necrotic tis - tient and obtaining consent, we gently sue is gone. To prevent them from wan - wash the wound (using only saline solu - dering away from the wound on their tion or water) and protect the periwound own, special dressings are used to confine skin with a skin barrier or protectant. To them to the wound bed and its tributaries keep maggots within the wound bed, we while letting air reach them (maggots are cover the periwound skin with a hydro - obligate oxygen breathers) and permitting colloid pad or similar material. We cut the efflux of wound exudate (maggots’ diges - pad to surround, not cover, the wound; tive enzymes liquefy the necrotic tissue). it then anchors the rest of the dressing. These dressings basically are maggot Thus, the pad functions as both a fence cages; the primary cage material usually is and a foundation on which to build the a fabric net. rest of the maggot cage. The simplest dressings to apply are pre - For large wounds that a simple pad made maggot cage dressings (for example, won’t cover, cut a hydrocolloid pad into LeFlap™ and LeFlap DuJour™), which strips and apply the strips to peripheral confine the maggots to simple planar skin like a fence. Then place the maggots wounds. Baglike dressings (such as into the wound bed at a dose of 5 to 10 LeSoc™) are useful for covering more complicated, nonplanar surfaces, such as toes, heels, and stumps. In Europe, mag - uring maggot gots often are placed inside bags, which D are sealed and laid over the wound (such debridement , the as Biobag by BioMonde ®). Although this containment dressing is easier to apply larvae dissolve infected, and remove (as long as the bag doesn’t break), studies show it leads to slower de - necrotic tissue. bridement, probably because the bag pre - vents larvae from directly accessing the en - tire wound bed, especially recesses and per cm 2 of wound base. If you need only undermined crevices. a few larvae, use a damp cotton swab to scoop them out. If larvae are available as Making your own maggot dressing maggot-impregnated gauze, simply re - While it’s easier to have a premade mag - move the gauze from the jar and place got dressing of the right size and shape, the desired amount directly on the knowing how to make your own dressing wound. If you need half the amount of at the bedside prepares you to use maggot maggots in the bottle, just use half of the therapy to any wound in any location. At - maggot-impregnated gauze. If you’re not tending a workshop or watching an expe - applying maggots within gauze, apply rienced maggot therapist is a good way to saline-moistened gauze loosely on top of learn how to make your own maggot the wound and maggots to provide scaf - dressing. folding for them to crawl about. Below we describe our methods, which Next, apply a layer of netting to serve are widely used in North America. Above as the top of the cage. You can use the all, never forget your patient’s other foot of a panty hose, tight netting from a needs—such as periwound skin protec - fabric store, or netted contact layer dress - tion, offloading, frequent turning, and ings (such as Wound Veil). Beware, good nutrition. though: Stretchable fabrics may let some

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 15 of the tiny larvae escape when first ap - sorbent material. The material should al - plied, as larvae are less than 1 mm wide low air into the cage dressing below and at that time. Instead, you can use a mag - should be changed several times daily and got-specific dressing made from fixed- whenever strikethrough occurs. If no weave polyester (for instance, Creature drainage occurs, the wound (and larvae) Comforts™ Polyester Net Dressing), which may be too dry. In that case, add sterile won’t stretch. Some therapists tape the saline solution, water, or irrigation fluid to fabric directly to the periwound skin or the cage dressing. Some therapists routine - hydrocolloid barrier, but we find that glu - ly spray the dressing lightly with saline so - ing it to the hydrocolloid provides a more lution every 4 to 6 hours for the first 24 secure dressing. hours or top the cage dressing with a Next, apply a latex-free glue, such as moistened gauze pad instead of dry gauze Nu-Hope Adhesive or LeGlue™, directly to so the moisture wicks into the dressing be - the hydrocolloid before placing the net low and hydrates the larvae. atop it, and apply another adhesive layer With experience, optimizing and cus - after the net is placed down, so the adhe - tomizing maggot dressings becomes easier sive layers above and below the net meet and faster. For a bedbound patient whose and form a strong bond through the fabric wound won’t be disturbed, you can simply pores. Topping the adhesive layer with ring the wound with zinc barrier paste and fabric tape or zinc oxide tape or a trans - apply a breathable net on top to contain parent membrane dressing provides extra the maggots. Use ostomy paste to seal a crease in the skin where the hydrocolloid can’t seal. Empowering patients Removing the dressing with knowledge and Maggot dressings generally are removed after 48 hours. By that time, most maggots control over their are satiated and ready to leave the wound. Sometimes the dressing is left on for 72 treatment helps decrease hours, but this increases the risk of a mag - got breakout, because larvae that have fin - pain and anxiety. ished feeding will try to pry the dressing off and escape. In some cases, the dress - security. We extend this frame peripherally ing is removed sooner than 48 hours—for over the skin for dressings at risk of com - example, if the patient reports pain that ing loose due to perspiration, soiling, or analgesics can’t adequately control. nearby flexion points, as well as for highly Regardless of timing, the procedure for mobile patients. Constructing this custom removing a maggot dressing is the same. cage dressing is more time-consuming Be prepared for fast-moving maggots try - than using a premade maggot dressing but ing to leave the wound as soon as you allows you to apply medicinal maggots to open the dressing. To make it easy to col - any wound that needs them, almost any - lect the larvae, place a biohazard bag where on the body. around the wounded limb or tucked under During maggot debridement, the larvae the wounded buttock. Then loosen the dissolve infected, necrotic tissue. Of tape and adhesives, peel back the cage course, this material will (and must) drain dressing with one hand like a banana out of the porous cage. So we top the peel, and simultaneously wipe the mag - cage layer with light gauze or a similar ab - gots with a wet gauze pad in the other

16 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor hand, sandwiching the maggots between old, they become large enough for the pa - your hands. In this way, most maggots tient to feel as they crawl about the won’t be seen and won’t escape. Those wound. Anticipate pain during maggot that manage to escape will drop into the therapy in patients with underlying wound plastic bag. If any maggots are still feeding pain; use analgesics liberally to prevent or or hiding, remove them by irrigation with relieve it. Other ways to reduce pain are water or saline solution or brush them off to administer fewer or smaller larvae (to with a gauze pad or cotton swab. If some increase the time before they can be felt) maggots are still holding on, simply cover and to remove larvae early (because larvae them and the wound bed with a moist grow larger and more active with time and gauze pad. When the gauze pad is re - are most uncomfortable when full-grown moved the next day, the last larvae will be and trying to leave the wound bed). done working and will be buried within Empowering patients with knowledge the gauze pad. and control over their treatment helps de - Always discard maggot dressings in a crease pain and anxiety. We routinely tell plastic bag. Knot the top of the bag and them that when analgesics no longer con - throw it out with wound dressing waste. trol pain to their satisfaction, we’ll remove Double-bagging is best in case the outer bag rips from other items in the waste bin. Applying and removing a maggot dress - ing sounds like a lot of work, but after One of the most you see the results of your first treatment, you’re likely to deem the effort worth - useful educational while. By your fourth application, you should be able to apply a simple maggot experiences is a one- dressing in just 5 or 10 minutes. on-one conversation Managing pain and anxiety with an experienced The most common adverse events of maggot therapy are patient discomfort or a former and patient (or provider) anxiety. Always colleague read package inserts carefully before maggot therapy patient. starting therapy. Take steps to prevent maggots and their secretions from con - tacting the intact periwound skin, which the maggot dressings; all they have to do is susceptible to maceration, dermatitis, is ask. This puts them in control, reduces and cellulitis from prolonged exposure their anxiety, and increases their overall to liquefied necrotic drainage. Also, the pain threshold. Of course, you have to skin is highly sensitive to movement and make good on your promise. We ensure pressure. our patients have 24-hour access to some - Maggots crawling over intact skin may one who can assist immediately with feel like a caterpillar in the hand—tickly, dressing removal. itchy, or even unnerving. Most patients Occasionally, patients and therapists don’t feel pain within the wound bed, al - raise concerns about the foul odor arising though some do complain of pain, espe - as infected necrotic tissue liquefies. This is cially with dressing changes. Such patients normal and generally occurs only at the are likely to feel pain with maggot thera - start of treatment, when most of the decay - py, too. When larvae are about 24 hours ing flesh is removed. Be aware that the

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 17 smell comes from the patient’s fetid When you add maggot therapy to your wound, not the maggots. Once most of the wound care toolbox, you’ll have more op - infected necrotic tissue has been removed, tions for helping your patients. Access the odor and drainage decrease dramatically many resources available to learn about or disappear altogether. maggot therapy and take advantage of every opportunity to practice your dressing Coping with your own anxiety skills. Finally, read this article again and Patients aren’t the only ones who may ex - again, if necessary, to help you advance perience anxiety. Maggot therapy practi - quickly along your path to becoming not tioners may become anxious, too. Anxiety just a wise wound care therapist but also a about maggot therapy usually stems from skilled biotherapist. ignorance, so become educated about Editor’s note: For information on setting maggot therapy. A great deal of education - up a maggot therapy service and providing al material is available. You can read re - patient education, read the September- view articles on maggot therapy to learn October issue of Wound Care Advisor . n about the basic principles and practices of maggot therapy. Visit the website of the Selected references Armstrong DG, Salas P, Short B, et al. Maggot thera - BioTherapeutics, Education & Research (BTER) py in “lower-extremity hospice” wound care: fewer Foundation and attend conferences and amputations and more antibiotic-free days. J Am Po - workshops, such as the Wild on Wounds’ diatr Med Assoc . 2005;95(3):254-7. annual maggot therapy workshop. On its Dumville JC, Worthy G, Bland JM, et al; VenUS II website, the BTER Foundation posts in - team. Larval therapy for leg ulcers (VenUS II): ran - domised controlled trial. BMJ . 2009;338:b773. structional videos on making custom-fit Fitzgerald RH, Armstrong DG. Palliative advanced maggot dressings. wound care. Vein Magazine . 2009;2(2):44-6. One of the most useful educational ex - www.veindirectory.org/magazine/article/palliative_a periences is a one-on-one conversation dvanced_wound_care. Accessed June 20, 2014. with an experienced colleague or a former Horobin AJ, Shakesheff KM, Pritchard DI. Promo - maggot therapy patient. In our practice, tion of human dermal fibroblast migration, matrix remodelling and modification of fibroblast morphol - we encourage prospective patients to talk ogy within a novel 3D model by Lucilia sericata lar - with previous patients. If this isn’t feasible, val secretions. J Invest Dermatol . 2006;126(6):1410-8. you can have prospective patients watch Jukema GN, Menon AG, Bernards AT, Steenvoorde video interviews of past patients. P, Rastegar AT, van Dissel JT. Amputation-sparing treatment by nature: “surgical” maggots revisited. Clin Infect Dis . 2002;35(12):1566-71. Many benefits, few risks Marineau ML, Herrington MT, Swenor KM, Eron LJ. Maggot therapy is similar to other wound Maggot debridement therapy in the treatment of treatments in many respects, but different complex diabetic wounds. Hawaii Med J . 2011; in a few ways. Medicinal maggots have 70(6):121-4. been subjected to controlled trials of effi - Markevich YO, McLeod-Roberts J, Mousley M, Mel - cacy and safety, and their production and loy E. Maggot therapy for diabetic neuropathic foot wounds: a randomized study (abstr). European As - distribution are regulated by the FDA as sociation for the Study of Diabetes; 36th Annual single-use medical devices. But unlike Meeting; Jerusalem, Israel; 2000. most other devices, they are alive and Mumcuoglu KY. Clinical applications for maggots in therefore highly perishable. They can’t be wound care. Am J Clin Dermatol . 2001;2(4):219-27. stocked far ahead of use, and they have to Sherman RA. Maggot therapy for foot and leg be corralled during and after use. wounds. Int J Low Extrem Wounds . 2002;1(2):135-42. Nonetheless, the similarities far out - Sherman RA. Maggot therapy for treating diabetic foot ulcers unresponsive to conventional therapy. weigh the differences—just as the benefits Diabetes Care . 2003;26(2):446-51. of maggot therapy far outweigh the risks. Sherman RA. Maggot therapy takes us back to the

18 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor future of wound care: new and improved maggot vivo study. Adv Skin Wound Care . 2005;18(8):430-5. therapy for the 21st century. J Diabetes Sci Technol . Steenvoorde P, Jacobi C, Wong C, Jukema G. Mag - 2009;3(2):336-44. got debridement therapy in necrotizing fasciitis re - Sherman RA. Maggot versus conservative debride - duces the number of surgical debridements. ment therapy for the treatment of pressure ulcers. Wounds . 2007;19(3):73-8. Wound Repair Regen . 2002;10(4):208-14. Tantawi TI, Gohar YM, Kotb MM, Beshara FM, El- Sherman RA. Mechanisms of maggot-induced Naggar MM. Clinical and microbiological efficacy of wound healing: what do we know, and where do MDT in the treatment of diabetic foot ulcers. J we go from here? Evid Based Complement Alternat Wound Care . 2007;16(9):379-83. Med . 2014;2014:592419. www.hindawi.com/jour - Townley WA, Jain A, Healy C. Maggot debridement nals/ecam/2014/592419/. Accessed June 20, 2014. therapy to avoid prosthesis removal in an infected to - Sherman RA, Mumcuoglu KY, Grassberger M, Tanta - tal knee arthroplasty. J Wound Care . 2006;15(2):78-9. wi TI. Maggot therapy. In: Grassberger M, Sherman Wayman J, Nirojogi V, Walker A, Sowinski A, Walk - RA, Gileva OS, Kim CMH, Mumcuoglu KY, eds. Bio - er MA. The cost effectiveness of larval therapy in therapy—History, Principles and Practice: A Practi - venous ulcers. J Tissue Viability . 2000;10(3):91-4. cal Guide to the Diagnosis and Treatment of Disease Using Living Organisms . Springer; 2013:5-29. Wollina U, Liebold K, Schmidt WD, Hartmann M, Fassler D. Biosurgery supports granulation and de - Sherman RA, Shapiro CE, Yang RM. Maggot therapy bridement in chronic wounds—clinical data and re - for problematic wounds: uncommon and off-label mittance spectroscopy measurement. Int J Dermatol . applications. Adv Skin Wound Care . 2007;20(11): 2002;41(10):635-9. 602-10. Sherman RA, Wyle FA, Vulpe M. Maggot therapy for The authors work at the BioTherapeutics, Edu - treating pressure ulcers in spinal cord injury pa - cation & Research (BTER) Foundation in Irvine, tients. J Spinal Cord Med . 1995;18(2):71-4. California. Ronald A. Sherman is director. Steenvoorde P, Jacobi CE, Oskam J. Maggot de - Sharon Mendez is a member of the board of di - bridement therapy: free-range or contained? An in- rectors. Catherine McMillan is a research intern.

(continued from page 11) presence of bacteria in the wound. The Educational resources rusty smell is the best smell to uncover when it comes to wounds. Here are some resources that can be helpful for patients and their caregivers. In addition to color, drainage, and odor, • Wound management at home , from the Visiting caregivers should know that a sign of infec - Nurse Healthy System, which includes symp - tion is if the temperature around the wound toms of wound infection and tips for manag - begins to feel hot or the skin around the ing wounds wound becomes hard. The patient’s pain • Wound care frequently asked questions , from HealthFirst also should be decreasing. not increasing. • Wound management: A Nurses Guide, a video available on YouTube; although geared An individual plan towards nurses, it may be helpful for some These guidelines can be enlarged on or caregivers further simplified according to the educa - tion level, experience, and willingness to givers feel confident to recognize prob - learn the caregivers show. Use the ques - lems and know the steps to follow when tions they ask as a guideline on how the patient’s condition changes. n much information to give them. Building a partnership with caregivers Selected reference Dealey C. The Care of Wounds: A Guide for Nurses. will help reduce stress levels, raise confi - 4th ed. Wiley-Blackwell: 2012. dence levels, reduce the risk of infection, and improve outcomes. It can also reduce Judy Bearden is director of clinical services for calls and unnecessary visits when care - Tapestry Hospice in Calhoun, Georgia.

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 19 Apple BITES Dose from WCEI

What you need to know about transparent film dressings

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.

ACCESS : Examples of transparent film ransparent film dressings are thin sheets dressings. Tof transparent polyurethane (polymer) coated with an adhesive. These dressings are available in a variety of sizes and shapes. Indications Examples of when a transparent film Description dressing may be beneficial include: Transparent film dressings provide a • partial-thickness wounds with no or moist, healing environment; promote au - minimal drainage tolytic debridement; protect the wound • when protection is needed for intact from mechanical trauma and bacterial in - skin, for example, protection of bony vasion; and act as a blister roof or “sec - prominences such as elbows and heels ond skin.” Because they’re flexible, these from friction dressings can conform to wounds located • to promote debridement of eschar in awkward locations such as the elbow. • to protect and secure I.V. catheters The transparency makes it easy to visual - • to secure another dressing. ize the wound bed. Transparent film dressings are water - Precautions and considerations proof and impermeable to bacteria and Consider the following when deciding contaminants. Although these dressings whether to choose this type of dressing: can’t absorb fluid, they’re permeable to • A transparent film dressing won’t adhere moisture—allowing one-way passage of to a moist surface because its adhesive carbon dioxide and excess moisture vapor properties are deactivated by moisture. away from the wound. • Don’t use this dressing in patients who

20 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor have moderate to heavy exudate, third- film and center the dressing over it. degree burns, suspected or active infection, Don’t stretch the dressing during appli - fungal infection, or active herpetic lesions. cation. • These dressings can cause periwound 11 Smooth the dressing in place from the maceration. center outward. • Transparent film dressings aren’t recom - 12 Remember that the dressing should be mended for patients with fragile or thin at least 1" larger than the wound. skin, especially elderly patients, or in Check individual manufacturer recom - patients receiving steroids because re - mendations because some dressings re - moval may cause epidermal stripping or quire a 2" border. skin tears. 13 Dispose of the waste; then remove your gloves and discard them.

View: Applying a How to remove Follow these steps to remove a transpar - transparent film dressing ent film dressing. 1 Lift a corner of the dressing and stretch How to apply it horizontally along the skin surface to Follow these steps to apply a transparent break the adhesive bond. film dressing. 2 Continue stretching from the edge of 1 Wash your hands and put on gloves. the dressing toward the center. 2 Remove the soiled dressing and place it 3 When two sides of the dressing are par - in a trash bag. (Note the date on the tially removed, grasp both sides and bandage before removing it.) stretch them horizontally and parallel to 3 Remove your gloves, wash your hands, the skin until the entire dressing lifts. and put on new gloves. 4 Clean the wound with normal saline so - Frequency of dressing changes lution or prescribed cleanser. The average time between transparent 5 Dry the tissue surrounding the wound film dressings is 3 to 5 days, although the by patting it with a 4" × 4" gauze pad. dressing may be left in place up to 7 6 Remove your gloves, wash your hands, days. The frequency of change can vary and put on new gloves. based upon manufacturer recommenda - 7 Make sure the skin is clean and dry. tions. If the transparent dressing becomes Some manufacturers recommend defat - loose, if leakage is present, or new skin ting the skin with alcohol to increased irritation or redness is noted, change the dressing adhesion. Apply a liquid barri - dressing and reassess whether continued er film or moisture barrier to the peri - use is appropriate. n wound area to protect the skin from wound exudate. Nancy Morgan, cofounder of the Wound Care Education Institute, combines her expertise as a 8 For deep wounds, apply wound filler or Certified Wound Care Nurse with an extensive packing material as indicated. background in wound care education and pro - 9 Peel the liner from the dressing to ex - gram development as a nurse entrepreneur. pose the adhesive surface. Information in Apple Bites is courtesy of the Wound 10View the wound or site through the Care Education Institute (WCEI) , copyright 2014.

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 21 Business CONSULT Creating effective education programs on a shoestring How we learn budget The first thing to consider when teaching staff is how to reach the adult learner. Following a few tips will Adults learn in different ways. Some learn leave clinicians wanting by listening (auditory), others by looking (visual), and some through a hands-on more. (tactile or kinesthetic approach). Each ed - ucational session you teach should give By Jennifer Oakley, BS, RN, WCC, DWC, OMS your attendees something to listen to, something to look at, and something to t’s time again for annual staff education, do with their hands, or some type of Iand you, the certified wound clinician, “hands-on” demonstration, to keep every - need to teach the staff at your organiza - one involved. (See Matching techniques to tion. You dream of staff entering a state- learning style .) of-the-art classroom with computers at In addition, consider the background each station, mannequins, wound anato - and scope of practice of your audience. my models, and enough products for each For example, your presentation on pres - student to do hands-on demonstrations. sure ulcers might focus on prevention But when you open your eyes, you’re sit - when you’re speaking to nursing assis - ting in a room with ordinary tables and tants, but focus on staging, care plan de - chairs, your laptop, a screen, a brain full velopment, and treatment when your au - of knowledge, and a very tight budget. dience is a group of nurses. It can be challenging year after year to keep staff interested enough to attend Tools of the trade these mandatory education sessions. Let’s It’s important to ask yourself, What do I be honest: Staff are busy people. The last physically need in the classroom to teach thing they want to do is leave all the the staff? Be careful, as this is where your work they need to do to come to a train - “wants” often overtake the actual “needs.” ing session they don’t think they need. You may not have the funds in your budget They may feel they aren’t learning any - to buy that mannequin with 14 wounds and thing new because year after year it’s the 2 stomas nor the 12 laptops for your class - same boring content being taught to them room. But I bet your budget allows you to in the same boring way. To avoid that afford some fun; after all, fun is free! problem, you need to regularly reevaluate Laughter has been shown to prompt how you’re teaching and to whom you dopamine release and stimulate the frontal are teaching, and think of creative ways to lobe to enhance thinking. This “feel good” present the material. feeling lasts for hours, so the smile you

22 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor Matching techniques to learning style

You can incorporate various techniques into your presentation to ensure you’re reaching all create in the classroom carries back onto three types of learners. the unit and ultimately to the patient’s Type of Sample teaching bedside. Incorporating humor and fun in - learner techniques to your education programs will not only keep staff coming back year after year but Auditory: Prefer Lecture, discussion also build a stronger team. discussion of concepts groups, question and You don’t need the best high-end com - they have heard answer sessions puter programs, wound models, or man - Visual: Learn by Pictures, clip art, nequins to teach wound or stoma assess - seeing posters ment. You can use other budget-friendly methods to provide fun, effective educa - Tactile (or Hands-on kinesthetic): Learn demonstrations tion without breaking the piggy bank. by touching, like Start by jumping online. Search for free to perform tasks downloads that allow you to create Mi - ® For more information on learning styles, crosoft PowerPoint -based games from access this video . Although the setting is a templates in Jeopardy or other formats, or college, the principles still apply. even make crossword puzzles. Download free pictures and clip art to capture the at - tention of visual learners and enhance the tice, practice; try to have one practice ses - learning experience. Give handouts for sion in the room where you will be those tactile learners to take notes on, un - speaking. Time your presentation so you derline, and follow along with your talk. know you haven’t tried to pack in too Enlist sales representatives for help. Fre - much information. A way to avoid this quently, they will provide free education problem is to establish one or two overall about a product or topic and include goals for the typical 60-minute presenta - hands-on demonstrations. Those lower-ex - tion and build in time for questions. Think tremity wraps or negative pressure modal - of questions that might arise so you’re ities are great topics for hosting a lunch- ready with answers. If a question comes and-learn session with a sales rep. Be sure up that you don’t know the answer to, the rep understands the need to focus on simply say, “I don’t know the answer. I’ll education, not make a sales pitch. find out and get back to you.” You can also get creative and solve your own budget crisis by making your Stay on task own training tools. (See DIY training tools During the presentation, keep focused on on a budget .) your agenda. If a person raises a question that’s off topic, you can say that you’ll talk Set the stage with him or her at the break. Next, take a look at the environment Remain fair and unbiased during the you’re teaching in. Do you have enough presentation and cite your sources for in - room? Is there enough seating? How is the formation. Always be approachable. Re - lighting? Will everyone be able to see and member, you’re the staff’s source for infor - hear you? mation and if they don’t feel you’re Before your presentation, practice, prac - approachable, they won’t ask questions or

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 23 DIY training tools on a budget

Here are examples of do-it-yourself training tools you can create for little cost. Once you open your imagination, the possibilities are endless.

1 Create your own game 4 Finished stoma dice. Attach foam to each model. Participants can side of a six-sided measure the height Styrofoam cube. Then and size of the stoma attach photos of all six and assess: stages of pressure ulcers. • color of the stoma As students roll the dice, • lumen location ask questions regarding • mucocutaneous junction stage, tissue type, treatment, and other • peristomal skin. facts. This model can also be used for learning how to properly fit and apply 2 Use inexpensive skin barriers. Crayola ® Air-Dry-Clay (about $6 for a 2.5 lb 5 Wound model bucket) to create created with clay wound and stoma models. (The author made a stoma model and a 14-cm × 14-cm wound model, and had clay left over.) Allow the models to dry for a day or two; then use acrylic paint and sponges to give color and texture (see progression). You’re now ready to assess staff’s knowledge. You can even 6 Finished wound give them scenarios on the wound or stoma model. Participants and have them select appropriate treatment. can measure the length, width, and depth; practice packing a wound; Stoma model created 3 examine different tissue types; and with clay assess: • undermining • tunneling • epibole. Participants then document their assessment. request clarification when they’re unclear. Passion for the profession You also need a way to check if partici - We always want staff to feel valued. Helping pants have learned the main points of the them stay current in their knowledge will presentation. A brief verbal or written quiz help them keep the same passion for their in the format of a question-and-answer profession they had when starting out in session will help you assess this and pro - their careers. If, as the educator, you do your vides an additional opportunity for rein - job well, it’s likely that staff will do their job forcing important information. that way, too. Pay it forward with a smile. n Finally, end on time to show you re - Jennifer Oakley is a clinical instructor for spect the staff’s time. Wound Care Education Institute.

24 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor Wear Your Certifi cation With Pride. Check out the new NAWCO® Online Clothing Store!

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www.nawccb.org Confronting outside of work, the threat or reality of gossip or smear tactics may arise. conflict with As research shows, fears of confronting conflict can affect clinicians no matter higher-ups where they work. For example, in the United Kingdom, a 2013 survey of 8,262 Find out how to address nurses found that almost one-fourth had vertical conflict in the workplace.

By Pam Bowers, RN, and Liz Ferron, MSW, LICSW

onflict in the workplace is a fact of Clife, and dealing with it is never easy. Sometimes it seems easier to ignore it and hope it will take care of itself. But in healthcare organizations, that’s not a good strategy. Unresolved conflict almost al - ways leads to poor communications, avoidance behavior, and poor working re - lationships—which can easily affect pa - tient safety and quality of care. Much has been written about horizontal hostility and bullying and the impact on employee morale, performance, and satis - faction. But what happens when the con - flict is with someone to whom you report, such as a supervisor? Or perhaps it’s an - other higher-up—someone you don’t re - port to directly but who can influence your job and career; for instance, a physi - cian who’s a department chair or a hospi - tal administrator. In such cases, the power differential can pose an added challenge to confronting conflict, making it harder for you to do your job. Although intimida - tion can be outright, sometimes it’s more subtle. Examples include being left out of meetings, receiving a less desirable sched - ule, or not being given important informa - tion that the rest of the team has. In smaller communities where coworkers are more likely to have social relationships

26 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor been discouraged or warned about raising present the issue in a coherent, profes - concerns around patient safety. What’s sional way. Doc ument your concerns in more, 46% had tried to raise such con - advance to help you express them more cerns in the previous 6 months; of those articulately and discern any behavior pat - nurses, 44% said fear of victimization or terns. Request a time and place to talk reprisal would make them think twice that allow privacy and are convenient for about reporting such issues again. It’s no wonder many clinicians view dealing with conflict directly as risky. Clinicians fear They fear retaliation or even job loss for addressing conflicts with a manager or retaliation or even job other higher-up. For patients, the down - stream effects of conflict avoidance can be loss for addressing catastrophic. Conflict also can cause: • poor team dynamics conflicts with a • nothing getting resolved • breakdown of trust manager or other • need for work arounds • misplaced aggression. higher-up.

Addressing conflict constructively all involved. If you expect an emotionally While dealing with conflict can be risky, charged conversation, consider including a you have to weigh the risks of con - union representative or someone from the fronting it against those of avoiding it— human resources department or employee for your patients and your own psycho - assistance program (EAP), to bring objec - logical well-being. We recommend a tivity and help diffuse tension. direct approach. For one thing, your When sharing your concerns, remain leader may be unaware of your concerns professional. Be friendly but direct. Pres - or how you’ve been affected by work - ent the facts and demonstrate respect. place conflict. You need to bring these Make sure to speak for yourself by using forward to make her or him aware of “I” statements, not “you” statements. Here conflict and have the chance to address are examples of how to present concerns it constructively. in a constructive way. Another reason to bring concerns for - ward is to preserve your personal integri - Sample statement #1: ty. Without an opportunity to speak up, "Yesterday, when I was changing Mr. X's you can easily become passive, discour - dressing, I felt you wanted me to rush to aged, and cynical and let negative feelings finish up. Do you remember that? I felt build. This approach compromises your embarrassed and flustered, and I don’t job performance and team unity. think those are good feelings to have If your concern relates to an isolated or when I’m working. It seemed like the task immediate incident, wait to cool down be - you needed me for could have waited. fore approaching your leader so you can But perhaps I’m missing something. Am

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 27 I?...I would have appreciated your waiting How to love and patiently for me. I know you’re busy and have a lot going on, but it would have care for yourself meant a lot to me.” unconditionally Sample statement #2: When stress brought her “The last few times I was in your office talking with you, I felt somewhat dimin - life to a grinding halt, the ished when you took phone calls, as if author was forced to learn our conversation wasn’t important. Were how to truly care for you even aware of that happening? I was thinking you might not be, and that’s why herself. I wanted to bring this up. I know you By Yolanda G. Smith, MSN, RN, CCRN have a lot of demands on your time and are dealing with important matters, but it would mean a lot to me and my working re you able to relax, have fun, and relationship with you if I had your full at - Aenjoy the simple pleasures of life? Or tention when we meet.” do you: • have trouble falling or staying asleep? Listen respectfully • smoke, drink, or eat to reduce tension? After you’ve shared your concerns, listen • have headaches, back pain, or stomach closely to your leader’s response—and problems? don’t argue. If you can’t resolve the issue, • get irritated or upset inform the other party that you’ll need to over insignificant go to his or her supervisor. (See Case things? studies in conflict management .) If you • have too decide to do that, stay calm, state your much to do concerns objectively, and be clear on and too little what kind of resolution you want and the time to actions you’d like that person to take. Be - do it? fore the conversation ends, make sure you’re both clear on the next steps and Wound care their timing. n clinicians are committed, Selected reference compassionate, Royal College of Nursing. Nurses need support when raising concerns. April 24, 2013. http://thisis - and conscientious nursing.rcn.org.uk/public/updates/nurses-need- about caring for pa - support-when-raising-concerns. Accessed October tients, friends, col - 29, 2013. leagues, children, and signifi - cant others. Yet many have difficulty The authors work at Midwest EAP Solutions giving the same loving, unconditional care in St. Cloud, Minnesota. Pam Bowers is a nurse peer coach. Liz Ferron is a senior EAP to ourselves, and they end up caring for consultant. others at our own expense. They’re al -

28 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor ways putting oxygen masks on others, so ed self-care and self-nurturing. I didn’t to speak, while leaving ourselves deprived cherish and love myself first. of the oxygen they need. Some clinicians may even think it’s altruistic to care for Surrendering others but selfish to care for oneself. So I surrendered. I saw that I could no I was forced to start taking better care longer rationalize or continue my un - of myself when my mind, body, and spirit healthy behaviors, and I sought to find stopped me one day and said, “I can’t let out how to bring my life into balance. As you continue.” My typical day began at a result, I made permanent changes in my 4:00 A.M., when I’d wake up and start life. I made a commitment to myself. thinking about what I had to do. I’d get out of bed at 5:30 A.M., shower, grab a quick breakfast, and leave by 6:30. By 8:00, I was ready to begin present - You have to make ing my daylong nursing seminars. Midday, I rushed through lunch so I could get the decision to care back to class before the nurses in my seminar returned from lunch break. By for yourself . 4:30 P.M., my driver picked me up. By 6:30, I was in my home office reviewing medical records (I’m a legal nurse consult - My sensory overload incident taught me ant). By 11:00 P.M., I was in bed. that as clinicians, we’re good at managing That was my schedule the week of Au - stress at work, at home, and in our per - gust 2, 2004. But on August 6 at 10:35 sonal lives. In fact, we’re so good we A.M., my life changed in a flash. don’t realize when we’re having our own emotional reactions to stress. Stress reac - Grinding to an emotional standstill tions have become our norm. While teaching a critical-thinking work - To minimize stress and bring my life in - shop with 25 nurses, I became acutely to balance, I learned and implemented confused and disoriented with memory these five essential self-care principles and loss. I was emergently hospitalized at the practices: facility where I lectured, and went 1. Accept that self-care isn’t selfish. It’s through 4 days of extensive neurologic vital to our happiness and our testing, laboratory work, medication thera - emotional, physical, and spiritual well- py, and sleep. When all the test results being. I do something for myself every came back negative, I was diagnosed with day. I begin and end my day with self- sensory overload. care activities, such as meditation, Subsequently, I realized that while I’d breathing, Reiki, a StairMaster workout, been busy growing my business, I’d journaling, t’ai chi, prayer, dance, grati - lacked balance in my life—focusing my at - tude, and eating healthy, nutritious tention on meeting others’ needs and run - meals. ning my business. Ultimately, I now see, I 2. Manage time effectively. Time manage - lost my identity to my business. I neglect - ment is essential. I decided to establish

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 29 Seven elements of a balanced life

The foundation for a balanced, integrated, healthy life hinges on the essential elements described below.

Element Nurturing activities

Emotional and mental self ...... Get in touch with your feelings and express them more freely.

Finances ...... Believe you can create greater prosperity.

Intimacy ...... Experience more caring and trust in intimate relationships.

Physical body ...... Learn to love and care for your body.

Relationships ...... Commit to more authentic and honest communication.

Soul and spirit ...... Develop a vital and personal spiritual path.

Work and career ...... Balance the drive for success with your personal life.

Monday-through-Thursday business proving your sleep habits, gaining more hours. control over your time, getting adequate 3. Learn how to say no comfortably and exercise, managing your stress, dealing confidently. with clutter, and learning to say no. It’s 4. Set limits. I came to see my clients’ about putting yourself first and investing emergencies weren’t my emergencies; time and effort into your own health and they stemmed from their own failure to well-being. manage their time effectively. It wasn’t No one can do this for you. You have unusual for my attorney clients to call to make the decision to care for yourself— me on Friday afternoon requesting and then do it. You must come to realize information they needed Monday morn - you deserve to live a healthy, balanced ing—which meant I’d have to work life. Only you can make that happen. An through the weekend. internal drive born of love and compas - 5. Live, love, and laugh every day. sion for yourself will empower you to im - plement self-care practices every day. I used my experiences to develop stress management programs and a holistic self- Planning self-care care nursing wellness model to enlighten The secret to self-care is planning. Virtual - and empower others to live a happy, joy - ly all the self-care changes I’ve made (in - ous life by loving themselves—mind, cluding giving up fast and fried foods, caf - body, and soul. (See Seven elements of a feine, sugar, artificial sweeteners, and balanced life .) chocolate) came from making a plan and sticking to it. No one can do it for you You probably know what you’d like to Self-care means eating healthy foods, im - improve in your own life. If I asked you to

30 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor Self-care examples

Once you’ve committed to caring for yourself, search for activities that make you happy. Look at all the possibilities until you find those that really move you.

Physical realm Emotional realm Mental realm Spiritual realm

Take a t’ai chi, yoga, Breathe deeply. Begin your day with Meditate with incense or dance class. Inhale calm a positive affirmation. and candles. and tranquility; exhale stress and worry.

Reduce your intake Be proud of Replace negative beliefs Practice unconditional of caffeine, fats, and yourself. with positive thoughts. love and forgiveness sugar. Acknowledge your of yourself and others. accomplishments.

Soak in a hot bath, Listen to your Express your thoughts Pray, if you’re so with candles lit and favorite music. and feelings in a journal. inclined. music playing. name your most important self-care goal, I gling to maintain a balance, and a sudden bet one would come to mind immediately. increased demand on one side throws So why haven’t you done anything to everything off balance. reach your goal? And if you have, why So I’ve shifted my focus from work-life haven’t you stuck with the effort? The balance to work-life integration , which im - three obstacles I hear about the most are: plies a synergy among the various aspects • “I don’t know how to get started.” of our lives, resulting in more productive • “I’m too busy.” energy expenditure. Work-life integration is • “I can’t seem to follow through with about combining work and personal life— what I start.” including family, relationships, and person - al growth—in ways that are mutually sup - Can you relate to any of these? How portive and rewarding. Work and personal about all three? A major barrier I identified life aren’t independent aspects of life; we was admitting I couldn’t change other have to give ourselves permission to have people, so I let go of the desire to do this. both equally. By examining the role un - I can’t change anyone else; nor is it my healthy beliefs and perceptions play in our responsibility to convince anyone to lives, we can begin to reevaluate our change. The only thing I can change is choices and create a greater integration be - myself. tween our work and personal lives.

Work-life integration Changing your life one step at a The term work-life balance implies all as - time pects of your life should be in equilibri - Once you’ve identified personal barriers to um. This suggests we’re constantly jug - (continued on page 34)

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 31 You want to touch me wher e? Using intimate touch in wound care By Debra Clair, PhD, APRN, WOCN, WCC, DWC

roviding wound care requires a spite your education, knowledge, skills, great deal of knowledge and and certifications, you may encounter skill. To become a wound care problems when wound care requires you Pnurse entails taking classes, gain - to touch the patient in a sensitive or em - ing and maintaining certifications, and barrassing area. Touching the patient in acquiring on-the-job experience. But de - these areas is called intimate touch . Intimate touch can cause feelings of discomfort, anxiety, and fear—for both you and your patient. This article offers advice on how to decrease everyone’s anxiety and discomfort around intimate touch.

Initiating intimate care: The right approach To perform a thorough assessment, you must examine all areas of the skin sur - face. No matter where the patient’s wound is located, you’re responsible for addressing it and performing the required care. But some nurses avoid examining ar - eas that would involve intimate touch. As for patients, many feel they have no con - trol when receiving any type of health care, and may be especially uncomfort - able during intimate touch. Have you ever thought about what’s most important to your patients when in - timate touch is required? Interviews re - veal patients want to know in advance if they will be touched and, if so, why. They’d also like to be able to choose whether a male or female nurse provides this care, as well as when this care will be performed. (See Gender preferences .) Being able to make these choices gives them some control, reducing their sense of helplessness.

32 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor To make patients feel as comfortable as possible, strive to create an atmos - Gender preferences phere of privacy and remain professional and purposeful at all times. Start by ex - Many hospital nurses believe more patients re - quest female nurses than male nurses. Perhaps plaining what you need to do. Then ask patients regard female nurses as nurturing mother when the patient would like the care to figures and feel that intimate touch is part of this be done (if your schedule is flexible). If role. But in the author’s personal experience, possible, let the patient choose how he many female patients prefer male nurses no mat - or she would like to be positioned and ter what type of care is needed. Some state that covered. Is the patient too warm? Too male nurses are more sympathetic and spend more time with them. hot? Is she concerned about exposing a particular part of her body? Asking these questions tells patients you care and do this. Without hesitation, they respond - want to reduce their discomfort. ed “Yes.” During intimate touch, the patient When I evaluated the patient, I found doesn’t want an audience. If you need a large amount of slough and nonviable other healthcare providers to assist tissue in the ulcer beds. I explained the you with wound care, take only those debridement process and, with the pa - absolutely required into the patient’s tient’s permission, debrided the ulcers. room—for instance, if you’ll need help Then I made a treatment plan and wrote moving the patient, if the patient previ - orders for a daily dressing change along ously made you feel uncomfortable, or with an order for cleaning the penis well if you have concerns about being alone before each application. with him or her during intimate touch. The next week, I returned to find the Before touching the patient, ask for per - patient’s penis and pubic hair covered mission. with a large amount of crust from the I don’t take nursing students into the daily wound gel dressing change. Obvi - room with me when intimate touch is re - ously, the penis hadn’t been cleaned quired unless the patient gives permis - regularly. When I looked into the reason, sion. If the patient does give permission, I found the nurses were uncomfortable I try to determine if she did so because holding the patient’s penis to clean it she felt obligated or if she really doesn’t well. mind having a student in the room. The other day, I cared for a patient Sometimes, patients think I’ll be angry if who’d had an erection for several weeks they deny permission.

Intimate touch encounters How male and female nurses Recently, I cared for an elderly patient feel about intimate touch who had pressure ulcers on his penis Some nurses, both male and female, worry about stemming from edema. He and his wife the perceived sexual connotations of touching a were in the room when I entered. I intro - patient intimately. They worry a patient may inter - duced myself and explained why I was pret their touch as sexual and think the nurse is there. I told them I would be evaluating making an inappropriate advance. Some female his wounds and making decisions about nurses don’t feel comfortable touching another care. I also explained I would be looking woman in intimate places; others feel less com - fortable with male patients. On the other hand, for signs of infection or dead tissue. I some male nurses sense that male patients don’t asked the couple if they had any ques - want to be touched by another male. tions and if it would be okay for me to

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 33 but was embarrassed to tell anyone. Even Selected references though the erection was painful, he wait - Blas A. Nursing students learn how to handle inti - ed so long to see a urologist that penis mate situations as they prepare for the real-life pro - fession [monograph online]. The Beacon . September amputation was a possibility. He’d toler - 29, 2011. http://upbeacon.com/2011/09/29/the-nurses - ated the pain (and risked possible ampu - have-the-magic-touch. Accessed May 29, 2014. tation) out of fear of having someone ex - Green C. Philosophic reflections on the meaning of amine, touch, or possibly make fun of an touch in nurse–patient interactions. Nurs Phil . 2013; intimate body part. These two encounters 14(4):242 -53. provide insight into some of the issues Harding T, North N, Perkins R. Sexualizing men's related to intimate touch. (See How male touch: male nurses and the use of intimate touch in and female nurses feel about intimate clinical practice. Res Theory Nurs Pract . 2008;22(2): 88-102. touch .) MacWilliams RB, Schmidt B, Bleich MR. Men in nursing: understanding the challenges men face Putting knowledge into action working in this predominantly female profession. Now that you understand the issues Am J Nurs . 2013;113(1):38-44. around intimate touch, you’re better pre - O’Lynn C, Krautscheid L. Original research: ‘how pared to perform it more adeptly and should I touch you?: a qualitative study of attitudes comfortably. Keep in mind your patients’ on intimate touch in nursing care. Am J Nurs . 2011;111(3):24-31. statements or preferences about intimate

touch. Watch others’ behaviors during in - Debra Clair is a wound care and hyperbaric timate touch care activities so you can therapy provider at Robinson Memorial Hospi - deepen your knowledge base. n tal Wound Care Center in Streetsboro, Ohio.

(continued from page 31) formed my life and now live a life of bal - positive self-care, you can start to change ance, joy, happiness, pleasure, and well - your behavior one step at a time. Now is ness. I love myself mind, body, and soul, the time to act. Set self-care goals and es - every day. n tablish a self-care protocol. Then hold yourself accountable. Be creative. Let your Selected references inner child have fun by engaging in activi - Smith P. To Weep for a Stranger: Compassion Fa - tigue in Caregiving . Mountain View, CA: Healthy ties that make you feel good. (See Self- Caregiving, LLC; 2009. care examples .) Wicks RJ. Bounce: Living the Resilient Life . New I’ve learned self-care is a way of life York, NY: Oxford University Press; 2009. that enables me to truly love myself and Wicks RJ. Overcoming Secondary Stress in Medical to accept and respect myself for who I and Nursing Practice: A Guide to Professional Re - am. When I started practicing self-care silience and Personal Well-Being . New York, NY: daily, my energy soared and my mood Oxford University Press; 2005. changed. I developed an inner peace, tranquility, and calmness, plus a clarity of Yolanda G. Smith is a holistic nurse educator; thought I’d never experienced before. I’ve founder and director of Holistic Self-Care: Just for Me; and founder of Workforce Transforma - learned self-care equals growth, self-love, tion, LLC. Her website is www.Selfcarejustfor and nurturance. I’ve chosen self-care and me.com. You may contact her at Yolanda@ never looked back. I’ve completely trans - selfcarejustforme.com.

34 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor Consider writing an article!

Wound Care Advisor invites you to consider submitting articles for publication Best in the new voice for wound, skin, and ostomy PRA CTICES A g management specialists. uide to foo diabet t ulcers ic View: By Don Diabe na Sardi tic foo na, RN, M t exam HA, WC C, CWCM This cha S, DWC ® ® rt expla ischem ins the ic, neur as the official journal of wcc s, dwc s, omss, and differen diab opathic ces am etic foo , and ne ong t ulcers uroisch Diffe to select , makin emic rentia the bes g it easi SM ting d t treatm er for yo iabet ent for y u Isc ic foo our pa lle s, the journal is dedicated to delivering succinct hemic t ulce tient. I ulcers rs Neuro pathic ulcers insights and pertinent, up-to-date information that An N atomic eurois loc chem ation ic ulce B rs • etween toes o • Over r tips o phalang f toes multidisciplinary wound team members can • Bor eal hea ders or ds • Plantar fe dorsal metata et aspect • Plant rsal he of ar heel ads • Over M plantar • argin an bony p s of foo d defor romine medi t, espe immediately apply in their practice and use to mities nces al surfa cially o • Area m ce of n s subje etatar first be cted to sophal aring o weight • Over angeal n plant lateral joint Wound • Areas s ar surfa me aspect ubjecte ce tatarso of fifth charac dorsa d to str T phalang teristic l portio ess (eg • ips of eal joi advance their professional growth. D s n of ha , toes; be nt • eep, pa mmer t neath t le wou oes) oenails • Even w nd bed ound m • Gang argins Re rene or • d base • Red necros , with h ness a is granula ealthy B t borde r appe • lanche rs of ul • Even arance d or pu cer wound • Pale pin periw rpuric Ca margi k or ye ound ti • llus for ns • Even llow w • Sev ssue mation wound ound b ere pa of ulce at bor Ro margi ed C in r ders • unded ns • elluliti • Pain or oblo s less, un bony p ng sha we are currently seeking submissions for these • Mini b less co romine pe ove mal exu y infect mplica • Call nce r date ion ted us; may • Round P or ma ed or o • ainless y not b A ove blong , owing e prese ssociat r bony shape • Minim to neu nt f ed V promin al exud ropathy indings • ariable ence ate departments: exudate • Thin, shiny, d • Abs ry skin ent or d TB iminish • PI < 0. ed puls • Dry sk 7 mm H es in • TcPO < g • Bou 2 30 mm nding p • Skin c Hg TB ulses ool to • PI ≥ 0.7 • Thin, mo touch, p mm H shiny, • Best Practices , which includes case studies, ttled ale, or • TcPO > g • Ab dry skin N 2 30 mm sent or • o findin • Warm Hg T diminis gs of p foot • BPI < 0 hed pu neurop eripher • Evi .7 mm lses athy al dence o • TcPO Hg • Hair n f perip 2 < 30 m loss on europa heral • Skin m Hg Th ankle thy cool t clinical tips from wound care specialists, and • ick dys and foo • Atrop E o touch trophic t hy of sm • vidence , pale, • Pallor toenai • Dis all mu of per or mott on elev ls tended scles o • Hair lo ipheral led dep ation; C dorsal f feet ss on neuro endent • yanos foot ve • Thi ankle a pathy C rubor is ins ck dyst nd foo • yanosi rophic t s • Pallor o toenail S n elev s other resources for clinical practice ource: ru ation Wound bor ; depe Care E ndent ducatio n Instit ute. TB 20 PI = toe w brachia ww.Wo l press undCa ure ind reAdvi ex; TcP sor.co O2 = tr m anscut aneous July/ oxyge Augus n press • Business Consult , which is designed to help t 2012 • ure. Issu e 1, Nu mber 2 • Wound Care A wound care specialists manage their careers and dvisor stay current in relevant healthcare issues that affect Business skin and wound care. CONSULT if you’re considering writing for us, please click here “But I left voic e A progressive p O roblem messa n November 16, ges and 2000, the nurse v Mr. Cody f isited to review our author guidelines. the guidelines or the first time. D a no she uring that visit, te…” did an admission assessment and n that the press oted B ure sore, located y Nancy J. Brent, M of th at the area will help you identify an appropriate topic and learn S, RN, JD e tailbone, measu red 5 cm by 0.4 c wide and 0.2 c m m deep. She bel fte pressu ieved the n nurses get nam re ulcer could be ed in a lawsuit completely heale when they within 3 weeks d how to prepare and submit your manuscript. are involved in c . The nurse calle ne learly Cody’s d Mr. O gligent conduct t physician and le hat cause ft him a injury to or s an sage co voice mes- the death of a pa ncerning her visit ples tient. Exam- and her findings. include administe On November following these guidelines will increase the chance ring the wrong m 19, a second visi ication to the ed- place and t took wrong patient o the nurse obser tionin r not posi- m ved and docu- g a patient corre ented that Mr. C ctly in the opera ody’s pressure s suite prior to tive “100%” p ore was surgery. Sometim ink and no odor that we’ll accept your manuscript for publication. er, the es, howev- was detected. negligent behav On November ior of a nurse is 20, she attempted as clear to the not er visit bu anoth- nurse involved t did not see Mr of th in the care t . Cody because e patient. he front gate sur rounding his hom That was ap locked. T e was parently the circ he nurse buzzed the re umstance in b the gate door- ported case, Olst ell several times en Health Service to no avail. She Inc v. Cod 1 s, note left a if you haven’t written before, please consider doing y. In September on the front gate wa 2000, Mr. Cody for the Cody fam s the victim of a and left a voice ily crime that result message for Mr paraplegia. ed in physic . Cody’s He was admitted ian. tatio to a rehabili- n center and disc The next visit so now. our editorial team will be happy to work harged on Novem took place on No 15, 2000. His p ber 21. The p vember hysician ordered ressure ulcer was health daily home pin now only “90% care services in o k” and had a “fe rder to monitor tid” odor; this co “almost healed” his tion did no ndi- with you to develop your article so that your Stage 2 decubit t improve over t 2 us pressu he next 2 sore. The home re hours. The 4 health care agen nurse documente signed a cy as- her d this fact in registered nurse nurses’ notes. A (RN) to Mr. Cod gain, she left a v and, after Mr. Co y mail messag oice dy’s health care e for the physici colleagues can benefit from your experience. would n insurance the an concerning ot approve daily se findings. v visits, a reduced isit plan was app roved by Mr. Cod physician. y’s for more information, click here to send an email to the managing editor.

32 www.Wound CareAdvisor.com July/Aug ust 2012 • Issue 1, Number 2 • Woun d Care Advisor Clinician RESOURCES

Be sure you’re familiar with these valuable resources for you and your patients.

Colorectal cancer resources

ADA clinical practice guideline tools

The website for the American Diabetes Association (ADA) has a special section on Clinical Practice Recommendations. In ad - dition to reading, searching, and down - loading the recommendations, clinicians can access • a slide presentation that contains key clinical recommendations from the ADA • an app with the guidelines • a position statement on the manage - Fight Colorectal Cancer has a comprehen - ment of hyperglycemia in patients with sive resource library for patients, including: type 2 diabetes • a link to “My Colon Cancer Coach,” • a position statement on nutrition thera - which provides a personalized report to py for the management of adults with help guide patients in making treatment diabetes. decisions • archives of webinars (past topics in - For a fee, clinicians can also order clude healthy changes that may reduce pocket cards with the clinical practice rec - recurrence, highlights from a GI cancer ommendations. symposium, and making sense of acronyms) Carbapenem-resistant • a link to the National Comprehensive Enterobacteriaceae control and Cancer Network guidelines for patients prevention kit • videos on colon cancer signs and symp - toms, peripheral neuropathy, and a pa - Access “ Carbapenem-resistant Enterobacteri - tient answer line aceae (CRE) control and prevention toolkit ” from • a family history worksheet the Agency for Healthcare Research and • a newly diagnosed information card Quality. The toolkit includes how to and a screening information card that structure a management program, best can be downloaded practices, how to measure the impact of • newsletters from the organization. interventions, and tools and resources. In

36 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor PAD patient education resource

the United States, most CRE cases are caused by the plasmid-borne Klebsiella pneumoniae carbapenemase (KPC) gene circulating among Enterobacteriaceae , Vascular Medicine has published “ Vascular most commonly among K. pneumoniae Disease Patient Information Page: Peripheral ar - isolates. KPC-producing organisms have tery disease (PAD) .” The question-and-an - spread epidemically in the United States swer format of the resource includes risk and around the world among hospitalized factors, signs and symptoms, diagnosis, patients. treatment, and prevention. n Available anytime... anywhere Read in print or on-line on your computer or tablet!

American Nurse Today is the official journal of the American Nurses Association (ANA) and is a monthly award-winning, broad-based nursing journal. • Award-winning relevant editorial American Nurse Today ’s hallmark is publishing useful resources and • Broad-based topics information that all nurses can use—no matter what specialty or • Peer-reviewed, clinical and practical practice setting as well as keep you up-to-date about ANA’s advocacy • Stay up to date on best practices for the nursing profession. • Enhance patient outcomes The journal is published 12 times a year – 6 print issues and 6 electronic • Career and business editorial issues. Whether you prefer to read print journals or online nursing • Mind/Body/Spirit articles — “taking editorial, American Nurse Today is available anytime, anywhere. care of the caregive r ” For subscription information, go to www.AmericanNurseToday.com/subscribe.aspx Or call 215.489.7000 ext. 119 to order by telephone.

Published b y , 259 Veterans Lane, Doylestown, PA 18901. 215-489-7000 NAWCO NEWS

Nominations for WCC ® Outstanding Achievement and Scholarship Awards now open

ominations for the 8th • Collaborates with col - Outstanding WCC of the annual WCC Outstand - leagues and other wound Year Ning Achievement and care professionals to facili - • Demonstrates superior ex - Scholarship Awards are open tate research pertise in the clinical prac - until August 1, 2014. These • Communicates research tice of wound care prestigious awards are given findings through publica - • Mentors and promotes the annually to three outstanding tion and presentation at development of other WCCs from across the country professional meetings wound care professionals and one qualified individual • Demonstrates utilization • Utilizes current research aspiring to become wound of research in practice or and evidence-based care certified. education wound care literature in All achievement and schol - • Mentors the development professional practice arship winners will receive of other researchers • Participates actively in travel expenses and paid reg - community outreach, istration for the 2014 Wild on Outstanding Work In wound care legislation, or Wounds (WOW) conference, Diabetic Wounds professional wound care where they will be recog - • Contributes to the promo - organizations nized. WOW 2014 will be held tion of diabetes education • Collaborates with other September 17-20 at the Rio • Volunteers professional wound care professionals Hotel and Convention Center time in the treatment of to promote the delivery of in Las Vegas. diabetic wounds quality care Anyone may nominate an • Recruits/mentors other outstanding WCC for each of wound care professionals WCC Scholarship the three award categories and in the prevention and (sponsored by one wound care clinician for treatment of diabetic JoernsRecoverCare) the scholarship. One form wounds The scholarship covers the must be used for each nomi - • Organizes community out - cost of the tuition for the nee, and nominees must meet reach events on the pre - WCEI Skin & Wound Manage - the criteria shown below. Click vention of diabetic ment course and the NAWCO here to access the nomination wounds national certification exam fee. form. Submitted forms are the • Serves as a liaison be - The individual who receives sole property of NAWCO ®. tween the healthcare set - the scholarship must be a ting and the community in wound care professional who Outstanding Research In diabetic wound care aspires to further his or her Wound Care education in wound care by • Contributes to the devel - earning the WCC credential opment of evidence-based and who meets the WCC eligi - wound care through re - bility requirements as set forth search by NAWCO.

38 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor NAWCO® to sponsor WOW the highly anticipated presentation of the National Conference annual WCC Outstanding Achievement and Scholarship Awards. Click here for WOW in - The National Alliance of Wound Care and formation. Ostomy (NAWCO), the largest wound care and ostomy certification organization in the United States, is pleased to announce that it is sponsoring the annual Wild on Wounds (WOW) national conference , scheduled for September 17-20 at the Rio Hotel and Con - vention Center in Las Vegas. WOW represents hundreds of wound care clinicians and the largest contingency of WCC ® (wound care certified) profession - als gathered at any wound care conference. This 3-day educational event, appropriately themed “Skin is In,” is the place where wound care clinicians, both certified and not, come together to learn best practices for today’s standards of care, reacquaint with peers, and build their own unique professional network. WOW is growing from every direction. More than 700 practicing nurses, therapists, and physicians who influence wound care decisions from all care environments are t c e j

expected. Also planned are: o r P

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• 50 basic to advanced educational sessions s r u N • 11 how-to and hands-on programs r e k a M

• renowned speakers and industry experts. , g n u o Y

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“We look forward to connecting with our n n A

: current wound care certificants as well as o t o h meeting future candidates at WOW,” says P Cindy Broadus, RN, BSHA, LNHA, CLNC, WCC® ‘MakerNurse’ honored at CHRM, WCC, DWC, OMS, executive direc - White House tor for NAWCO. WOW 2014 is the leading wound care conference for NAWCO’s more Each day, 3.1 million registered nurses than 17,000 certified clinicians. around the country are “making” creative NAWCO will participate in several func - solutions to improve the lives of patients, tions at the WOW conference, including caregivers, and even their coworkers. On speaking directly with hundreds of clini - June 17, Roxana Reyna, BSN, RNC-NIC, cians during the exhibit time and making WCC, (pictured above) from Driscoll Chil -

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 39 dren’s Hospital in Corpus Christi, Texas, New certificants participated as an “Honored Maker” at the nation’s first White House “ Maker Faire ” for Below are WCC, DWC, and OMS certifi - her creative efforts in wound care for pedi - cants who were certified in April and atric patients. May 2014. The MakerNurse initiative, led by the Massachusetts Institute of Technology’s Lit - Benjamin Adduru Tracy Brown tle Devices Lab with support from the Sarah Adkins Terry Bryant Robert Wood Johnson Foundation, was Imelda Aguila Teresa Buckley launched in September 2013 with the goal Angela Ahrens Curtis Bullington of honoring the inventive spirit of nurses Gregory Albrecht, Monica Burger across America. Over the past 9 months, DPM Tina Canada the initiative has collected stories from Mary Ann Ambrose Greta Carlson nurses about how they’re creating solutions Edward Anderson Courtney Carroll every day at the bedside to improve patient Ifeanyi Anigbo York Sing Chan, DO care. As a result, MakerNurse discovered Heather Armenta Karen Chandler hundreds of nurses who are reinventing Deborah Arnone Karen Christmas their tools and materials. Michael Atkinson Diana Clay At the White House Maker Faire, Maker - Nathalie Bak Laura Cole Nurse announced the launch of a new on - Jennifer Barnhill Sara Collett line community that will elevate and accel - Judy Baron-Brumant Thomas Collier erate the ingenuity of nurses working Angela Barrows Michelle Collins across the United States. Additionally, the Emily Bartling April Collins initiative will release a series of robust tools Jennifer Basford Josephine Cooper and resources to empower nurses to make Sheena Battles Camille Copeland and innovate at the bedside, improving pa - Elaine Beardsley Kristy Crandell, MD tient care and health. Dallene Beltran Carlen Crockett NAWCO ® congratulates Roxana Reyna as George Benedict Diane Curren an Honored MakerNurse who, by using in - Michael Benjamin Linda Curto novative and creative advanced wound Annette Benton Rong Dai care techniques to eliminate the need for Elizabeth Berg Kathryn Daniels immediate surgery, alleviates the pain and Mark Bero Shalisa Davis suffering of children and infants born with Kelly Berry Barbara Davis their organs outside of their umbilicus. Mary Berry Psalmuelle De Leon Her daily “making” also consists of pre - Connie Betts LuAnn Dean venting skin and wound care complica - Ellen Bilotta Juliana Deboviel tions by modifying foam and other dress - Mary Boom Laura Deet ings to create a protective barrier. Reyna Jenifer Bouchard Debra Dempsey helps teach other nurses how to make Johanna Boyd Terry Dennis these modifications to provide continuity Victoria Branciforti Carl Depalma of care. Tabitha Brewer Susan Devita Join the MakerNurse community (maker Susan Broussard Marianne Dickun nurse.org ) and share your story. n Lexie Brown Joanne Diehl

40 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor Jennifer DiSalvo Bethany Goldsmith Daniel Jones Sunny McCormick Kristina Donley Veronica Gonzales Adrienne Jones Toni McDermott Mylinda Downing Terri Good Terri Jourgensen Dawn McElhaney Margo Dresch Melissa Gorbet Judy Kappes Darlene McGuire Randy Dutter Shelley Guerrera Erick Kebenei Charissa McKinnie Jennifer Eck Sheila Gwin Kimberly Kelly Tamela McKinzie Nancy Edwards Liberty Hackworth Shineka Kindred- Shanda McNew Meghann Effenheim Cynthia Hale Smith Jean Mead Triva Egan Richard Hall Jennifer Kirkland Mary Miller, MD Shelly Eizyk Sherry Hall Rose Mary Klein Alicia Minard Debbie Elliott Jeffrey Hallett Joann Kolosa Talma Mincey Irina Elner Tanya Hampton Sally Kos Qin Ming Ugochukwu Emezie Nancy Hanahue Devra Kronfeld Emily Modin Jincy Endsley Shannon Hardesty Kelli Krpec Amy Moeves Michelle Escobar Theresa Harding Ann Lade Alan Mong, MD Gina Facen Larry Harness Natalie Lajoie Robert Montemayor Lisa Falcon Regina Harrell Lillian Lally Heidi Montgomery Kristen Farmer Kerstin Harrison Theresa Lamas Sharon Moore Troy Felix Elvia Harrison Shaunna Lampkin Heather Morehous Regina Fick Lora Hartland Robin Landgraf Herlinda Morris Katie Fik Emily Harvey Jill Leblanc Sarah Moses Clevesta Flannigan Meagan Headrick Cheann Legaspi Mary Muhs Michele Flores Janice Helton West Ann Marie Levis Karen Murnan Katrina Flores Arana Mary Hernandez Mary Lindon Kelly Myers Alexandria Foley Stephanie Hetrick Billy Looney, Jr. Dana Neel Dana Frank Mary Hicks Gregory Lott Mona Netherland Elaine Frantum- Angela Hobson Thomas Lubeski, Penny Newark Reed Katherine Hogard DO Mary Newman Paula Franzi Moeck - Amanda Hopkins Tara Ludwig Manena Ng’Ambi li Rachelle Houlihan Cindy Lynch Don Ngo Jay Son Fua April Howard Debbie MacGillivary Jasmine Noordeloos Elizabeth Gabel Jessica Huber Adrean Magee Jessica Nott Ryam Galang Mandy Hubler Amy Manocchio Krista Nygaard Jennifer Gallo Carla Hughes Jennie Martin Diane O’Brien Elizabeth Gardner Patricia Hunt Rebecca Martin Kimberly O’Brien Crystal Gardner Kathleen Hunter Maricela Martinez- Elijah Ochung Elizabeth Geonzon Stephanie Irwin Kimbrell Theresa Odukale Sharon Geraghty Lesley Istre Richelle Mas Sadiat Olayiwola Renee Gibbs Khadijah Jalloh Kristin Mathewson Dianne Oldcrow Nancy Gilligan- Amy Japp Gilda Mayeta Connie Oliver Anderson Susan Jaskiewicz Marianne McAllister Marni O’Neill Lisa Gladden Terry Jaster Angela McCain Kimberly Oropeza Baley Glaze Nancy Johnson Erin McCarthy Andrea Oser

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 41 Jesusa Oviedo Wendy Sidorenko Annabelle Walsh Tara Beering Jenny Pawlewicz Shannon Sikes Karen Waltz Soule Shannon Benjamin Michelle Pennington Helena Silman- Laura Ward Portia Benjamin Russell Petersen, Jr Cohen Lisa Ware Teresa Bernaldo Lolitha Phillips Stephanie Simmons Cornell Washington Carrie Bilek LaDonya Pierce Wanda Smith Cynthia Weaver Jessica Boutin Lindsey Poh Sharonda Smith Stacey Whalon Linda Braubitz Beth Polak Susan Smith Kayla White Renee Braun Courtney Polasik Michelle Snyder Anita Whitesides Donna Breese Wanda Porter Jennifer Speed Trisina Whiting Doris Brogdin Angela Pritzlaff Megan Speer Sarah Wigchers Nanna Buckley Karen Queen Tamera Speer Gail Wilcox Kim Buhl Leah Rafanan Lynn Stackhouse Carla Wilkerson Wendy Bunch LuAnn Reed Erika Stanley Rebecca Wilks Tammy Byrd Monica Reinhardt Leslie Steffey-Davis Jennifer Williams, Kristi Cabral Roxanne Remus Stephany Stewart MD Valerie Callaway Jessica Rico Stephanie Stockwell David Witty Audrey Campbell Aimee Riel Susan Stokes Sandra Woodard Paul Cancio Kimberly Rigdon Angela Stone White Maria Cariaga Holly Ritenour- Chriselle Sun Mary Xenopoulos Tracy Carter Hooks Larry Sutton, DO Minangeles Zeas Carol Cattaneo Elnora Robinson Jessica Sylvia Ashley Zent Wendy Chen Anita Robinson Laura Syoen Misti Zotz Rhonda Chesser Catherine Robinson Arthel Tamakloe Chris Zysk Nicholas Cianci Marta Rodriguez Benjo Tan Vera Clemens Kim Rodriguez Janell Tatum Recertified Belen Clemons Jerry Rodriquez Victoria Taylor certificants Patricia Cook Niesha Russell Laura Tellier Monica Crivits Below are WCC Hyang Ryoo Karyn Temple Kellie Crossland certificants who Barbara Sadowski Heidi Thompson McGarey-Peters were recertified Freda Sansone Danielle Thompson Annette Currin in April and May Monica Sarver Kelly Totman Roberts 2014. Marialyce Saunders Deala Trahan Karen Cuslidge Tamara Schirtzinger Kay Tucker Bonita Alderette Roberta Dabbelt Lori Schmick Leann Tucker Charity Ampong Janice David Margery Schmitt Misty Tummins Traci Anderson Ada Dickerson Casey Schumacher Deana Turgeon Maryann Andres Anne Dolloff Bridget Sebastian Sara Tuvell Jeannie Andries Debra Doubell Candice Seibold Lisa Uhl Suzan Antonio Carolyn Duenwald Betsy Shannon Cynthia Valderrama Tamela Baggett Freda Duffy Barbara Shepherd Brooke Vanderpool Dorothy Bailey Jessie Dunn Bal Shrestha, MD Monica Vasquez Karen Barker Carolyn Dvorak Ma Corazon Sia Nicole Wall Laura Beebe Brett Emry

42 www.WoundCareAdvisor.com July/August 2014 • Volume 3, Number 4 • Wound Care Advisor Sue Eugster Petrice Kam Julya Rempel Vickie Faux Elaine Karlson Sarah Rhodes Wycliff Tayo Fawibe Tammy Kelley Rita Richmond Audrey Ferguson Brian Kellum Kimberly Rojas Marlene Flanders Cheryl King Denise Rosnick Aimee Fleeson Arlene Kobulnicky Jane Rudman Donna Fraley Jason Kowalski James Russell Roberta Futrell Sarah Krasnick Jenica Rusu Christina Gabbard Arun Lakshmipathy, Lynn Saunders Mark Gagnon MD Michele Schneider Sarah Galbraith James Lang Andrea Schoenfeld Samantha Gates Theresa Lewis Edward Seals Bonnie Gensch Fred Liedecke Elizabeth Sharp Jeannie Gibson Marti Livinghouse Eileen Sherburne Kathy Gillit Christa Logue Evelyn Sills Kathleen Gorman Hope Lopez Patricia Smith Rekha Goswami, Sylvia Madden Anita Smith MD Alicia Madore Debra Smith Kathleen Green Suzan Martz Sherol Soutar Earle Carla Green Ellen Mays Nicole Spacek Darcie Groeper, DO Carol McCardle Elizabeth Spears Elaine Hales-Barlow Christy McNease Deborah Spilker Kathy Hall Barbie Mir Lauren Emerald Heldt Melinda Moore Richard Squillace Linda Henry Mercedes Moreno Hayley Stansberry Maryland Hicks Christine Morris Joan Stewart Kurt Holifield Amy Mund Cheryl Stoneburner Corinne Hollister Joseph Myler Kristin Thompson Dawn Hover Kristine Nelson Judith Turay Cynthia Hromadka Lorna Nichols- Jennifer Ty- Margaret Ickes Turner DeGuzman Barbara Irish Linda Orlowski Jo Tracy Vaughn- Tamara Irwin Karen Overdorf Lopez Marcel Jenkins Jamie Paro Maria Vicharelli Jane Jeys Caroline Pendzick Ma Gina Villanueva Yongmei Jin Mary Ann Petrolati Teresa Wallace Kathryn Johnson Caroline Pfaff Debbie Wheelis Crystal Johnson Susan Poirier Vicky White Barbara Jones Lorraine Poliey Mary Wiley Tracy Lynn Jones Jacqueline Ponessa Celli Wisneski Rodgers Melba Poole Nancy Wong Rosalyn Jordan Donna Reddell Ronda Worrall Rhoda Kahn LuAnn Reed Ancy Zacharia n

Wound Care Advisor • July/August 2014 • Volume 3, Number 4 www.WoundCareAdvisor.com 43 “Mom, I miss you so much…” Type 2 diabetes steals the lives we cherish most. 5LHYS`HX\HY[LYTPSSPVUH`LHY)\[P[JHUILWYL]LU[LK 5LHYS` TPSSPVU(TLYPJHUZOH]LWYLKPHIL[LZ)\[ILJH\ZLWYLKPHIL[LZKVLZU»[ HS^H`ZOH]LZ`TW[VTZUPULV\[VM[LUWLVWSL^OVOH]LP[KVU»[L]LURUV^P[ 2UV^`V\YYPZRILMVYLP[»Z[VVSH[L,ZWLJPHSS`PM`V\»YLV]LYVYV]LY^LPNO[ 4VYLPTWVY[HU[S`KVZVTL[OPUNHIV\[P[,H[IL[[LYZ[H`HJ[P]LHUKSVZL^LPNO[ You have a lot to live for. Stop Diabetes®. For yourself, and the people you love.

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