Wound Management

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Pocket Guide

i D• Western East ern

Health Health

~· · Central

Health Labrador-Grenfell H ealth

TABLE OF CONTENTS Assess Arterial Circulation---------------- 2

Fundamentals of Wound Management---------- 3

Treating the Healable Wound- --- ------ 4

Wound Assessment --------- ------ 5-6

Wound Infection------------------- 7

Types of Debridement------------------ 8

Pressure Injury Staging---- ------------- 9-10

Pressure Injury Prevention---------------· 11-12

Pressure Injury Stage 1----------------- 13

Pressure Injury Stages 2, 3, & 4 ------------- 14

Incontinence Associated Dermatitis (IAD)----- -- -- 15

Arterial VS. Venous Wounds---------------- 16

Venous Leg Wound-------------------- 17

Arterial Wound- --- ---------------- 18

Diabetic Foot Wound------ ------------ 19

Skin Tears----------------------- 20

Categories of Wound Management Products-------· 21

Wound Management Products------------- · 22

Glossary of Terms----- -------------· 23

Bibliography --------------------- 24

Notes-------------------------· 25-26

Acknowledgements----------------- - 27

*Balded italicized words are defined in the Glossary of Terms

ASSESS ARTERIAL CIRCULATION 2

Adequate blood supply to affected area is essential for wound hea ling. Stable eschar on the heel or ischemic limb should not be softened or removed.

It is appropriate to use moist wound healing products when arterial circulation is present and your assessment indicates the goa l is to heal the wound.

It is appropriate to use dry wound care products when there is stable eschar on the heel, arterial circulation is not present and/or your assessment indicates the goal is to keep the wound f rom getting worse (see page 22 for examples of moist healing and dry wound care products).

When assessing arterial ci rculation, check the limb for: location of Extremity Pulses

O Presence or absence of pulses

OCapillary refill O Colour and temperature

of affected area

Brach:.,ia:.:..jl 1111

8 Presence or absence of Posterior

hair on affected limb Tibia

8 Pain wa lking, at rest , or w it h elevation

8Redness that blanches wit h elevation

emoral

Popliteal

Dorsal is ~1-- Pedis

FUNDAMENTALS OF WOUND MANAGEMENT 3

1.Risk Assessment and Prevention: Use risk assessment tool (e.g., Braden Scale)

2.Considerations for Chronic Wounds

Client • Ability to adhere to care plan • Psychosocial needs • Social support network • Quality of life issues • Educational needs • Pain tolerance

I'••••'•••••••'••'•'•'••••••••• o •••• •• •• ••• •• ••• •• •'' • ••• • : . . 1 Practice Tip 1 l Delayed wound healing 1 l will occur when: l l • Hemoglobin is less than l j 100 g/L ~ 1 • Albumin is less than 30 1 ~ g/L ! . . • . . ... .........................................................

Cause • Investigate why the wound developed • Complete a careful history • Perform a physical assessment {e.g., vascular status if leg or

foot wound is present) • Complete and review supportive diagnostic tests (e.g. pre­

albumin, albumin, CBC, X-ray, HGBA1C, glucose) • Implement interventions to address the cause of the wound

or contributing factors for delayed healing

Wound •Wound assessment •Wound cleansing •Consider debriding •Identify and treat infection •Apply appropriate dressing

, ........................................................ .. . . 1 Practice Tip 1 l Exposed bone in wound l l bed is a strong indicator of l 1 a bone infection. Bone 1 l changes may not show on l l X-ray for a minimum of 4 \ 1 weeks. Explore treatments ~ l for osteomyelitis. \ . . ......................................................... ""

TREATING THE *HEALABLE WOUND Complete wound assessment

+ Cleanse with normal saline

..--~~~~·- + Debrlde n.:nclc/flbrlnous ttssue If signs and symptoms of

If present ,,.,....., • .: infection are present, consider:

Hydrate wound bed with wound

hydration and moisture retentive

products

• Wound culture • Topical anti biotic products • Collaboration with prescriber

to develop treatment plan

Determine if the wOfltld bed is dry, moist or wet

Maintain a moist wound bed with

products

+ Fill dead space, if present

+ Healing wound

+ Wet

Absorb exudate with exudate management

products

4

--------------, 1 f; M~r; !~formation: 1

,--------------1 *See page 18 for treatment 1

1 considerations if the goal : 1 is not to heal the wound 1

: • see page 7 for wound infection 1 • See page 8 for types of debridement I

L -------------------- L-------------•

WOUND ASSESSMENT 5

Exudate Descri ·on -.:.:.--~----------~~----~ Serous Clear thin wate fluid no blood, us or debris)

Sanguineous Red thin wate fluid. Bloo but not frank blood Yellow/ reen, thick, o a ue, us, cloud , foul odour

Tophi Thick white curds. Urate tissue de osits caused b gout Exudate Amount Nil Li ht Moderate Hea Odour None Mild Foul Wound Edges Description

Attached No sides or walls; even or flush with wound bed; flat

Unattached Sides or wall present; base of wound is deeper than edge

Intact Physically and functionally complete

Wound Bed

Eplthelialization--+-- Light or dark pink skin; regeneration of epidermis.

Hypergranulation

Granulation --Slough

Excessive production of granulation tissue; friable (bleeds easily).

Beefy/pinkish red, bumpy, shiny tissue.

Moist yellow/white/green/grey necrotic tissue. Can be stringy, thick or thin.

Thick, black leathery crust of necrotic tissue.

Caution: Stable eschar on a heel or ischemic limb should not be softened or removed.

Periwound Skin lnduration

Maceration

Callous

Erythema

Measurement Len h Width De th Undermining

Tunnel Sinus

Wound Pain

WOUND ASSESSMENT

Hardened tissue that can be elevated or extend beyond wound edges. White, wrinkled, and waterlogged soft skin caused by prolonged contact with excess fluids.

Buildup of hard dead skin which can occur around a wound due to prolonged pressure or gait changes.

Redness of the skin usually caused by vasodilation, infection or injury.

Oescrl tion-Alwa s measure in centimeters cm

Extension of wound under periwound skin in any direction

Extension of wound in one direction from the wound bed Tunnel in the wound base going into deeper body tissue

Use ractice settin ain assessment and mana ement tools

6

. . ................ .......... .... .. ..... ...................................... ..........................................................

1Practice Tip: When measuring depth, undermining, tunneling, : ~nd sinus tracking: . 1 •Use a sterile soft tip device (e.g., Q-Tip, C&S swab) . . 1 •Gently insert device into the opening marking where the 1

• · measuring device meets the periwound skin. i

• •Do not probe unexplored areas if you cannot see the base. i •Use a clock method to describe locations of i

l undermining, tunneling, and sinus tracking. 12 o'clock tT\ ; 1 is towards the client's head (e.g., 4 cm undermining ~ • ; from 6:00 to 8:00 o'clock) . • • j •Indicate which side the client is lying on, if relevant. ~ .. ... ........................... ............................. ....................................................................... ..

WOUND INFECTION 7

Detecting infection begins with a wound assessment

Classic Signs of Local Infection

•Redness and swelling

•Delayed healing

• Loss of function

• Bleeds easily

•Pus/odour

•Dull appearance

•Increased pain

+Warmth

•Abnormal wound drainage •Wound breakdown

Swabbing for culture and sensitivity, when appropriate,

is used to identify the infecting microbe and appropriate antibiotics for treatment.

Swabbing Guidelines (Levine Technique)

Cleanse wound first with normal saline. Rotate the swab

tip in a 1 cm square area of clean granulation tissue for 5 seconds, using gentle pressure to release tissue exudate.

This may cause the client some discomfort. If the wound

is deep, swab at the bottom of the cavity. If the wound is dry, pre-moisten the swab in the culture medium before

pressing on the tissue.

:··············································································································· ······················ . . ~ Practice Tip: Do not swab pus, exudate, hard eschar or . ~ necrotic tissue. If there is no healthy granulation tissue . j present, there is no value in swabbing the wound.

. • • • • . • • . . • • • • • • • • . • .

·•··••·· ··· ······ ·· ········· ···· ·········· ··· ···••••••··•·· ···•••••··••· ··· •••·•••··· ··••····· ••··•••·· •••• : ··· ·· ··············•·· ····

TYPES OF DEBRIDEMENT Caution: Confirm the presence of arterial circulation, especially in lower extremities, and the absence of malignancy before debriding a wound (see page 2 for components of arterial assessment).

8

Debridement is the process of removing dead/necrotic tissue from a wound. Wounds cannot completely heal until necrotic tissue is removed. Methods of debridement are:

O Autolytic: Using the body's own digestive enzymes to break down necrotic tissue. Moist wound healing products help maintain a moisture balance that promotes a wound envi ronment favorable for autolytic debridement (see page 22 for examples of moist wound healing products).

8 Mechanical: Using force to remove dead tissue from a wound. Irrigation and gentle cleansing/removing loosely attached necrotic tissue, while not causing pain, are appropriate forms of mechanical debridement.

8 Sharp: Using a scalpel, curette, or scissors t o remove necrotic tissue. This is the fastest type of debridement and can only be completed by proficient team members.

8 Enzymatic/Chemical/Biological: Using enzymes, chemicals, leeches or maggots to remove necrotic tissue.

, ..•...............••........................... .................. ...................••••••......................••••............•..• , j Practice Tip: Debridement methods 3 and 4 requ ire a i . . j prescriber's order. i ; ••• • • •••• ....................... ....................... . . ............................ ............. t •••••• •••••••••• • • ••••• • • ••••••••• ,;

PRESSURE INJURY STAGING

Deep Tissue Injury:

Non-blanchable deep red, purple or maroon localized area of discoloured non intact, intact skin or blood-filled blister due to damage of underlying soft tissue from intense or prolonged pressure and/or shear at the bone­muscle interface. Pain and temperature changes often precede skin colour changes.

Stage 1:

Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area.

Stage 2:

Partial thickness, loss of dermis presenting as a shallow open ulcer with a red/pink moist wound bed, without granulation or necrotic tissue. May also present as an intact or open/ruptured serum-filled blister.

9

PRESSURE INJURY STAGING 10

Stage 3:

Full thickness tissue loss. Adipose (fat) may be visible, but bone, tendon or muscles are not exposed. Necrotic tissue may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Stage 4:

Full thickness tissue loss with exposed bone, fascia, cartilage, ligament, tendon or muscle. Necrotic tissue may be present on some parts of the wound bed. Often includes undermining and tunneling.

Unstageable - Depth Unknown:

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Extent of tissue damage cannot be confirmed .

s-•

......,. ,...., 511111-c ....... used .......... ~ of tho - ,,...... Ubr ,.,,_.,,_(My ll, 2016).

PRESSURE INJURY PREVENTION 11

The Braden Scale is used to identify clients at risk of developing pressure injuries. The RN or LPN completes the Braden Scale following the schedule outlined below and when there is a significant change in the client's health status.

INTERVENTIONS

Community All clients who are chair or bed bound (on Initial home visit) then yeerfy Acute Care Within 24 hours of admi.sslon. For a score of 18 or lower repeat as per the fok>wlng schedule:

• Critical Care: Dally • Med/Surg: Mon/Wed/Fri • ALC: Weekly for four weeks. then quarterfy • Rehab & Mental Health Acute Care: Weekly

LTC Within 48 hours of admission, then -ekly for four weeks. then quarterfy Acute Care Within 24 hours of admission. For a score of 16 or lower repeat as per the fok>wing schedule:

• PICU: Daily • Medical/SurgiceVMental Health Units: Mon/Wed/Fri

Protect skin integrity and manage moisture: • Do daily skin observation/assessment.

• Use a protective barrier ointment on all incontinent clients.

• Use incontinence absorbent products that wick and hold moisture. Change bed linen when damp.

• Use pH balanced non-sensitizing skin cleansers and moisturizers.

• Individualize the bathing schedule and use warm water.

Minimize pressure and shear forces: • Reposition client in chair QlH and in bed Q2H. • When appropriate, keep head of bed less than 30°

and/or the client at less than 30° when side lying.

• Float heels by placing pillows lengthwise beneath the legs from the base of heels to slightly below knee.

• Do not use intravenous {IV) bags, donut-like pillows

or similar devices to relieve pressure.

• Use assistive or protective devices/maneuvers when

moving clients.

•Do not massage over bony prominences and

reddened areas.

• Consider the use of therapeutic support surfaces.

• Consult Occupational Therapy and/or Physiotherapy

if needed.

• Minimize the time the client stays in bed, if clinically appropriate.

• Monitor coccyx/sacrum and heels closely for tissue injury.

Nutrition:

• Maintain good nutrition and hydration.

• Offer support with eating, if needed.

• Consider dietary consult.

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PRESSURE INJURY STAGE 1 13

Complete Braden Scale according to your organizational policy and implement individualized prevention

interventions with an emphasis on relieving pressure and/or shear forces.

Reddened Intact Skin

' • ' ' • Non-.blanchlng redness; • Skin blanches; turns white

skin does not turn white when slight pressure is when slight pr6$$Ure is

I applied

applied

•This indicates capillaries are ruptured and skin integrity is impaired

+ • Apply barrier for 'j

protection - . l -+ ' ,

Implement preventive measures and review plan with client, family and caregivers

+ Skin remains intact

•

PRESSURE INJURY STAGES 2, 3 & 4 14

·- Complete medical history and physical assessment

• Implement standard intervention for pressure injury prevention and treatment. Re-evaluate as per organizational policy .. • Confirm if arterial circulation is adequate to support healing

• • Yes

----· •Meticulous wound care

0 t

•Do not de bride

•Dry the wound bed •Prevent further trauma

•Manage pain and odour ____ +

Determine possibility for revascularization

-----•--Maintain quality of life

r------------------------------1 For More Information: 1 I • See page 2 for components of assessing arterial circulation I 1 • See pages 3 and 4 for fundamental of wound management : : • See pages 21 and 22 for wound product related information 1

~-----------------------------·

INCONTINENCE-ASSOCIATED DERMATITIS (IAD) 15

IAD is skin damage caused by prolonged exposure to urine and/or feces. IAD is not a pressure injury.

lnconttnence Associated Dermatttts Usual Oiaracterlst1cs

Cause Skin irritation caused by contact with moisture from urine and/or feces

Surroundlns Warmer and/or ITmer; pink or white tissue due Tissue to maceration

Necrotic Tissue Not present

Location Diffuse; can indude skin folds; not usually over bony prominence

Depth Superficial/partial thickness skin loss

Presentation of Bluish-purple or deep red; b/anchable or non Injury blanchable; diffuse or irregular edges

Prevention of IAD • Establish a continence program and minimize using

incontinence absorbent products. • Support good nutrition and fluid intake. • Establish a gentle cleansing routine by using a pH balanced

no-rinse cleanser. Do not scrub or rub the skin. • Moisturize to replace natural oils. Use a moisturizer in

combination with a protective barrier ointment to protect skin from irritants.

• Monitor and treat skin infections with prescribed antifungal, anti-yeast, or antibacterial creams, powders, or ointments. These medications can be applied and then covered with a protective barrier ointment.

ARTERIAL VS. VENOUS WOUNDS

Usual Arterial (lschemic) Wound Characteristics Location: Anywhere on the legs or feet, especially distally and over pressure points Wound Bed: Pale, grey and/or yellow Wound Edges: Well defined with a "punched out" appearance. Often deep Periwound Skin: Ory; no surrounding inflammatory response. Shiny red with minimal edema

Exudate: Minimal; serous or purulent Pain: Could be severe

Usual Venous Wound Characteristics

16

Location: Common in anterior, pretibial and gaiter (sock) area and medial malleolus

Wound Bed: Moist, shallow, deep red or yellow with fibrinous slough

Wound Edges: Irregular

Periwound Skin: Macerated, edematous, and heavily exudating. Could be dry and flaky

Exudate: Moderate to large amount; usually serous Pain: Achy feeling in legs

VENOUS LEG WOUND

Complete medical history and physical assessment

+ Consult Physician, Nurse Practitioner, and/or

Wound Care Specialist for a more detailed arterial assessment and direction for compression therapy

+ + Confirm if arterial circulation is adequate to support healing

+ Yes +. __

•Do not de bride

17

• Gold standard maintenance treatment when Anldfl Bnldtlal Inda (AEJ4 is between 0.8 and 1.2 is life-long compression therapy. A prescriber's order is required for compression therapy

•Ory the wound bd

•Prevent further trauma

•Manage pain and odour

• Corn;ultation with a vascular surgeon should be considered when AB/ is less than 0.8 or greater than 1.2

• Educate client about venous leg wounds, importance of elevatingthe leg(s) and participating in an exercise program

• Meticulous wound care

__ +._ Determine possibility for

revascularization

Maintain quaity of life

·------------------------------' For More Information: 1 1 • See page 2 for components of assessing arterial circulation : : • See pages 3 and 4 for fundamental of wound management 1 1 • See pages 21 and 22 for wound product related information 1

------------------------------·

ARTERIAL WOUND

Complete medical history and physical assessment

+ Consult physician, Nurse Practitioner, and/or Wound care Specialist for a detailed arterial

assessment and direction for consultations for potential revascularization options

+ Confirm rt arterial circulation is adequate to

support healing

• Yes

+ • Meticulous wound

care

+ No y

•Do not debride

•Dry the wound bed

•Prevent further trauma

•Manage pain and odour

Maintain quality of life

------------------------------~ I for More Information: 1 : • See page 2 for components of assessing arterial circulatfon I

1 • See pages 3 and 4 for fundamentals of wound management : I • See pages 21 and 22 for wound product related Information 1

L-----------------------------4

•

18

DIABETIC FOOT WOUND

Complete medical history, monoftlament testing for loss of protective sensation and physical assessment

+ Consult physician, Nurse Practitioner, and/or

Wound Care Speclalist for a more detailed arterial assessment (e.g., Anlcl• Broch/al Inda (AB/), digital

pressures)

+ + confirm if arterial circulation is adequate to support healing

+ + Yes

+ No

+ • Do not debrlde

19

• Gold standard for treatment and maintenance is o/f lood/ng of pressure with proper footwear, callous debridement and meticulous wound care

•Dry the wound bed

•Prevent further trauma •Manage pain and odour

• Provide education about diabetes, good foot care practic.es and treatment plan

+ __ Determine possibility for

revascularization

+ Maintain quality of life

------------------------------: For More Information : 1 • See page 2 for components of assessing arterial circulation 1

1 • See pages 3 and 4 for fundamentals of wound management I 1 • See pages 21 and 22 for wound product information 1 I I

----- ------ ------- - -------- - --~

SKJNTEARS A skin tear is a result of blunt trauma, friction, and/or shear forces that causes separation of the layers of skin. Skin tears can be partial or full thickness, depending on the amount of tissue involved.

Prevention of Skin Tears

• Identify clients at risk of developing skin tears.

•Complete a skin observation/assessment at least once

20

per shift. Document findings to include: colour, character, integrity, dryness, and elasticity. Pay special attention to the arms, especially the forearms, and the lower legs.

• Complete good skin hygiene and hydration. Dry skin can result from frequent bathing and lack of proper moisturizing. Dry skin increases susceptibility to friction and shear forces which can lead to the development of skin tears.

• Practice appropriate and responsible client bathing, turning, positioning, and transferring.

• Encourage good nutrition; consult a dietitian, if needed.

• Implement programs that minimize opportunities for trauma (e.g., fall prevention, dementia management, and appropriate dressing selection, application and removal).

CATEGORIES OF WOUND MANAGEMENT PRODUCTS

1. Exudate Management: Absorbs and manages exudate.

21

2. Moisture Retention: Keeps moisture near t he wound bed.

3. Wound Hydration: Adds moisture to the wound.

4. Odour Control: Manages/controls wound odour.

5. Skin Sealants: Barrier t hat prot ect s the skin.

6. Adhesive Remover: Removes residue f rom the skin.

7. Sodium Chloride Impregnated Gauze: Product with high

salt cont ent and must be applied to moist wound bed. Helps with autolytic debridement and cont rol of bacterial

growth.

8. Antimicrobials: Agent t hat inhibits the growth of

microbes.

9. Wound Contact Layers: Does not stick to the wound bed.

10. Negative Pressure Systems: Applies negative pressure (suction) t o the wound bed.

11. Dry Wound Care Products: Aims t o keeps the wound bed dry.

:····· ········· ························································· ············ ······················· ·························:

j Practice Tip: Please refer to manufacturers' guidelines/product : 1 monographs for information related to wound management j products . • . ... .......... ..... ..... ......................................... .................... ...... ..... ........................ ...... ..........

WOUND MANAGEMENT PRODUCTS 22

Broad Category Generic category Product Examples • Moist Wound Healing Products

Exudate Management Calcium Alginate . NuDerm

Foam Aquacel Foam, Mepilex

Hydrofiber Aquacel

M oisture Retention Hydrocolloid Duoderm, Comfeel

Film Tegaderm

Wound Hydration Wound Hydration lntrasite Gel

Odour Control Charcoal and Silver Actisorb Silver 220

Skin Sealants Alcohol free No Sting Skin Prep, Brava, Cavllon

Adhesive Remover Brava, Remover Wipes

Sodium Chloride Mesa It

lmpre2nated Gauze

Antimicrobials Silver, Iodine, Honey, PHMB, Aquacel Ag + Extra,

Methylene Blue/Gentian Acticoat, lnadine, PHMB

Violet gauze, lodosorb, Hydrofera Blue, Silvercel, Acticoat FleK 3&7

Wound Contact Layers TELFA, Petroleum Based, Jelonet, Mepitel, Adaptic, Silicone Based Restore

Negative Pressure Cardinal Neg Pressure, VAC Svstems PICO, Renasys GO, Avelle

' ~ Dry Wound Care Products

Antiseptic Povidone Iodine Brldine, Dexidin 2 Dry Dressings TELFA, Gauze, ABO/

Combine Pad Secure Dressings Cloth Tape, Kling, Digit

Dressings, Surgilast, Stockinette

GLOSSARY OF TERMS 23

Ankle Brachia! Index (ABI): Systolic pressure at the ankle divided by systolic pressure at arm; auscultated via Doppler usually in a vascular lab. Provides an indication of arterial status.

Blanching: Skin becomes paler when pressure applied.

capillary Refill: Amount of time it takes for blanched area to turn back to pink when pressure is released from the nailbed; normally 2 seconds or less.

Friction: Movement or rubbing of skin against an external surface.

Monofilament Testing: Used to assess loss of protective sensation/ ability to feel pain.

Necrotic Tissue: Devitalized (dead) tissue; eschar or slough.

Off Loading: Avoidance of mechanical stress to a wounded area.

Periwound: Skin region immediately surrounding the wound.

Pressure: Continuous physical force on or against an object by another object.

Pressure Injury: Previously known as pressure ulcer. An area of localized damage to skin and underlying tissue caused by pressure and/or shear forces.

Shear: Pressure with a lateral shifting resulting in internal ripping and/or grinding of tissue.

Support Surface: A specialized device for pressure redistribution designed for management of tissue load, micro-climate, and or other · therapeutic functions.

Wound Bed: Uppermost viable tissue layer of the wound.

Wound Edges: Rim or border of the wound.

BIBLIOGRAPHY 24 1. Beeckman, D. (2017). A decade of research on incontinence-associated dermatitis

(IAD): Evidence, knowledge gaps and next steps. Journal of Tissue Viability, 26(1), 47-56. dol: http://dx.doi.org/10.1016/J.jtv.2016.02.004

2. Bergstrom, N., et al. (1998). Predicting pressure ulcer risk. A multisite study of the predictive validity of the Braden Scale. Nursing Research, 47(5), 261-269.

3. Botros, M ., et al. (2017). Best practice recommendations for the prevention and management of diabetic foot ulcers. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound care canada. (Chapter 6). Retrieved from: https ://www. wou ndsca nada.ca/docman/ public/health-ca re-professional/bpr­workshop/895-wc-bpr-prevention-a nd-manage ment-of-dla betic-f oot-ulcers-1S 73rle­final/file.

4. Braden, B., et al. (2007). Risk assessment in pressure ulcers prevention. In D.L. Krasner, G.T. Rodeheaver, & R.G. Sibbald, (Eds.). Chronic wound care: a clinical source book for healthcare professionals (4th ed.). HMP Communications, pp 593-608.

5. LeBlanc, K., et al. (2017). Best practice recommendations for the prevention and management of skin tears. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound care Canada. (Chapter 4). Retrieved from: https://www.woundscanada.ca/docman/public/health-care-professional/bpr­workshop/552-bpr-prevention-and-management-of-skin-tears/file

6. National Pressure Ulcer Advisory Panel. (2016). Pressure Injury definition and illustrations. Retrieved July 13, 2016 from NPUAP website: www.npuap.org/ documents/PU_Oefinition_Stages.pdf. Definitions and Illustrations (pp 9-10) property of National Pressure Ulcer Advisory Panel.

7. Norton, L., et al. (2017). Best practice recommendations for the prevention and management of pressure injuries. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care canada. (Chapter 3). Retrieved from: https://www.woundscanada.ca/docman/public/health-care-professlonal/bpr­workshop/172-bpr-prevention-and-management-of-pressure-lnjurles-2/file

8. Orsted, H., et al. (2017). Best practice recommendations for the prevention and management of wounds. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada. (Chapter 2). Retrieved from: https://www.woundscanada.ca/ doc man/ pu blic/health-care-professional/bpr­workshop/165-wc-bpr-prevention-and-ma nage ment-of-wou nds/fi le

9. Provincial Wound and Skin care Committee (2008). Provincial Wound and Skin Care Manual. St. John's, NL. Retrieved from: http://westemhealth.nl.ca/uploads/PDFs/ wound%20care%20manual%20for%20dianne%20clements%20flnal.pdf

10. Registered Nurses' Association of Ontario (2016). Assessment and Management of Pressure Injuries for the lnterprofessional team, (3rd ed.). Toronto, ON: Registered Nurses' Association of Ontario. Retrieved from: http://mao.ca/sites/mao-ca/flles/ Pressure_lnjuries_BPG.pdf

11. Spear, M . (2014). When and how to culture a chronic wound: A culture is a valuable tool in wound care If used correctly. Wound Care Advisor, 3(1), 23-2S. Retrieved from: https://woundcareadvisor.com/when-and-how-to-culture-a-chronic-wound-vol3-nol/