2021 Guideline for Management of Patients With Lower-Extremity Wounds Due to Diabetes Mellitus and/or Neuropathic Disease: An Executive Summary.

This article provides an executive summary of the Wound, Ostomy, and Continence Nurses Society's (WOCN) "2021 Guideline for Management of Patients With Lower-Extremity wounds Due to Diabetes Mellitus and/or Neuropathic Disease." This executive summary presents an overview of the systematic process used to update and develop the guideline and recommendations from the guideline for screening and diagnosis, assessment, and management and education of patients with lower-extremity wounds due to diabetes mellitus and/or neuropathic disease. In addition, the executive summary provides suggestions for implementing recommendations from the guideline. The guideline is a resource for WOC nurse specialists and other nurses and health care professionals who work with adults who have/or are at risk for lower-extremity wounds due to diabetes mellitus/neuropathic disease. The complete guideline includes the evidence and references supporting the recommendations, and it is available in print and electronically from the Wound, Ostomy, and Continence Nurses Society, 1120 Rt 73, Suite 200, Mount Laurel, New Jersey, 08054; Web site: www.wocn.org.

2019 Guideline for Management of Wounds in Patients With Lower-Extremity Venous Disease (LEVD): An Executive Summary.

This article provides an executive summary of the 2019 Guideline for Management of Wounds in Patients with Lower-Extremity Venous Disease (LEVD) published by the Wound, Ostomy and Continence Nurses Society (WOCN). The executive summary presents an overview of the systematic process used to update and develop the guideline. It also lists the specific recommendations from the guideline for assessment, prevention, and management of LEVD and venous leg ulcers (VLUs). In addition, the guideline includes a new section regarding implementation of clinical practice guidelines. The LEVD guideline is a resource for WOC nurse specialists and other nurses, physicians, therapists, and health care professionals who work with adults who have or who are at risk for VLU.

WOCN Society Position Paper: Avoidable Versus Unavoidable Pressure Ulcers/Injuries.

The issue of whether pressure injuries are avoidable or preventable has been and continues to be an issue of great debate and discussion for many years, and it has significant legal and regulatory implications related to prevention of wounds due to pressure. The following position paper outlines the position of the Wound, Ostomy and Continence Nurses Society (WOCN) on avoidable versus unavoidable pressure injuries. It includes the following information: statement of position, purpose/rationale for the position, definitions of avoidable versus unavoidable pressure injuries, alternative definitions, historical overview, supportive statements from expert opinion and research in the literature, and recommendations for research.

2014 Guideline for Management of Wounds in Patients With Lower-Extremity Arterial Disease (LEAD): An Executive Summary.

The purpose of this article is to provide a summary of the recommendations from the 2014 Guideline for Management of Wounds in Patients With Lower-Extremity Arterial Disease (LEAD), published by the Wound, Ostomy and Continence Nurses Society (WOCN). This article provides an overview of the process used to update and develop the guideline, and specific recommendations from the guideline for assessment, referral for further evaluation, interventions (ie, debridement, dressings, infection, antibiotics, nutrition, pain management, compression issues, medications, surgical options, and adjunctive therapies), and patient education and risk-reduction strategies. The LEAD guideline is a resource for physicians, nurses, therapists, and other healthcare professionals who work with adults who have/or are at risk for wounds due to LEAD. The full text of the published guideline, which includes the available evidence supporting the recommendations and a complete reference list, is available from the WOCN Society, 1120 Rt. 73, Suite 200, Mount Laurel, NJ, 08054; Web site: www.wocn.org. Refer to the Supplemental Digital Content (Supplement Digital Content 1, http://links.lww.com/JWOCN/A31) associated with this article for the complete reference list for the guideline. The guideline has been accepted for publication by the National Guideline Clearinghouse (www.guideline.gov/).

A randomized, investigator-blinded, controlled pilot study to evaluate the safety and efficacy of a poly-N-acetyl glucosamine-derived membrane material in patients with venous leg ulcers.

BACKGROUND: Standard care for venous leg ulcers (VLUs) has remained unchanged over several decades despite high rates of initial treatment failure and ulcer recurrence. OBJECTIVE: We sought to evaluate the efficacy, safety, and tolerability of an advanced, poly-N-acetyl glucosamine (pGlcNAc), nanofiber-derived, wound-healing technology among patients with VLUs (Talymed, Marine Polymer Technologies Inc, Danvers, MA). METHODS: In this randomized, investigator-blinded, parallel-group, controlled study, eligible patients were randomized to treatment with standard care plus pGlcNAc (applied only once, every other week, or every 3 weeks) or to standard care alone. The primary end point was the proportion of patients with complete wound healing at week 20 in the intent-to-treat population (all randomized subjects), with last observation carried forward. RESULTS: Among 82 randomized patients, 71 completed the study with 7 lost to follow-up and 4 discontinued because of systemic infection. There were no significant group differences with regard to baseline demographic, illness, and VLU characteristics. At 20 weeks, the proportion of patients with completely healed VLUs was 45.0% (n = 9 of 20), 86.4% (n = 19 of 22), and 65.0% (n = 13 of 20) for groups receiving standard care plus pGlcNAc only once, every other week, and every 3 weeks, respectively, versus 45.0% (n = 9 of 20) for those receiving standard care alone (P < .01 for pGlcNAc every other week vs standard care). The novel pGlcNAc advanced wound-healing technology was well tolerated and safe. LIMITATIONS: Limitations were small sample size and patients unblinded to treatment allocation. CONCLUSION: These pilot study results suggest that the pGlcNAc advanced wound-healing technology is well tolerated and effective.

Swab culture of purulent skin infection to detect infection or colonization with antibiotic-resistant bacteria.

Prescribing systemic antibiotics without susceptibility testing has significant shortcomings, especially in long term care facilities with high rates of multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus. Tissue biopsy or aspiration sampling of infected tissue is the "gold standard" for culture of skin and soft tissue infection and is especially important with serious infection, systemic toxicity, or failure of initial therapy. Swab cultures are probably the most commonly used method to determine the resistance pattern of skin pathogens treated in nursing home residents. However, they are controversial, especially when obtained from chronic wounds. The culture may be obtained from an uninfected wound and lead to unnecessary antibiotic therapy. If material superficial to the infected living tissue is sampled, colonizers may be isolated. This report is focused on swab culture obtained by the Levine technique, after debridement or cleaning down to viable tissue when an acute purulent skin infection has been diagnosed based on clinical criteria. Swab cultures should not be used to determine IF a wound is acutely infected; rather the role may be to identify potential pathogens when deep tissue biopsy is not elected. The swab culture may identify the pathogen or overlying MDRO colonization, a risk factor for MDRO infection. MDRO isolation should heighten the clinician's level of concern if the prescribed antibiotic did not "cover" the MDRO or potential pathogen that was isolated. Properly performed swab cultures could play a role in the identification of methicillin-resistant Staphylococcus/MDRO infections treated in nursing homes.

Measuring toe pressures using a portable photoplethysmograph to detect arterial disease in high-risk patients: an overview of the literature.

Lower extremity arterial disease (LEAD) is estimated to affect one third of individuals older than 65 years of age, occurs in younger individuals who use tobacco or have diabetes mellitus (DM), and often remains undiagnosed until a patient pres- ents with ischemia-related symptoms or complications. Valid and reliable noninvasive tests such as the ankle-brachial index (ABI) are recommended to detect LEAD. However, ABI results can be inconclusive or the index can be elevated (i.e., >1.3) in persons with calcified ankle arteries due to DM, renal failure, or arthritis. In these instances, obtaining toe pressure (TP) measurements, which correlate well with angiographic findings, is advised, providing the patient does not have vasoconstriction with cold toes or vasospastic disease. In such cases, TP can be obtained using a portable pho- toplethysmograph (PPG), which offers a simple and inexpensive method for healthcare providers in a variety of clinical settings to assess for the presence of LEAD. Portable PPG TP measurements have been found to have a high level of agreement with vascular laboratory PPG tests to detect LEAD, as well as good sensitivity and a high specificity. Adopting a TP measurement protocol of care to assess high-risk individuals such as patients with DM and elevated ABIs potentially can have a major impact on early identification of LEAD and reduce the risk of ischemia-related complications, including lower extremity wounds and amputations.

Are toe pressures measured by a portable photophlethysmograph equivalent to standard laboratory tests?

PURPOSE: The purpose of this study was to determine if toe pressures (TPs) obtained by a registered nurse using a portable photophlethysmograph (PPG) were equivalent to TPs obtained by a registered vascular technologist (RVT) using standard laboratory equipment. DESIGN: A within-subjects, comparative design was used for the study. SETTING AND SUBJECTS: Thirty subjects referred to a vascular laboratory for arterial studies were recruited. All tests were performed in the outpatient vascular laboratory of a large, urban medical center. METHODOLOGY: Toe pressures were measured on subjects by the same RN and RVT during the same visit. Data were analyzed using the Bland-Altman method that compares bias (mean difference) and precision (limits of agreement) of measurements to previously determined criterion for clinically important limits of difference (±15 mm Hg) in order to assess equivalence and repeatability of measurements. Kappa statistic was calculated to assess RVT/RN agreement to detect lower extremity arterial disease (LEAD) (ie, TP<50 mm Hg). Sensitivity and specificity of the portable PPG measures were determined. RESULTS: Precision for RVT-RN TPs exceeded the previously determined cutoff criteria (±15 mm Hg), but precision for repeated RN PPG measures fell within the clinically important limits. Kappa statistic calculation (κ=0.76) revealed substantial agreement (90%) between the RVT and RN measures to detect LEAD (<50 mm Hg). The portable PPG technique had good sensitivity (79%) and high specificity (95%) for detection of LEAD. CONCLUSION: Although TPs obtained by the portable PPG were not equivalent to standard laboratory tests, the portable technique agreed sufficiently with the RVT to detect LEAD. The good sensitivity and high specificity of the portable PPG make it suitable for nurses and other primary care providers to use for high-risk patients or patients with wounds, when the ankle brachial index either is elevated above 1.3 or cannot be performed. Photophlethysmograph is also suitable to assess healing potential and the need for referrals to the vascular laboratory, surgeon, or the need for adjunctive therapies.

Identifying and treating wound infection.

The presence of infection is a major causative factor for delayed or nonhealing wounds. Indiscriminate and routine wound cultures are not recommended, but after the clinical diagnosis of infection is made, culture is recommended to identify the causative organisms and guide antibiotic therapy. The purpose of this article is to discuss how to identify and confirm wound infection and the use of topical and systemic antibiotic agents to treat wound infection.

Swab cultures for diagnosing wound infections: a literature review and clinical guideline.

Infection is a major causative factor in delayed and nonhealing wounds. Indiscriminate and routine wound cultures are not recommended, but a culture is indicated to identify the causative organisms and to guide antibiotic therapy when clinical suspicion of an infection exists. Although tissue biopsy is considered the gold standard to diagnose infection, it is rarely used in clinical settings. Swab culture is the most frequently employed method of confirming wound infection in the United States, but a standardized procedure is lacking. Properly performed swab cultures provide useful data to augment diagnostic and therapeutic decision making. The specific aim of the review is to propose a research-based guideline to perform swab cultures as a basis to improve clinical practice and encourage research to establish the reliability and validity of the swab technique.

What's new in lower-extremity arterial disease? WOCN's 2008 clinical practice guideline.

Lower-extremity arterial disease (LEAD) affects 8 to 10 million people in the United States, resulting in pain, tissue loss, infection, limb loss, and an impaired quality of life. LEAD is underdiagnosed, undertreated, and often unrecognized. The purpose of this article is to provide a summary of the recommendations from the 2008 evidence-based, clinical practice guideline, Guideline for the Management of Patients With Lower-Extremity Arterial Disease, recently released from the Wound, Ostomy and Continence Nurses Society. This article presents an overview of the process used to develop the guideline, a discussion of risks for LEAD, and specific recommendations for assessment, interventions, patient education, and risk-reduction strategies.

Measuring venous insufficiency objectively in the clinical setting.

The purpose of this article is to propose a screening procedure to assess venous insufficiency with a hand-held photoplethysmography (PPG) instrument in the clinical setting. PPG is noninvasive technology that is used as part of venous assessment of the lower extremities. Although duplex ultrasound remains the industry gold standard for assessment, there are many situations in which access or expertise is not available. The measurement of venous refill time with PPG, one measure of venous insufficiency, is becoming increasingly more prevalent in research settings; however, PPG is underused in clinical settings. Rapid venous refill time

Evaluation of lower extremity arterial circulation and implications for nursing practice.

Lower extremity arterial disease (LEAD) affects millions of Americans, causing impaired function and a high risk of nonhealing wounds, infection, and limb loss. This chronic, progressive condition is often silent until a life- or limb-threatening complication occurs and impacts the quality of life of individuals and their families and results in high healthcare costs. Assessment forms the cornerstone of effective nursing care, yet despite several national guidelines, LEAD remains unrecognized in half of persons with the condition. This article presents an overview of assessment of LEAD, including descriptions of the risks, pathogenesis, and common characteristics of arterial disease.

Lower extremity venous disorders: implications for nursing practice.

Lower extremity chronic venous disorders are significant and common causes of vascular morbidity and mortality worldwide. Venous ulcer relapse rates are as high as 72% and account for approximately 80% to 90% of all lower extremity ulcers. Venous disorders, much like arterial disease, are often progressive and chronic in nature, resulting in enormous economic and human costs in terms of treatment, pain, and suffering. Individuals with skin changes are at high risk of recurrent leg ulcers, which negatively affect the quality of life for both the individual and the family. Prevention efforts should target anatomical vein dysfunction, edema, and skin changes to prevent leg ulcers. This article presents an overview of both clinical and laboratory assessments of lower extremity chronic venous disorders, including descriptions of the risks and pathogenesis for differential diagnosis and implications for nursing.

Are ankle and toe brachial indices (ABI-TBI) obtained by a pocket Doppler interchangeable with those obtained by standard laboratory equipment?

PURPOSE: The aim of this study was to determine if the ankle and toe brachial indices obtained by an experienced registered nurse (RN) using a pocket Doppler were within acceptable levels of agreement with those obtained by a registered vascular technologist (RVT) using standard laboratory equipment. DESIGN: A within-subjects comparative design was used. SETTING AND SUBJECTS: Thirty subjects who were referred to a vascular laboratory for arterial studies were recruited. All tests were performed in the outpatient vascular laboratory of a large, urban medical center. METHODOLOGY: Ankle and toe brachial indices were measured on each subject by the RN and the RVT during each visit. Data were analyzed using the Bland-Altman method to assess the level of agreement between the RN's pocket Doppler and the RVT's standard laboratory equipment. RESULTS: Differences between each instrument's ankle brachial indices were within the a priori 15% limit of agreement. Differences between each instrument's toe brachial indices exceeded the a priori 15% limit of agreement. CONCLUSION: The ankle brachial index obtained by using a pocket Doppler by an experienced RN is interchangeable with vascular laboratory testing for detection of lower extremity arterial disease (LEAD). The pocket Doppler-derived toe brachial index was not interchangeable with vascular laboratory testing for detection of LEAD.

Issues and challenges in staging of pressure ulcers.

Wound assessment is a key element of effective wound care, and assessment of pressure ulcers includes accurate determination of wound stage. Although the original staging system established by Shea was based on his understanding of the pathology involved in pressure ulcer development, subsequent staging systems (and the one currently in use) were intended simply to establish the level of tissue damage. Recently, clinicians have drawn attention to numerous limitations associated with the current staging system, including the inability to differentiate between an inflammatory response involving intact skin and a deep tissue injury (deep bruising) underneath intact skin. This is a clinically significant difference because clinicians have noted that most inflammatory responses resolve with intervention, whereas most areas of deep tissue injury progress to full-thickness ulcers even when appropriate intervention is provided. A second area of controversy involves partial-thickness (Stage 2) lesions; because many of these lesions are caused by maceration and/or friction (as opposed to pressure) clinicians are frequently unclear regarding which of these lesions should be staged. In response to these concerns, the National Pressure Ulcer Advisory Panel convened a consensus forum and published white papers to clearly outline the issues; they solicited clinician feedback on the white papers and the Wound, Ostomy, Continence Nurses Society provided a written response. This article summarizes the key points of the white papers, WOCN Society response, and consensus forum discussion.