Managing venous stasis ulcers

By Kulbir Dhillon, MSN, FNP, APNP, WCC

Venous disease, which encompasses all conditions caused by or related to diseased or abnormal veins, affects about 15% of adults. When mild, it rarely poses a problem, but as it worsens, it can become crippling and chronic.

Chronic venous disease often is overlooked by primary and cardiovascular care providers, who underestimate its magnitude and impact. Chronic venous insufficiency (CVI) causes hypertension in the venous system of the legs, leading to various pathologies that involve pain, swelling, edema, skin changes, stasis dermatitis, and ulcers. An estimated 1% of the U.S. population suffers from venous stasis ulcers (VSUs). Causes of VSUs include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Preventing VSUs is the most important aspect of CVI management.

Treatments for VSUs include compression therapy, local wound care (including debridement), dressings, topical or systemic antibiotics for infected wounds, other pharmacologic agents, surgery, and adjunctive therapy. Clinicians should be able to recognize early CVI manifestations and choose specific treatments based on disease severity and the patient’s anatomic and pathophysiologic features. Management starts with a full history, physical examination, and risk-factor identification. Wound care clinicians should individualize therapy as appropriate to manage signs and symptoms.

Compression therapy

Treatment focuses on preventing new ulcers, controlling edema, and reducing venous hypertension through compression therapy. Compression therapy helps prevent reflux, decreases release of inflammatory cytokines, and reduces fluid leakage from capillaries, thereby controlling lower extremity edema and VSU recurrence. Goals of compression therapy are to reduce symptoms, prevent secondary complications, and slow disease progression.

In patients with severe cellulitis, compression therapy is delayed while infection is treated. Contraindications for compression therapy include heart failure, recent deep vein thrombosis (DVT), unstable medical status, and risk factors that can cause complications of compression therapy. Ultrasound screening should be done to rule out recent DVT. Arterial disease must be ruled out by measuring the ankle-brachial index (ABI). Compression is contraindicated if significant arterial disease is present, because this condition may cause necrosis or necessitate amputation.

High compression levels should be used only if the patient’s ABI ranges from 0.6 to 1.0. With an ABI between 0.9 and 1.25, the patient likely can tolerate treatment with four-layer compression or a long-stretch compression wrap. For patients with an ABI between 0.75 and 0.9, use single-layer compression with cast padding and a Coban wrap in a spiral

Keep in mind that use of a compression wrap depends on the patient’s comfort level and degree of leg edema. In patients who have mixed venous and arterial insufficiency with an ABI between 0.5 and 0.8, monitor for complications of arterial disease. Don’t apply sustained high levels of compression in patients with ABIs below 0.5. (See Comparing compression levels.)

Pneumatic compression

The benefits of intermittent pneumatic compression are less clear than those of standard continuous compression. Pneumatic compression generally is reserved for patients who can’t tolerate continuous compression.

Local wound care

Wound debridement is essential in treating chronic VSUs. Removing necrotic
tissue and bacterial burden through debridement enhances wound healing. Types of debridement include sharp (using a curette or scissors), enzymatic, mechanical, biologic (for instance, using larvae), and autolytic. Maintenance debridement helps stimulate conversion of a chronic static wound to an acute healing wound.


Dressings are used under compression bandages to promote healing, control exudate, improve patient comfort, and prevent the wound from adhering to the bandage. Vacuum-assisted wound-closure therapy can be used with compression bandages.

A wide range of dressings are available, including:

• hydrofiber dressings
• acetic acid dressings
• silver-impregnated dressings, which have become more useful than topical silver sulfadiazine in treating VSUs
• calcium alginate dressings
• proteolytic enzyme agents
• synthetic occlusive dressings
• extracellular matrix dressing
• bioengineered skin substitutes. Several human-skin equivalents created from human epidermal keratinocytes, human dermal fibroblasts, and connective tissue proteins are available for VSU treatment. These grafts are applied in outpatient settings.


Common in patients with VSUs, bacterial colonization and infection contribute to poor wound healing. Oral antibiotics are recommended only in cases of suspected wound-bed infection and cellulitis. I.V. antibiotics are indicated for patients with one or more of the following signs and symptoms of infection:

• increased erythema of surrounding skin
• increased pain, local heat, tenderness, and leg swelling
• rapid increase in wound size
• lymphangitis
• fever.

Progressive signs and symptoms of infection associated with fever and other toxicity symptoms warrant broad-spectrum I.V. antibiotics. Suspected osteo­myelitis requires an evaluation for arterial disease and consideration of oral or I.V. antibiotics to treat the underlying infection.

Other pharmacologic agents

A wide range of other drugs also can be used to treat VSUs. (See Other drugs used to treat VSUs.)


Surgery can reduce venous reflux, hasten healing, and prevent ulcer recurrence. Surgical options for treatment of venous insufficiency include saphenous-vein ablation, interruption of perforating veins with subfascial endoscopic surgery, and treatment of iliac-vein obstruction with stenting and removal of incompetent superficial veins by phlebectomy, stripping, sclerotherapy, or laser therapy.

Patients should be evaluated early for possible surgery. An algorithm based on a review of literature indicates that patients whose wounds don’t close at 4 weeks are unlikely to achieve complete wound healing and may benefit from surgery or other therapy.

To help determine if surgery may be warranted, assess venous reflux using duplex ultrasonography, which can reveal CVI, assess physiologic dysfunction, and identify abnormal venous dilation. Consider a vascular consult for surgical management of patients with superficial venous reflux disease or perforator reflux disease.

Surgery aims to correct valve incompetence leading to increased intraluminal pressures. (Venous valve injury or dysfunction may contribute to CVI development and progression.) Surgical reconstruction of deep vein valves may be offered to selected patients with advanced severe and disabling CVI who have recurrent VSUs.

The literature shows that surgical vein stripping isn’t superior to medical management. Endovenous laser ablation (EVLA), a minimally invasive procedure, yields greater benefits than vein stripping and other types of surgery.

Skin grafting

Skin grafting may be done in patients with large or refractory venous ulcers. It may involve an autograft (skin or cells taken from another site on the same patient), an allograft (skin or cells taken from another person), or artificial skin (a human skin equivalent). Skin grafting generally isn’t effective if the patient has persistent edema (common with venous insufficiency) unless the underlying venous disease is addressed.

Adjunctive therapies

Adjunctive therapies, such as ultrasound, pulsed electromagnetic fields, and electrical stimulation, can aid in treating VSUs that fail to close despite good conventional wound care and compression therapy.

Patient education

Be sure to teach patients with VSUs about treatment and prevention to promote successful management. Advise them to:

• elevate their legs above heart level for 30 minutes three to four times daily (unless medically contraindicated),
to minimize edema and reduce intra­abdominal pressure. Increased intra­- abdominal pressure in severely and
morbidly obese patients can increase iliofemoral venous pressure, which transmits via incompetent femoral veins, causing venous stasis in the legs.
• perform leg exercises regularly to improve calf muscle function
• use graduated compression stockings as ordered to prevent dilation of lower-extremity veins, pain, and a heavy sensation in the legs that typically worsen as the day progresses
• minimize stationary standing as much as possible
• treat dry skin, itching, and eczematous changes with moisturizers and topical corticosteroids as prescribed. (See Skin care for CVI patients.)

Also help patients identify risk factors for CVI (such as smoking and overweight), which can affect management. Teach them about therapeutic compression stockings, including their use, benefits, and care instructions. Remind them to wear stockings every day to prevent venous edema and VSU recurrence. Finally, urge them to adhere to the plan of care and get regular follow-up care.

Selected references
Abbade LP, Lastória S. Venous ulcer: epidemiology, physiopathology, diagnosis and treatment. Int J Dermatol. 2005;44(6):449–56.

Alguire PC, Mathes BM. Medical management of lower extremity chronic venous disease. Availabe at: Accessed December 4, 2013.

Baranoski S, Ayello EA. Wound Care Essentials: Practice Principles. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2007.

Bryant R, Nix D. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, Mo: Mosby; 2011.

Habif TB. Clinical Dermatology: Expert Consult. 5th ed. St. Louis, Mo: Mosby; 2009.

Kimmel HM, Robin AL. An evidence-based algorithm for treating venous leg ulcers utilizing the Cochrane Database of Systematic Reviews. Wounds. 2013:25(9);242-50.

Kistner RL, Shafritz R, Stark KR, et al. Emerging treatment options for venous ulceration in today’s wound care practice. Ostomy Wound Manage. 2010;56(4):1-11.

O’Meara S, Al-Kurdi D, Ologun Y, et al. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database Syst Rev. 2010;(1):CD003557.

Patel NP, Labropoulos N, Pappas PJ. Current management of venous ulceration. Plast Reconstr Surg. 2006;117(7 Suppl):254S-60S.

Wollina U, Abdel-Naser MB, Mani R. A review of the microcirculation in skin in patients with chronic venous insufficiency: the problem and the evidence available for therapeutic options. Int J Low Extrem Wounds. 2006:5(3);169-80.

Kulbir Dhillon is a wound care nurse practitioner at Mercy Medical Group, Dignity Health Medical Foundation in Sacramento, California.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

A case of missed care

By Lydia A. Meyers RN, MSN, CWCN

Missed care, a relatively new concept in the medical community, refers to any part ofrequired patient care that is omitted of delayed. It’s not the same as a mistake or error, but like them, missed care can negatively affect patient outcomes.

I want to share the case of a patient admitted into home health care for wound care. The case includes several areas of missed care from many different different sources.

About Ms. Smith

Ms. Smith (not her real name), an 83-year-old woman, lives alone in a senior apartment complex. She is alert, with no signs of dementia.Two months before her first home care visit, Ms. Smith hit her right ankle on a table and subsequently developd a non-healing arterial wound. Her left leg showed scars from a previous wound that was diagnosed as pyoderma granulosum.

Ms. Smith was referred to a wound clinic for testing related to the non-healing right ankle wound. The testing showed that arterial flow was sufficent and there were no signs of infection. (See Arterial and venous wounds.) The clinic physician ordered compression for both legs. When Ms. Smith couldn’t tolerate a three-layer wrap, she was switched to a gauze bandage roll and ACT™ wraps and the wound began to heal.

When Ms. Smith’s regular home care nurse could not make a visit, another was sent. After removing the wrappings, the nurse found a blister on the the left leg and documented the new wound in the patient’s medical record.

The original wound on the right leg healed in the next 3 months, and the wound on the left leg progressed to almost complete healing. Ms. Smith didn’t feel comfortable with the wound center so her visits were cancelled. Her current home care nurse continued the treatment as ordered.

The home healthcare agency continued with the treatment as ordered by the physician until the left leg wound progressively increased in size. Ms. Smith was then referred to another wound clinic, where she received debridement and collagenase as a wound dressing. The wound increased in size after each debridement unitl it covered more than half of the lower leg. The wound clinic physician told Ms. Smith he would not continue her care at the clinic. The physician said amputation was the only option and that the patient had dementia, making her unable to make her own decisions.

Ms. Smith was upset at the idea of choices being made for her, as well as how the wound looked, so she called me to get advice. She accepted the recommendation to contact another physician, who discontinued the collagenase. Subsequently, the wound started to slowly improve.

The fear Ms. Smith felt about her wound and how it looked was real. Left to continue with the same dressing and treatment, it would have continued to get larger. She could have lost her leg and then her independence.

Missed opportunities

The missed care in this situation was the lack of the correct dressing, lack of communication related to changes in the wound, and lack of patient-centered care. Worsening of the wound can be connected to the healthcare system involved in Ms. Smith’s care. Her history of pyoderma granu­losum meant the dressing should never have included collagenase and the wound should not have been debrided. The home health nurses failed to communicate to the wound clinic and the primary care physician about how the wound was worsening. The wound clinic physician did not discuss options with the patient. Part of the reason for the missed care was the agency required nurses to visit too many patients. The visits had to be shortened with the lack of time to do what was needed for the patient. Too often in health care, financial pressure takes priority over patient care.

So what can be done to avoid this type of missed care? The agency should monitor the nurses’ workload so adjustments can be made as needed, particularly because overwork can lead to errors. The nurses and agency should collaborate to ensure patients’ wounds are properly evaluated and that a healthy work environment is present. Kalisch writes that nurses with higher job satisfaction have fewer incidences of missed care.

A wound care team, with a certified wound care nurse at the head, would help ensure proper asseement and interventions. The ideal team would include representatives from physical therapy, occupational therapy, dietary therapy, and nursing.

Finally, any time a provider or agency decides to no longer provide full care, the patient must be given options for where alternative care can be provided and a detailed “handoff” of the patient to the new provider needs to be made.

Improved care

Ultimately, Ms. Smith left the wound clinic and was evaluated by other physicians. Since leaving the clinic and no longer having daily debridements, her wound has decreased in size and new epithelial tissue is forming at the wound base. Two of her three specialists have agreed that the leg can be saved, and Ms. Smith underwent a skin graft to promote additional healing.

Selected references
Calianno C, Holton SJ. Fighting the triple threat of lower extremity ulcers. Nursing. 2007;37(3):57-63.

Kalisch BJ Landstrom GL, Hinshaw AS. Missed nursing care: a concept analysis. J Adv Nurs. 2009;65(7)1509-17.

Kalisch B, Tschannen D, Lee H. Does missed nursing care predict job satisfaction? J Healthc Manag 2011;56(2):117-31.

Tierney AJ. Editor’s choice. The concept of ‘missed nursing care’. J Adv Nurs. 2009;65(7):1355.

Watson J. Human Caring Science: A Theory of Nursing. Boulder, Colo: Jones & Bartlett Learning; 2012.

Trinite T, Loveland-Cherry C, Marion L. The U.S. Preventive Services Task Force: an evidence-based prevention resource for nurse practitioners. J Am Acad Nurse Pract. 2009;21(6):301-6.

Lydia A. Meyers is traveling wound care nurse. She is currently working in the state of California.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

The long and short of it: Understanding compression bandaging

By Robyn Bjork, MPT, WCC, CWS, CLT-LANA

Margery Smith, age 82, arrives at your wound clinic for treatment of a shallow, painful ulcer on the lateral aspect of her right lower leg. On examination, you notice weeping and redness of both lower legs, 3+ pitting edema, several blisters, and considerable denude­ment of the periwound skin. She is wearing tennis shoes and her feet have relatively little edema, but her ankles are bulging over the edges of her shoes; both socks are wet. Stemmer’s sign is negative. The wound on the right leg is draining copious amounts of clear fluid; it’s dressed with an alginate, which is secured with conforming roll gauze. No signs or symptoms of infection are present.

Staff report Mrs. Smith recently had pneumonia and, at that time, started sleeping in her recliner at night due to difficulty breathing. She has chronic heart failure (HF) and usually has 1+ pitting edema of the legs, but had no skin problems before that. Acute HF has been ruled out. She also has Alzheimer’s disease and wanders at night. She can’t operate her recliner’s electronic controls independently and fell twice trying to get out of the chair after the staff elevated the leg rest for her. Now they elevate her legs on a low stool and use a chair alarm.

In the past, Unna’s boots were applied to both legs. But Mrs. Smith became agitated, and staff cut them off when a circumferential wound developed on the upper calf. Venous Doppler exam reveals an old deep vein thrombosis in the right leg. Ankle-brachial index (ABI) is 0.65 in the right leg and 0.7 in the left. Based on her ABI, a colleague informs the staff that compression therapy is contraindicated because Mrs. Smith has peripheral arterial disease (PAD). Meanwhile, her ulcer is getting worse and the family is unhappy with the situation.

How would you heal this wound? As you’ve no doubt noticed, wound healing is more complicated than just wound assessment and treatment. To select the most appropriate bandaging system, you must understand the concepts of extensibility, recoil, containment, and working and resting pressures. This article can help you understand bandaging principles so you can confidently and effectively treat edema and heal wounds such as those of Mrs. Smith.

Extensibility: Long-stretch vs. short-stretch bandages

Extensibility is simply how much a bandage stretches.

Long-stretch bandages contain elastic fibers that enable stretching to approximately 140% to 300% of their original length. Ace™ bandages are an example.
Short-stretch bandages are woven with cotton fibers and stretch to about 30% to 60%. Examples include the Rosidal K® and Comprilan® bandages typically used in lymphedema management. A short-stretch system used in venous ulcer management is the Coban™ 2 layer compression system.

Some compression systems used in wound care have three or four layers. Although the total applied pressure of the bandaging system may be indicated in millimeters of mercury of force (mm Hg), individual layers may not be labeled as short-stretch or long-stretch. To test for yourself, simply stretch each layer to determine its type.

Working pressure and containment

Different bandaging systems have different effects on the venous and arterial systems and ultimately on edema. The effects relate to working and resting pressures, which I like to describe as containment and recoil. As a wound care clinician, you need to understand how short-stretch and long-stretch bandaging systems differ so you can make the right choices for your patients. (See Comparing short-stretch and long-stretch bandages.)

Roughly 60% to 80% of the body’s total blood volume resides in the venous circulation, ranging from 60 to 150 mL. The 2012 International Lymphoedema Framework’s position document for compression therapy states that blood pressure in the foot veins is 10 to 20 mm Hg in a supine position and 80 to 100 mm Hg in a standing position. During ambulation, when the calf muscle pump is functioning and vein valves are competent, blood pressure decreases to 30 mm Hg.

During walking or weight shifting, calf-muscle contraction is the primary means of returning blood to the heart through the veins. Pressure generated from the calf muscle can reach up to 300 mm Hg, propelling 60% of venous volume proximally with each contraction. Multilayered short-stretch bandages create an external force against calf-muscle contraction. They cause generation of inward pressure because they don’t allow calf muscles to bulge outward when they contract and shorten. This force compresses and pumps the veins, propelling blood toward the heart; graduated compression of bandages (more pressure at the ankle than calf) prevents backward blood regurgitation through incompetent veins. This is called working pressure. Thus, multilayered short-stretch bandaging systems cause high working pressure. Multilayered short-stretch bandages also act as a semirigid force to prevent expansion of edema. They offer excellent containment of all forms of edema.

In contrast, long-stretch bandages stretch as edema increases. They also provide little resistance to calf-muscle contraction. Therefore, they have low working pressure, don’t promote the calf-muscle pump, and provide poor edema containment.

View: Calf-muscle pump video

Resting pressure and recoil

Resting pressure is the inward force a bandaging system exerts on a limb at rest, such as when the patient sleeps. It results from recoil of elastic fibers or the weave of cotton fibers in a bandage. Long-stretch bandages, which have elastic fibers, have high extensibility and recoil and therefore high resting pressure.

This sustained resting pressure poses a problem for patients with arterial disease. For example, at night, perfusion of an extremity decreases as the heart rate slows, blood pressure decreases, and the legs are elevated. Patients may tolerate a bandaging system with a long-stretch layer during the day but may experience increased pain at night. In contrast, short-stretch bandages exert low resting pressure due to their limited recoil and are safer for patients with concurrent PAD.

According to experts, short-stretch bandaging systems with up to 40 mm Hg of compression can be applied safely to patients with ABIs above 0.5 and absolute ankle systolic blood pressure higher than 60 mm Hg. One study found short-stretch compression increased arterial blood flow to the limb and periwound skin by 28% when 31 to 40 mm Hg of compression was applied and increased venous ejection fraction by 103%.

Making the right choice for Mrs. Smith

For Mrs. Smith, I’d start with a lightweight, padded, short-stretch bandaging system such as the Coban Lite 2 layer compression system, made up of a thin foam inner layer and an outer short-stretch Coban layer. (Note: Most Coban rolls are medium stretch unless labeled short stretch.) This will enable her to walk at night. Short-stretch bandages have low resting pressure, so they’re safe to apply even though she has underlying PAD. The foam padding will protect her skin and avoid constriction and edging at the proximal aspect of the bandage. Also, the short-stretch system will recoil a bit as edema decreases, preventing the bandage from sliding down. When she walks, it will exert high working pressure to improve venous return.

Since Mrs. Smith’s recovery from the acute bout of pneumonia, staff need to reestablish the pattern of her sleeping in bed instead of the recliner, to decrease her dependent edema. This will keep her bandages from becoming tighter and uncomfortable at night. Once her venous and dependent edema improve, her skin ulcer will heal rapidly and the leg blisters and redness will resolve. Alginate or foam can still be used effectively under the bandaging system, and skin protectant can be applied to prevent further denudement.

Click here if you’re concerned whether to apply compression to a patient with HF, like
Mrs. Smith.

Click here to download the International Lymphoedema Framework’s consensus document for compression therapy.

Selected references
Dieter R, Dieter RA Jr, Dieter RA III. Venous and Lymphatic Diseases. New York, NY: McGraw-Hill; 2011.

Földi M, Földi E (eds). Földi’s Textbook of Lymphology: For Physicians and Lymphedema Therapists. 3rd ed. Mosby, Urban & Fischer; 2012.

International Lymphoedema Framework. Best Practice for the Management of Lymphoedema. 2nd ed. Compression Therapy: A position document on compression bandaging. 2012.
. Accessed August 30, 2013.

Mosti G, Iabichella ML, Partsch H. Compression therapy in mixed ulcers increases venous output and arterial perfusion. J Vasc Surg. 2012;55(1):122-8.

Zuther JE, Norton S. Lymphedema Management: The Comprehensive Guide for Practitioners. 2nd ed. New York, NY: Thieme; 2012.

Robyn Bjork is a physical therapist, certified wound specialist, and certified lymphedema therapist. She’s also the founder and chief executive officer of the International Lymphedema and Wound Care Training Institute, a clinical instructor, and an international podoconiosis specialist.

Improving outcomes with noncontact low-frequency ultrasound

By Ronnel Alumia, BSN, RN, WCC, CWCN, OMS

Achieving excellent wound care outcomes can be challenging, given the growing number of high-risk patients admitted to healthcare facilities today. Many of these patients have comorbidities, such as obesity, diabetes, renal disease, smoking, chronic obstructive pulmonary disease, and poor nutritional status. These conditions reduce wound-healing ability.

At the same time patient acuity has been rising, reimbursement for some types of care has been declining. For certain hospital-acquired conditions, such as stage III or IV pressure ulcers and certain surgical-site infections, reimbursement has been eliminated. Thus, clinicians can’t choose products based solely on their proven ability to obtain a good clinical outcome; they also must consider economic factors. Noncontact low-frequency ultrasound (NLFU) can help improve clinical outcomes and provide cost savings.

Ultrasound: Simple but effective

NLFU delivers sound waves to tissues through a saline mist. Unlike most wound care treatments, whose effects are limited to the surface, NLFU penetrates into and below the wound bed to reach previously inaccessible tissues. (See A glimpse of NLFU in action by clicking the PDF icon above.)

View: See how NLFU works

Ultrasound energy produces biophysical effects from mechanical stimulation of cells, promoting wound healing. A mechanical vibration, ultrasound is transmitted at a frequency above the upper limit of human hearing—20 kHz. The most common form of therapeutic ultrasound uses devices that operate in the 1- to 3-MHz range to treat various musculoskeletal disorders with a thermal effect. Diagnostic ultrasound, in contrast, operates in a high-frequency (20 to 40 MHz) range. It has a wide number of uses, from fetal monitoring to echocardiography.

In contrast, NLFU delivers low-frequency (40 kHz), low-intensity (0.2 to 0.6 W/cm2) ultrasound energy to the wound bed with no thermal effect. With most ultrasound therapy, a gel serves as a conduit to deliver sound waves to tissues. However, NLFU uses a saline mist, which eliminates contact with tissue and thus is painless.

NLFU can be performed by nurses with special training. The patient usually undergoes the procedure at the bedside three to five times per week, with the machine preset to a certain number of minutes based on wound measurement (length × width). Typically, the course of therapy ends when the desired outcome is achieved or the patient is discharged or transferred out of the facility.

The science of NLFU

The micromechanical forces produced by ultrasound energy at a cellular and molecular level have a wide range of effects on the wound-healing process, including reduction of bacteria within and below the wound bed. Unlike other body cells, bacteria have a rigid cell membrane; repeated pressing of sound waves can disrupt the bacterial membrane, causing cell death. (See NLFU: The science behind the solution by clicking the PDF icon above.)

Laboratory tests show NLFU reduces a wide range of bacteria, including some of the hardest to treat, such as methicillin- resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Acinetobacter baumannii. In a clinical study of patients who had stage III pressure ulcers with high levels of bacteria, punch biopsies were used to determine baseline and posttreatment bacterial counts. Results showed significant reduction in S. aureus (93.9%), A. baumannii (94%), and Escherichia coli (100%) after six NLFU treatments over a 2-week period. In live animal studies, NLFU disrupted the bacterial biofilm after just three treatments. (See NLFU and the healing process by clicking the PDF icon above.)

Sustained inflammation is a common barrier to healing. NLFU reduced pro- inflammatory cytokines in two studies—one involving patients with chronic diabetic foot ulcers and the other involving patients with nonhealing venous leg ulcers. This reduction correlated to reduced wound areas in these previously nonhealing wounds. In one of these studies, researchers reported a decrease in MMP-9, a matrix metalloproteinase that breaks down new granulation tissue and delays healing.

Studies also show NLFU increases vasodilation, stimulates vascular endothelial growth factor and angiogenesis, promotes early release of growth factors, and provides greater amounts of high-quality collagen. The overall result of these cellular effects is accelerated healing.

Clinical outcomes

Use of NLFU is supported by clinical data, including a meta-analysis, three randomized-control trials, 11 peer-reviewed studies, and multiple case series. A 2011 meta-analysis compiled data from eight published studies reporting the effect of NLFU on wound size and healing rates in 444 patients with various chronic wounds. It found 85% wound-area reduction in a mean of 7 weeks, wound-volume reduction of 80% at a mean of 12 weeks, and 42% complete wound closure at 12 weeks. By comparison, a meta-analysis of standard-of-care treatment found only 24% complete wound closure at 12 weeks. Thus, NLFU achieves almost twice the healing of the standard treatment.

Besides consistently speeding healing of open wounds, NLFU is an effective early treatment for suspected deep-tissue injuries (sDTI). In a study of 127 sDTIs treated with standard of care alone (63) or standard of care with NLFU (64), only 22% of standard-of-care-alone sDTIs resolved without opening or progressed only to a stage II pressure ulcer, compared to 80% in the NLFU arm. At my hospital, we found similar results in our patient population using NLFU to resolve sDTIs before they became full-thickness wounds. (See Clinical outcomes and cost savings from NLFU by clicking the PDF icon above.)

NLFU has been used in wound care settings across the country for several years. Increasingly, it’s being used in acute-care settings as clinicians are grasping its substantial clinical and economic benefits. This technology can help healthcare providers meet both clinical and economic outcome goals. NLFU is rapidly becoming the new standard for early sDTI intervention.

Selected references

Centers for Medicare & Medicaid Services. Hospital-acquired conditions in acute inpatient prospective payment system hospitals. October 2012. Medicare/Medicare-Fee-for-Service-Payment/Hospital AcqCond/downloads/hacfactsheet.pdf. Accessed July 13, 2013.

Driver VR, Yao M, Miller CJ. Noncontact low- frequency ultrasound therapy in the treatment of chronic wounds: a meta-analysis. Wound Rep Reg. 2011;19(4):475-80.

Escandon J, VIvas AC, Perez R, Kirsner R, Davis S. A prospective pilot study of MIST therapy’s effectiveness on bacterial bioburden reduction and wound progression in refractory venous leg ulcers. Poster presented at Symposium on Advanced Wound Care; Orlando, FL. April 17-20, 2010.

Honaker JS, Forston MR, Davis EA, Wiesner MM, Morgan JA. Effects of noncontact low-frequency ultrasound on healing of suspected deep tissue injury: a retrospective analysis. Int Wound J. 2013;10(1):65-72.

Kavros SJ, Miller JL, Hanna SW. Treatment of ischemic wounds with noncontact, low-frequency ultrasound: the Mayo Clinic experience, 2004-2006. Adv Skin Wound Care. 2007;20(4):221-6.

Kavros SJ, Schenck EC. Use of noncontact low-frequency ultrasound in the treatment of chronic foot and leg ulcerations: a 51-patienr analysis. J Am Podiatr Med Assoc. 2007;97(2):95-101.

Lai J, Pittelkow MR. Physiological effect of ultrasound mist on fibroblasts. Int J Dermatol. 2007;46(6):587-93.

Liedl DA, Kavros SJ. The effect of MIST ultra-sound transport technology on cutaneous microcirculatory blood flow. Abstract presented at Symposium on Advanced Wound Care, 2001.

Margolis DJ, Kantor J, Berlin JA. Healing of diabetic neuropathic foot ulcers receiving standard treatment. A meta-analysis. Diabetes Care. 1999;22(5):692-5.

Serena T, Lee SK, Lam K, Attar P, Meneses P, Ennis W. The impact of noncontact, nonthermal, low-frequency ultrasound on bacterial counts in experimental and chronic wounds. Ostomy Wound Manage. 2009;55(1):22-30.

Seth AK, Nguyen KT, Geringer MR, et al. Noncontact, low-frequency ultrasound as an effective therapy against Pseudomonas aeruginosa–infected biofilm wounds. Wound Repair Regen. 2013;21(2):266-74.

Thawer HA, Houghton PE. Effects of ultrasound delivered through a mist of saline to wounds in mice with diabetes mellitus. J Wound Care. 2004;13(5):171-6.

Yao M, Hasturk H, Kantarci A, et al. A pilot study evaluating noncontact low frequency ultrasound and underlying molecular mechanism on diabetic foot ulcers. Int Wound J. 2012 Nov 19. doi:10.1111/iwj.12005.

Ronnel Alumia is a wound care and ostomy nurse at Acuity Specialty Hospital of New Jersey in Atlantic City.

Preventing pressure ulcers starts on admission

By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN

The first 24 hours after a patient’s admission are critical in preventing pressure ulcer development or preventing an existing ulcer from worsening. A skin inspection, risk assessment, and temporary care plan should all be implemented during this time frame. Essentially, it’s the burden of the care setting to prove to insurers, regulators, and attorneys the pressure ulcer was present on admission and interventions were put into place to avoid worsening of the condition. Of course, patients also benefit from having their condition identified and treated promptly.

Taking a close look

Newly admitted patients must undergo a thorough skin inspection within 24 hours of admission. Many times, a wound care nurse is designated to perform this task. Although wound care nurses bring great expertise, their lack of availability can sometimes delay assessment. To avoid delay, all nurses must be capable of completing a skin inspection and accurately documenting their findings. A wound care nurse can educate nurses in skin inspection and documenting skin concerns.

Assessing risk and planning care

Performing a risk assessment within the first 24 hours ensures interventions are put in place to prevent skin breakdown and promote healing. That’s done as part of developing a temporary care plan. The care plan should contain interventions designed to minimize, stabilize, or remove identified risk factors. The interventions need to be put in place as soon after admission as possible.

Whenever possible, try to identify risk factors and/or wounds before the patient’s admission to ensure interventions are in place before the patient arrives.

Even if the care setting allows several days to complete a care plan, a temporary care plan for prevention of skin breakdown is strongly recommended within the first 24 hours. At a minimum, the temporary care plan should address the following:

• support surface for the bed and the wheelchair/sitting surface
• individualized turning and repositioning schedules for patients and helping patients to be as mobile and active as possible
• incontinence management, if needed
• keeping the skin clean and dry
• keeping the heels elevated off the bed
• addressing nutritional/hydration concerns for wound healing, dietary referral
• referrals to therapy, as appropriate
• daily inspection of the skin by nonlicensed staff and weekly skin inspections by licensed staff
• risk assessment per policy.
If the patient has a wound, the temporary care plan should also include:
• applying topical treatment, as ordered
• monitoring the patient for signs and symptoms of infection
• reporting any decline or changes to the primary care provider and family designee
• completing a comprehensive assessment of the wound at least weekly.

If nurses are uncomfortable with developing a care plan based on the risk assessment, it might be helpful for a manager or wound care expert to develop a “cheat sheet” with potential interventions that correlate with the individual risk factors identified. Once the temporary care plan is developed, it should be communicated to the nurses, nursing assistants, and and others on the interdisciplinary team.

Meeting your goal

Your goal as a clinician is to prevent the development of a pressure ulcer and ensure proper interventions are in place to promote healing in pressure ulcers present on admission. If you complete a skin assessment and risk inspection and then develop and communicate a care plan within the first 24 hours of admission, you should be successful in achieving that goal.

Jeri Lundgren is director of clinical services at Pathway Health in Minnesota. She has been specializing in wound prevention and management since 1990.

Power up your patient education with analogies and metaphors

By Janice M. Beitz, PhD, RN, CS, CNOR, CWOCN, CRNP

Quality patient education is essential for comprehensive health care and will become reimbursable under healthcare reform in 2014. However, it’s difficult to provide effective education when time for patient interactions is limited. You can enhance your instruction time—and make your teaching more memorable—by using the techniques of analogy and metaphor.

Powerful tools

Analogy and metaphor are figures of speech that have been used since the time of Aristotle and Plato. (See Comparing analogy and metaphor by clicking the PDF icon above.) Why are they so powerful for patient education? Because analogy and metaphor can make abstract concepts real, helping patients understand why they are ill and how suggested changes will help correct underlying causes.

Analogy and metaphor create a form of cognitive “scaffolding” on which patients can hook new material to information they already understand. Educational theorist David Ausubel suggests that learners (such as patients) require frameworks into which new information can be assimilated. An analogy or metaphor can act as an anchoring concept or an organizer for providing such a framework.

Research supports that analogies and metaphors can improve communication with seriously ill patients, such as those with advanced cancer. Casarett and colleagues conducted a cross-sectional study of audio-recorded conversations between patients and physicians. The results demonstrated that analogies and metaphors improved patient understanding and communication.

Using analogy and metaphor effectively

How can analogy and metaphor be used in patient education? The uses are limited only by the clinician’s creativity.

A primary care practitioner uses analogy to discuss good self-care practices. She tells patients that persons with quality self-care drive their bodies like Cadillacs while self-
neglecters drive their bodies like jalopies.

Even bad life circumstances can be used educationally. A psychiatric colleague uses the metaphor of a toaster: Acute illness is like a toaster. You put something in (the patient) and it comes out better than it was before (in terms of resilience). An oncology specialist colleague discusses the role of heredity (genetic predisposition) and environment in cancer development: Genes load the gun; environment pulls the trigger.

A metaphor for chronic wound healing is the light switch: The prolonged inflammatory process of delayed healing is similar to a light switch stuck in the “on” position. Interventions, such as debridement and other advanced modalities, aim at switching the light (inflammation) off. Another colleague specializing in GI disorders likens constipation to “not taking the garbage out enough.”

In a relatively recent systematic review of effective teaching strategies and methods of delivery for patient education, the analysis of published research studies found that the best patient education strategies were culturally appropriate, patient specific, and structured. Analogy and metaphor can address all three characteristics if well planned.

The literature also suggests that Humor (used appropriately) can augment the use of Analogy and Metaphor and allow teachers to HAM it up for better learning. Humorous analogies or metaphors that are relevant to patients’ interests offer maximum effectiveness. The vividness and active engagement that typify funny meta­phors and analogies have the capability to instruct in ways beyond words alone. Laughter and humor may allow the patient to experience a “refreshing pause” cognitively and help “ha-ha” become “aha!”

Metaphors and analogies can describe the education or learning process itself. The clinical educator helps the patient “plant seeds,” “peel away the layers,” or “switch on a light bulb.” The educator can capture boring, lifeless lecture material and “bring it to life.” This outcome is particularly helpful in more abstract areas, such as mental health issues and science concepts.

Optimal outcomes

Understanding quality patient education is important for optimal patient outcomes. Techniques such as analogy and metaphor can help patients learn more effectively and create a positive, relaxed learning environment. More importantly, metaphor and analogy appeal to multiple learning senses and can instruct in ways eclipsing the limits of words.

Selected references

Ausubel DP. Educational Psychology: A Cognitive View. New York, NY: Holt, Rinehart, and Winston; 1968.

Casarett D, Pickard A, Fishman J, Alexander S, Arnold RM, Pollak K, Tulsky J. Can metaphors and analogies improve communication with seriously ill patients? J Palliat Med. 2010;13(3):255-60.

Clark AM. Getting street wise: a metaphor for empowering nurses for evidence-based practice [editorial]. Nurse Educ Today. 2013;33:3-4.

Friedman AJ, Cosby R, Boyko S, Hatton-Bauer J, Turnbull G. Effective teaching strategies and methods of delivery for patient education: a systematic review and practice guideline recommendations. J Cancer Educ. 2011;26:12-21.

Garner R. Humor, analogy, and metaphor: H.A.M. it up in teaching. Radical Pedagogy. 2005;6:2.*qzYyjGFuedV09FP4crWmZ/
. Accessed April 7, 2013.

Hume K. Unexpected connections: teaching through metaphor and analogy. Teach Magazine. May 3, 2011. Accessed April 7, 2013.

Hydo SK, Marcyjanik DL, Zorn CR, Hooper NM. Art as a scaffolding teaching strategy in baccalaureate nursing education. Int J Nurs Educ Scholarsh. 2007;4(1):1-13.

Neibert K, Marsch S, Treagust DF. Understanding needs embodiment: a theory-guided re-analysis of the role of metaphors and analogies in understanding science. Sci Educ. 2012;96(5):849-77.

Sutherland JA. Teaching abstract concepts by metaphor. J Nurs Educ. 2001;40(9):417-19.

Janice M. Beitz is professor of nursing at Rutgers University School of Nursing in Camden, New Jersey.

Forging a communication bond with prescribers

By T. Michael Britton, RN, NHA, WCC, DWC

As wound care professionals, we’ve all experienced a time when we felt that our patient didn’t have the appropriate wound treatment orders. However, the physician, nurse practitioner, or other prescriber wouldn’t follow your recommendation. This situation is not only frustrating but can delay the healing process. This article explores why a prescriber might not follow your recommendation and offers solutions. It focuses on physicians, because I’ve had the most experience with them.

Know the physician’s “type”

For 5 years, I was vice president of a company that managed physicians. I started asking them, “What makes you follow or not follow the wound clinician specialist’s orders?” Responses varied, but one response gave me an important insight. The physician told me there are three types of physicians: those who know, those who think they know, and those who don’t know.

With this in mind, the first thing you need to do is identify which of the three physician types you’re dealing with. Ask mutual coworkers who’ve worked with the physician, as well as the physician’s peers, for input so you get a feel for his or her personality. Then tailor your interaction based on your findings. For example, if a physician is the “think they know” type, prepare ahead of time what your response will be in case the physician disagrees with your recommendation. If a physician falls into the “don’t know” category, you’ll need to provide more detailed information about the nature of your recommendation.

Start off on the right foot

Your first interaction with the physician is crucial because it sets the stage for your ongoing relationship. When you introduce yourself, include all your credentials and don’t be embarrassed to talk about your training and experience. If possible, you already should have assessed the patient and reviewed the chart. It may be helpful to have someone familiar to the physician and who knows your expertise provide the introduction.

Make your case

Physicians say that clinicians who make a recommendation commonly aren’t prepared to provide the information the physician needs to make an informed decision. Having your information organized and readily available increases the chance that the physician will accept your recommendation. Many tools can help you get organized. One of the most user-friendly is SBAR—Situation, Background, Assessment, Recommendation. (See SBAR communication tool.)

Before you call or see the physician, be sure you can answer “yes” to the following questions:
• Have I seen and assessed the patient myself (instead of relying on someone else’s report)?
• Am I calling the right physician to address this situation? For example, can the patient’s primary care physician address the problem or do I need to call one of the consulting specialists?
• Do I know the admitting diagnosis and admission date?
• Have I read the most recent progress and nurses’ notes?
• Do I have the patient’s chart available so I can easily access information, such as age, current medication, wound treat­ments, allergies, laboratory results, and most recent vital signs?
• Do I know the patient’s resuscitation status?

Know what to do in the case of inappropriate treatment

If you believe the physician’s prior treatment orders were inappropriate, calmly express your concerns, and give rationales for your opinion. Be ready to cite a reputable source, such as protocols or research studies, to validate your position. Use correct medical terminology but don’t overcomplicate your language. Share your ideas for alternatives and try to get permission for a trial period.

Also tap into other resources, such as pharmacists, other physicians, and even product representatives, for information or support to make your case. For instance, a pharmacist may be able to bolster your argument for making a switch from one antibiotic to another.

If all else fails, report the problem to the appropriate supervisor.

Know when to suggest and when to recommend

It’s important to understand the difference between a suggestion and a recommendation. A suggestion implies a possibility or proposal. A recommendation is something presented as worthy of acceptance or trial. The difference is in the direction of the flow. A recommendation flows from upper level to lower level and between equals; a suggestion flows from lower level to upper level. Making a recommendation when the situation calls for a suggestion can lead to someone in a higher position than you being offended or feeling that you have overstepped your boundaries. On the other hand, using a suggestion when a recommendation is needed can result in the other party taking it as an option, something they don’t have to do; therefore, they don’t follow through.

An example of a suggestion from lower level to upper level is when a unit nurse says to the physician, “Dr. Jones, we are currently changing Ms. Johnson’s dressing three times a day. Studies have shown that dressings should be removed as infrequently as possible to prevent excess wound cooling.”

Here’s an example of a recommendation between equals is this interaction between a unit nurse and a wound care nurse: “We should change Ms. Johnson’s dressing change from three times a day to every day. Her drainage has decreased and we can reduce the wound’s exposure time.” Note that the unit nurse provided a rationale for her recommendation.

Here’s another example of a recommendation: As the wound care expert, you’re consulted to evaluate a patient in a long-term care facility who continues to have skin breakdown. After reviewing the medical record, you realize the patient is being turned only once every 3 to 4 hours. When you meet with staff on the floor, you state,
“Ms. Johnson has had two pressure ulcers in the past 6 months, and has a history of diabetes, which can affect healing. She’s at high risk for skin breakdown, so she needs to be turned every hour.” Again, note that support is provided for the recommendation.

Pick your battles

It’s not important to win every battle. Instead, remember that you want to win the war. There will always be some physicians and other prescribers who aren’t willing to follow your suggestions. As professionals, we have to accept that. Of course, if a physician’s unwillingness to follow your suggestion puts the patient at risk for harm, you’ll need to take your case to the next level.

Download SBAR tool

T. Michael Britton is president and CEO of Consult Us, LLC, in Montgomery, Alabama.

Wounds on the Web: Accessing the best online resources

By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

Knowledge is exploding online, making it essential that you’re comfortable using the Internet. You can also go online to save time and find a job, among other tasks. (See Online value.)

However, you also need to keep in mind that anyone can put information on the Internet. As the caption of a cartoon by Peter Steiner, published in The New Yorker says, “On the Internet, nobody knows you’re a dog.”

Be sure to evaluate the information, including such criteria as validity, authorship, integrity, and timeliness (be wary of undated information). Here are specifics to check.


Who is the intended audience for the website? Children, teenagers, adults? General audience, professionals, students, researchers? Members of a certain group or proponents of a certain viewpoint? Content varies according to audience.


Why was the website created? To sell, advertise, inform, persuade? The purpose of a website may not be stated clearly, so review content to discern its purpose.


Here are some questions to ask about the website:
• Has the website been created by a layperson or a well-known organization?
• Who sponsors the website? What is the sponsor’s reputation?
• Is contact information provided?

You can often find this information under headings such as “About us” or “Our Philosophy.”


Consider these questions for authors of online content:
• What credentials does the author have? If you don’t know what a credential means, search for it online.
• What are the author’s experience and expertise? Consider looking up the author’s name in a search engine, using three forms:
• without quotes: Firstname Lastname
• enclosed in quotes as a phrase: “Firstname Lastname”
• enclosed in quotes with * between the first and last name: “Firstname * Lastname” (The * can stand for any middle initial or name in Google only.)
• What is the end of the main URL address (called the domain extension)? This tells you the type of organization associated with the URL.

Domain extension/Organization type

.com Commercial company, usually for-profit
.edu Educational institutions, usually colleges and
.gov Government agency
.mil Limited to use by the U.S. military
.net Network, sometimes an internet service provider
.org Organizations, usually nonprofit


The following questions help you determine objectivity:
• Is any bias evident? Does the author present the information objectively from various points of view, or from one particular point of view?
• Does the author or sponsor have a known affiliation that would indicate a specific agenda or bias?
• To what extent does the information attempt to persuade or sway the audience?
• Does the information include vague statements, generalizations, stereotypes, or emotional appeals?


Ask the following:
• Where did the author get the information? As in printed journals and books, you should expect support for the information, such as references or links.
• If there are links to other pages as sources, are they to reliable sources?
Do the links work? Do links to references work and are the references from reputable sources? Keep in mind that it’s possible to create fake references.
• Is permission to reproduce copyright information provided? If so, this
typically means the website values its content.
• If the site has health information, does it display the Health on the Net Foundation Code of Conduct (HONcode) symbol? This means HON has evaluated the website and has deemed it meets HON’s ethical principles. Absence of the symbol doesn’t mean there is a problem with the site, but its presence is another point in the site’s favor.

By asking questions like these, you can ensure you access accurate information for you and your patients.

Donna Sardina is Editor-in-Chief of Wound Care Advisor and cofounder of the Wound Care Education Institute in Plainfield, Illinois.

What’s causing your patient’s lower-extremity redness?

By Robyn Bjork, MPT, CWS, WCC, CLT-LANA

The ability to understand or “read” lower-extremity redness in your patient is essential to determining its cause and providing effective treatment. Redness can occur in multiple conditions—hemosiderin staining, lipodermatosclerosis, venous dermatitis, chronic inflammation, cellulitis, and dependent rubor. This article provides clues to help you differentiate these conditions and identify the specific cause of your patient’s lower-extremity redness.

Hemosiderin staining and lipodermatosclerosis

Hemosiderin staining is dark purple or rusty discoloration of the lower legs caused by chronic venous disease. A 2010 study found hemosiderin staining in all subjects with lipodermatosclerosis and venous ulcers. When vein valves fail, regurgitated blood forces red blood cells (RBCs) out of capillaries. Dead RBCs release iron, which is stored in tissues as hemosiderin, staining the skin.

Hemosiderin staining and active lipodermatosclerosis may be misdiagnosed as cellulitis. Active lipodermatosclerosis causes painful, sharply demarcated red patches on medial aspects of the lower leg. Unlike in cellulitis, redness in lipodermatosclerosis is localized to areas of hemosiderin staining and induration. Also, the skin isn’t hot and the patient is afebrile and unresponsive to antibiotics. Lipodermatosclerosis progresses to fibrosis and constriction, causing an inverted champagne-bottle appearance of the legs.

Treat active lipodermatosclerosis with compression therapy and topical corticosteroids, if needed. Control chronic venous hypertension with compression, and hemosiderin staining will fade. Refer the patient for potential corrective venous surgical procedures.

Venous dermatitis

Defined as inflammation of the epidermis and dermis, venous (stasis) dermatitis is common in patients with lower-extremity venous disease. Signs and symptoms include scaling, crusting, weeping, erythema, erosions, and intense itching. This disorder increases the risk of contact sensitivity. Advise the patient to avoid such products as lanolin, balsam of Peru, rubber, adhesives, fragrances, dyes, preservatives, skin sealants, silver sulfadiazine, neomycin, and bacitracin—all known to exacerbate venous dermatitis.

Venous dermatitis commonly is confused with cellulitis. A 2011 study found that 28% of 145 patients hospitalized for cellulitis had been misdiagnosed. The most common mistaken diagnosis was venous dermatitis. Unlike cellulitis, venous dermatitis causes itching and crusting; also, the skin isn’t acutely painful or hot and the patient is afebrile.

Treat acute venous dermatitis with compression therapy and mild-potency topical corticosteroids. Apply corticosteroids sparingly to affected areas once or twice daily for 2 weeks; be aware that premature discontinuation can lead to recurrence, while prolonged use can cause skin thinning and reduced efficacy. Domeboro soaks also decrease weeping, irritation, and itching. Paste bandages impregnated with calamine or zinc oxide are soothing and drying. However, some patients may react to the preservatives in paste bandages, so a patch test is prudent.

Chronic inflammation

Lymphedema causes chronic inflammation. About 50% of plasma proteins leak into the interstitial space daily and are recycled through the lymphatics. Lymphatic failure traps proteins in the tissues; the proteins act like sponges, attracting and binding fluid. The proteins then denature, triggering a chronic inflammatory response. This response sometimes is misdiagnosed and treated as chronic cellulitis.

Compared to cellulitis, high-protein chronic inflammation is diffuse and nontender, with light redness and mildly increased warmth. Local skin changes may include thickening or papillomatosis (a lumpy, bumpy appearance). A positive Stemmer’s sign confirms lymphedema. Complete decongestive physiotherapy promotes protein reabsorption and resolves chronic inflammation.


Cellulitis is a rapidly spreading infection of the dermis and subcutaneous tissue. In adults, it most commonly stems from Staphylococcus aureus infection of the legs. Erysipelas, a superficial form of cellulitis, involves the lymphatic system and is differentiated by “streaking” toward a regional lymph node.

Cellulitic skin is hot, acutely painful, edematous, and indurated. Redness spreads and the borders usually are irregular, sharply defined, and slightly elevated. Blisters, hemorrhagic bullae, abscesses, erosions, and necrosis may develop. About 30% to 80% of patients with lower limb cellulitis are afebrile. The white blood cell count, erythrocyte sedimentation rate, and C-reactive protein levels commonly are elevated, but normal values don’t rule out cellulitis.

Treat cellulitis with oral antibiotics effective against staphylococcus and streptococcus. Adding a brief course of oral corticosteroids significantly shortens cellulitis duration. Severe cases may necessitate hospitalization and I.V. antibiotics, plus abscess incision and drainage. Control edema with bed rest and leg elevation.

Recurrent cellulitis is common in patients with lymphedema. With compromised skin immunity, bacteria invade and spread with little resistance. If lymphedema is present, refer the patient for treatment after acute cellulitis resolves. If the patient already is being treated for lymphedema, suspend manual lymphatic drainage and compression until acute cellulitis resolves.

The most common disorders mistaken for lower-limb cellulitis are venous dermatitis, lipodermatosclerosis, irritant dermatitis, and lymphedema. It also may be mistaken for deep vein thrombosis (DVT) or dependent rubor. Rule out DVT using venous duplex ultrasound. Dependent rubor disappears with leg elevation, whereas cellulitic redness doesn’t.

Click here to view image of cellulitis.

Dependent rubor

Dependent rubor is a fiery to dusky-red coloration visible when the leg is in a dependent position but not when it’s elevated above the heart. The underlying cause is peripheral arterial disease (PAD), so the extremity is cool to the touch. To test for dependent rubor, position the patient supine and elevate the legs 60 degrees for 1 minute; then examine sole color. PAD causes the soles to change from pink to pale in fair-skinned people and to gray or ashen in dark-skinned people. The faster the pallor appears, the worse the PAD. Pallor within 25 seconds of leg elevation indicates severe occlusive disease, which warrants further evaluation for potential revascularization.

Next, observe skin color changes with the patient in a sitting position. Normally, the foot and leg should remain pink with elevation and dependency. In PAD, the color changes from pale to pink and then progresses to purple-red or bright red. The longer dependent rubor takes to reappear, the worse the PAD. Rubor that appears in 25 to 40 seconds indicates severe ischemia. If rubor disappears quickly with elevation and returns in less than 25 seconds, consider the possibility that the patient has venous reflux, not PAD. In this case, pooled blood causing the rubor drains rapidly from the veins when the leg is elevated and regurgitates back into the tissues when the leg is dependent.

If you detect dependent rubor, obtain the ankle-brachial index (ABI) to confirm PAD. For moderate PAD (ABI of 0.5 to 0.79), refer the patient for a routine vascular specialist consultation. For severe PAD (ABI below 0.5), maintain dry, stable wound eschar and urgently refer the patient to a vascular specialist for potential revascularization.

Click here to view images and read a case study on dependent rubor.

Knowledge summary

“Reading” the common causes of leg redness helps you determine what’s causing your patient’s redness so you can provide effective treatment. Remember—chronic venous disease causes hemosiderin staining, lipodermatosclerosis, and venous dermatitis. Dermatitis is itchy and crusty; lipodermatosclerosis causes sclerosis and an inverted champagne-bottle appearance of the legs. Relieve inflammation and itching with topical corticosteroids and treat venous disease with compression and corrective surgery. Lymphedema causes chronic inflammation; treat with complete decongestive physiotherapy. Cellulitis is a spreading skin infection that’s acutely painful and hot; treat with antibiotics. PAD causes dependent rubor, which disappears with leg elevation.

Selected references
Abbade LP, Lastória S, Rollo Hde A. Venous ulcer: clinical characteristics and risk factors. Int J Dermatol. 2011;50(4):405-11.

Bailey E, Kroshinsky D. Cellulitis: diagnosis and management. Dermatol Ther. 2011;24(2):229-39.

Beasley A. Management of patients with cellulitis of the lower limb. Nurs Stand. 2011;26(11):50-5.

Bryant R, Nix D. Acute and Chronic Wounds:
Current Management Concepts. 4th ed. St. Louis, MO: Mosby; 2011.

Buttaro TM, Trybulski J, Polgar P, Sandberg-Cook, J. Primary Care: A Collaborative Practice. 4th ed. St. Louis, MO: Mosby; 2012.

Caggiati A, Rosi C, Casini A, et al. Skin iron deposition characterises lipodermatosclerosis and leg ulcer. Eur J Vasc Endovasc Surg. 2010;40(6):777-82.

David CV, Chira S, Eells SJ, et al. Diagnostic accuracy in patients admitted to hospitals with cellulitis. Dermatol Online J. 2011;17(3):1.

Dieter R, Dieter RA Jr, Dieter RA III. Venous and Lymphatic Diseases. New York, NY: McGraw-Hill; 2011.

Foeldi M. Földi’s Textbook of Lymphology: For Physicians and Lymphedema Therapists. 3rd ed. Mosby, Urban & Fischer; 2012.

Hirschmann JV, Raugi GJ. Lower limb cellulitis and its mimics: part I. Lower limb cellulitis. J Am Acad Dermatol. 2012;67(2):163.e1-12.

Hirschmann JV, Raugi GJ. Lower limb cellulitis and its mimics: part II. Conditions that simulate lower limb cellulitis. J Am Acad Dermatol. 2012;67(2):177.e1-9

Keller EC, Tomecki KJ, Alraies MC. Distinguishing cellulitis from its mimics. Cleve Clin J Med. 2012;79(8):547-52.

Krasner, DL, et al. Chronic Wound Care 5: A Clinical Source Book for Healthcare Professionals. (Kindle ed.). Malvern, PA: HMP Communications; 2012.

Nazarko L. Diagnosis and treatment of venous eczema. Br J Community Nurs. 2009;14(5):188-94.

O’Connell DG, O’Connell JK, Hinman MR. Special Tests of the Cardiopulmonary, Vascular, and Gastrointestinal Systems. Thorofare, NJ: Slack Incorporated; 2011.

Sussman C, Bates-Jensen B. Wound Care: A Collaborative Practice Manual for Health Professionals. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.

Uzun G, Mutluoglu M. Images in clinical medicine. Dependent rubor. N Engl J Med. 2011;364(26):e56.

Robyn Bjork is a physical therapist, a certified wound specialist, and a certified lymphedema therapist. She is also chief executive officer of the International Lymphedema and Wound Care Training Institute, a clinical instructor, and an international podoconiosis specialist.

Is your wound-cleansing practice up to date?

By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

With so much focus on dressing choices, it’s easy to forget the importance of wound cleansing. Cleaning a wound removes loose debris and planktonic (free-floating) bacteria, provides protection to promote an optimal environment for healing, and facilitates wound assessment by optimizing visualization of the wound. You should clean a wound every time you change a dressing, unless it’s contraindicated.

Here’s a review of how to choose and use a wound cleanser so you can see if your practice is up to date.

Choosing a wound cleanser

The ideal wound cleanser is hypoallergenic, nontoxic to viable tissue, readily available, cost effective, and stable. The wound cleanser should also:

• be effective in the presence of organic material, such as blood, slough, or necrotic tissue
• reduce the number of microorganisms that form on the surface of the wound
• have a delivery force less than 15 pounds per square inch.

Common wound cleansers

Below are common types of wound cleansers:

Normal saline solution. Normal saline solution is the preferred cleansing agent because as an isotonic solution, it doesn’t interfere with the normal healing process. It’s also cost effective and available in many different formats, including unit dose, half liters, liters, and spray bottles.
Commercial cleansers. Ingredients in commercial cleansers may include surfactants, wetting agents, moisturizers, and/or antimicrobials.

  • Surfactants are agents that facilitate removal of wound contaminants. Each surfactant molecule has a hydrophilic (water-loving) head that is attracted to water molecules and a hydrophobic (water-hating) tail that repels water and simultaneously attaches itself to wound contaminants, oils, or grease.

These opposing forces loosen the particles and suspend them in the water.

Skin cleansers. Skin cleansers are
formulated to remove fecal matter, so they should never be used on open wounds, as they tend to be stronger than a wound cleanser and toxic to wound tissues.
Lactated Ringer’s solution. Lactated Ringer’s solution provides sodium, potassium, and calcium chloride to the wound, while safely cleaning it and avoiding damage to viable cells. Be careful when the solution is used for continuous irrigation or allowed to dwell inside body cavities; otherwise the solution could be absorbed into the bloodstream, leading to circulatory overload.
Potable (drinkable) tap water. Potable tap water can be used if there is no other alternative. Check the quality of the water source. Advantages of tap water for wound cleansing are efficiency, cost effectiveness, and accessibility. However, use normal saline solution instead of water for wounds with exposed bone or tendon.

Click here to see examples of wound cleansers.

How to clean a wound

Before you start, make sure the cleansing solution is at room temperature or slighter warmer. It can take up to 40 minutes after cleaning for a wound to regain its original temperature, and up to 3 hours for miotic cell division and leukocytic activity to return to normal.

Once the solution is warm, wash your hands and put on gloves.

View a video on wound cleaning

Manual cleansing technique
For a linear wound or incision:
1. Pour irrigation solution into the irrigation tray. Moisten clean 4″×4″ gauze pads in the solution; squeeze out excess.
2. Gently wipe the wound from top to bottom in one motion, starting directly over the wound.
3. Discard the used gauze pad.
4. Using a new moistened 4″×4″ gauze pad, repeat cleaning, using a gentle downward stroke parallel to the incision.
5. Repeat steps, working outward from the incision in lines parallel to the incision.
6. Remember to use a new 4″×4″ gauze pad for each downward stroke.
7. If needed, dry the wound, following the same procedure as for cleaning, using dry gauze pads.

For an open wound:
1. Pour the irrigation solution into the irrigation tray. Moisten 4″×4″ gauze pads in the solution; squeeze out excess.
2. Gently clean the wound in a full or half circle, beginning in the center and working toward the outside.
3. Use a new 4″×4″ gauze pad for each circle.
4. Clean at least 1 inch beyond the end of the new dressing or 2 inches beyond the wound margins if you aren’t applying a dressing.
5. If needed, dry the wound, using the same procedure as for cleaning. Gently pat the wound dry, using dry gauze pads.

Spray cleansers
1. Spray cleansers may be applied directly to the wound or sprayed onto clean 4″×4″ gauze pads and then applied to the wound.
2. Check your organization’s policy for required personal protective equipment (PPE). Generally, wound irrigation
that involves squirting, spraying, or pressure release of fluid will require the use of PPE (such as gloves, gown, and mask with eye shield) to prevent exposure to debris and airborne microorganisms.
3. Protect the environment, equipment, and other supplies from contamination from spray aerosolization by covering or removing the supplies.
4. Hold the spray bottle approximately
1 inch from the wound bed. Aim the nozzle at the wound and squeeze the bottle, directing the stream of cleanser along the base and sides of the wound.
5. Blot up excess moisture with a clean gauze pad.
6. Dry the surrounding skin.

Cleaning with a saline bullet
1. Position the patient so that the cleansing solution will flow by gravity from the upper end of the wound to the lower end.
2. Twist off the top.
3. Position the container at any angle required to access the area to be moistened or cleaned.
4. Apply firm pressure to the container to obtain the desired flow rate.
5. Blot up excess moisture with a clean gauze pad.
6. Dry the surrounding skin.

After you have finished cleaning the wound, dispose of the waste in a trash bag; then remove and discard your gloves and any other PPE you used.

Selected references

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick reference guide. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

Hess CT (ed.). Clinical Guide to Wound Care. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.

Kosier B. Fundamentals of Nursing: Concepts, Process, and Practice. 6th ed. Upper Saddle River, NJ: Prentice-Hall, Inc; 2000.

Ovington LG. Hanging wet-to-dry dressings out to dry. Adv Skin Wound Care. 2002;15(2):79-84.

Wound Source. Wound cleansers. Accessed April 1, 2013.

Donna Sardina is Editor-in-Chief of Wound Care Advisor and cofounder of the Wound Care Education Institute in Plainfield, Illinois.

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