Content Outlines

The course content outlines are listed below. Use the outlines to see the overview of the course or to search for topics and their locations in the course. Use Ctrl-F to search for keywords or topics on this page.


 

 

Week 1 | History of Wound Care, Certification, Professional Organizations and the CWCN Role

  • History of Wound Care
    • Three healing gestures: washing the wound, making plasters, bandaging
    • Early civilization and wound care
    • Civil War
    • 19th Century innovations
    • Moving to present day
  • WOCN Society
    • Beginnings of Enterostomal Therapy Nursing
    • WOCN history
  • Value of Certification
  • WOCNCB
  • Scope of CWCN practice
  • CWCN Role Components
    • Research
    • Educator
    • Consultant
    • Leader
  • Other Wound Organizations
    • Association for the Advancement of Wound Care (AAWC)
    • American Board of Wound Management (ABWM)
    • The American College of Clinical Wound Specialists (ACCWS)
    • American Professional Wound Care Association (APWCA)
    • Wound Care Education Institute (WCEI)
    • Wound Healing Society (WHS)
    • National Pressure Ulcer Advisory Panel (NPUAP)
    • European Pressure Ulcer Advisory Panel (EPUAP)

Week 1 | Evidence-Based Practice

  • What is evidence-based Practice? 
    • 5 Steps for EBN practice
    • What makes good evidence?
    • Why do nurses need to EBP?
    • Barriers to nurses using EBP
    • Searching for Evidence Pyramid F. HowtoLocateE-Resources
  • Search for the Best Evidence to Answer the Question - Search Databases Efficiently for Research Journal Articles
    • MEDLINE
    • CINAHL/CINAHL Plus
  • Locating E-Journals
    • Open Access and Free Journal Sites
    • Search for Practice Guidelines
    • National Guideline Clearing house guideline.gov
  • Search for Evidence Summaries
    • DynaMed: Prevention
    • Nursing Reference Center
  • Use a Meta-Search Engine to Find Evidence Sites

 

Week 1 | Healthcare Practices Legal or Ethical Issues

  • Wound management provider responsibilities when interacting with patients
  • Professional boundaries
  • Responsibilities to oneself
  • Social media
    • Positive benefitsImproved communication/quicker coordination of care
    • Sharing of information to improve practice
  • Pitfalls Violation of patient’s rights due to quick pace of social media Not allowing enough critical thinking time

Week 2 | Skin Anatomy and Function

  • TRIP Database
  • Systematic review vs. Meta-analysis
  • Cochrane Database of Systematic Review
  • Finding Systematic Review and Meta-Analyses in PubMed
  • Finding Systematic Review and Meta-Analyses in CINAHL
  • Navigating the Web beyond Basic Google to Find Evidence?
  • Google Advanced Search Features
  • Google Scholar
  • Must Evaluate Web Resources: Evaluation Strategies
  • Criteria for Evaluating Web Sites
    • Structure & function of the skin
      • Epidermis: Average thickness is .1 mm. The stratum spinosum and basale are
        the germinative layers and source of new cells.
        •  Five layers
          • Stratum corneum (hornylayer)
          • Stratum lucidum (clearlayer)
          • Stratum granulosum (granularlayer)
          • Stratum spinosum (prickle-celllayer)
          • Stratum basale (basallayer)
      • Basement Membrane Zone
        • Lamina lucida
        • Laminadensa
      • Dermis
        • Provides nutrient supply to the epidermis
        • Two layers
          • Papillary – the dermis is firmly attached to the epidermis through undulating rete ridges or pegs of the epidermis.
          • Reticular–dense network of collagen fibers
          • Dermal structures include: arteries, veins, capillaries, venules, lymph vessels, nerves, sweat and sebaceous glands, Meissner’s and Vater’s corpuscles, hair follicles.
        • Dermalproteins
          • Collage (typesI,V,VI) provides tensile strength
          • Elastin provides elasticity
      • Subcutis
        • The dermis merges into the subcutaneous layer anchored by connective 
          tissue strands.
        • Source of fat stores, mechanical cushion, and insulation.
      • Blood supply
        • Capillary pressures
        • Tissue vulnerability–skin vs. muscle and adipose tissue
      • Major Functions of Skin
        • Protection
        • Defense
        • Absorption
        • Secretion
        • Thermoregulation
        • Sensation
           
    • Environmental Skin Effects and Age Related Changes
      • Ultra-violet radiation exposure
      • Soaps
      • Factors affecting skin hydration
        • Medications
          • Steroids
          • Other - antimicrobials, antihistamines, tricyclic antidepressants, analgesics, oral contraceptives.
      • Fetal and young skin compared to adult and older skin
        • Connective tissue and cellular differences
        • Changes in skin layer thickness
        • Vulnerabilities associated with age (injury, absorption, separation of epidermal and dermal layers, dryness)

Week 2 | Using Research Results and Generating Data for Practice

  • Evidence based practice 
    • Focus: efficacy, safety, feasibility of the treatment, and how it affects other important outcomes.
  • Sources of Evidence
    • Types of studies: case reports, case series, cohort studies, clinical trials, multisite RCTs
  • Evaluating study designs
    • Masking 
    • Group similarities and differences 
    • Influence of other factors in care – did they affect outcome
  • Evaluating study results
    • Relative risk reduction 
    • Absolute risk reduction 
    • Number needed to treat 
    • Preciseness of results on treatment effect
  • Application of findings to individual practice 
  • Collecting data in practice 
    • Standardization of data collection 
    • Choice of outcome 
    • Systems for data aggregation 
    • Human subject issues 
  • Formal Research Generation 
    • Sponsored by commercial interests vs. institutional 
    • Establishing a formal research study 
  • Writing for Publication 
    • Where to start 
    • Options: case reports, poster presentations 
    • Manuscripts 

Week 2 | Review of Education Approaches for Patients/Supporters

  • Why Must Nurses Educate Patients/Families?
    • Is essential part of nursing practice
    • Patients need information
    • Patients have right to information and education
  • Expectations of Registered Nurses When Teaching Patients
    • Begin with thorough assessment of variety of issues
  • Expectations of Advanced Practice Nurses When Teaching Patients
    • Have all the expecation of RNs
    • As mid-level care provder, need to work collaboratively with other team members
    • Support patient/family learning
  • Expecations of Certified Wound Care Nurses When Teaching Patients
    • Similar again to the RN, but having access to additional expertise and materials
  • Get to Know the Person
    • Establish rapport
    • Determine levels of existing knowledge
    • Identify to the patient how this will benefit them
  • Establish Teaching Goals
    • Work together with patient/supporters
    • Yield to their needs, rather than your own
    • Plan accuracy in the information to be provided
  • Standard Methods for Teaching
    • Individual/family sessions
    • Formalized group sessions
  • Alternative Methods of Providing Education
    • Computers, videos, apps
    • Printed materials
    • Commercial programs
  • Material Preparation
    • Font size, grammar, spelling
    • Reading level
    • Terms used
  • Provide the Educational Information
    • Clear, provide enthusiasm, be supportive
    • Direct information to person being taught
    • Ask for recall
  • Working with Interpreters
    • Mandated that facilities provide interpreters
  • DHHS Interpreter Standards
  • Tips in Utilizing Interpreters
    • Meet in advance
    • Speak to the patient, not to each other
  • Documentation of Education/Learning Provided
    • Document needs identification
    • Document following teaching to show evidence of learning

Week 3 | Wound Healing Physiology

  • Physiology of Healing
    • Types of Healing
      • Primary
      • Secondary
      • Partial thickness
      • Full thickness
  • Major Wound Healing Phases
    • Hemostasis
    • Inflammation
    • Proliferation
      • Matrix
      • Angiogenesis
      • Epithelization
    • Remodeling
      • Collagen changes
      • Contraction
  • Cast of Cellular Characters
    • Platelets
    • Neutrophils
    • Monocytes/Macrophages
    • Fibroblasts
    • Vascular Endothelial Cells
    • Epithelial Cells
  • Hemostasis
    • Vascular responses
    • Immune activation
    • Platelet degranulation
    • Clot formation
    • Growth factor release
  • Cell signaling
    • Adhesion molecules
      • Transmembrane proteins
      • Intracellular signaling
    • Major families
      • Integrins
      • Selectins
      • CAMs
      • Cadherins
    • Role of Adhesion Molecules in Healing
      • Cell expression
      • Cellular interactions with CAM’s
    • Growth factors-molecular directors of healing
      • Proteins
      • Regulatory functions – cell migration, mitosis, gene expression, protein synthesis
    • Major Growth Factor Families Involved in Healing – family, sources, actions
      • Platelet derived growth factors (PDGF, VEGF)
      • Transforming Growth Factors – Beta
      • Fibroblast Growth Factors (FGF)
      • Insulin-like growth factor (IGF-1, IGF-2)
      • Epidermal growth factor (TGF-alpha, EGF)
  • Inflammation -- first 5 days after injury
    • Cellular infiltration by cell type
    • Provisional matrix-components and functions
    • Phagocytosis
    • Growth factor production
    • Clinical features
  • Tissue Proliferation – 7-21 days after injury
    • Matrix production
      • Wound module – what is it? How does it stimulate healing
      • Provisional matrix
      • Collagen production
        • Co-factors
        • Steps in synthesis by fibroblasts
        • Extracellular modifications and crosslinking
        • Differences in new versus mature collagen
      • Angiogenesis
        • Stimulatory signals within wound environment
        • Functions
        • Basement membrane changes and formation of capillary loops
        • Proteases
      • Epithelialization
        • Signals for cellular migration
        • Process of epithelial repair
  • Remodeling of the newly established matrix
    • Role of proteases
    • Changes in collagen
    • Wound strength

Week 3 | Wound Assessment

  • Develop a structured approach   
    • Assess the patient
    • Conduct a focused wound assessment
    • Perform a lower extremity exam
    • Identify the barriers to healing
    • Identify/confirm the wound etiology
    • Develop a comprehensive plan of care
      • Minimize or eliminate the etiologic factors and barrier to healing
      • Topical plan of care
    • Evaluate the plan
  • Patient Assessment  
    • Onset and duration of wound 
    • Treatment History 
    • Co-morbid conditions; past medical and surgical history 
    • Factors affecting healing 
    • Pertinent family history 
    • Current medications, allergies 
    • Recent lab values/culture results 
    • Nutritional and hydration status 
    • Functional status 
    • Incontinence 
    • Psychosocial issues
    • Knowledge base ​
  • Focused Wound Assessment  
    • Anatomic Location: Linking to wound etiology
    • Wound Size (in cm.)
      • Length
      • Width
      • Depth
      • Surface area
      • Wound shape
    • Wound Classification
      • Partial thickness/Full thickness
        • Partial thickness: Confined to the skin layers; skin damage that does not penetrate below the dermis and may be limited to the epidermal layers only. 
        • Full Thickness: Tissue damage involving total loss of the epidermis and dermis extending into the subcutaneous tissue and possibly into muscle or bone.
      • NPUAP Staging System for Pressure Injuries
      • Classification systems for specific types of wounds
  • Wound Base (% tissue type, color, consistency, adherence to wound bed, structures present) 
    • Non-viable tissue (%): eschar, slough = full thickness damage
      • Eschar: Black or brown necrotic, devitalized tissue; tissue can be loose or firmly adherent, hard or soft, dry or wet.
      • Slough: Soft moist avascular (devitalized) tissue; may be white, yellow, tan, or gray, may be loose or firmly adherent.
    • Viable (%): granulation, clean, non-granulating, epithelial.
      • Granulation tissue: Pink/red, moist tissue composed of new blood vessels, connective tissue, fibroblasts, and inflammatory cells, which fills an open full-thickness wound when it starts to heal. Typically, appears deep pink to red with an irregular, “berry-like” surface. 
      • Clean, nongranulating: Absence of granulation tissue; wound surface appears smooth and red as opposed to cobblestone or berry-like.  
      • Epithelialization: Regeneration of the epidermis across a wound surface. Pink, fragile-looking layer of new cells, may appear as islands.
    • Hypergranulation tissue
    • Granulation tissue quality  
  • Wound Edges/Margins (degree of attachment to the wound base, distinctness, thickness). Record location using the face of a clock and extent in cm.  
    • Undermining: Tissue destruction extending under intact skin along the periphery of a wound; commonly seen in shear injuries. 
    • Tunneling/Sinus Tract Course or path of tissue destruction occurring in any direction from the wound surface or edge of the wound; results in dead space. 
    • Non-proliferative wound edges/Epibole: Edges of top layers of epidermis have rolled down to cover the lower edge of epidermis, including basement membrane, so epithelial cells cannot migrate from wound edges. Presents clinically as a sealed edge of mature epithelium. Wound edge may present clinically as hard/thickened and/or discolored ( e.g. yellowish, gray, white). Also known as closed wound edges. 
  • Presence and Character of Exudate  
    • Color
    • Odor 
    • Consistency 
    • Volume: Wound dry-no exudate, Moist wound- small, Wet/saturated- moderate, Saturated, wound bathing in fluid- large. 
  • Presence or absence of symptoms of infection
    • Local signs 
      • Erythema 
      • Increased amount and/or change in character of exudate
      • Odor 
      • Increased local warmth
      • Edema or induration
      • Pain or tenderness
    • Systemic signs
      • Fever
      • Chills
      • Leukocytosis
      • Elevated glucose in patient with diabetes
      • Pain in a neuropathic extremity
    • Criteria for Critical Colonization and Infection
      • Critical Colonization: NERDS 
      • Deep tissue infection: STONES
  • Condition of the periwound skin 
    • ​Color
    • Texture
    • Temperature
    • Integrity
    • Lesions
  • Pain assessment (at rest and during dressing changes)
  • Mnemonic:

Little--Location
Snails--Size
Can--Classification
Be--Base
Eaten---Edges
Easily---Exudate
If---Infection 
Prepared--Periwound
Properly--Pain

Week 3 | Assessing and Caring for Surgical Wounds

  • Intentional injury that disrupts blood vessels and causes clotting and cascade of events that leads to wound closure within 2 to 4 weeks
  • History of Surgery—18th Century surgeons were apprentices of barbers and butchers
  • The Surgical Wound
    • Generally – acute wounds – Should heal quickly when incision is closed
    • Goals for Surgical Wounds
      • Prevent complications - SSI (surgical site infection)
      • Re-establish tissue integrity and function
      • Make cosmetically acceptable
  • Closure options for surgical wounds
    • Primary
    • Secondary
    • Tertiary
  • Used to Close Surgical Wounds
    • Sutures
    • Staples
    • Other approaches to closure
  • Removal of Staples/Sutures
    • Based on location, skin thickness, tension, cosmetic desire
    • 3-5 days
  • Impediments to Surgical Wound Closure
    • Poor Wound PERFUSION!
    • Non-viable tissue
    • Hematoma or seroma 
    • Surgical Site Infection (SSI)
  • Surgical Wounds: Complications
    • Hemorrhage
    • Dehiscence
    • Evisceration
    • Fistula
  • Other closure issues
    • Mechanical issues during/after surgery
    • Systemic Issues
      • Increased blood glucose
      • Cardiovascular disease
      • Obesity
      • Malnutrition
    • Personal activities
      • Smoking/drugs
  • Scar Formation
    • Hypertrophic – Within the area of the incision
    • Keloid – Beyond incision site ​

Week 4 | Wound Healing: The Role of Nutrition

Part 1

  • Comprehensive nutritional assessment
    • Medical history
    • Patient interview
    • Focused physical exam
    • Biochemical assessment
      • Albumin
      • Transferin
      • Transthyretin/prealbumin
      • Retinol binding protein
      • Causes for decreased visceral proteins
  • Relationship of nutrition and wound healing
    • Carbohydrates
    • Fats
    • Protein
      • Arginine
    • Vitamin C
    • Vitamin A
    • Minerals
      • Zinc
      • Iron
  • Metabolic impact of wounds
    • Kcalorie requirements
    • Protein requirements
    • Fluid needs
    • Vitamin and mineral needs

Part 2

  • Risk Factors for healing
    • Impact of diabetes
    • Advanced age
    • Polypharmacy
    • Malnutrition
    • Weight loss
  • Nutrition risk factors for pressure ulcers
    • Physiologic and biochemical impact of malnutrition
  • Research in nutrition and wound healing
    • Studies
      • Open Ulcers
      • Weight restoration
      • Protein supplements
  • Nutritional support to enhance healing
    • Assess adequacy of intake
    • If suboptimal intake
      • Supplements
      • Tube feeding
        • Positives
        • Concerns
        • PEG tubes
          • Advantages
          • Disadvantages
      • Parenteral nutrition
      • Multivitamin therapy
        • Vitamin C
        • Zinc
        • Fatty acids
        • Vitamin A
    • Reassess effectives of plan 

Week 4 | Pathophysiology of Wound Healing

  • Brief review of complexity of normal healing and systems affected by pathological changes.
    • Timing of cell migration to site of injury
    • Major cells and proteins involved in healing
      • Platelets
      • Leukocytes
      • Lymphocytes
      • Fibroblasts
      • Vascular endothelial cells
      • Epithelial cells
      • Growth factors
      • Adhesion molecules
    • Components of the wound matrix​
  • Inflammation – Friend or Foe?
    • Role of Neutrophils
    • How microbes are destroyed by the non-specific immune system
    • Phagocytosis
    • Role of macrophages
    • Immune related tissue damage
  • Growth factors and alterations in non healing wounds
    • Roles and effects of growth factors
    • Cellular recognition of growth factors
    • Internal cellular responses to growth factor stimulation
  • Cell cycles
    • Normal
    • Changes in chronic wounds
    • Cellular senescence​
  • Proteases
    • Roles in wound healing
    • Matrix metalloproteinases (MMP’s)
    • Tissue inhibitors of MMP’s
    • Importance to wound healing​
  • Concept integration: Why wounds don’t heal
    • Healing trajectory
    • Acute wounds and healing problems
    • Chronic wounds and healing problems
    • Wounds/injury etiology
    • Tissue factors
    • Pathology
    • Recurrence
    • Local wound environment
      • Proteases, TIMPs
      • Growth factors
      • Bacteria
      • Cellular senescence


Week 4 | Principles of Wound Management

  • Initial focus 
    • Patient history and presentation 
    • Identify factors that impact wound healing. 
    • Thorough wound assessment 
    • Confirm wound etiology  
    • Set realistic goals: maintenance vs. comfort vs. healing 
  • Control or Eliminate the Causative Factors (i.e.) 
    • Pressure ulcers: eliminate mechanical forces 
      • Pressure redistribution 
      • Measures to reduce friction and shear 
    • Arterial ulcers: enhance perfusion 
    • Venous ulcers: promote venous return with compression.
    • Neuropathic ulcers: off-load pressure 
  • Provide Systemic Support to Reduce Existing or Potential Co-factors. 
    • Optimize nutrition 
    • Provide adequate hydration 
    • Reduce edema 
    • Control blood glucose levels 
    • Promote blood flow 
  • Identify and manage critical colonization/infection. 
    • Appropriate and accurate wound culturing/biopsy 
    • Use of topical antimicrobials 
    • Systemic antibiotics 
    • Rule out osteomyelitis  
  • Maintain a Physiologic Local Wound Environment: Wound bed preparation 
    • Cleanse the wound: select appropriate solution and delivery method. 
    • Debridement 
      • Objectives for debridement 
        • Removal of non-viable tissue.
        • ​Reduce Bioburden 
        • Facilitate visualization of the wound base
        • Interrupts the cycle of the chronic wound 
      • Indications for debridement 
      • Contraindications for debridement
      • Classification of debridement 
        • Selective 
        • Non-selective 
      • Types of debridement  
        • Autolytic 
        • Chemical-Enzymatic 
        • Biologic
        • Mechanical  
        • Sharp 
      • Selection of debridement method. 
    • Maintain an appropriate level of moisture 
    • Eliminate dead space 
    • Control odor 
    • Eliminate or minimize pain 
    • Protect the surrounding skin 


Week 4 | Skin Tears

  • Skin tear definition and prevalence.
  • Intrinsic factors associated with skin tear risk.
    • Very young (neonate) and very old (>75 y.o.).
    • Female.
    • Caucasian.
    • Cognitive impairment
    • Inadequate nutritional intake.
    • Long-term corticosteroid use.
    • History of previous skin tears.
    • Altered sensory status.
    • Cognitive impairment.
    • Limb stiffness and spasticity.
    • Polypharmacy.
    • Presence of ecchymosis, hematoma and/or edema.
  • Extrinsic factors associated with skin tear risk.
    • Assistance required for bathing, dressing, toileting and transferring.
    • Frequent bathing leading to dry skin.
    • Having blood drawn.
    • Using assistive devices.
    • Applying and removing stockings, tapes and dressings.
  • Skin tear prevention
  • Skin tear classification
    • Payne-Martin
      • Category I
        • Skin tear can fully approximate wound.
        • Linear skin tear. Full thickness wound; the epidermis and dermis are pulled apart as if an incision had been made exposing tissue below. No tissue loss.
        • Flap-type skin tears. Epidermal flap can be reapproximated so that no more than 1 mm. of dermis is exposed.
      • Category II
        • Skin tears with partial tissue loss.
          • Scant tissue loss. 25% or less of epidermal flap is lost.
          • Moderate to large tissue loss. More than 25% of the epidermal flap is lost.
      • Category III
        • Skin tears with complete tissue loss.
          • Epidermal flap is absent.
          • STAR classification system.
  • Skin tear management 


Week 5 | Wound Management Documentation

  • Purpose 
  • Key Elements 
    • Reason for consultation 
    • Brief medical history 
    • Wound history 
    • Factors impacting healing 
      • ​Tissue perfusion/oxygenation 
      • Nutritional status 
      • Infection 
      • Diabetes 
      • Corticosteroids 
      • Age 
      • Stress 
      • Immunosuppression 
    • Focused wound assessment 
    • Short and Long Term Goals 
    • Treatment recommendations 
    • Plan for follow-up 
    • Assessment of Healing
      • % true area reduction
      • Bates-Jensen Wound Assessment Tool (BWAT).  
      • Pressure Ulcer Scale for Healing (PUSH)  
  • Documentation formats A. Flowsheets B. Narrative C. Electronic Medical Records  
  • Photography  
  • Documentation Practice 


Week 5 | Selection and Use of Topical Products

  • Complexity of Managing Wounds 
  • Process of Wound Management  
    • ​Review steps to thorough assessment 
    • Evaluate all components of the wound 
    • Prepare wound for dressing material 
    • Apply correctly selected product 
  • Review of Principles of Wound Management 
    • Moisture level 
    • Pearls for closure 
  • Making Product decisions 
  • Wound Cleansing Recommendations 
  • Topical Product Categories 
  • Terminology in Dressings 
  • Product Category Information 
    • Alginates 
    • Collagen 
    • Composites 
    • Contact Layers 
    • Enzymatic Debrider 
    • Exudate Absorbers 
    • Foams 
    • Gauze Products 
    • Hydrocolloids 
    • Hydrofiber 
    • Hydrogels 
    • Specialty Items 
    • Transparent Films 
    • Antimicrobials 
      • Silver Based Dressings 
      • Cadexomer Iodine 
      • PHMB 
      • Honey Based Products 
      • Hydrofera Blue 
  • Compression Materials 
    • Different types  
    • Varying Layers 
    • Specific Category Information 
  • Establishing a Formulary 
  • Summary 


Week 5 | Caring for the Patient with Obesity

  • Scope of the obesity problem
    • Definitions
      • Obesity: lifelong, progressive, life threatening, genetically related, multifactorial disease of excess fat storage (American Society of Bariatric Surgery).
      • Bariatrics: The branch of medicine that deals with the causes, prevention and treatment of obesity.
    • Body Mass Index (BMI): An adult’s weight in relation to his or her height. BMI = weight in kg ÷ (height in meters)2
      • BMI of < 18.5 = Underweight
      • BMI of 18.5-24.9 = Normal weight
      • BMI of 25-29.9 = Overweight
      • BMI of 30-34.9 = Obesity Class I
      • BMI of 35-39.9 = Obesity Class II
      • BMI of 40-49.9 = Obesity Class III
  • Obesity trends 
    • Adults 
    • Gender specific 
    • Children and adolescents 
    • Racial and ethnic groups 
  • Medical complications of obesity 
    • Type 2 diabetes 
    • Hypertension 
    • Dyslipidemia 
    •  Ischemic heart disease 
    • Stroke 
    • Obstructive sleep apnea 
    • Asthma 
    • Nonalcoholic steatohepatitis (fatty liver disease) 
    • GERD
    • Degenerative joint disease 
    • Infertility 
    • Polycystic ovarian disease 
    • Metabolic syndrome 
    • Stress urinary incontinence 
    • Venous disease 
    • Depression 
    • Gallstones 
    • Skin ulcers and infection 
  • Weight bias 
    • Stereotypes and psychological impact 
    • Impact on care 
  • Environmental concerns 
    • Language 
    • Appropriate sized medical equipment/setting 
    • Safe patient handling 
    • Bariatric body dynamics: implications for care 
      • Apple or apple ascites 
      • ​Apple pannus distribution 
      • ​Pear abducted distribution 
      • Pear adducted distribution 
    • Bulbous gluteal region 
    •  Abdominal pannus
      • Care issues 
      • Pannus grading system 
  • Obesity and skin issues 
    • Risk factors 
    • Cutaneous manifestations: implications for care 
      • Acanthosis Nigricans 
      • Skin tags 
      • Striae Distensae 
      • Intertrigo 
        • Prevention 
        • Skin fold management 
      • Lypmhedema/Elephantiasis Nostra 
      • Venous ulcers 
      • Pressure ulcers 
      • Surgical wounds 
  • Obesity treatment 
    • Treatment options 
    • Selection criteria 
    • Surgical treatment 
      •  Indications 
        • BMI >40 kg/m2 
        • BMI 35Ð39.9 kg/m2 and life-threatening cardiopulmonary disease, severe diabetes, or lifestyle impairment 
        • Failure to achieve adequate weight loss with nonsurgical treatment
      • Contraindications
        • History of noncompliance with medical care 
        • Certain psychiatric illnesses: personality disorder, uncontrolled        depression, suicidal ideation, substance abuse 
        • Unlikely to survive surgery 
      • Surgical options
        • Purely Restrictive 
          • Laparoscopic adjustable gastric banding (LAGB) 
          • Sleeve Gastrectomy
        • Restrictive > Malabsorptive: Roux-en-Y gastric bypass (RYGB) 
        • Malabsorptive > Restrictive: Biliopancreatic diversion w/ duodenal  switch (BPD-DS) 
      • Complications
      • Outcomes


Week 6 | Tubes and Drains - Percutaneous Tubes

  • Percutaneous Tubes
    • Tubes placed through the skin to another organ or body space
    • Indication
  • Tubes covered
    • Gastrostomy tubes (includes PEG tubes)
    • Jejunostomy tubes
    • Gastrojejunostomy tubes
    • Nephrostomy tubes
    • Biliary tubes
  • Gastrostomy Tubes
    • Placed into the stomach
    • PEG=percutaneous endoscopic gastrostomy tube
    • Low profile gastrostomy tube (LPGT)
    • Contraindications for placement
    • Pediatric considerations
    • Tube insertion by interventional radiology
  • Jejunostomy tubes
    • Indication
    • Tube tip is placed post pyloric into jejunum
  • Gastrojejunostomy Tubes
    • Indication:
    • Usually can convert existing G tube to GJ tube
  • Site care for gastric, jejunal and gastrojejunostomy tubes
    • Stabilize
    • Check tube position
    • Monitor insertion site for skin breakdown
    • Cleanse site
    • Dressing is optional
  • Tube Care
    • Avoid inserting catheters or tubes not intended for enteral feeding
    • Tube securement
  • Complications
    • Leakage
    • Moisture Associated Skin Damage
    • Candidiasis
    • Ulcerations
    • Hypergranulation tissue
    • Cellulitis
    • Device Related Pressure Injury
    • Tube Misplacement or Displacement
    • Accidental Removal of Recently Placed Tubes
      • Less than 14 days
      • More than 30 days
      • MARK
  • Tube Removal, but site does not heal
  • Preventing tube clogs
  • Declogging feeding tubes
  • Nephrostomy tubes
  • Biliary tubes
  • Tubes to drain abscesses


Week 6 | Enterocutaneous Fistula Management

  • Clinical presentation 
  • Etiology: Postoperative vs Spontaneous 
  • Risk Factors 
  • Fistula Terminology 
  • Fistula Classification 
    • Simple or Complex 
    • Location 
    • Volume of output 
  • Enteroatmospheric Fistulas 
  • Principles of ECF management 
    • Recognition and stabilization 
    • Anatomic definition and decision 
    • Definitive operation  
  • Medical Management 
    • Spontaneous closure 
    • Factors that prevent spontaneous closure 
  • Surgical Management Options  
  • Nursing goals 
  • Comprehensive nursing assessment 
  • ​Treatment Decisions 
    • Skin protection 
    • Containment Devices 
      • Dressings 
      • Pouches 
      • Drains 
      • Negative pressure wound therapy 
  • Odor Control 

 


Week 6 | Pressure Injury Scope, Etiology and Staging

  • Pressure Injury Scope 
    • Overview 
      • Significance       
      • Scope of the problem 
      • Prevalence: Number of patients with at least one pressure injury who exist in a given population at a given point in time. 
      • Incidence: Number of patients who were initially injury free who develop a pressure injury within a particular time period in a defined population. 
  • Pressure Injury Etiology
    • Pressure Injury: A localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure injuries; then significance of these factors is yet  to be elucidated. 
    • Pressure from devices. 
    • Mucosal pressure injuries: pressure injuries found on the mucous membrane with a history of a medical device in use at the location of the injury. 
    • Causative factor is pressure which is dependent upon: 
      • Intensity of pressure. 
      • Duration of pressure. 
      • Tissue tolerance: the condition or integrity of the skin and supporting structures that influences the skin's ability to redistribute pressure.  
    • Factors affecting tissue tolerance 
      • Intrinsic 
        • Nutritional debilitation 
        • advanced age 
        • Low blood pressure 
        • Stress
        • Smoking 
        • Elevated body temperature 
      • Extrinsic 
        • Friction 
        • Shear 
        • Moisture
    • Pathophysiologic theories of pressure injury development 
      • Ischemia caused by occlusion of capillaries. 
      • Reperfusion injury. 
      • Impaired lymphatic function. 
      • Mechanical deformation of tissue cells.
    • Common pressure injury locations 
    • Heel pressure injuries
  • National Pressure Ulcer Advisory Panel Staging System: used only classify pressure injuries based on the depth of tissue destruction.  
    • Deep Tissue Pressure Injury (DTPI) 
    • Stage 1 
    • Stage 2 
    • Stage 3
    • Stage 4
    • Unstagable 
  • Practice classifying tissue damage.


Week 6 | Indications for Hyperbaric Oxygen Therapy

  • History 
  • Indications 
    • Routine 
    • Emergent 
  • Hyperbaric physiology 
  • Determination of patient candidates 
    • Venous stasis 
    • Diabetic wounds 
    • Radiation injury 
    • Compromised flaps and grafts 
    • Acute wounds 
  • Contraindications 
  • Insurance considerations 
  • Case Studies
    • Calciphylaxis
    • Peripheral Vasculitis
    • Diabetic ulcers
    • Radiation injury
    • Necrotizing Fasciitis