Jump Start Your Career as a Wound Care Nurse. Diane L. Krasner PhD RN FAAN
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1 Jump Start Your Career as a Wound Care Nurse Diane L. Krasner PhD RN FAAN
2 Good News: There are opportunities for all levels of nurses as Wound Specialists!
3 3 OBJECTIVES Identify the growing need for specialized wound care nurses Discuss the essentials of wound care Appraise the resources available for nursing students & new graduates on the Why Wound Care? website
4 CONFLICT OF INTEREST DISCLOSURE I, Diane L. Krasner, certify that, to the best of my knowledge, no affiliation or relationship of a financial nature with a commercial interest or organization has significantly affected my views on the subject on which I am presenting.
5 DIANE KRASNER PHD RN FAAN LIA VAN RIJSWIJK DNP MSN RN CWCN CO-CHAIRS, WHY WOUND CARE CAMPAIGN
6 WWC? MISSION To inform nursing students, recent graduates and nursing faculty about rewarding careers in wound care
7 WWC? VISION To increase the number of nurses who choose a career in wound care so as to enhance safe, effective care for people with, or at risk for, wounds.
8 Diane L. Krasner PhD RN CWCN CWS MAPWCA FAAN Wound & Skin Care Consultant & Adjunct Clinical Faculty, Nursing, Harrisburg Area Community College York Campus, Nurse Evaluator, NNAAP, CEP American Red Cross York Chapter & Expert Witness York, PA
9 RN since 1979 WOCN (Wound Ostomy Continence Nurse) since 1985 Wound & Skin Care Consultant since 1989 Expert Witness since 1989
10 Case #1 Wound Care with Negative Pressure Wound Therapy, HBOT & an Interprofessional Team Approach
11 NEGATIVE PRESSURE WOUND THERAPY (NPWT) & HYPERBARIC OXYGEN THERAPY (HBOT) s/p Arteriogram, Hematoma, Muscle Flap & then Necrotizing Fasciitis Transferred to our major medical center for debridement and HBPT NPWT used simultaneously at patient s three wound sites Delayed primary closure Krasner, DL. (2002). Managing wound pain for patients with vacuum-assisted closure (VAC) devices. Ostomy Wound Management. May 2002.
12 Krasner, DL. (2002). Managing wound pain for patients with vacuum-assisted closure (VAC) devices. Ostomy Wound Management. May 2002.
13 Krasner, DL. (2002). Managing wound pain for patients with vacuum-assisted closure (VAC) devices. Ostomy Wound Management. May 2002.
14 Krasner, DL. (2002). Managing wound pain for patients with vacuum-assisted closure (VAC) devices. Ostomy Wound Management. May
15 Krasner, DL. (2002). Managing wound pain for patients with vacuum-assisted closure (VAC) devices. Ostomy Wound Management. May
16 Krasner, DL. (2002). Managing wound pain for patients with vacuum-assisted closure (VAC) devices. Ostomy Wound Management. May
17 Cases #2 & #3 Palliative Wound Care
18 Photo Courtesy of Diane L. Krasner
19 MRS. L. S/P CHEMOTHERAPY WOUND Krasner DL, McKinney W, Augustine S, Schaale S. (2008). Silver Dressings and Palliative (Symptom Management) Wound Care: a Case Series. Journal of Wound Technology (No. 2, October 2008),
20 WOUND CARE Cleansing Topical Anesthetic Non-adherent dressing Minimize number of dressing changes Krasner DL, McKinney W, Augustine S, Schaale S. (2008). Silver Dressings and Palliative (Symptom Management) Wound Care: a Case Series. Journal of Wound Technology (No. 2, October 2008),
21 PAIN MANAGEMENT Chronic Wound Pain Mixed Pain Pattern: Swelling Ischemia Neuropathic pain Krasner DL, McKinney W, Augustine S, Schaale S. (2008). Silver Dressings and Palliative (Symptom Management) Wound Care: a Case Series. Journal of Wound Technology (No. 2, October 2008),
22 MR. S. END STAGE ARTERIAL DISEASE Krasner DL, McKinney W, Augustine S, Schaale S. (2008). Silver Dressings and Palliative (Symptom Management) Wound Care: a Case Series. Journal of Wound Technology (No. 2, October 2008),
23 Krasner DL, McKinney W, Augustine S, Schaale S. (2008). Silver Dressings and Palliative (Symptom Management) Wound Care: a Case Series. Journal of Wound Technology (No. 2, October 2008),
24 Krasner DL, McKinney W, Augustine S, Schaale S. (2008). Silver Dressings and Palliative (Symptom Management) Wound Care: a Case Series. Journal of Wound Technology (No. 2, October 2008),
25 Krasner DL, McKinney W, Augustine S, Schaale S. (2008). Silver Dressings and Palliative (Symptom Management) Wound Care: a Case Series. Journal of Wound Technology (No. 2, October 2008),
26 To cure occasionally, To relieve often, To comfort always. - Hippocrates
27 The Growing Need for Wound Care Specialists
28 Increasing population with chronic conditions and related wounds Current shortfall of Wound Nurse Specialists well documented Wound Specialist Nurses needed across the continuum of care van Rijswijk L, Krasner DL. Calling all nursing students: how much wound care is in your future? Ostomy Wound Management, March 2016.
29 EXAMPLES LPNs Treatment Nurses & APN Wound Specialists in Skilled Nursing Facilities RNs on Wound Specialty Units in Acute Care & Outpatient Wound Centers Certified Wound Nurses across the continuum of care DNP & PhD Wound Specialists needed to conduct wound research, outcomes research and support the implementation of evidence-based practices
30 Certifications for Nurses* American Board of Wound Management (CWS): LPNs, RNs, APNs, DNPs & PhDs NAWCO (WCC): LPNs, RNs, APNs, DNPs & PhDs Wound Ostomy Continence Certification Board (CWOCN; CWCN): RNs, APNs, DNPs & PhDs * Additional information at:
31 Wound Care: Apply What You Know About Nursing Concepts & Principles
32 Assessment Risk Assessment Healable - Maintenance & Non-healable
33 Annually there are over 6.5 million Americans with non-healing wounds
34 This number is expected to rise due to: Diabetes Obesity Alzheimer s Disease
35 TYPES OF WOUNDS AAWC Used with permission
36 AAWC Used with permission SKIN TEAR
37 AAWC Used with permission UNSTAGEABLE PRESSURE ULCER
38 AAWC Used with permission DIABETIC FOOT ULCER
39 VENOUS ULCER AAWC Used with permission
40 INCONTINENCE-RELATED SKIN BREAKDOWN AAWC Used with permission
41 INFECTED WOUNDS AAWC Used with permission
42 AAWC Used with permission
43 THREE PATHWAYS: HEALABLE MAINTENANCE NON- HEALABLE/PALLIATIVE KRASNER, DL. (EDITOR). (2014). CHRONIC WOUND CARE: THE ESSENTIALS. MALVERN, PA: HEALTH MANAGEMENT PUBLICATIONS.
44 Individual/ Team (micro) to Organization (Meso) to External: Community/ Region National/ International (Macro) The International Interprofessional Wound Caring Model Individual Wound Care Expertise SCOPE Organization Community/ Region National/ International FOCUS Social responsibility Population health Research Continuous Professional Development & Lifelong Learning Knowledge Transfer to Practice/ Quality Improvement HOW (Embed change) Policy, regulation, operations: Departments of Education, Health, Labor Healthcare Professional s Caring Krasner, DL. (Editor). (2014). Chronic Wound Care: The Essentials. Malvern, PA: Health Management Publications. Person & Circle of Care Communities of Practice Interprofessional Team 2012 Krasner, Rodeheaver, Sibbald, Woo
45 Documentation should illustrate a consistent Interprofessional Patient-Centered Team Approach to care Krasner, DL. (Editor). (2014). Chronic Wound Care: The Essentials. Malvern, PA: Health Management Publications.
46 Wound Care: Utilize Your Critical Thinking Skills
47 THE AVOIDABLE VS.UNAVOIDABLE PRESSURE ULCER DEBATE
48 If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed-sore, it is generally the fault not of the disease, but of the nursing. - Florence Nightingale Notes on Nursing, 1859 HISTORICAL ROOTS FOR THE AVOIDABILITY OF PRESSURE ULCERS
49 Jean-Martin Charcot The Decubitus Ominosis Lecture on Diseases of the Nervous System 1877 Levine JM, JAGS 53: , 2005 HISTORICAL LINKS BETWEEN PRESSURE ULCERS & DEATH / UNAVOIDABILITY
50
51 JEAN MARTIN CHARCOT VS. HENRI BROWN-SEQUARD THE AVOIDABLE VS. UNAVOIDABLE DEBATE BEGINS J Levine. JAGS 1992; 40:
52 Alois Alzheimer Frau August D Died April 8, 1906 Septicemia due to decubitis ulcers in end stage Alzheimer s Disease Shenk D, The Forgetting 2001, p. 22
53 Skin Failure Langemo & Brown 2006 Kennedy Terminal Ulcer Karen Lou Kennedy 1989 FAST FORWARD TO THE TWENTIETH CENTURY...
54 Skin Changes At Life s End (SCALE) 2009 SCALE Documents downloadable from
55 SCALE Wounds (2009) SCALE Documents downloadable from Photos Courtesy of Diane L. Krasner
56 SCALE STATEMENT 1 Physiological changes that occur as a result of the dying process (days to weeks) may affect the skin and soft tissues and may manifest as observable (objective) changes in skin color, turgor, or integrity, or as subjective symptoms such as localized pain. These changes can be unavoidable and may occur with the application of appropriate interventions that meet or exceed the standard of care. The SCALE Expert Panel. Skin Changes At Life s End (Chapter 23). In Krasner, DL. (Editor). (2014). Chronic Wound Care: The Essentials. Malvern, PA: Health Management Publications.
57 Photos Courtesy of Diane L. Krasner
58 NPUAP 2010 AVOIDABLE ULCER An avoidable pressure ulcer can develop when the provider did not do one or more of the following: evaluate the individual s clinical condition and pressure ulcer risk factors; define and implement interventions consistent with individual needs, individual goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. NPUAP, 2010; OWM 2011; 57(2): 30.
59 NPUAP 2010 UNAVOIDABLE ULCER An unavoidable pressure ulcer can develop even though the provider evaluated the individual s clinical condition and pressure ulcer risk factors; defined and implemented interventions consistent with individual needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the interventions as appropriate. NPUAP, 2010; OWM 2011; 57(2): 30.
60 UNAVOIDABLE PRESSURE INJURY: STATE OF THE SCIENCE AND CONSENSUS OUTCOMES Laura E. Edsberg, Diane Langemo, Mona Mylene Baharestani, Mary Ellen Posthauer, Margaret Goldberg Journal of Wound Ostomy Continence Nursing 2014; 41(4): Lippincott Williams & Wilkins July/August Issue, 22 pages
61 2014 NPUAP CONSENSUS CONFERENCE FEBRUARY 27, 2014 Introduced the terms: Pressure Injury Unmodifiable risk factors Unmodifiable intrinsic risk factors (N=11) (e.g. impaired tissue oxygenation Unmodifiable extrinsic risk factors (N=8) (e.g. immobility) Edsberg et al. JWOCN 2014; 41(4);
62 Surgical Debridement (Aggressive) vs. Enzymatic Debridement (Palliative) vs. No Debridement (Maintenance) Photos Courtesy of Diane L. Krasner
63 Wound Care: Scope & Standards, CPGs, Safety & Quality
64 SCOPE OF PRACTICE Reflects State Nurse Practice Acts May differ from state to state for RNs Different for RNs & LPNs (e.g. RNs assess; LPNs monitor) CNAs / NAs practice under nurses direction
65 STANDARDS OF PRACTICE (ANA, SCOPE & STANDARDS OF PRACTICE, 2 ND EDITION, 2010) Care Planning Communication Consults Documentation Ethics
66 STANDARD OF CARE What a reasonably prudent nurse would do with a similar patient in similar circumstances in a similar setting.
67 STANDARD OF CARE = ACTUAL CARE STANDARD OF CARE IS NOT: Clinical Practice Guidelines Best Practices Policies & Procedures Information in textbooks
68 NPUAP EPUAP PPPIA CPG 2014 Available at
69 AMDA CPG PUs in LTC
70 To Err is Human: Building a Safer Health System Institute of Medicine National Academy Press 2000 Crossing the Quality Chasm: A New Health System for the 21st Century Institute of Medicine National Academy Press 2001
71 If Disney Ran Your Hospital: 9 1/2 Things You Would Do Differently Second River Healthcare Press 2004
72 The Checklist Manifesto: How to Get Things Right Atul Gawande Metropolitan Books 2010
73 Why Hospital Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care John J. Nance, JD Second River Healthcare Press 2008
74 Charting the Course Launching Patient-Centric Healthcare Sequel to Why Hospitals Should Fly John J. Nance, JD Kathleen Bartholomew, RN, MN Second River Healthcare Press 2012
75 SYSTEMS APPROACH FOR THE SOLUTION STREAMLINE DOCUMENTATION & TRAIN YOUR STUDENTS TO USE CHECKLISTS THAT CAPTURE CRITICAL DETAILS TO IMPROVE QUALITY AND SAFETY
76
77 Quality Educational Resources Complimentary for Registered Users (Nursing Students, Recent Graduates, Faculty )
78 WOUND CARE ESSENTIALS TOOLKIT Basic & Advanced Modules (PowerPoints) to download Chronic Wound Care: The Essentials - 25 chapters in.pdf format to download Two videos on Wound Assessment and Documentation & Pressure Ulcers: Assessment and Management Access to Ostomy Wound Management tablet edition and the SAWC Network
79 WOUND CARE ESSENTIALS TOOLKIT Also information on: Wound Educational Programs Certifications Associations... And much, much more!
80 Basic Modules (PowerPoints) Advanced Modules (PowerPoints)
81 BASIC MODULES (POWERPOINTS TO DOWNLOAD) Including: Wound Assessment Risk Factors Diabetic Foot Wounds Pressure Ulcers Venous Ulcers Types of Dressings
82 ADVANCED MODULES (POWERPOINTS TO DOWNLOAD) Including: Pain Assessment & Management Legal Issues Venous Ulcers SCALE
83 WWC? MODULE #1 COMMON TYPES OF WOUNDS Diane L. Krasner PhD, RN, FAAN & Lia van Rijswijk DNP, MSN, RN, CWCN
84 WWC? MODULE #1 ACUTE WOUNDS Etiology: - Trauma - Surgery AAWC Used with permission Definition: Acute wounds usually progress through all phases of the healing process in an orderly and timely sequence AAWC Used with permission
85 WWC? MODULE #1 CHRONIC WOUNDS Etiology: Various, e.g. AAWC Used with permission - Insufficient blood supply - Infection - Repeat trauma AAWC Used with permission - Less-than-optimal nutritional or overall health status - Less-than-optimal wound environment/care AAWC Used with permission Definition: A wound that has failed to proceed through an orderly and timely healing process to produce anatomic and functional integrity within a reasonable period of time (2 to 3 months) AAWC Used with permission Cowan, L., Stechmiller, J., Philips, P. & Schultz, G. (2014)Science of wound healing: Translation of bench science into advances for chronic wound care. In: Krasner, D.L. (Ed). Chronic Wound Care: The Essentials. Malvern, PA., HMP Communications. Downloadable at
86 WOUND CLASSIFICATION OVERVIEW
87 WWC? MODULE #1 KEY NURSING CONCEPTS - Assessment - Infection - Infection Control - Pain - Patient Education - Prevention - Self Care Deficit - Safety
88 WWC? MODULE #1 KEY NURSING DIAGNOSES - Potential for Alteration in Skin Integrity - Potential for Alteration in Tissue Integrity - Impaired Skin Integrity - Impaired Tissue Integrity - Oral Mucous Membranes, Altered - Knowledge Deficit r/t - Self Care Deficit r/t
89 WWC? MODULE #1 KEY NURSING PRACTICE ISSUES Registered Nurses (RN) assess wounds; Licensed Practice Nurses monitor wounds per state nurse practice acts - Physicians diagnose wound etiology; some Advance Practice Nurses diagnose wound etiology per state nurse practice acts - Correct etiology is key to selecting the correct clinical practice guideline to follow for an individualized patient & wound plan of care
90 WWC? MODULE #1 WEBSITES FOR FURTHER INFORMATION ON TYPES OF WOUNDS - Association for the Advancement of Wound Care - Canadian Association for Wound Care - National Pressure Ulcer Advisory Panel - World Union of Wound Healing Societies - Wound Ostomy Continence Nurses Society
91 For every complex problem There is a simple solution and it is wrong. - H. L. Menken
92 The real voyage of discovery Consists not in seeking new landscapes But in having NEW EYES - Marcel Proust
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Chronic Wound Care: The Essentials e-book
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8/11/2009. Staging Assessment Nutrition Pain Support Surfaces Cleansing. Debridement Dressings Infection Biophysical Agents Surgery Palliative Care
8//9 Joyce Black, PhD, DNP, RN, CPSN, CWCN, FAPWCA Past President, NPUAP AHCPR guidelines 99, 99 Various Wound Groups WOCN, WHS, Medical Directors Focus was narrow, not adding to evidence EPUAP on nutrition
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