WoundCare ADVISOR · 2017-03-30 · services will give you the unique skills needed when...

Official journal of

WoundCareADVISOR

Practical issues in wound, skin, and ostomy management®

November/December 2015 • Volume 4 • Number 6

www.WoundCareAdvisor.com

A Publication

Role of the ostomyspecialist clinicianin ileal pouch anal

anastomosissurgery

Skin care forbariatric patients

How to choose the right tape for

your patient

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2 www.WoundCareAdvisor.com November/December 2015 • Volume 4, Number 6 • Wound Care Advisor

staff

Group PublisherGregory P. Osborne

Executive Vice President/PublisherBill Mulderry

Director, Marketing & Program Mgmt.Tyra London

Editor-in-ChiefDonna Sardina, RN, MHA, WCC,

CWCMS, DWC, OMSEditorial Director

Cynthia Saver, RN, MSEditor

Kathy E. GoldbergCopy EditorJulie CullenArt Director

David BeverageProduction ManagerRachel BargeronAccount Managers

Susan Schmidt, Renee Artuso,John Travaline

PuBlished By

HealthCom Media259 Veterans Lane, Doylestown, PA 18901

Telephone: 215/489-7000Facsimile: 215/230-6931Chief Executive OfficerGregory P. Osborne

Digital Program ManagerMichael Ferrari

Social Media ManagerLizzie Witt

Finance Director/OperationsMaryAnn Fosbenner

Finance Manager/OperationsNancy J. Dengler

Wound Care Advisor (ISSN 2168-4421) is published byHealthCom Media, 259 Veterans Lane, Doylestown, PA18901. Printed in the USA. Copyright © 2015 by Health-Com Media. All rights reserved. No part of this publica-tion may be reproduced, stored, or transmitted in anyform or by any means, electronic or mechanical, includ-ing photocopy, recording, or any information storageand retrieval system, without permission in writing fromthe copyright holder. Send communication to Health-Com Media, 259 Veterans Lane, Doyles town, PA 18901.

The opinions expressed in the editorial and advertis-ing material in this issue are those of the authorsand advertisers and do not necessarily reflect theopinions or recommendations of the National Al-liance of Wound Care and Ostomy®; the EditorialAdvisory Board members; or the Publisher, Editors,and the staff of Wound Care Advisor.

Editorial Mission: Wound Care Advisor providesmultidisciplinary wound care professionals withpractical, evidence-based information on theclinical management of wounds. As the officialjournal of the National Alliance of Wound Careand Ostomy®, we are dedicated to deliveringsuccinct insights and information that our read-ers can immediately apply in practice and useto advance their professional growth.

Wound Care Advisor is written by skin and woundcare experts and presented in a reader-friendly elec-tronic format. Clinical content is peer reviewed.

The publication attempts to select authors who are knowl-edgeable in their fields; however, it does not warrant theexpertise of any author, nor is it responsible for any state-ments made by any author. Certain statements about theuse, dosage, efficacy, and characteristic of some drugsmentioned here reflect the opinions or investigational ex-perience of the author. Any procedures, medications, orother courses of diagnosis or treatment discussed or sug-gested by authors should not be used by clinicians with-out evaluations of their patients’ conditions and possiblecontraindications or danger in use, review of any applica-ble manufacturer’s prescribing information, and compari-son with the recommendations of other authorities.

editor-in-chief

Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMSCo-Founder, Wound Care Education Institute

Lake Geneva, WI

editorial advisory Board

Nenette L. Brown, RN, PHN,MSN/FNP, WCC

Wound Care Program CoordinatorSheriff’s Medical Services Division

San Diego, CA

Debra Clair, PhD, APN, RN, WOCN,WCC, DWC

Wound Care ProviderAlliance Community Hospital

Alliance, OH

Kulbir Dhillon, NP, WCCWound Care SpecialistSkilled Wound Care

Sacramento, CA

Fred BergVice President, Marketing/Business

DevelopmentNational Alliance of Wound Care and

OstomySt. Joseph, MI

Cindy Broadus, RN, BSHA, LNHA,CLNC, CLNI, CHCRM, WCC,

DWC, OMSExecutive Director

National Alliance of Wound Care and Ostomy

St. Joseph, MI

Gail Hebert, MS, RN, CWCN, WCC,DWC, OMS

Clinical instructorWound Care Education Institute

Plainfield, IL

Joy Hooper, BSN, RN, CWOCN,OMS, WCC

Owner and manager of MedicalCraft, LLCTifton, GA

Catherine Jackson, RN, MSN, WCCClinical Nurse Manager

Inpatient and Outpatient Wound CareMacNeal Hospital

Berwyn, IL

Jeffrey Jensen, DPM, FACFASDean and Professor of Podiatric

Medicine & SurgeryBarry University School of Podiatric

MedicineMiami Shores, FL

Rosalyn S. Jordan, RN, BSN, MSc,CWOCN, WCC

Director of Clinical EducationRecoverCare, LLC

Louisville, KY

Jeff Kingery, RNVice President of Professional

DevelopmentRestorixHealthTarrytown, NY

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

Vice President of Clinical ConsultingJoerns

Charlotte, NC

Courtney Lyder, ND, GNP, FAAN Dean and Professor

UCLA School of NursingLos Angeles

Nancy Morgan, RN, BSN, MBA,WOC, WCC, DWC, OMS

Co-Founder, Wound Care EducationInstitute

Plainfield, IL

Steve Norton, CDT, CLT-LANACo-founder, Lymphedema & Wound Care

Education, LLCPresident, Lymphedema Products, LLC

Matawan, NJ

Bill Richlen, PT, WCC, CWS, DWCOwner

Infinitus, LLCChippewa Falls, WI

Lu Ann Reed, RN, MSN, CRRN,RNC, LNHA, WCC

Adjunct Clinical InstructorUniversity of Cincinnati

Cincinnati, OH

Stanley A. Rynkiewicz III, RN, MSN,WCC, DWC, CCS

AdministratorDeer Meadows Home Health and

Support Services, LLCBHP Services

Philadelphia, PA

Cheryl Robillard, PT, WCC, CLTClinical SpecialistAegis TherapiesMilwaukee WI

Donald A. Wollheim, MD, WCC,DWC, FAPWCA

Owner and Clinician, IMPLEXUS WoundCare Service, LLC Watertown, WI

Instructor, Wound Care EducationInstitute

Plainfield, IL

Present Your Wound Care CredentialsWith Distinction.

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FEATURES

12 Role of the ostomy specialist clinician in ileal pouch anal anastomosis surgery By Leanne Richbourg, MSN, RN, APRN-BC, CWON-AP, CCCN, GCNS-BC

Providing education about this procedure can help restore patients to wellness.

27 Providing skin care for bariatric patients By Gail R. Hebert, MS, RN CWCN, DWC, WCC, OMS

Specialized knowledge of common conditions and their treatments can help us meet this challenge.

DEPARTMENTS

7 From the Editor Seeing healthcare from a new perspective

9 Clinical Notes

18 Apple Bites Cutaneous candidiasis

20 Best Practices Time to select a support surface

Staying out of sticky situations: How to choose the right tape for your patient

39 Business Consult Is your therapy department on board with your wound care team?

43 Clinician Resources

45 NAWCO News

November/December 2015 • Volume 4 • Number 6www.WoundCareAdvisor.comCONTENTS

page 12

31 Prove the Value Program Demonstrating the clinical and financial outcomes of advanced surface technologies. Content provided by Hill-Rom.

page 27

page 21

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Clears the way for healthy tissue

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Collagenase SANTYL® Ointment is indicated for debriding chronic dermal ulcers and severely burned areas.

Occasional slight transient erythema has been noted in surrounding tissue when applied outside the wound. One case of systemic hypersensitivity has been reported after 1 year of treatment with collagenase and cortisone. Use of Collagenase SANTYL® Ointment should be terminated when debridement is complete and granulation tissue is well established.

Please see complete prescribing information on adjacent page.

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DESCRIPTION: Collagenase SANTYL® Ointment is a sterile enzymatic debriding ointment which contains 250 collagenase units per gram of white petrolatum USP. The enzyme collagenase is derived from the fermentation by Clostridium histolyti-cum. It possesses the unique ability to digest collagen in necrotic tissue.

CLINICAL PHARMACOLOGY: Since collagen accounts for 75% of the dry weight of skin tissue, the ability of collagenase to digest collagen in the physiological pH and temperature range makes it particularly effective in the removal of detritus.1

Collagenase thus contributes towards the formation of granulation tissue and subsequent epithelization of dermal ulcers and severely burned areas. 2, 3, 4, 5, 6

Collagen in healthy tissue or in newly formed granulation tissue is not attacked. 2, 3,

4, 5, 6, 7, 8 There is no information available on collagenase absorption through skin or its concentration in body fluids associated with therapeutic and/or toxic effects, degree of binding to plasma proteins, degree of uptake by a particular organ or in the fetus, and passage across the blood brain barrier.

INDICATIONS AND USAGE: Collagenase SANTYL® Ointment is indicated for debriding chronic dermal ulcers 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and severely burned areas. 3, 4, 5, 7, 16, 19, 20, 21

CONTRAINDICATIONS: Collagenase SANTYL® Ointment is contraindicated in patients who have shown local or systemic hypersensitivity to collagenase.

PRECAUTIONS: The optimal pH range of collagenase is 6 to 8. Higher or lower pH conditions will decrease the enzyme’s activity and appropriate precautions should be taken. The enzymatic activity is also adversely affected by certain detergents, and heavy metal ions such as mercury and silver which are used in some antiseptics. When it is suspected such materials have been used, the site should be carefully cleansed by repeated washings with normal saline before Collagenase SANTYL®

Ointment is applied. Soaks containing metal ions or acidic solutions should be avoided because of the metal ion and low pH. Cleansing materials such as Dakin’s solution and normal saline are compatible with Collagenase SANTYL® Ointment.

Debilitated patients should be closely monitored for systemic bacterial infections because of the theoretical possibility that debriding enzymes may increase the risk of bacteremia.

A slight transient erythema has been noted occasionally in the surrounding tissue, particularly when Collagenase SANTYL® Ointment was not confined to the wound. Therefore, the ointment should be applied carefully within the area of the wound. Safety and effectiveness in pediatric patients have not been established.

ADVERSE REACTIONS: No allergic sensitivity or toxic reactions have been noted in clinical use when used as directed. However, one case of systemic manifestations of hypersensitivity to collagenase in a patient treated for more than one year with a combination of collagenase and cortisone has been reported.

OVERDOSAGE: No systemic or local reaction attributed to overdose has been observed in clinical investigations and clinical use. If deemed necessary the enzyme may be inactivated by washing the area with povidone iodine.

DOSAGE AND ADMINISTRATION: Collagenase SANTYL® Ointment should be applied once daily (or more frequently if the dressing becomes soiled, as from incontinence). When clinically indicated, crosshatching thick eschar with a #10 blade allows Collagenase SANTYL® Ointment more surface contact with necrotic debris. It is also desirable to remove, with forceps and scissors, as much loosened detritus as can be done readily. Use Collagenase SANTYL® Ointment in the following manner:

Rx only

1 – Prior to application the wound should be cleansed of debris and digested material by gently rubbing with a gauze pad saturated with normal saline solution, or with the desired cleansing agent compatible with Collagenase SANTYL® Ointment (See PRECAUTIONS), followed by a normal saline solution rinse.2 – Whenever infection is present, it is desirable to use an appropriate topical antibiotic powder. The antibiotic should be applied to the wound prior to the application of Collagenase SANTYL® Ointment. Should the infection not respond, therapy with Collagenase SANTYL® Ointment should be discontinued until remission of the infection.3 – Collagenase SANTYL® Ointment may be applied directly to the wound or to a sterile gauze pad which is then applied to the wound and properly secured.4 – Use of Collagenase SANTYL® Ointment should be terminated when debride-ment of necrotic tissue is complete and granulation tissue is well established.

HOW SUPPLIED: Collagenase SANTYL® Ointment contains 250 units of collagenase enzyme per gram of white petrolatum USP.

Do not store above 25˚C (77˚F). Sterility guaranteed until tube is opened.

Collagenase SANTYL® Ointment is available in 15 gram, 30 gram, and 90 gram tubes.

REFERENCES: 1. Mandl, I., Adv Enzymol. 23:163, 1961. 2. Boxer, A.M., Gottesman, N., Bernstein, H., & Mandl, I., Geriatrics. 24:75, 1969. 3. Mazurek, I., Med. Welt. 22:150, 1971. 4. Zimmermann, WE., in “Collagenase,” Mandl, I., ed., Gordon & Breach, Science Publishers, New York, 1971, p. 131, p. 185. 5. Vetra, H., & Whittaker, D., Geriatrics. 30:53, 1975. 6. Rao, D.B., Sane, P.G., & Georgiev, E.L., J. Am. Geriatrics Soc. 23:22, 1975. 7. Vrabec, R., Moserova, J., Konickova, Z., Behounkova, E., & Blaha, J., J. Hyg. Epidemiol. Microbiol. Immunol. 18:496, 1974. 8. Lippmann, H.I., Arch. Phys. Med. Rehabil. 54:588, 1973. 9. German, F. M., in “Collagenase,” Mandl, I., ed., Gordon & Breach, Science Publishers, New York, 1971, p. 165. 10. Haimovici, H. & Strauch, B., in “Collagenase,” Mandl, I., ed., Gordon & Breach, Science Publishers, New York, 1971, p. 177. 11. Lee, L.K., & Ambrus, J. L., Geriatrics. 30:91, 1975. 12. Locke, R.K., & Heifitz, N.M., J. Am. Pod. Assoc. 65:242, 1975. 13. Varma, A.O., Bugatch, E., & German, F.M., Surg. Gynecol. Obstet. 136:281, 1973. 14. Barrett, D., Jr., & Klibanski, A., Am. J. Nurs. 73:849, 1973. 15. Bardfeld, L.A., J. Pod. Ed. 1:41, 1970. 16. Blum, G., Schweiz, Rundschau Med Praxis. 62:820, 1973. Abstr. in Dermatology Digest, Feb. 1974, p. 36. 17. Zaruba, F., Lettl, A., Brozkova, L., Skrdlantova, H., & Krs, V., J. Hyg. Epidemiol. Microbiol. Immunol. 18:499, 1974. 18. Altman, M.I., Goldstein, L., & Horwitz, S., J. Am. Pod. Assoc. 68:11, 1978. 19. Rehn, V.J., Med. Klin. 58:799, 1963. 20. Krauss, H., Koslowski, L., & Zimmermann, W.E., Langenbecks Arch. Klin. Chir. 303:23, 1963. 21. Gruenagel, H.H., Med. Klin. 58:442, 1963.

Manufactured by: Smith & Nephew, Inc.Fort Worth, Texas 76107US Gov’t License #2004

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© 2014 Smith & Nephew, Inc.SANTYL is a registered trademark of Smith & Nephew, Inc.140385-0814

Wound Care Advisor • November/December 2015 • Volume 4, Number 6 www.WoundCareAdvisor.com 7

From theEDITOR

As healthcare clinicians, our world isfull of tasks to be completed. Someare new, but many are tasks we re-

peat every day and thus have becomeroutine—things we could almost do in oursleep.

But what’s routine for us may not beroutine for our patients. For some patients,these routine tasks of ours may be theirfirst encounter with a healthcare situation.

When a member of my family neededhealth care recently, I observed as a fami-ly member, not a clinician, and learnedwhat it’s like to be on the other side ofthe clinician’s routine. What follows aresome shareworthy observations.• Read health record notes in the comput-

er before talking with the patient. Ask-ing patients about the care they’ve al-ready received or what medicationsthey’ve been given doesn’t build theirconfidence in your care.

• Keep the patient updated. If you’rewaiting for an order, lab result, or call-back from X-ray, tell the patient this—ifpossible, more often than once a shift.Think how powerless and vulnerableyou would feel lying in a strange bedaway from home with no control.

• Don’t be too cheery and giggly. Remem-ber—the patient is sick and may not befeeling well. Also, you may have greatcoworkers and a great job, but whenyou’re conducting the patient assess-

Seeing healthcare from a new perspective

ment, the patient and family don’t wantto hear a 20-minute description of thefun you have in your department. Thiscould make them think you’re so busychatting that you’re not paying attentionto detail. Focus on the patient and yourassessment instead of trying to becomethe patient’s buddy.

• Check bandages at least every shift, evenif you’re not going to change them. Ifyou’re checking them with a casualglance or combining this with anothertask, make sure the patient knowsyou’re checking.

• Inspect surgical drains or collection de-vices at least once every shift, and emptythem as indicated. Surgical drains canbe extremely scary to patients, whomay feel as if their guts or blood aredraining from their body.

• If the patient’s skin is hairy, shave ortrim the hair before applying tape or atransparent film dressing. If you don’tfeel comfortable removing the hair, askanother clinician for help. Always ex-plain to the patient the reason for hairremoval. (Most patients prefer hair re-moval to the alternative of hair-pullingpain.) A self-adherent elastic wrap is agreat alternative to tape for securingbandages on hairy skin, although youstill need to use caution when remov-ing it.

• Before changing a surgical or wounddressing, find out if the patient has seenthe incision or wound; if not, ask if he orshe wants to see it. When appropriate,it’s best for patients to understand what’sunder the bandage. They may be re-lieved to find out that what they’d beenenvisioning as a fist-sized wound ismuch smaller—or, if it’s a large wound,they may be surprised by its size.

• Don’t complain about the computer ortell patients you have poor computerskills as you’re typing information intotheir health record.

• If the patient is required to use a com-puter stylus to sign something in thehealth record, make sure to clean it be-fore handing it to him or her. Do thiseven if the stylus has already been dis-infected, because the patient doesn’tknow that.

• Ask visitors to leave the room beforeyou provide care or discuss the patient’shealth condition. This way, you sparethe patient the burden of having to askfriends or family to leave.

• Don’t rush discharge. Make sure you’vereviewed everything, including post-care follow-up and whom to contactfor help. Verify that transfer arrange-ments are in place. Most important, ensure that the patient and familymembers have received and under-stand patient and caregiver education.(The teach-back method is a great way to determine their understand-ing. For more information, visithttp://www.teachbacktraining.org.)

As clinicians, we should strive to makeevery patient encounter special, not rou-tine. Remember—it’s always about thepatient.

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

Editor-in-ChiefWound Care Advisor

Cofounder, Wound Care Education InstitutePlainfield, Illinois



ClinicalNOTES

Modified Braden risk scoreproposed

A study in Ostomy Wound Managementstates the risk classification of patients us-ing Braden Scale scores should comprisethree (rather than five) levels: high risk,with a total score ≤11; moderate risk, witha total score of 12 to 16; and mild risk,with a total score ≥17.

The retrospective analysis of consecutive-ly admitted patients at risk for pressure ulcerto an acute-care facility included 2,625 pa-tients, with an age range from 1 month to98 years; 3.1% developed a pressure ulcer.

The authors of “A retrospective analysisof pressure ulcer incidence and modifiedBraden Scale score risk classificationsA”conclude that the modified Braden Scale“may be more convenient and feasible inclinical practice.”

Amputations and foot-relatedhospitalization in dialysispatients

“Amputations and foot-related hospitalisa-tions disproportionately affect dialysis pa-tientsB,” even though the incidence of footulcers is the same in dialysis patients andpatients with an ulcer history.

The study in International Wound Jour-nal included 150 consecutive patients withdiabetes who were on dialysis and 150patients with a history of foot ulceration.Each patient was followed for 30 months.

Plantar shear plays importantrole in foot ulcers

Considering both plantar shear and pres-sure, as opposed to pressure alone, ismore effective in preventing foot ulcers,according to a study in Diabetes Care.

“Peak plantar shear and pressure and footulcer locations: A call to revisit ulcerationpathomechanicsC” notes that pressure is apoor predictor of foot ulcer in patientswith diabetes, and pressure-reducing ther-apeutic footwear has minimal effect inpreventing recurrent ulceration.

The authors write that their findings in-dicate that plantar shear has a “clinicallysignificant role in ulceration” and that ul-cers at different sites may have differentpathologies. They also call for more re-search on plantar shear.

Lower extremity amputation inpatients with diabetes

A longitudinal study in Diabetes Care re-

http://www.o-wm.com/article/retrospective-analysis-pressure-ulcer-incidence-and-modified-braden-scale-score-risk



http://onlinelibrary.wiley.com/doi/10.1111/iwj.12146/abstract



http://care.diabetesjournals.org/content/early/2015/09/13/dc15-1596.full.pdf+html



ports that people with diabetes who haveundergone lower-extremity amputation“are more likely to die at any given pointin time” compared to those who have notexperienced amputation.

“Diabetes, lower-extremity amputation, anddeathD” notes that complications from dia-betes account for only some of the variation.

AHA releases new CPR guidelines

The American Heart Association has pub-lished the “2015 GuidelinesE Update forCardiopulmonary Resuscitation (CPR) andEmergency Cardiovascular Care (ECC)” inthe journal Circulation F. The guidelinesrecommend chest compressions at a rateof 100 to 120 per minute and to a depthof at least 2 inches (avoiding depthsgreater than 2.4 inches). Other recommen-dations include having clinicians performsteps simultaneously to reduce the time tothe first chest compression.

Bystanders should use mobile phones toimmediately call 911, placing the phoneson speaker, so the dispatcher can offer as-sistance. Untrained bystanders should pro-vide Hands-Only CPR, and bystanders whoare trained in CPR should add breaths in a30:2 compressions-to-breath ratio.

Diabetes increases risk of fracture

“Type 1 diabetes is associated with an in-creased risk of fracture across the life span:

A population-based cohort study using TheHealth Improvement Network (THIN)G” in-cluded patients with and without diabetes,who were matched on parameters such asage and sex.

The risk of fracture was lowest in malesand females younger than 20 years andhighest in men ages 60 to 69, according tothe study, which was published in Dia-betes Care. Lower extremity fractures ac-counted for a higher proportion of inci-dent fractures in participants with diabetescompared to those without. Secondaryanalyses for incident hip fractures identi-fied the highest hazard ratio of 5.64 inmen ages 60 to 69 and the highest hazardratio of 5.63 in women ages 30 to 39.

Nurses play important role inquality of life for ostomy patients

“Analysing the role of support wear, clothingand accessories in maintaining ostomates'quality of lifeH,” published in Gastrointesti-nal Nursing, notes that nurses with expert-ise in stoma care can help patients withostomies achieve optimal quality of life byusing their expertise to guide patients inmaking decisions that will help them re-turn to the activities, sports, hobbies, andlifestyle they enjoyed before surgery.

Liposuction may be helpful forlymphedema

“Complete reduction of arm lymphoma follow-


http://care.diabetesjournals.org/content/38/10/1852.abstract


http://newsroom.heart.org/news/american-heart-association-cpr-guidelines:-quick-action-more-teamwork-key-to-saving-more-lives?preview=2b8e

http://circ.ahajournals.org/content/132/18_suppl_2.toc





http://www.magonlinelibrary.com/doi/10.12968/gasn.2015.13.7.23



http://journals.lww.com/plasreconsurg/Citation/2015/10001/Complete_Reduction_of_Arm_Lymphedema_Following.183.aspx

ing breast cancer—A prospective twenty-oneyears’ studyI” concludes that liposuction iseffective for treating chronic, nonpittingleg lymphedema in patients who don’t re-spond to conservative treatment.

The study, published in Plastic andReconstructive Surgery, included 146women, with a mean age of 63 and amean duration of arm swelling of 9

years. It notes that reduced volume ismaintained through constant use of com-pression garments. ■

Online ResourcesA. http://www.o-wm.com/article/retrospective-analysis-pressure-ulcer-incidence-and-modified-braden-scale-score-risk

B. http://onlinelibrary.wiley.com/doi/10.1111/iwj.12146/abstract

C. http://care.diabetesjournals.org/content/early/2015/09/13/dc15-1596.full.pdf+html

D. http://care.diabetesjournals.org/content/38/10/1852.abstract

E. http://newsroom.heart.org/news/american-heart-association-cpr-guidelines:-quick-action-more-teamwork-key-to-saving-more-lives?preview=2b8e

F. http://circ.ahajournals.org/content/132/18_suppl_2.toc

G. http://care.diabetesjournals.org/content/38/10/1913.abstract

H. http://www.magonlinelibrary.com/doi/10.12968/gasn.2015.13.7.23

I. http://journals.lww.com/plasreconsurg/Citation/2015/10001/Complete_Reduction_of_Arm_Lymphedema_Following.183.aspx

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Restorative proctocolectomy withileal pouch anal anastomosis(IPAA) is the gold standard forsurgical treatment of ulcerative

colitis (UC) or familial adenomatous poly-posis (FAP). It’s also done to treat colonand rectal cancers, such as those causedby Lynch syndrome (LS). IPAA allows thepatient to maintain fecal continence andevacuate stool from the anus after colonand rectum removal. A temporary ileo -stomy may be part of the overall process,but there’s no need for a permanentstoma. (See Understanding ulcerative

colitis, FAP, and Lynch syndrome.) Contraindications for IPAA include:

• Crohn’s disease, which can recur at anypoint along the GI tract

• incompetent anal sphincter tone (mostcommon in older adults)

• diseases of the distal rectum or anal canal.

Preoperative education You can help improve your patient’s qual-ity of life and health status by providingeducation about IPAA. When preparingthe patient for surgery, explain the proce-dure and discuss how it will change GItract anatomy. Because the patient is like-ly to have a stoma, describe what thestoma will look like, how to care for it,how to use pouches to contain stoma out-put, what lifestyle adjustments to expect,and psychological preparation.

Explain that by the 12th postoperativemonth, the patient’s physical and psycho-logical health, independence level, andgeneral overall quality of life is likely toimprove significantly over preoperative lev-els. By 3 years, quality of life scores mostlikely will match those of the healthy pop-ulation in terms of physical health, inde-pendence, spirituality, and environment.Psychological health and social relation-ships scores also typically improve, al-though not quite to the extent as thehealthy population.

Role of the ostomy specialist clinician in ileal pouch anal anastomosis surgery Providing education about this procedure can help restore patients to wellness. By Leanne Richbourg, MSN, RN, APRN-BC, CWON-AP, CCCN, GCNS-BC


Surgical technique Proctocolectomy with IPAA can be doneas a one-, two- or three-stage procedure.(See Comparing types of proctocolectomies).

Taking care to preserve the pelvicnerves, the surgeon creates a reservoir from30 cm to 40 cm of distal ileum and con-nects it to the anal canal at or just abovethe dentate line (where columnar epitheli-um transitions to squamous epithelium).The most common pouch configuration isthe two-limbed pouch, called the J-pouch.

Although two-stage surgery with a di-verting loop ileostomy is the most com-

mon, a three-stage procedure is optimalfor patients who are markedly debilitatedby disease due to severe exacerbations,nutritional compromise, and high-dosesteroid therapy. For those with indetermi-nate colitis and suspected Crohn’s disease,step one of the three-stage procedure al-lows for further testing before ileal pouchcreation. The one-stage procedure withouta diverting ileostomy is linked to in-creased risk of pouch leakage, pelvic in-fection, and subsequent pouch failure.

Proctocolectomy with IPAA may be per-formed through an open abdominal inci-

Restorative proctocolectomywith ileal pouch anal anasto-mosis may be used to treat ul-cerative colitis (UC), familialadenomatous polyposis (FAP),and Lynch syndrome.

Ulcerative colitisThe cause of this inflammatorybowel disease remains un-known, but current researchpoints to a possible combina-tion of genetic, immunologic,and environmental factors(such as bacteria or viruses).The disease affects approxi-mately 700,000 people in theUnited States. Surgery may berequired in patients with fulmi-nant colitis, toxic megacolon,dysplasia, cancer, or extrain-testinal manifestations—or ifother therapy fails.

To help you remember ex-traintestinal manifestations ofUC, use the mnemonic A PieSac:A: Aphthous ulcersP: Pyoderma gangrenosumI: IritisE: Erythema nodosum S: Sclerosing cholangitisA: ArthritisC: Clubbing of fingers

FAPFAP stems from an autosomaldominant-inherited gene muta-tion involving adenomatouspolyposis coli, which causehundreds to thousands ofpolyps in the GI tract. Polypsare most common in the colon(adenomas are colon polyps)and rectum, but they also canarise in the stomach and smallbowel. A child of a parent withFAP has a 50% chance of inher-iting the defective gene.

Once multiple precancerouspolyps are detected, colectomyis the treatment of choice. FAPpatients have a 90% chance ofdeveloping colorectal cancer by age 45. The National Com-prehensive Cancer Network(NCCN) recommends people atrisk for FAP start surveillancebetween ages 10 and 15, to in-clude APC gene testing and an-nual flexible sigmoidoscopy orcolonoscopy.

Lynch syndrome People with Lynch syndrome(the preferred term for heredi-tary nonpolyposis colorectalcancer, an autosomal domi-nant-inherited genetic muta-

tion disorder) also may havepolyps. The genetic mutationinvolves DNA mismatch repairgenes.

Lynch syndrome is morecommon in the right colon, butalso can develop in other sec-tions of the GI tract, as well asthe ovaries and endometrial lin-ing of the uterus. NCCN recom-mends people with a family his-tory of Lynch syndrome startsurveillance between ages 20and 25 (or 2 to 5 years beforethe age at diagnosis of theyoungest affected family mem-ber, if younger than age 25).Evaluation should include test-ing for genetic abnormalitiesand colonoscopy every 1 to 2years.

Patients may needhelp in under-standing these var-ious conditions.

Online resources may be helpful.Examples include ”What is LynchsyndromeA”, Familial adenomatouspolyposisB”, and ”What is ulcera-tive colitisC”. Of course, youshould always first screen videosfor accuracy before recommendingthem to patients.

Understanding ulcerative colitis, FAP, and Lynch syndrome

https://www.youtube.com/watch?v=zDXS0QBGoKY

https://www.youtube.com/watch?v=zDXS0QBGoKY

https://www.youtube.com/watch?v=F6pqpLRGneE

https://www.youtube.com/watch?v=F6pqpLRGneE

https://www.youtube.com/watch?v=JMApMBY0CfQ

https://www.youtube.com/watch?v=JMApMBY0CfQ


sion or a laparoscopic approach. Laparo-scopic surgery takes an average of 80 min-utes longer and requires more I.V. fluids.However, it’s associated with shorter hos-pital stays, shorter time to ostomy closure,shorter operating-room times, shorter staysfor ostomy reversal surgery, less adhesionformation, and lower infertility rates. Thetwo methods don’t differ in blood loss,need for postoperative opioids, return ofbowel function, or hospital readmissionrates. An open abdominal approach usual-ly is done in patients with fulminant colitisor acute colitis complicated by colonicperforation or toxic megacolon.

ComplicationsDuring the first postoperative month,symptomatic portal-vein thrombosis oc-curs in up to 6% of patients; asympto-matic clots may arise in up to 40%. Thecause is unknown but may relate to trac-tion on the superior mesenteric veinwhen the small bowel moves down into

the pelvis in patients with systemic in-flammation from ulcerative colitis. Signsand symptoms may mimic those of anacute abdomen, including nausea, vomit-ing, fever, abdominal distention, andpain. Computed tomography is used toidentify thrombi. Treatment involves 3 to6 months of anticoagulation.

Postoperative management afterileostomy creation Initially, your main role is to provide edu-cation about ileostomy self-care. Teachyour patient how to apply, empty, and re-place the ostomy pouch. (See Providingeducation to the new ostomate.)

After surgery, high stool output fromthe diverting ileostomy is a common prob-lem. Although definitions of high outputdiffer somewhat, I tell patients that highoutput means more than 1,200 mL in 24hours. This condition is most commonwithin the first 2 to 3 postoperative weeksand usually resolves.

Readmission for dehydration typicallyoccurs during the second postop week.To help prevent dehydration, instruct pa-tients to drink eight to ten 8-oz glasses offluid daily, preferably avoiding fruit juice,soft drinks containing sugar, caffeinateddrinks, and alcohol.

Measuring stool outputAdvise the patient to keep track of howmuch stool he or she is passing in 24hours. I usually advise patients to emptythe pouch when it’s one-third to one-halffull, four to six times daily. This equatesto about 1,200 mL of output. If the pouchrequires more frequent emptying, the pa-tient needs to quantify the output further.

I’ve found some discharged patientsdon’t comply with measuring stool outputusing a urinal or “potty hat.” So I give pa-tients a photograph of three pouches con-taining colored water in quantities of 100mL, 200 mL, and 300 mL. This helps themvisually judge how much output is in the

One-stage procedure: proctocolectomy with ilealpouch creation and restoration of bowel continuity

Two-stage procedure: Stage 1: proctocolectomy, ileal pouch creation,

diverting loop ileostomyStage 2: radiologic evaluation of pouch healing,

ileostomy closure, restoration of bowel continuity

Three-stage procedure: Stage 1: colectomy, preservation of rectum or

rectosigmoid stump, end ileostomyStage 2: proctectomy completion, ileal pouch

creation, diverting loop ileostomyStage 3: radiologic evaluation of pouch healing,

ileostomy closure, restoration of bowel continuity

Note: See an example of proctocolec -tomy surgery, access the video at“Laparo scopic assisted restorativeproctocolectomy with ileal j-pouch-anal anastomosisD.”

Comparing one-, two-, and three-stage proctocolectomies

https://www.youtube.com/watch?v=rEYzh8VKqEE






pouch. Antidiarrheal medications, such asloperamide, can be titrated to keep outputwithin the normal range.

About 6 weeks after surgery, instructthe patient to practice pelvic floor muscleexercises three times daily, if the surgeonapproves. This strengthens the musclesneeded for fecal continence once thestoma is closed.

Postoperative management afterileostomy closureAfter ileostomy closure, patients with anileoanal pouch must begin training theirnew reservoir—a process that can take upto a year. Initially, they may have up to 20small bowel movements daily and mayneed to get out of bed multiple times atnight to pass stool. Eventually, this decreas-es to six bowel movements in 24 hours, in-cluding overnight. At 1 year postop, about95% of patients who’ve had ileoanal pouchsurgery report being very satisfied withtheir decision. For the remaining 5%, long-term functional results are poor.

To slowly increase pouch holding ca-pacity, teach patients not to respond to

every urge to move the bowels. Initially,advise them to wait 5 minutes after sittingon the toilet before responding. Whenthat’s accomplished, tell them to increasethe wait time by another 5 minutes, andthen 10 minutes, and to continue increas-ing it in this manner. Also advise them tobegin to move further and further awayfrom the toilet during wait time. The goalis to gain confidence in the ability to with-hold stool and avoid accidents.

Complications of ileal pouch surgery in-clude pouchitis; pouch-anal anastomoticstrictures; small-bowel obstruction; and in-tra-abdominal, peri-pouch, and anastomot-ic cuff abscesses. (See Understanding po-tential complications.)

Perianal skin careStool leakage is common at first, alongwith trouble differentiating between flatusand stool. Teach patients how to performmeticulous perianal skin care. Tell them towash the area thoroughly at least oncedaily using a pH-balanced skin cleanserand warm water. To clean up after eachbowel movement, advise them to use al-

Ileoanal pouch surgery cancause various complications.

Pouchitis, an acute inflamma-tion of the ileoanal pouch, canlead to diarrhea, urgency, fever,malaise, lethargy, and abdomi-nal pain. Most experts believe itstems from an imbalance of in-testinal bacteria within thepouch. Incidence is 20% in thefirst year, 40% in the first dec -ade, and 70% in the seconddecade. A 2010 systematic re-view of the literature found thatthe probiotic VSL#3, a cocktail ofeight different strains of intes-tinal bacterial, helped preventpouchitis. For treatment of acutepouchitis, ciprofloxacin was

more effective than metronida-zole, although both are consid-ered mainstays of therapy.

Topical steroids, such as bu -des o n ide, can be given by en-ema to reduce inflammation dur-ing the acute stage. If pouchitisdoesn’t respond to therapy, thepatient should be screened forcytomegalovirus and Clostrid-ium difficile. Cytomegalovirus istreated with an antiviral drug,such as ganciclovir; C. difficile,with vancomycin.

About 15% of ileoanal pouchpatients develop a pouch-analstricture, typically 6 to 9months after surgery. Usualcauses include cuff abscess

leading to dense scarring,mesenteric tension, and partialanastomotic separation. Signsand symptoms of stricture in-clude tenesmus (uncomfortablefrequency and urgency, with afeeling of incomplete evacua-tion) and watery stools. Patientscan be taught to dilate the stric-ture using Hegar stainless steeldilators or their own gloved andlubricated finger, starting withthe smallest finger. Adequatedilation is achieved when theanal opening allows insertion ofthe index finger up to the inter-phalangeal joint. Refractorystrictures require surgical inter-vention.

Understanding potential complications


cohol-free moist wipes, which are lessabrasive than toilet paper.

Encourage patients to protect perianalskin by applying an ointment containingpetrolatum, dimethicone, or zinc oxide af-ter each bowel movement. Alternatively,they may use an alcohol-free liquid skin-barrier film wipe once daily. Aloe vera gelis an effective treatment for skin irritation,providing antimicrobial action, reducingpain, and shortening healing times. De-pending on leakage amounts, advise pa-tients to protect underclothes with a panty

liner or incontinence-containment product.Encourage them to continue regular pelvicfloor muscle exercises, as strong musclesare crucial for preventing leakage.

Dietary guidelinesAdvise patients to eat a low-fiber diet forabout 4 weeks after ostomy closure, untilbowel swelling resolves. Then instructthem to start increasing fiber intake untilstools become firmer. Inform them thatfoods that can contribute to anal irritationinclude spicy foods and foods high in in-soluble fiber, such as stringy fruits andvegetables (oranges, coleslaw, celery,corn, nuts, popcorn, coconut, and Chinesevegetables). Teach patients that stool witha thicker consistency is less likely to leak.(See Foods that thicken stool.)

When stool is thin and frequent, urgepatients to eat potassium-rich foods, suchas meat, banana, apricots, tomatoes, milk,and potatoes. Tell them they may need toadd salt to their food to replace potassiumand sodium lost through diarrhea and oth-er fluid losses.

Explain that foods and beverages highin sugar or caffeine can worsen diarrhea.Tell patients to limit fruit juice, caffeinatedtea and coffee, honey, candy, sugary andcaffeinated soft drinks, chocolate, andbaked goods high in sugar.

Teach patients to add 1 tsp of solublefiber, such as psyllium husks (Metamucil),to 1 cup of fluid one or more times perday, titrated to maintain a more solid stoolconsistency. To prevent dehydration, en-courage them to continue to drink eight toten 8-oz cups of fluid daily.

For patients who continue to have largequantities of thin stool, recommend an an-tidiarrheal medication, such as loperamide(Imodium), if the surgeon permits. Instructthem to start with one 2-mg dose 30 min-utes before breakfast, lunch, and dinnerand another dose at bedtime. If this isn’teffective, tell them they may double thedose, not to exceed 16 mg per 24 hours.

Be sure to cover the following points when provid-ing patient education: • how to purchase ostomy supplies• signs and symptoms of dehydration• adequate fluid intake to prevent dehydration• appropriate food choices to promote healing

and prevent food blockage• what to do if a food blockage occurs• how to recognize and treat peristomal skin com-

plications, such as irritant contact and allergicdermatitis

• stomal complications, such as prolapse or ischemia

• decreased absorption of sustained-release medications

• how to prevent peristomal hernia• appropriate clothing choices• appropriate recreational pursuits• how to maintain intimate and sexual relationships • when and how to contact the surgeon and

ostomy clinician.

Providing education to the new ostomate


Know that some patients will have to stayon this medication for a long time.

You can improve patient outcomesAs the ostomy specialist clinician, yourrole is to assist patients along the continu-um from illness to heath. Providing thor-ough patient education throughout thisprocess is crucial to helping them achievetheir ultimate goal of wellness. ■

Selected referencesAmerican Society of Clinical Oncology. FamilialAdenomatous Polyposis. September 2015. cancer.net/cancer-types/familial-adenomatous-polyposis

Bartels SA, D’Hoore A, Cuesta MA, et al. Significant-ly increased pregnancy rates after laparoscopicrestorative proctocolectomy: a cross-sectional study.Ann Surg. 2012;256(6):1045-8.

Fajardo AD, Dharmarajan S, George V, et al. Laparo-scopic versus open 2-stage ileal pouch: laparoscopicapproach allows for faster restoration of intestinalcontinuity. J Am Coll Surg. 2010:211(3);377-83.

Gionchetti P, Calafiore A, Riso D, et al. The role ofantibiotics and probiotics in pouchitis. Ann Gas-troenterol. 2012;25(2):100-5.

Heikens JT, de Vries, J, Goos, MR, et al. Quality oflife and health status before and after ileal pouchanal anastomosis for ulcerative colitis. Br J Surg.2012;99(2);263-9.

Heikens JT, de Vries J, Goos MR et al. Evaluation oflong-term function, complications, quality of lifeand health status after restorative proctocolectomywith ileo neo rectal and with ileal pouch anal anas-tomosis for ulcerative colitis. Colorectal Dis. 2013;15(6);e323-9.

Hiranyakas A, Rather A, da Silva G, et al. Loopileostomy closure after laparoscopic versus opensurgery: is there a difference? Surg Endosc. 2013;27(1):90-4.

Holubar SD, Cima RR, Sandborn WJ, et al. Treat-ment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis.Cochrane Database Syst Rev. 2010;6;CD001176.

Hull TL, Joyce MR, Geisler DP, et al. Adhesions after la-paroscopic and open ileal pouch-anal anastomosis sur-gery for ulcerative colitis. Brit J Surg. 2012;99(2);270-5.

Larsen S, Bendtzen K, Nielsen OH. Extraintestinalmanifestations of inflammatory bowel disease: epi-demiology, diagnosis, and management. Ann Med.2010;42(2):97-114.

National Cancer Institute. Genetics of ColorectalCancer–for health professionals. Updated July 6,2015. cancer.gov/types/colorectal/hp/colorectal-genetics-pdq/#link/_89

Psillos AI, Catanzaro J. Ileal pouch anal anastomosis: anoverview of surgery, recovery, and achieving postsurgi-cal continence. Ostomy Wound Manage. 011;57(12);22-8.

Sagar PM, Pemberton JH. Intraoperative, postopera-tive and reoperative problems with ileoanal pouch-es. Br J Surg. 2012;99(4):454-68.

Stocchi L. Laparoscopic surgery for ulcerative colitis.Clin Colon Rectal Surg. 2010;23(4):248-58.

Wound, Ostomy, and Continence Nurses Society(WOCN). Management of the Patient With a FecalOstomy: Best Practice Guideline for Clinicians.Mount Laurel, NJ: WOCN; 2010.

Leanne Richbourg is a wound and ostomy clini-cal nurse specialist at Duke University Hospitalin Durham, North Carolina.

Online ResourcesA. https://www.youtube.com/watch?v=zDXS0QBGoKY

B. https://www.youtube.com/watch?v=F6pqpLRGneE

C. https://www.youtube.com/watch?v=JMApMBY0CfQ

D. https://www.youtube.com/watch?v=rEYzh8VKqEE

Tell patients that the following foods make stoolfirmer and less frequent:

Foods that thicken stool

• Applesauce• Bananas• Boiled white rice• Cheese• Crackers

• Creamy peanut butter• Pretzels • Tapioca pudding• White pasta• White potatoes

Cutaneouscandidiasis By Nancy Morgan, RN, BSN, MBA, WOC, WCC,DWC, OMS

Each issue, Apple Bites brings you a toolyou can apply in your daily practice. Here’san overview of cutaneous candi diasis.

Cutaneous candidiasis is an infec-tion of the skin caused by theyeast Candida albicans or other

Candida species. Here’s a snapshot ofthis condition.

Cause Yeast fungi, which include the Candidaspecies, are normal flora found through-out the human GI tract. These fungi thrivein a warm, moist environment, so certainconditions, such as poor hygiene, tightclothing, moist skin under surgical orwound dressings, high humidity, and constantly moist skin can result in over-growth. When the overgrowth occurs onskin, it’s called cutaneous candidiasis.Other conditions that can contribute to cu-

taneous candidiasis include compromisedimmunity, antibiotics, stress, and diabetes.

Characteristics• Location—most commonly found in in-

tertriginous areas, such as in the axillae,groin, body folds, gluteal folds, digitalweb spaces, and glans penis, as well asbeneath the breasts

• Appearance—in people with light skintones: bright- to dull-red central areawith peripheral red vesicles (satellite le-sions); in people with dark skin tones:darker than surrounding skin, colormay vary from dark-red to purple, pur-ple-blue, violet, or eggplant

• Distribution—consolidated or patchy• Shape—diffuse differential areas; small

round erythematous papules, pustules,plaques, and/or satellite lesions

• Depth—partial thickness; superficialepidermal infection

• Wound bed—pink or beefy red; associ-ated crusting or scaling with cheesywhite exudate

• Margins—Diffuse and irregular edges;satellite lesions (outside the advancingedge of candidiasis) are the most im-portant diagnostic feature

• Key diagnostic indicator—itching and/orburning.

ManagementThe first strategy is to remove moisture:• Place absorptive fabric in skin folds.• Teach the patient and caregiver(s)

meticulous skin care.


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• Change linen and gowns as frequentlyas needed to keep dry.

• Minimize friction and shear to the skinwhen cleansing, and use a pH-based,skin-friendly cleanser. No-rinse cleans -ers are particularly useful.

• Dry the skin well, especially in the skinfolds.

At the first sign of redness, itching, ordiscomfort, apply an over-the-counter(OTC) or prescription antifungal powder ora silver powder/cream to the area daily perpackage instructions. Examples include:• Nystatin • Clotrimazole (Lotrimin, OTC)• Miconazole (Micatin, OTC)• Econazole (Spectazole)• Ketoconazole (Nizoral)

• Oxiconazole (Oxistat).

If, after 10 to 14 days of treatment withan antifungal product, the rash is not re-solving, consider switching to anotherpreparation because Candida resistancecan occur. ■

Nancy Morgan, cofounder of the Wound CareEducation Institute, combines her expertise as aCertified Wound Care Nurse with an extensivebackground in wound care education and pro-gram development as a nurse entrepreneur.

Information in Apple Bites is courtesy of the WoundCare Education Institute (WCEI), © 2015.

Online ResourcesA. http://www.woundsource.com/product-category/skin-care/an-timicrobialsantifungals

B. http://www.wcei.net/

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http://www.woundsource.com/product-category/skin-care/antimicrobialsantifungals

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Time to select asupport surface By Donna Sardina, RN, MHA, WCC, CWCMS, DWC,OMS

Having the proper support surface forbeds and wheelchairs is imperative

in preventing pressure ulcers. “Pressure”ulcers are named that for a reason—pres-sure is the primary cause of interruptionof blood flow to the tissue. Unfortunately,guidelines for support surface selectiontend to make recommendations for thetype of surface to use after a pressure ul-cer has developed. Another factor thatcomplicates matters is the development ofdeep-tissue injuries. These injuries start atthe bone level, which means that often,tissue damage is extensive before we seevisible signs and realize that the supportsurface we chose might not have been effective enough.

Being proactive in preventing pressureulcers requires that a pressure redistribu-tion surface is provided for the bed andwheelchair when the patient is admitted.Even when you decide to apply a supportsurface early, choosing the specific surfacecan be difficult.

Choosing a support surfaceWhat makes support surface selection sochallenging is that we are all different inbody weight, size, distribution of weight,and sensitivity to pressure, humidity, andtemperature. What might be cool and com-fortable (and prevent a pressure ulcer) forone patient might be too firm and hot foranother. Of course, it’s not possible to haveevery type of support surface in stock. Cli-nicians and administrators should considerthe following characteristics when workingwith manufacturers to determine the op-tions to provide. The products that best fitthe following areas should be considered: • Microclimate: Does the product diffuse

heat and prevent humidity?• Immersion: What is the immersion capa-

bility? Immersion is the ability to “sink”into a support surface. The more a pa-tient can sink into the surface withoutbottoming out (there should be at least1" of space between the buttock and thebed frame), the less likely there will bepressure points.

• Envelopment: What is the envelopmentdegree of the surface? Envelopment isthe ability of the support surface to con-form to body contours. The more thesurface can conform to body contours,the more effective it will be in prevent-ing pressure.

• Shear and friction: Does the cover of thesupport surface help reduce shear andfriction?

Another important question is, “For upto what stage ulcer is the mattress recom-mended?”

Following upYour responsibility doesn’t end with theinitial application of the support surface on


BestPRACTICES

admission. You need to re-evaluate thechoice of support surface every time youconduct a risk assessment of skin integrityand when any of the following occurs: • decline in mobility status• decline in activity level. This factor is of-

ten overlooked in patients who are inde-pendent in their mobility. Even thoughthey are independent, they may chooseto sit for prolonged periods or prefer tostay in the same positon.

• acute illness or injury that may renderpatients bedbound or decrease their ac-tivity level

• change in weight; weight loss may ac-centuate a bony prominence or weightgain can affect the ability to move.

• development of a pressure ulcer.

Taking prompt actionSupport surfaces can be expensive, but se-lecting the right support surface early andchanging it as needed is more cost effec-tive in the long run if pressure ulcers areprevented or a current pressure ulcer healsmore quickly. You also need to considerthat to prove a pressure ulcer was unavoid-able, the care setting needs to show thatinterventions were in place before its de-velopment. Choosing—and documenting—appropriate support surfaces will help pro-vide that proof.

For more information on support surfaceselection, refer to the National PressureUlcer Advisory Panel’s “Prevention andTreatment of Pressure Ulcers: ClinicalPractice Guideline.” You can order theguidelines onlineA and download a copyB ofthe Quick Reference Guide. Another re-source is the evidence-based support surfacealgorithmC available from the Wound, Os-tomy and Continence Nurses Society. ■

Donna Sardina is editor-in-chief for Wound CareAdvisor.

Staying out ofsticky situations:How to choosethe right tape foryour patient By Ann-Marie Taroc, MSN, RN, CPN

Are you using the wrong kind of med-ical tape on your patients? Although

we strive to provide the safest care possi-ble, some nurses may not realize that med-ical tape used to secure tubes and dress-ings can cause harm. The harm may stemfrom using the wrong product or using aproduct incorrectly, which can cause adhe-sive failure or skin injury.

Many different medical tapes are avail-able. To prevent injury, you need tochoose the right tape for each patient. Butknowing which tape is right can be chal-lenging even for experienced nurses. Tochoose and use tape successfully, youneed to understand the components ofmedical tape and base tape selection onyour patient assessment findings.

Medical tape has three jobs—to providean initial stick, increase adhesion, and re-main intact. The initial stick isn’t sufficientfor the tape to stay in place. To improve


http://www.npuap.org/resources/educational-and-clinical-resources/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guideline/

http://www.npuap.org/resources/educational-and-clinical-resources/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guideline/

http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf

http://algorithm.wocn.org/#home

http://algorithm.wocn.org/#home

adhesion, you must apply pressure. Tapemust stay intact, but oil and emollients canseparate the adhesive from the backing orfrom the patient’s skin. Using an emollientproduct, such as an adhesive remover orlotion, can help you remove tape withoutinjuring the skin.

For tape to serve its purpose, the prod-uct you choose must suit ambient condi-tions. For example, moisture can preventthe adhesive from securing to the skin; oilfrom sebaceous glands may cause tape tofail and peel off.

Tape-related injuryMedical adhesive-related skin injury (MAR-SI) occurs when tape causes stripping,separation, or tearing of the epidermallayers. Erythema can occur when you re-move tape from the skin. Stripping mayoccur when the tape is stronger than theskin layers, causing removal of superficial

dermal layers on tape removal. Blistersmay form if you apply tape with tensionand the product restores its shape butpulls apart epidermal layers. Tears can oc-cur when you apply or remove tape withtension or if friction arises, causing skinlayers to separate.

Tape componentsAlthough not all medical tapes are alike,all of them are pressure-sensitive adhe-sives. Tape is a combination of backingand adhesive; we activate the adhesive byapplying pressure—for instance, when werub the tape on the patient’s skin. Warmthpromotes contact of the tape to the skin’sirregular surface.

The combination of backing and adhe-sive determine a tape’s qualities. The vari-ety of adhesives and backings available of-fers an array of products designed to excelunder specific conditions.


This table summarizes the qualities of acrylate and silicone tapes, helping you choose the most appropriatetape for each patient. Adhesion ratings range from high (1) to low (7), although this rating isn’t entirely linear. A blank cell indicates no information on the feature in question is available.

Long-term Initial InitialType Water adhesion adhesion to adhesion Bidirectionalof tape resistance Breathability stretchability to dry skin damp skin to dry skin tear

Acrylate tape

Cloth N 4 1 1

Nonwoven Y Y Y 1 4 3soft cloth*

Silk* Y N 2 6 2 Y

Paper/ Y Y 3 3 4 Yplastic blend

Clear plastic Y 6 5 5 Y

Paper* Y 5 2 6 N

Foam Y Y 7 7 7 N

Silicone tape Y Y 4 2 4 Y

*Product performance may vary by manufacturer and condition of patient’s skin. Content courtesy of 3M

Comparing medical tapes

BackingTape backing can be paper, cloth, foam, oranother material. These materials vary instrength, water resistance, breathability, andstretch. (See Comparing medical tapes.)

AdhesiveAdhesive is the glue that enables the back-ing to stick and do its job. Medical tapeshave acrylate or silicone adhesives.• Acrylate is a low-sensitizing adhesive

and works with a variety of backings.Incorrect use can result in MARSI. Notall acrylate tapes are the same; somehave a higher initial adhesion on dampskin, whereas others have increased ad-

hesion over time.• Silicone, a newer adhesive, is gentle

and conforms easily to the skin’s sur-face. Its gentleness allows for easy re-moval but not the strength needed tosecure critical tubing.

Assessing the patientTo choose the right tape for your patient,start by assessing your patient. First, exam-ine the skin at the site where you’ll securethe tape. Look for hair and sebaceous andsweat glands there, as these may impairtape adhesion.

Next, determine if your patient hasmoist, dry, or fragile skin. The skin’s con-


Cause Corrections Considerations

Improper tape selection: tape is not Select tape based See Comparing medical tapes.matched to clinical need (eg, too on the clinical aggressive, does not stretch) need/indication

Skin is not adequately prepared: Proper skin • Clip/trim hairhair is not removed; skin is soiled, preparation before • Clean and dry the skin to remove soilwet/moist or residue is left on the tape application and residueskin; preps are not allowed to dry; • Apply barrier film for skin to protect at-risk adhesion promoters (tackifiers) are skinindiscriminately used • Allow barrier film to dry completely before applying tape • Avoid routine use of tackifiers

Tape is applied incorrectly: tape is Proper application • Tape strip should be long enough tostretched or applied with tension; technique extend at least one-half inch beyond theapplied in wrong direction dressing or device • Orient tape to allow stretch (ie, in the direction of expected swelling or movement • Apply tape without stretch or tension: replace acrylate tape or reposition silicone tape if swelling/distention occurs • Apply gentle firm pressure after application, stroking the tape in place

Tape is removed incorrectly: tape is Proper removal • Remove tape slowly keeping tape removed rapidly or pulled vertically; technique horizontal and close to the skinunderlying skin is not supported • Remove in the direction of hair growthduring removal • Support exposed skin at the peel line as tape is removed

Table and content courtesy of 3M

Managing tape-related problems

dition helps you decide if you must use atape that breathes, removes gently, or se-cures firmly.

Consider the tape’s purpose. For exam-ple, if you need to secure an endotrachealtube on a moist face, the tape must beable to stay intact and secure; in this case,cloth tape might be best. In contrast, adressing on a moving joint needs a tapethat stretches and accommodates formovement, such as a foam or soft clothtape. Your assessment findings help youdecide whether to use a tape that stretch-es, breathes, or repels moisture.

Next, evaluate for potential stressors,such as tension, flexion, friction, andmovement. These influence product selec-tion because you want to avoid separationof the epidermal layers, peeling of dress-ings, and tube dislodgement.

In some situations, a patient may havefragile skin but require a strong tape; ex-amples include neonates, older adults, andpatients with edematous skin. See Manag-

ing tape-related problems for tips on howto manage problems commonly encoun-tered when using medical tape.

Evaluating MARSI riskTape should stick to the skin without caus-ing injury. Selecting tape for a particularpurpose goes beyond assessing the tapelocation and ambient conditions. You alsomust consider the patient’s underlying di-agnosis and overall health. Screen for fac-tors that increase the patient’s MARSI risk.Age can be a major risk factor.• Neonates have thinner skin than adults.

This means the epidermal layers maypeel away easily during tape removal.

• Elderly patients are at risk for skin tearsfrom moisture and loss of elasticity andstrength.

Other risk factors include certain under-lying diagnoses, medications, and other as-pects of the patient’s current health status.Is your patient’s skin fragile or insensate?


Intrinsic factors Extrinsic factors

Extremes of age (neonate/premature infant Drying of the skin due to harsh skin cleansers,and the elderly excessive bathing, low humidity, etc.

Race/ethnicity Prolonged exposure to moisture

Dermatologic conditions (ie, eczema, dermatitis, Certain medications (ie, anti-inflammatory chronic exudative ulcers, epidermolysis agents, anticoagulants, chemotherapeutic bullosa) agents, long-term corticosteroid use)

Underlying medical conditions (ie, diabetes, Radiation therapyinfection, renal insufficiency, immuno-suppression, venous insufficiency, venoushypertension, peristomal varices)

Malnutrition Photodamage

Dehydration Tape/dressing/device removal

Repeated taping

Source: McNichol L, Lund C, Rosen T, Gray M. Medical adhesives and patient safety: state of the science: consensusstatements for the assessment, prevention, and treatment of adhesive-related skin injuries. J Wound Ostomy Conti-nence Nurs. 2013;40(4):365-80. Used with permission.

Factors that increase MARSI risk

Such medications as corticosteroids can al-ter skin strength and elasticity, making itsusceptible to tearing on tape removal. Apatient with altered sensation, as fromneuropathy or stroke, may not feel painwhen the tape tears or strips the skin. (SeeFactors that increase MARSI risk.)

Case studiesYour knowledge of medical tapes and thepatient’s needs can help you avoid feelingoverwhelmed by the large selection oftapes available—or from being surprisedwhen a tape fails. The case studies belowdescribe how to choose the right tapebased on its purpose and location, ambi-ent conditions, and patient assessmentfindings.

Mr. MMr. M, age 67, is hospitalized for an ab-dominal incision dehiscence; he has type 1 diabetes. You need to secure his ab -dominal dressing, which will have to bechanged more than once daily because ofthe large amount of drainage. The goal isto protect his skin while ensuring thedressing stays in place so Mr. M can con-tinue to get out of bed.

You determine he needs a tape that will

stick to a surface that moves. Mr. M’s skinis dry but the wound produces moisturethat may compromise tape adhesion. Hisdry skin and age put him at risk for skintearing from loss of elasticity and moisture.Also, he’s at risk for compromised healingdue to diabetes.

Considering the tape’s purpose and loca-tion and ambient conditions, you select atape that secures the dressing without caus-ing injury—one that’s both gentle to re-

move and provides sufficient adhesion tosecure the dressing. For Mr. M, appropriatetape choices include both silicone and pa-per. Paper tape (with acrylate adhesive) isnearly as gentle as silicone. Acrylate papertape causes trace amounts of skin strip-ping, while silicone tape offers greater ini-tial and long-term adhesion than papertape. Mr. M needs to stay mobile, so thepreferred choice is silicone tape, which of-fers better initial adhesion. By incorporat-ing your assessment findings and knowl-edge of the features of pressure-sensitiveadhesives, you were able to determinewhich tape would best suit his needs.


The goal is to

protect his skin while

ensuring the dressing

stays in place so

Mr. M can continue to

get out of bed.

J.R.J.R., age 27, has a nasogastric (NG) tube inplace for gastric decompression after re-moval of a perforated appendix. You notethat he has oily, moist facial skin, whichmay cause the tape adhesive to fail, result-ing in the NG tube falling out. J.R. is dis-tressed when he learns the tube may haveto be replaced if it falls out, so you decideto choose a tape that will help prevent dis-lodgement. The tape should be able to se-cure a relatively heavy tube while main-taining adhesion over time.

Considering the tape’s purpose and loca-tion and ambient conditions, you know youshould pick a tape with high initial andlong-term adhesion. Silk tape provides highinitial adhesion to dry skin, but cloth tapeoffers better initial adhesion to both dry andmoist skin. Washing J.R’s skin would createan ideal environment for a silk-like tape. ButJ.R. needs a tape that also provides adhesionover time; the moist, oily environment of hisface can cause adhesive to fail. So the pre-ferred choice for him is cloth tape, due toits increased initial adhesion on damp skin.Of course, J.R. will need ongoing evalua-tion to prevent tube dislodgement.

In an attempt to minimize injury, youmight have chosen a gentle tape with insuf-ficient adhesion instead of cloth tape. Buttape that doesn’t secure sufficiently may al-low dislodgment of critical tubing; adhesivefailure occurs when tape doesn’t remain se-cured to the skin, tubing, or device.

As these case studies show, the condition

of your patient’s skin and overall health in-fluences tape selection. For both Mr. M andJ.R., understanding the tape’s purpose andlocation and the ambient conditions wasthe launching point for tape selection. Withimproved knowledge of pressure-sensitiveadhesives, you can evaluate tape productsand select an appropriate product based onthe patient’s individual needs. Your knowl-edge guides product selection and helps re-duce the potential for injury. ■

Ann-Marie Taroc is a staff nurse at Seattle Chil-dren’s Hospital in Seattle, Washington, and ad-junct faculty at Seattle University College ofNursing in Seattle, Washington.

Selected references3M Skin & Wound Care Division. Solutions for Se-curing Dressings and Devices: Because Tape Mat-ters. 2012. http://multimedia.3m.com/mws/media/784590O/3m-medical-tapes-full-line-catalog.pdf?fn=70-2010-8488-9.pdf

Czech Z, Kowalczyk A, Swiderska J. Pressure-sensi-tive adhesives for medical applications. In: Akyar I,ed. Wide Spectra of Quality Control. InTech; 2011;309-32. www.intechopen.com/books/wide-spectra-of-quality-control/pressure-sensitive-adhesives-for-medical-applications

Grove GL, Zerweck CR, Houser TP, et al. A random-ized and controlled comparison of gentleness of 2medical adhesive tapes in healthy human subjects. JWound Ostomy Continence Nurs. 2013;40(1):51-9.

Holmes RF, Davidson MW, Thompson BJ, et al. Skintears: care and management of the older adult athome. Home Healthc Nurse. 2013;31(2):90-101.

McNichol L, Lund C, Rosen T, et al. Medical adhe-sives and patient safety: state of the science: consen-sus statements for the assessment, prevention, andtreatment of adhesive-related skin injuries. J WoundOstomy Continence Nurs. 2013;40(4): 365-80.

Online ResourcesA. http://www.npuap.org/resources/educational-and-clinical-resources/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guideline/

B. http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf

C. http://algorithm.wocn.org/#home



H ow would you react if youheard a 600-lb patient was be-ing admitted to your unit?Some healthcare professionals

would feel anxious—perhaps becausethey’ve heard bariatric patients are chal-lenging to care for, or they feel unpre-pared to provide their care.

With the obesity epidemic showing nosigns of abating, you’re likely to encounterbariatric patients at some point. How canyou care for them with the dignity and respect they deserve? If we expect to conduct “business as usual” on our units,we’ll be caught off guard without thetools and knowledge we need to makethe experience a positive one for the pa-tient, family, and staff. This article reviewshow to prepare for and manage one ofthe most challenging aspects of caring forbariatric patients—providing skin care.

Skinfolds: A special focus of care Bariatrics is the branch of health care thatspecializes in treating people with obesityand associated conditions. Defined as abody mass index (BMI) over 30, obesity re-flects how a person’s weight relates toheight. Bariatric patients have an excessive-ly large size, with excess adipose tissue un-der the skin and throughout the body.

Skinfolds may develop in various loca-tions—including behind the neck; underthe arms, breasts, and abdomen; betweenthe inner thighs; and under the pannus(an overlapping tissue flap formed fromthe abdomen that extends downward likean apron). Complications commonly arise

in skinfolds and include intertriginous der-matitis, candidiasis, and pressure ulcers.(See Understanding skinfold complicationsin bariatric patients.)

OBESE: An apt mnemonic Use the word OBESE as a mnemonic toolto help you remember key clinical issuesin bariatric skin management.O: Observe for atypical pressure ulcer de-

velopment.B: Be knowledgeable about common skin

conditions.E: Eliminate moisture on skin and in skin-

folds.S: Be sensitive to the patient’s emotional

distress.E: Use equipment to protect the skin and

for safe patient handling.

Observe for atypical pressure ulcerdevelopment.Bariatric patients are at higher risk forpressure ulcers, as their extra paddingdoesn’t necessarily protect them from theforces of pressure and shear. Although the

Providing skin care for bariatric patients Specialized knowledge of common conditions and their treatments can help clinicians meet this challenge. By Gail R. Hebert, MS, RN CWCN, DWC, WCC, OMS


data supporting higher risk for this popu-lation aren’t cut and dried, most expertclinicians believe the risk is higher, so besure everyone knows that fat pads don’tprovide protection.

Also, bariatric patients commonly aremalnourished and less mobile than others,making it hard for them to avoid excesspressure on the skin. Many have multiplecomorbidities, such as diabetes, that fur-ther increase their pressure ulcer risk. Welack a risk assessment instrument specifi-cally designed for this population, so wemust use our clinical skills and experienceto anticipate risk.

In this population, pressure ulcers candevelop in atypical and unique locations—

hips, lower back, buttocks, in skinfolds,and in areas with medical devices, such astubes. Also, foreign objects, such as medi-cine cups and TV remote controls, can getlost in the bed and lead to pressure areas.Bariatric patients require frequent turningand repositioning to help prevent break-down from pressure and shear forces.

Be knowledgeable about common skinconditions.Intertriginous dermatitis is an inflammato-ry skin condition commonly seen in theskinfolds of bariatric patients. It resultsfrom the weight of skin, which createsskin-on-skin contact coupled with frictionforces and trapped moisture from perspi-ration. Dermatitis most often occurs inskinfolds behind the neck, under the armsand breasts, under the abdomen or pan-nus, on the side, and on the inner thigh.

Intertriginous dermatitis is partial thick-ness and typically presents in a mirror-image pattern on each side of the skinfold.Initially, the involved area of the skinshows mild redness, which may progressto more intense inflammation with erosion,oozing, drainage, maceration, and crusting.Associated findings include pain, itching,burning, and odor. As clinicians, we shouldanticipate this problem and not wait for in-tertriginous dermatitis to develop. To helpprevent and intervene for intertriginousdermatitis, read “Eliminate moisture on skinand in skinfolds” below. (For informationon other common skin conditions inbariatric patients, see Candidiasis, acan-thosis nigricans, and chafing.)

Eliminate moisture on skin and inskinfolds.Many barriers to healthy skin in bariatricpatients can be eliminated by reducingmoisture on the skin, avoiding skin-to-skin contact, minimizing heat build-up onthese tissues, and keeping the skin clean.Using absorbent materials can accomplishthese goals. For instance, Interdry AG®

Obese patients have increased body mass, whichgenerates more heat. In an effort to restore a nor-mal internal temperature, the body sweats. As aperson’s weight increases, the ratio of skin surfaceto internal body mass decreases, impeding thebody’s ability to cool itself. Skin stays moist withperspiration as the body continues to use thiscooling method, which is only partially effective.

Because bariatric patients commonly have exces-sive moisture on the skin, their skinfolds are highlysusceptible to such complications as dermatitis,candidiasis, and pressure ulcers. Poor tissue oxy-genation in these patients contributes to the prob-lem. Buildup of adipose tissue in the abdomen im-pedes the diaphragm’s ability to flatten duringinspiration, which can cause shallow breathing andimpaired tissue and blood oxygenation.

Adipose buildup around the rib cage also posesan obstacle to chest expansion. Adipose tissue it-self is poorly vascularized with fewer blood ves-sels, making it more likely to break down and healslowly. Poorly oxygenated skin is more susceptibleto infection and injury.

Understanding skinfold complications in bariatric patients

Normal skin Excess adipose tissue


Textile (from Coloplast, Inc.) is impregnatedwith ionic silver, which provides broad-spectrum antibacterial and antifungal actionfor up to 5 days. It’s designed to wick awaymoisture and reduce skin-to-skin friction.

Clean the patient’s skin frequently witha pH-balanced cleanser, using gentlestrokes to avoiding harming fragile tissues.Avoid scrubbing. Handheld showers andno-rinse cleansers can simplify this pro -cess. Advise patients to wear loose-fittingclothing made of absorbent fibers.

Be sensitive to the patient’s emotionaldistress.Everyone involved in caring for bariatricpatients should receive sensitivity trainingto increase their awareness and compas-sion. Many of us hold an unconsciousnegative view of these patients, which canmanifest in our interactions with them.

Bariatric patients have reported many inci-dents of unprofessional treatment by staffwho are otherwise excellent caregiversbut lack empathy and understanding.

To make matters worse, bariatric pa-tients frequently suffer from depression,altered self-esteem, and social isolation.Take care not to demonstrate prejudicethrough your actions and words, or toshow reluctance to render care due to fear of injury, inadequate equipment, in-adequate staffing, or a misunderstandingof obesity.

Use equipment to protect the skin andfor safe patient handling.Equipment must be the proper size and

Candidiasis, acanthosis nigricans, and chafing

Be aware of possible obesity bias.View: “Weight bias in healthcare,” from Yale Rudd Center.A

Candidiasis on the skin ofbariatric patients results fromCandida albicans, which lovesthe moist, dark, warm environ-ment of skinfolds. Poor hygiene(due to difficulty washing be-cause of excessive body size),hot weather, and tight clothingpredispose bariatric patients tothis problem.

Typically, candidiasis presentsas a consolidated or patchy areaof redness with small roundpapules, pustules, or plaques; insome cases, satellite lesionsarise away from the central redarea. Patients usually complainof burning, itching, or both.

To prevent candidiasis, keepthe skin dry and clean. At the firstsign of a problem, take promptaction. Start by applying an over-the-counter or prescription anti-fungal powder or a silver powderor cream, according to manufac-turer’s recommendations.

Be aware that C. albicans maybecome resistant to antifungalagents. If your patient’s rash

doesn’t resolve after 2 weeks oftreatment, consider switching toanother preparation. Keep theoption of oral medication inmind if the rash persists and failsto respond to local treatment.

Acanthosis nigricans is the mostcommon skin manifestation inobese patients. It may be con-fused with poor hygiene, causingwhat may look like dirt in skin-folds. This skin condition resultsfrom insulin resistance that leadsto insulin spillover into the skin.

Lesions are hyperpigmented,thickened, velvety textured mac-ules and patches that may itchand appear warty or leathery.They can arise anywhere butmost often show up on intertrigi-nous areas of the axilla, groin,and posterior neck.

No cure for acanthosis nigri-cans exists, but controlling bloodglucose levels can improvesymptoms. For cosmetic treat-ment, preparations withtretinoin, metformin, octreotide,or topical calcipotriol can be

used; laser therapy may be anoption, too.

Chafing is caused by skin irrita-tion from repetitive friction, usu-ally caused by skin-to-skin con-tact or contact between tightfabric and skin. The most sus-ceptible areas are the innerthighs, under the breasts, andskinfolds, armpits, and nipples.The skin injury is partial thick-ness and red, with edema; inmany cases, it causes bleedingand pain.

For prevention, advise pa-tients to wear clothing made ofmoisture-wicking fabrics (for in-stance, bike shorts) and to uselubricants on the affected skin,such as petroleum-based prod-ucts or moisture barrier oint-ments, skin sealants, or specialtyathletic items. Instruct them tocover affected areas with zinc-based ointments or no-sting skinsealants. Inform them not to usenormal saline solution on chafedareas as it could cause burningand pain.

http://www.uconnruddcenter.org/weight-bias-stigma-videos-exposing-weight-bias






construction to prevent rubbing and creat-ing pressure points against the skin (forexample, from the side panels of a too-small wheelchair). Reposition patients fre-quently to prevent skin breakdown; also,reposition any tubes and tube fixation de-vices. Use support surfaces of the appro-priate weight limit to prevent bottomingout. With skin moisture a common con-cern, most bariatric patients should use alow-air-loss mattress.

Transferring and moving patients pres-ents a hazard to both staff and patients.Ideally, healthcare facilities should havethe proper equipment on hand and readyfor use when the patient reaches the unit.The best way to ensure the right type andamount of equipment is to work withcompanies that specialize in safe patient-handling programs. They can conduct aneeds analysis and provide evidence-based recommendations that can be re-viewed before equipment purchase orrental. Although facility administrators maybelieve they lack the budget for equip-ment purchase, I would advise them theydon’t have the budget not to purchase it.A single lawsuit or injury claim by a pa-tient or a workers compensation claim bystaff can cost considerably more than theinvestment in proper patient-handlingequipment.

Meeting the challengeSpecialized knowledge of common condi-tions and appropriate treatments can helpus meet the challenge of caring for ba ri -atric patients’ skin. That knowledge mustbe coupled with planning activities to ad-dress such issues as required staff, devices,and lifting and repositioning equipment.Accomplishing these goals long before youhear of a 600-lb patient on the way toyour floor will greatly enhance the chanceof a successful outcome. ■

Selected referencesBeitz JM. Providing quality skin and wound care forthe bariatric patient: an overview of clinical chal-

lenges. Ostomy Wound Manage. 2014;60(1):12-21.

Black JM, Gray M, Bliss DZ, et al. MASD part 2: in-continence-associated dermatitis and intertriginousdermatitis: a consensus. J Wound Ostomy Conti-nence Nurs. 2011;38(4):359-70.

Blackett A, Gallagher S, Dugan S, et al. Caring forpersons with bariatric health care issues: a primerfor the WOC nurse. J Wound Ostomy ContinenceNurs. 2011;38(2):133-8.

Bryant RA. Types of skin damage and differential di-agnosis. In: Bryant RA, Nix DP. Acute & ChronicWounds: Current Management Concepts. 4th ed. St.Louis, MO: Mosby; 2012;83-105.

Corbyn C, Rush A. Challenges of wound managementin bariatric patients. Wounds UK. 2010;6(4):62-71.

Cuddigan JE, Baranoski S. Wounds in special popula-tions: bariatrics. In: Baranoski S, Ayella EA, eds. WoundCare Essentials: Practice Principles. 3rd ed. Ambler, PA:Lippincott, Williams & Wilkins; 2012;542-51.

Doughty D. Differential assessment of trunkwounds: pressure ulceration versus incontinence as-sociated dermatitis versus intertriginous dermatitis.Ostomy Wound Manage. 2012;58(4):20-2.

Doughty D, Junkin J, Kurz P, et al. Incontinence-as-sociated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, andcurrent challenges. J Wound Ostomy ContinenceNurs. 2012;39(3):303-15.

Clark L, Black JM. Keeping the bariatric patient’sskin intact. Bariatric Times. May 17, 2011. bariatric-times.com/keeping-the-bariatric-patient%E2%80%99s-skin-intact/

Miller JH. Acanthosis nigricans. Medscape. July 15,2010; updated September 26, 2014. emedicine.med-scape.com/article/1102488-overview

National Pressure Ulcer Advisory Panel, EuropeanPressure Ulcer Advisory Panel and Pan Pacific Pres-sure Injury Alliance. Prevention and Treatment ofPressure Ulcers: Clinical Practice Guideline. HaeslerE, ed. Osborne Park, Western Australia: CambridgeMedia; 2014.

Sardina D. Skin and Wound Management CourseWorkbook. Lake Geneva, WI: Wound Care EducationInstitute; April 2011.

Swezey L. Top 5 ways to prevent skin breakdown inbariatric patients. April 2, 2014. woundsource.com/blog/top-5-ways-prevent-skin-breakdown-bariatric-patients.

Zulkowski K. Diagnosing and treating moisture-asso-ciated skin damage. Adv Skin Wound Care. 2012;25(5):231-6.

Gail R. Hebert is a clinical instructor with the WoundCare Education Institute in Plainfield, Illinois.

Online ResourceA. http://www.uconnruddcenter.org/weight-bias-stigma-videos-exposing-weight-bias


Content and funding provided by Hill-Rom

The following Case Study is a continuation of the Prove the Value information published inthe September/October 2015 issue of Wound Care Advisor, available at hereA. The Hill-RomProve the Value program is based on collecting and analyzing information on individuals whohave recently used or are current using a Clinitron bed or P500 wound surface and helpsdemonstrate the value of advanced wound care solutions through local assessments withinfacilities. Contact your local Hill-Rom representative for more information, click hereB.

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Online ResourcesA. http://woundcareadvisor.epubxp.com/i/566063-september-october-2015/32

B. http://www.hill-rom.com/usa/

Is your therapydepartment onboard with yourwound careteam? By Cheryl Robillard, PT, WCC, CLT, DWC

Patients in your clinical practice whodevelop wounds should prompt a call

for “all hands on deck” to manage the situ-ation, but some personnel may be missingthe boat. Physical therapists (PTs), occupa-tional therapists (OTs), and speech-lan-guage pathologists (SLPs) should be onboard your wound care ship so patientscan receive care they need. But unfortu-nately, sometimes they aren’t.

Several reasons can account for the lack

of therapy involvement in some facilities.They include a knowledge deficit of whatPTs, OTs, and SLPs can do to help healwounds, or misinformation such as themyth that therapy can’t get involved until awound has been present for 30 days. An-other reason may be lack of therapist’sknowledge or desire to treat wounds andtheir complications. Lastly, it could be a“turf” issue when several members of theteam could perform a similar intervention.

Let’s take a closer look at some of theseareas.

Therapy servicesAn understanding of the services therapistscan provide helps you know when tomake referrals.

Cognition assessment SLPs are experts in assessing a patient’scognition. The assessment includes learn-


BusinessCONSULT

ing ability, so they can help the team de-termine effective strategies for teaching.

Consider the nonadherent patient withdiabetes who has a foot wound. Diabetesis a risk factor for cognitive impairment,but how many of your patients with dia-betes have been tested for this impairmentso they—and you—know how to com-pensate?

Another problem is that patients withmild cognitive impairment can often “talkthe talk, but not walk the walk”: They maysay they understand but not truly “get it.”This is especially true with written infor-mation. Too much money has been wast-ed on literature given to patients whomight be able to read it but don’t compre-hend the information or can’t make theconnection between the information andwhat specifically they need to do.

You can use a simple screening testsuch as the SLUMS (St. Louis UniversityMental Status exam) or the MoCA (Montre-al Cognitive Assessment) for an initial as-sessment and refer patients to an SLP ifthe results are positive.

NutritionSLPs and OTs, working closely with dieti-tians, can assess and treat swallowing andfeeding issues that can impair the ability ofpatients to receive the nutrition they needfor wound healing. SLPs and OTs also caneducate staff and patients in good oralcare to help prevent such complications aspneumonia that can derail healing.

Skin careGeneral skin care isn’t only the functionof nursing—OTs and PTs can help. Ensur-ing that patients and caregivers have theknowledge and capability to inspect,cleanse, and moisturize the skin should be

part of a complete activities-of-daily-livingprogram, a specialty of OTs.

Urinary and bowel continence manage-ment, which is within the scope of prac-tice for PTs and OTs, can make a signifi-cant difference in avoiding contaminationof truncal wounds.

Pressure reduction and off-loading is an-other reason for referral to PTs and OTs.Splinting and contracture management canprevent some wounds and help in healingothers. PTs can assess sensation and exam-ine footwear, then teach patients andmake recommendations to prevent exces-sive pressure. They also can provide spe-cialty shoes or total contact casts. Deci-sions about pressure redistribution inseating systems and beds should involvePTs or OTs.

Edema managementEdema management, which may includemanual lymphatic drainage, compression,and exercise, is a good reason to refer pa-tients to PTs and OTs. Although some ofthese methods require additional trainingbeyond entry-level education, therapistsshould be able to provide them.

Psychosocial issuesOTs also address psychosocial issues perti-nent to wound healing. For example, a pa-tient confined to bed or home for extend-ed periods of time may experience socialisolation, learned helplessness, and depres-sion. A patient with a vascular wound whois at risk for amputation may experienceextreme stress. Or a patient may not beable to return to his or her previous pro-fession because of wound issues. OTs aretrained to provide psychotherapeutic inter-ventions aimed at improving and maintain-ing the highest quality of life.


DebridementDebridement of nonviable tissue, includ-ing both necrotic tissue and epiboly, ispart of clinical practice for PTs and spe-cially trained OTs. These therapists canuse scalpels, forceps, curettes, and scis-sors for conservative sharp debridement.Sterile instruments are used in a cleanenvironment to remove only nonviabletissue. This differs from surgical debride-ment, which is completed by physiciansin a sterile surgical environment and mayalso include removal of viable tissue toeffectively create a new wound. Debride-

ment may also be nonspecific, such asusing pulsed lavage, a high-pressuresaline jet with suction.

Please note that all of the interventionsdiscussed so far may be provided whenneeded, regardless of the length of time awound has been present.

Biophysical agentsBiophysical agents, also commonly knownas modalities, use various forms of energyto facilitate healing by decreasing inflam-mation, increasing circulation, decreasingedema, decreasing pain, and removing or


Several types of biophysical agents are available, including low- and high-frequency ultrasound(US), electrical stimulation (e-stim), short-wave diathermy (SWD), cold laser/infrared light, pulsedelectromagnetic field (PEMF), and pulsed radio frequency stimulation (PRFS).

Low-frequency US can be noncontact, as in MIST™ therapy, or contact, as in the Arobella Qous-tic™, Soring Sonica,™ and Misonix SonicOne™. These machines use sound waves to disruptnecrotic tissue and biofilms. The sound waves also cause acoustic streaming that can stimulatehealing. Unfortunately, these devices are relatively expensive and not consistently covered for re-imbursement, so they may not be accessible by all organizations.

Pulsed high-frequency US can be used to increase circulation, decrease edema, and soften necrotictissue. Available research has not consistently demonstrated its efficacy, so not all payers reimbursefor it. The machine for providing this therapy is commonly found in most therapy departments.

E-stim and SWD have been extensively studied, and research has shown them to be effective infacilitating wound healing. E-stim, using electrical currents, and SWD, using magnetic currents,both facilitate healing at the cellular level.

Centers for Medicare & Medicaid Services (CMS) developed a National Coverage Decision (NCD)for e-stim and SWD. This means that all insurance companies managing Medicare reimbursement(Medicare Area Contractors), must cover these treatments if these two conditions are met:

• The wound is a chronic stage III or IV pressure ulcer or an arterial, diabetic, venous stasis ulcer.Chronic is defined as not healed within 30 days.

• The wound shows no measurable signs of healing with at least 30 days of standard wound care.

The 30-day requirement, known as the “30-day rule” has caused confusion about when patientsare referred for therapy. It’s important to understand that the 30-day rule applies only to e-stim andSWD, not to other interventions discussed in this article.

Cold laser/infrared light (for example, Anodyne), PEMF, and PRFS have not been covered bymost payers because of inadequate research support, but may be available in your area.

Note: The information contained herein is not intended as coding advice. The information contained in this documentis provided for informational purposes only and represents no statement, promise, or guarantee by the author concern-ing levels of reimbursement, payment, eligibility, charges or that these policies and codes will be appropriate for spe-cific services or products provided or that reimbursement will be made. It is always the providers’ responsibility to de-termine and submit appropriate codes, charges, modifiers, and bills for the services that were rendered. Consult yourlocal CMS, MAC, or other applicable payer organization with regard to specific reimbursement policies, coverage, docu-mentation, and payment.

Types of biophysical agents

softening necrotic tissue. PTs and speciallytrained OTs can provide these modalities.Each modality has specific contraindica-tions and may have payer-specific limita-tions on provision. (See Types of biophysi-cal agents.)

Bringing therapists onboardNow that you know what therapistsshould be able to do for your wound pa-tients, what if your clinicians aren’ttrained in some of these areas? Discussthe problem with the department manag-er because there are many continuing ed-ucation courses available, as well as theWound Care Education Institute certifica-tion program.

An excellent way to increase involve-ment of therapists in wound care is tohave them participate in wound roundswith nurses. This is a great way for youto share your knowledge with them, al-low them to see various wounds andwound dressings, and have them deter-mine with you what wounds might needthe therapy interventions discussed inthis article.

Mowing down turf issuesEliminating turf issues begins with know-ing each discipline’s scope of practice. Youalso may need to take financial issues intoconsideration. Depending on your setting,if the PT can debride and be separately re-imbursed, freeing up nurses to focus onother medical issues, wouldn’t that be themost expedient course?

Another potential problem may be coor-dination of services. For example, althoughapplying a dressing is not a billable thera-py service, does it make sense to have atherapist undress the wound for a modalitythen leave the wound uncovered until a

nurse has time to apply the dressing? Resolving turf issues requires a collabo-

rative spirit from all team members to ne-gotiate what makes the most sense in yoursetting and determine what would be bestfor the patient’s healing.

Setting sailHaving therapists as active members ofyour wound care team will ensure you’reproviding the best state-of-the-art care forpatients’ wounds. Knowing what the dif-ferent therapies can do will help you de-termine which wounds require a thera-pist’s direct involvement. Lastly, navigatingbarriers to getting your therapists on boardyour wound care ship will help you reachtop speed in sailing to healing! ■

Selected referencesCheng G, Huang C, Deng H, Wang H. Diabetes as arisk factor for dementia and mild cognitive impair-ment: A meta analysis of longitudinal studies. InternMed J. 2012;42(5):484-91.

McCrimmon RJ, Ryan CM, Frier BM. Diabetes 2: dia-betes and cognitive dysfunction. Lancet. 2012;379:2291-2299.

Marseglia A, Xu W, Rizzuto D, et al. Cognitive func-tioning among patients with diabetic foot. J DiabetesComplications. 2014;28(6):863-868.

Nasreddine ZS, Phillips NA, Bedirian V, et al TheMontreal Cognitive Assessment, MoCa: a briefscreening tool for mild cognitive impairment. J AmGeriatr Soc. 2005;53(4):695-9.

Stechmiller JK. Understanding the role of nutritionand wound healing. Nutr Clin Pract. 2010;25(1):61-8.

Tariq SH, Tumosa N, Chibnall JT, et al. Comparisonof the Saint Louis University mental status examina-tion and the mini-mental state examination for detect-ing dementia and mild neurocognitive disorder—a pi-lot study. Am J Geriatr Psychiatry. 2006;14(11):900-10.

Whitmer RA. Type 2 diabetes and risk of cognitiveimpairment and dementia. Curr Neurol NeurosciRep. 2007;7(5):373-80.

Cheryl Robillard is a clinical specialist for AegisTherapies in Milwaukee, Wisconsin.


End your year by checking out these resources for your practice.

Sentinel event alert for falls

As part of its sentinel event alert “Prevent-ing falls and fall-related injuries in healthcare facilitiesA,” The Joint Commission hasassembled information and multiple re-sources, including:• analysis of contributing factors for falls• evidence-based suggestions for im-

provement• Joint Commission requirements relevant

to falls• links to toolkits and protocols• an infographic on preventing falls.

Falls with serious injury are consistentlyamong the top 10 sentinel events reportedto The Joint Commission Sentinel EventDatabase.

Position statements for NPUAP

The National Pressure Ulcer Advisory Panelpublishes several position statementsB of in-terest to wound care clinicians, including:• Hand check method: Is it an effective

method to monitor for bottoming out?• Pressure ulcers with exposed cartilage

are stage IV pressure ulcers

• Staging pressure ulcers• Mucosal pressure ulcers• Reverse staging.

The statements recap a topic or delineateNPUAP’s opinion on a specific issue.

Patient safety primer on high reliability

The Agency for Healthcare Research andQuality has released a Patient Safety PrimerC

on high reliability. High-reliability organi-zations operate in complex, high-hazarddomains for extended periods without se-rious accidents or catastrophic failures.

The primer describes characteristics ofhigh reliability and links to resources thatcan help organizations foster an environ-ment conducive to high reliability.

Civility resources

The American Nurses Association offersresourcesD on incivility, bullying, andworkplace violence, including:


ClinicianRESOURCES

http://www.jointcommission.org/sea_issue_55/?j=2664045&[email protected]&l=9552_HTML&u=55549862&mid=1064717&jb=0



http://www.npuap.org/resources/position-statements/

http://psnet.ahrq.gov/primer.aspx?primerID=31

http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/bullyingworkplaceviolence/default.aspx

• two infographicsE: “Bullying preventionstrategies for nurses” and “Civility bestpractices for nurses”

• the position statement “Incivility, Bully-ing, and Workplace Violence”

• links to other resources, such as a Na-tional Institute for Occupational Safetyand Health training program on occupa-tional violenceF.

Guideline synthesis on prevention of pressure ulcers

Access a comparisonG of two guidelines forthe prevention of pressure ulcers. The com-parison was done by the National Guide-line Clearinghouse, part of the Agency forHealthcare Research and Quality. ■

Online ResourcesA. http://www.jointcommission.org/sea_issue_55/?j=2664045&[email protected]&l=9552_HTML&u=55549862&mid=1064717&jb=0B. http://www.npuap.org/resources/position-statements/C. http://psnet.ahrq.gov/primer.aspx?primerID=31D. http://www.nursingworld.org/MainMenuCategories/Workplace-Safety/Healthy-Nurse/bullyingworkplaceviolence/default.aspxE. http://www.nursingworld.org/MainMenuCategories/Workplace-Safety/Healthy-Nurse/bullyingworkplaceviolence/Preventing-Bullying-and-Civility-Best-Practices.htmlF. http://www.cdc.gov/niosh/topics/violence/training_nurses.htmlG. http://www.guideline.gov/syntheses/synthesis.aspx?id=47794&search=ostomy

Anasept® Antimicrobial Skin & Wound Gel

Pathogenic Bacteria:Acinetobacter baumanniiCarbapenem Resistant E. coli (CRE) Clostridium difficileEscherichia coliMethicillin Resistant Staphylococcus aureus (MRSA)Proteus mirabilisPseudomonas aeruginosaSerratia marcescensStaphylococcus aureusVancomycin Resistant Enterococcus faecalis (VRE)Pathogenic Fungi: Aspergillus nigerCandida albicansKI

LLS T

HE FO

LLOW

ING:

http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/bullyingworkplaceviolence/Preventing-Bullying-and-Civility-Best-Practices.html

http://www.cdc.gov/niosh/topics/violence/training_nurses.html

http://www.cdc.gov/niosh/topics/violence/training_nurses.html

http://www.guideline.gov/syntheses/synthesis.aspx?id=47794&search=ostomy

http://anacapa-tech.net

Note from Executive Director

By Cindy Broadus, RN, BSHA, LNHA,CLNC, CLNI, CHCRM, WCC, DWC, OMS

WOW! WOW! WOW! That sums upthe feeling generated at the 12thAnnual Wild on Wounds Confer-

ence, held September 2-5 in Las Vegas.What an exciting 4 days! With more than1,100 attendees, the conference was busy,bustling, and full of nonstop activity. Ses-sions were available for all levels of clini-cians, from beginners to advanced, andwere based on 2014 participant feedback.This year, we added something new: Clini-cians could watch webinars in a dedicatedroom and obtain continuing education cred-it. We received a great deal of positive feed-back about the different learning options.

Once again, NAWCO had a question/an-swer area set up in the middle of the ac-tion. I’d like to thank our board of directorsand certification committee members forvolunteering their time to staff the area andanswer inquiries from attendees.

Each year NAWCO gives three awards todeserving clinicians who go above and be-yond the daily routine to provide exceptionalcare to their patients with wounds. It’s such arewarding experience for the awards commit-tee to receive and read the many nomina-tions. As always, there were many outstand-ing submissions, but only three could bechosen, making the selection process difficult.

In the previous issue, I reintroduced allof the award winners since the inception ofthe awards program in 2007 through 2014.The 2015 winners were announced and rec-ognized during the closing session, titled“Pay it Forward.” Board of directors Presi-

dent Debbie Dvorachek and Vice PresidentKatie Pieper presented the awards to thewinners.

Here are just some of the impressivecomments that were made about the awardwinners.

Outstanding Work in Diabetic Wounds:Margarita Joni Rose Villar, BSN, RN, WCC• “Consistently displays high ethical stan-

dards and maintains integrity with pa-tients as well as hospital staff.”

• “Volunteers to see clinic patients, edu-cates staff on total contact casting andits effects on healing the diabeticwound.”

• “Recruits/mentors other wound careprofessionals in the prevention andtreatment of diabetic wounds.”

Outstanding Research in Wound Care:Candice Curtin, BSN, RN, WCC, DWC, OMS• “Presented a poster at the 2015 VNAA

(Visiting Nurse Associations of America)conference.”

• “Received first-place poster award for acase study series done on Diabetic FootUlcer Management at the Desert FootPodiatry Conference in 2012.”

• “Working on validating a pressure ulcerstaging tool that will help cliniciansstage appropriately.”

Outstanding WCC of the Year: MarissaRichardson, RN, CRRN, WCC• “Provides the leadership role with


NAWCONEWS


wounds in the HealthSouth hospital inJonesboro, Arkansas.

• “Able to articulate proper technique atall levels of licensure.”

• “Provides wound care training and con-ducts one-on-one education with pa-tients on how to take care of theirwounds at home after discharge.”

NAWCO is proud and honored to havebeen able to recognize the achievements ofsuch a dedicated group of wound care clini-cians. All of us at NAWCO congratulate the2015 Award Winners.

Look for my introductions of the remain-ing board of director members in the nextissue of Wound Care Advisor.

Ariel AckermanHoward AguadaAudrey AkinlotanEkaette AkpabioVickie AllenHeather AlnwickNoori Al-Waili, MDWendee AmeroKelly AndersonMaria AnocheAngela ArcuriAnne AshtonRhonda BabineauxJennifer BaeckerLinda BaileySandra BaldwinRebecca BarkerNatalee BarnettApril BarreraBonnafe BaticadosChristine BeebeJessica BennettArlene BerdijoKaren BergerIndira BhagwandinJennifer BohrtzSusan Bourbon

Cherie BrawnerColleen BrennanJorge BringasJennifer BrokawDeborah BrownTeresa BuckleyJeanne BuckmanKimberly BurkKimberly BurtonLisa CampbellLinda CarriganSarah CasavantStephanie CassellAdriana CastellanosLiane ChambersNeferteria ChatmanAna Chavalo

CamposVolha ChernikYoung Kyung ChoCynthia ClareKimberly ClemensDonna ClevelandKristin CohenLori ColeMarilyn Collins

Rocha

Janessa CopenhaferTiffany CrawfordMary CregerKimberly CurryPaige DanielsonJessica DavidsonTeresa DavisMatthew DeckerMary DeliraLisa DickenK Slade DietzKarley DitgenRoger DodsonHillery DolfordIrene Dominguez

PrendesBertha Dowell-SmithRobert DuscherRachella EarlyKarla EddinsChristine EidsonNilma Elias SantiagoPatricia ElmoreHeather EzzellMarianna FaccoMara FaderJane FernauDonald FillmanChristopher FinlawRobin FinneyGeri FitchHon FongAngel Foster

Brandi FowlerIngrid FranklinDawn FreemanLilli-Ann GallagherGloria GarciaPeggy GardnerLynn GehrJennifer GeigerCharlene GermerTracy GetmanHelen GipsonKathleen GlascoKoupu GoffaSusan GortneyErica GouldElizabeth GraybillEngle GreenwoodJoseph GrimesNaomie GuiteauRobyn HalleyAshley HaltnessSonya HaptonstallCara HarrisChad HaugeConnie Helmer-

JordanShelly HerronElizabeth HirnSarah HizonLisa HobbsRegina HoeferlinLisa HolpinJodie Huddleston

New certificants

Below are WCC, DWC, and OMS certifi-cants who were certified from August toSeptember 2015.


Lynn HuettJenny HuffBrenda HughesJanet HullSusan HuonderPauline JamesJulie JamgochianSheryl JenkinsJhoni JohnsonJuanita JonesAnisha KadalimattomRoy KainRupert KarlAndrew Kastello, MDLori KentSabrina KhorLizza KisterCassandra KlemmWanda KrauseBetty KuoLea LavariasDavid LehningerRebecca LehtolaEvelyne LemyTiffany LollisLarisa LondonKristina LongCoreen LongBeatriz LunaJannet MangoldLeslie MarceloGeorgette MasonMarissa MastersonAndrea MeasorLynn MelloGaone MerafheMai MilanJanet MillerSuzanne MillerLaura MillevolteStephen MorgensternCrystal MosleyBarbara Murphy

Stacy NewbernAgnes NewlinYvonne NorrisStephanie NovakCaroline O’BrienShannon O’BrienMayola OnArthur OnofreEugenia OverfieldJulie OyenSocorro PaguiriganMalori PaplowSunita PatelDana PattonIrene PearsonTodd PeltonMichelle PerkinsTammy PerryLananh PhanSuann PhillipsIngrid PiedrahitaJustine PiperMelanie PooleBethany PrzybylskiLaurie RamirezMarta Ramos RiveraBrenda ReckerVivian RedmonJennell ReedTamara RetzlaffGeraldine RienstraLalaine RiveraKimberly RolfsonJisah RomeroKondeleye Ross-

JohnsonTeresa RothJanet RoundPaulina RuffaLaToya RussellBrenda SabataViviane SantosJennifer Schlag

Cory ScottJudi SegbefiaCheryl SicklesMelissa SivolaTerrill SkawKiersha SlowterJamie SparenbergSusan SpeedZarina StewardMary StewardsonElishia StillwellMichael StricklandWendy SutherlandJennifer SzalkowskiNicholas TanJudy ThompsonKelli ThornburgAngela TidwellRachel TolarDenise TomerlinJessica TownsendJennifer Townsend

VeraMisty TroyanBernadette TruhnStephen TynanCarolina UrangaElaine ValbuenaRosetta VilleneuveImmacula Volcy-

DesirRobyn WakelingCynthia WalkerFrances WardSara WashaStephanie WashlockMelissa WasmundJanette WattKenneth WearnerAmy WelchSarah WestraMelanie Whimpey-

Budd

Vanya WilliamsTiffany WilsonLinda WilsonTina WinfreySusan WirsingMissy WojtysiakAngie WopatMichelle WrightRachel Yip

Ma Nida AdvinculaElsa Aguilera, MDJennifer AntonelliAmber AshbrookMaggie AustrieRebekah BaldaufGail BaldwinTracy BallRamon BaneaMary BarnesMarlene BarnettLizbet BasultoKathreen BealsPaula BeckTammy BensonJoan BerryRenee BigbeePamela BlatterRobin BlevensKimberly BlitzerLorraine BoehmXzyjoy BongatSarah Booth

Recertified certificants Below are WCC,DWC, and OMS certificants whowere recertifiedfrom August toSeptember 2015.


Tara BordaAmanda BordenGaynell BowmanDenise BoykeStephanie BradshawTrovoyum BransonMary BraswellFrancesca BriemSabrina BriggsLunetha BrittonKaren BrownAmanda BurkeybileJimmy BuyaoHannah CardinMargaret CarfiBonnie CasterMarilyn ChristiansonLydia ClarkTheresa CoatesIngrid ConcepcionStephanie CookKristen CraneMeagan CulakJune CunninghamBeverly CunninghamValerie DavidsonRachelle DavisDebra DeFreitas-

CookElverta DelahayBarbara DeMatteisCaterina Di

GiovannaVicky DooleyRosario DrujaJanet DuffGabrielle DupreDebra EberweinColleen EdsonAlice Eide-MasonJennifer ElledgeKimberly EngenWendy England

Darlene EnglesCarletta ErnstFilipina EscobarCeazar FamilaraMa FelixKaren FelsChere FenselonKimberly FieldChristine FinchNina FinchamAnn FinnCassandra FoleyPriscilla ForeroChristine FournierTheresa Fox ReedBarbara FrancescoCrystal FranklynKathy FrodahlLaura FultonMarisol GallagherDavid Galloway, Jr.Muriel GarciaRoberta GasperPolly GillenAnna GillespieDeborah GipsonSara GoldbergLinda GoldenbergRita GormanChristina GrahamStephanie GrantJoie GriebelTeresa GrimmMaribel GuerreroViktoria HaasNajwa HaddadLizette HaliliLinda Hall PayneLinda HanrattySarah HaywoodGayle HedeenMiranda HendersonTara Hertel

Kyra HillSasha HoldenJanie HollenbachDeborah HornerStephanie HouleMarissa HudlerVashti IveyFilor IzanianAlicia JohnsonLynn JohnstonKimberly KarnesMelanie KehmeierConnie KerriganSteven KingAnita KrummDanielle KvamJeanelle LaoJeanne LawsonChristie LeathDawna LemelinErika Lewis-

HargroveKathleen LibuttiEunice LimLisa LockwoodDarylyn LongRichard Longley, MDDebra LoveridgeDebbie MaasJennifer MackieMary MacLeanKaren MagnaniLisa MaiolieTracey MajernikAmanda MaliaKathy MaloneRebecca MaloneHannah MandLucila ManlapazDawn MarineauKatie MarkesonKelli McDonaldHeather McHenry

Alison MeansMark MeltonRebecca MikulaClaudine MirandaDarlyne MitchellHeidi MitchellKelley MonroeMichelle MooreJessica MorrowTeresa MrstikJohn MuccitelliAnita MuroSharon MurrRosemary NataleKimberly Nelson-

HojnackeEileen NovotnyMary OakesKaren OberlinTracie PantingTracy ParisTammy ParkerNaquita Parker-

RichardsonSonja PenningtonJessie PeraltaNancy PeraltaAna PerezMabel PerezJennifer PetersonKimberly PetitTeresita PidoCarola PisaniDebra PizzorniKerri PrattMary Beth Pratt

YennaKerry PrendergastJudy PulettiKaren RayKasie ReedMartha ReidBonny Reinhart

Joel ReitzBradley RennerDarcie ReyHelen ReyesJeanne RiceRebecca Richter

BurkeLinda RickardsLaReine RickmonMelonie RieckClaudette RobinsonMichele RobinsonNicole RooneyKelley SaizSvetlana SakirskyTeresa SamselAngela SavageStacy Schiurring

Tracey SchofieldCindy SchottMeve ShakespeareElena ShurJudy SkaggsKelly SkinnerEllen SpillaneShannon Spivey-

MayoBecky SprayGemma SuhMelanie SuttonNaoko TakahashiRhonda TalbotConnie TaylorMykka TaylorMary ThomasMelody Thomas

Carol ThompsonAmy ThorntonMartha Thornton,

DPMNing TianCynthia TibertSamantha TirrellBeryl TobingSandra VaughanHelen VercelesChristina VigilKatherine WadeAlan WaishkeyKaren Walker-

AlbrightAngela WallisCynthia WatkinsKathy Watrous

Joann WatsonNorma WellsBarbara WestSamuel WhatleyBrenda WilliamsSharon Williams

BoboMichele YbarraFranco ZauliSheila ZimmerJennifer ZingoSarah Zitzelsberger

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