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Nurse to Nurse Wound Care

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Nurse to Nurse


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Nurse to Nurse


Donna Scemons, RN, FNP-BC, MSN, MA, CNS, CWOCN
President, Healthcare Systems, Inc.
Family Nurse Practitioner, Wound, Ostomy, and Continence Care
Denise Elston, RN, BSN, CWOCN
Consultant, Private Practice
Wound, Ostomy and Continence Care for Acute Care, Outpatient,

Home Health, Hospice and Long Term Care

New York Chicago San Francisco Lisbon London Madrid Mexico City
New Delhi San Juan Seoul Singapore Sydney Toronto

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DOI: 10.1036/0071493972


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please click here.

This book is dedicated to all the patients, caregivers,
family members, CWOCNs, educators, nurses,

physical therapists, physicians, and other healthcare professionals
who have taught and encouraged us throughout our professional

careers. Without these shoulders to stand on this book would
not have been possible. In this, it is our sincerest hope that other

healthcare professionals will find this text useful
in their clinical endeavors.

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For more information about this title, click here


Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
List of Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Chapter 1 Ethical Considerations in Wound
Evaluation and Management . . . . . . . 1

Chapter 2 Principles of Skin and Wound Care . 21

Chapter 3 Pressure Ulcer Assessment and
Management Principles . . . . . . . . . . . 57

Chapter 4 Lower Extremity Wounds of
Venous Insufficiency . . . . . . . . . . . . . . 99

Chapter 5 Arterial Insufficiency, Ulcer Assessment,
and Management Principles . . . . . . . . 133

Chapter 6 Neuropathic and Diabetic Ulcer
Assessment and Management
Principles . . . . . . . . . . . . . . . . . . . . . . . 161

Chapter 7 Lymphedema . . . . . . . . . . . . . . . . . . . . 183

Chapter 8 Assessment of Other Wound Types . . . 199

Chapter 9 Wound Management, Products, and
Support Surface Selection . . . . . . . . . 227

Chapter 10 Skin Assessment and
Documentation . . . . . . . . . . . . . . . . . . 321

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355

This page intentionally left blank


This book would not have been possible without the support
and understanding of Robin, Gaetano, Samuel, Jason, and my
partner in this endeavor, Denise Elston.

Thank you Bill, Goldine, Leslie, and Donna Scemons for your
support. And in memory of my father, Martin P. Elston, MD,
thank you for providing inspiration to me.

Thanks also to all the fine individuals at McGraw-Hill who
worked diligently with fledgling authors, were always encour-
aging, and confident that this could and would be completed.

DS and DE

Copyright © 2009 by The McGraw-Hill Companies, Inc.
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List of Acronyms

AAI Ankle/arm index
ABI Ankle brachial index
ACE American Association of Clinical Endocrinologists
ADA American Diabetic Association
ADLs Activities of daily living
AHRQ Association for Healthcare Research and Quality
ASO Arteriosclerosis obliterans
BP Blood pressure
CHF Congestive heart failure
CLT Complex lymphedema therapy
CPDT Complex physical decongestive therapy
CPT Complex physical therapy
CVI Chronic venous insufficiency
DVT Deep venous thrombosis
EGF Epidermal growth factor
ESR Erythrocyte sedimentation rate
FGF Fibroblast growth factor
HBO Hyberbaric oxygen
ILD Indentation load deflection
IL-1 Interleukin-1
LDL Low-density lipoprotein
MLD Manual lymph drainage
MODS Multiple organ dysfunction syndrome
NPUAP National Pressure Ulcer Advisory Panel
NS Normal saline
OT Occupational therapist
PAN Polyarteritis nodosa
PAOD Peripheral arterial occlusive disease
PDGF Platelet-derived growth factor
PN Polyarteritis nodosa
POC Plan of care
PT Physical therapist
PTSD Post-traumatic stress disorder
PV Pemphigus vulgari
PVD peripheral vascular disease

Copyright © 2009 by The McGraw-Hill Companies, Inc.
Click here for terms of use.

xii List of Acronyms

RBC Red blood cell
RN Registered nurse
ROM Range of motion
SLE Systemic lupus erythematosus
TBSA Total body surface area
TGF-β Transforming growth factor-beta
VLDL Very-low-density lipoprotein
WBC White blood cell
WOCN Wound ostomy continence nurse

Nurse to Nurse


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Chapter 1



• The ethical concepts discussed are presented from a western per-

• Application of ethical principles is necessary for any and all wound
— The role of ethics in wound management

• Ethics and ethical behavior including:
— Paternalism
— Autonomy
— Beneficence
— Nonmaleficence
— Fidelity
— Role fidelity
— Veracity
— Conflict of interest
— Confidentiality
— Justice

• Potential internet resources

Copyright © 2009 by The McGraw-Hill Companies, Inc.
Click here for terms of use.

2 Nurse to Nurse


Performing an evaluation, assessment, or management of any
type of wound is an ethical endeavor and may present ethical
challenges at times. In this chapter, the ethical principles and
concepts within Western health care—most commonly known
as biomedical ethics (the ethics of health-care)—will be dis-
cussed. The specific concepts of paternalism, autonomy, benef-
icence, nonmaleficence, fidelity, role fidelity, veracity, therapeu-
tic privilege, conflict of interest, confidentiality, and justice will
be addressed. It is important to note that the concepts herein
are viewed from a Western perspective, and the wise health-
care provider acknowledges this and provides care in a cultur-
ally aware manner.

The area of wound management provides an opportunity for
the patient, the family, and caregivers to acknowledge aspects of
their lives that otherwise may never have been addressed with
any health-care provider. Some of the areas that may be dis-
cussed are beliefs about health, illness, and healing; the cause
of the wound; and what the patient and family think will heal
the wound, or even if they believe the wound will heal. In
addressing these topics, the health-care provider may experi-
ence a single culture or belief system or a mixture of one or
more cultures and belief systems.

The privilege of professional access to the patient, the
family, and caregivers brings with it certain moral obligations
or moral duties. It is important for the nurse to consider the
concept of morals which in essence means the general “prin-
ciples of right and wrong in relation to human actions and

The Nurse’s Ethical Duty

The nurse might wonder why consideration of morals is of any
importance when what he or she is doing is providing clinical
services for some type of wound. The practice of wound
care is fraught with areas in which the morals or society’s

Ethical Considerations in Wound Evaluation 3

determination of right and good conduct of the health-care
professional may be seriously tested. Understanding the con-
cepts of morals, moral duty, and moral obligation are critical in
providing wound care.

The privilege of professional access to patients brings specific
obligations and duties, including the following:

• The patient’s interests are placed above the personal inter-
est of the nurse. If this duty is overlooked or forgotten, the
contract (standard of practice) among the health-care
provider, the health-care organization, and the patient is

— Example: The health-care provider conducts a seminar
and needs wound photographs to supplement the writ-
ten and verbal components of the presentation. The
provider takes photographs of the patient’s wounds
solely for the purpose of using them in the seminar. The
only reason for taking these photographs is for the con-
venience of the health-care provider, and therefore the
activity is actually for the nurse’s personal interest and
not for the patient’s best interest. To avoid any consid-
eration that the photographs are for personal interest,
the patient would need to grant the nurse informed
consent to use the photographs. The nurse would need
to assure the patient that any refusals on the patient’s
part would have no effect on the nurse-patient relation-
ship or the patient’s treatment.

• The patient’s privacy is protected from another individ-
ual’s or society’s desire to know details of the patient’s

— Who has the legal right to know about the patient’s

— What is the health-care provider’s responsibility in this?
This differs somewhat from state to state and country to
country. It is the health-care provider’s responsibility to
have a complete understanding of the legal rights of all

4 Nurse to Nurse

— Who does not have the legal right to know about the
patient’s condition? What is the health-care provider’s
responsibility in this? Once again, it is ultimately the
responsibility of the nurse to know the legal rights of the
patient, family, and health-care provider. However, in
many areas of the world, the general public does not have
any legal right to knowledge concerning the patient’s care,
progress, or prognosis. The health-care provider must
identify if the health-care organization has a policy or pro-
cedure concerning this challenge. If such a policy or pro-
cedure is available, it is generally considered appropriate
for the health-care provider to acknowledge and follow
these mandates.


Assess each organization’s policy and procedure concerning con-
fidentiality before providing information about a specific patient to
anyone other than another health-care provider who will be pro-
viding evaluation or treatment to the patient.

• Does the health-care provider have a duty to treat the patient
who has a wound(s)?
— There is no one correct answer to this question, but
guidelines do exist. In general, most health-care profes-
sions have created a “code of ethics” for referral when a
member has an ethical question. As an example, the
American Nurses Association (ANA) has published guide-
lines to assist nurses in determining if a moral duty for
treatment exists, or if it is merely a moral option.
— The criteria for making this type of decision include:
1. The patient is at significant risk of harm, loss, or damage if
the practitioner does not assist in treatment.

Ethical Considerations in Wound Evaluation 5

2. The practitioner’s intervention or care is directly rele-
vant to preventing harm.

3. The practitioner’s care will probably prevent harm, loss,
or damage to the patient.

4. The benefit the patient will gain outweighs any harm
the practitioner might incur and does not present more
than a minimal risk to the health-care provider.2

According to the ANA, if the answer to all four criteria is yes,
it would be considered a moral duty for the nurse to treat the
patient under the principle of beneficence. However, if all four
criteria could not be answered in the affirmative, the decision
to treat would become a moral option and not a moral duty. It
is important to remember that this information concerns the
ethical decision making only and is not to be construed as pre-
senting a legal argument for or against treatment. Failure to
treat may have potential legal consequences.


Review the code of ethics specific to the health-care provider’s
clinical discipline whenever concerns or questions arise that may
be of an ethical nature.


Ethics and ethical behavior are based on moral attitudes and
moral conduct, not on legal precedents. The moral purpose of
wound care is to preserve and/or improve healing, and to pre-
serve and/or improve the patient’s or caregiver’s independence.

The ethical decisions that occur in wound care are often
referred to as ethical dilemmas. One example is
• Under various reimbursement sources the decision has been

made that only a specified amount of money may be applied
to patients with wounds, or

6 Nurse to Nurse

• Specific amounts of treatment are authorized for patients with
wounds (e.g., a limited number of encounters or visits), or

Another example would be:

• Only specified types or brands of wound products are avail-
able for patients with wounds, or

• Specific levels of health-care providers are authorized to pro-
vide care based solely on monetary reasons.

The dilemma faced by the health-care provider is deciding
what is better for the individual patient, and does the duty exist
to provide care or products that may not be reimbursable.
There is no single, correct answer to this ethical dilemma.

Each situation must be evaluated and weighed on its own
merits. When faced with such decisions, the health-care
provider may choose to request the assistance of an ethics
committee, an ethicist, or another health-care provider with
more experience in dealing with these types of ethical dilem-
mas. Some reflection on the concept of paternalism would also
be helpful for the health-care provider faced with what he or
she considers an ethical dilemma.


Paternalism as a term has been dated from the 1880s by the
Oxford English Dictionary as meaning “the principle and practice
of paternal administration; government as by a father; the claim
or attempt to supply the needs or to regulate the life of a nation
or community in the same way a father does those of his chil-
dren.” Due to the reference to a father, it would seem that pater-
nalism creates a situation in which one person acts like a father
to or for another, and in doing so makes decisions about health-
care rather than allowing the individual to make his or her own
decisions. This was in fact the method used for several cen-
turies by many health-care providers. The health-care provider
knew what was best for the patient and therefore selected the
specific action without consideration for the patient’s decision-
making ability. Additionally, there is generally some type of
coercion or force involved on the part of the health-care

Ethical Considerations in Wound Evaluation 7

provider in the presence of paternalism. More insidious meth-
ods that may be seen as paternalistic involve deception, dishon-
esty, nondisclosure of information, partial disclosure of infor-
mation, or manipulation of information with the intent of
unduly influencing the patient or caregiver’s decision.

It is true that as a health-care provider it is an expectation
that the provider has superior knowledge, education, and
insight about the patient’s wound and overall health. Therefore,
the health-care provider has a special fiduciary relationship
with the patient and is in an authoritative position in which he
or she is expected to know more about the wound, wound
treatments, and so forth than the patient. However, from a
Western perspective, the health-care provider must not inter-
fere with or refuse to conform to the patient’s choices regarding
his or her welfare.

According to Beauchamp and Childress, paternalism is “the
intentional overriding of one person’s known preferences or
actions by another person, where the person who overrides jus-
tifies the action by the goal of benefiting or avoiding harm to
the person whose preferences or actions are overridden.”2 In
wound care, it is of significant importance for the health-care
provider to explain thoroughly everything to the patient and
caregiver, allow them time to ask questions, and allow them the
opportunity to make appropriate decisions relative to treatment
type, location, time frames, and expected outcomes. These
actions allow the patient to make autonomous decisions con-
cerning wound management.


In health-care, the term autonomy may be used with the con-
cept of self-determination. It literally means that the patient or
designee has the freedom to choose and implement that choice.
It presupposes that the patient or designee has the intellectual
competence and power to make treatment decisions. For the
health-care provider, it means that all available information has
been provided to the patient, caregiver, and or designee with-
out deception, dishonesty, nondisclosure of information, partial

8 Nurse to Nurse

disclosure of information, or manipulation of information. It
also means that the health-care provider respects the autonomy
of others (patient, caregiver, or designee).

Practicing wound management in a multicultural society
requires the health-care provider to continually update his or her
knowledge and understanding about the concept of autonomy in
cultures different from the provider’s. For example, in many trib-
al societies decisions about treatment can only be made after
thorough discussion with the patient’s community. Such discus-
sion may take several hours to several days depending on the
location of the patient, the location of the treatment center, and
the patient’s community. Additionally, it is the patient who deter-
mines what is meant by community. It is entirely possible that to
a specific patient community means the entire group or tribe and
may or may not have spiritual connotations.

It is under this ethical concept that the health-care provider’s
obligation to make disclosure is found. Using legal terms, this
translates to the principle of informed consent; however, in more
ethical terms, informed consent indicates that the patient or
designee has substantial understanding of the proposed wound
management and has not been forced or coerced into authoriz-
ing the nurse or health-care professional to provide specific care
or treatment. Therefore, the health-care provider should ask
these questions when determining that the patient or designee
has agreed to the proposed wound management program.

• Does the patient or designee have the competence to under-
stand the provided health-care information and to make a
decision based on this information?

• Has the patient or designee voluntarily offered his or her con-
sent for this wound management program without fear of or
actual force or coercion?

• Was the disclosure of information provided which could be
considered material to a decision of agreeing to or refusing
this management plan?

• Was all the information the health-care provider believes is
significant, presented?

Ethical Considerations in Wound Evaluation 9

• Was there a specific management plan explained including
expected time frames and outcomes?

• Was there a decision for or against the specific management

• Did the patient or designee actually authorize the specific
wound management plan?


Assess the organization’s policy and procedures concerning
ethics referrals whenever there are concerns or questions about a
patient’s autonomy or competence.


Beneficence refers to the ethics principle indicating a moral
obligation to “act for the benefit of others.”2 For the health-care
provider involved in wound management, beneficence is a duty
to promote the health and welfare of the patient by honoring
the patient’s autonomy. For the wound management patient, it
also means:
• Wound treatments should have a positive effect on the heal-

ing process, NOT simply create no regression in the healing
• All wound management activities are done to promote the
patient’s best interests.
• The health-care provider works to actively remove any con-
ditions that will cause harm to the patient and or caregiver.
• The health-care provider weighs the good versus the harm
when considering wound treatments.
• The health-care provider puts the patient’s interests foremost.

10 Nurse to Nurse


Doing good refers not only to the final outcome of a course of
treatment but also to each individual treatment session. The
health-care provider is expected to be able to acknowledge at the
end of each treatment or encounter that more good than harm
has been provided.


The ethical principle of nonmaleficence refers to a professional
obligation that all health-care providers owe to their patients.
This is the obligation to cause or inflict no harm including
deliberate harm, risk of harm, and harm that may occur during
an act of doing good. Generally, health-care professionals dis-
cuss nonmaleficence in terms of not causing the death of a
patient; however, it also means not causing pain or suffering,
not causing incapacitation, not causing offense to others, and
not depriving another person of a good life.

When considering nonmaleficence in wound manage-
ment, the health-care provider considers the mental compe-
tency of the patient or designee when providing explanations


Inquire at the beginning, throughout, and at the end of each
encounter what the patient has experienced. It is important to
inform the patient and caregivers that wound care is not intended
to cause pain. Therefore, ask each patient to inform the health-
care provider throughout the encounter and at the end of each
encounter of any discomfort or pain. If the patient reports discom-
fort or pain, adjust the treatment to reduce this to a level that is
acceptable to each individual patient.

Ethical Considerations in Wound Evaluation 11

or information. It is also important to select treatments that
cause little to no pain and to thoroughly discuss this with the
patient or designee before pursuing any treatment or lack of
treatment. Additionally, it is an important part of this ethical
principle to be as culturally aware as possible while maintain-
ing an open mind about the individual rationale for any action
or reaction.


Within the field of health-care bioethics, the term fidelity is
defined as promise-keeping.1 In general, the individual who
receives care from any health-care provider has an expectation
that each health-care provider will keep any promises made
directly to the patient, family, and or caregiver. Specifically, this
means that when the health-care provider says he or she will do
something, that is what is done, unless doing so is completely
beyond the health-care provider’s axis of control. In other words
health-care providers do what they say they are going to do. For
this reason, it is important that each health-care provider speak
only for him or herself and his or her actions or expected
actions. When providing wound care this means do not promise


Patients, family members, and caregivers may not hear all that is
said by the health-care provider the first time it is said. Therefore,
it is important to repeat information more than one time during
an encounter. Have information such as wound care instructions,
future appointments, and dietary recommendations written in
the patient’s spoken language and provided at each encounter.
Ascertain the reading level of the patient, family, and caregivers
before providing written materials. Pictures, if available may be
more useful than written instructions.

12 Nurse to Nurse

or guarantee anything about the wound, the wound care, or
future treatment that is not directly under one’s control.

Role Fidelity

Role fidelity refers to the legal scope of practice of each health-
care provider. Under specific levels of scope of practice, there
are designated constraints. For example, a professional nurse
cannot in most instances change an order for wound treatment
without conferring directly with the prescribing health-care
provider (MD, DPM, RNP, etc.). Promise-keeping relative to the
health-care provider’s role means faithfully practicing within
the scope of that role. Additionally, it is important to recognize
that wound care is not provided by one practitioner alone.
Wound care is a team effort; each member of the team recog-
nizes the benefits brought to the team by each team member.
Within this team, each member must practice within the con-
straints of his or her scope of practice as well as within any con-
straints of the team.


A scope of practice is most often the result of traditions within a
particular health-care specialty and legislation (state or national)
that specifies the privileges of each health-care specialty. Each
health-care provider who evaluates and/or provides wound care
should have a thorough knowledge of his or her scope of practice
and his or her role in the treatment of each patient who has a


According to the Oxford English Dictionary veracity is defined
as “speaking or stating the truth; habitual observance of the
truth; truthfulness.”

Ethical Considerations in Wound Evaluation 13

In regards to patients with wounds, this truth or truthful-
ness connects the patient and the health-care provider. This
connection means that it is expected that the patient tells the
truth to the health-care provider and also that the health-care
provider tells the truth to the patient or patient surrogate. In
regards to wound care, this is not about some philosophical
debate concerning what is really the truth; rather it is the dis-
closure of factual information from both parties. Traditionally,
the fiduciary relationship that exists between health-care
providers and the patients for whom they provide care is one
of unique and special veracity. For example, the patient has the
right to expect a higher level of veracity from his or her health-
care provider than he or she may expect from others in general
society. The health-care provider is bound by the concept of
role fidelity as determined by his or her scope of practice.

In the past it was deemed acceptable for the health-care
provider to tell the patient what he or she thought was best for
the patient to know. In some fields this was known as benevo-
lent deception. This form of paternalism was justified by saying
that the individual patient could not understand or handle the
truth about his or her condition, treatment, or prognosis.
Unfortunately, this type of deception leads the health-care
provider into what is commonly known in bioethics as a slip-
pery slope argument.

Today, the health-care provider shares with the patient as
much factual information as the health-care provider knows
and that which the patient wants to know. This amount of truth
is disclosed to assist the patient or surrogate in making well-
informed, autonomous decisions.

Therapeutic Privilege

Therapeutic privilege refers to a legal exception under informed
consent. Briefly, it means that the health-care provider does not
obtain consent for care in situations such as a life-threatening
emergency, patient incompetence, or patient mental instability.
Exercising therapeutic privilege is best left to licensed physi-
cians and is rare when providing care to patients with wounds.

14 Nurse to Nurse


Provide truthful information within the scope of practice to
patients and their surrogates.

Conflict of Interest

In general, the health-care professions are thought to exist pri-
marily to render services to patients who need care. A conflict
of interest arises when the health-care provider has or poten-
tially has an interest in the patient other than the provider’s
obligation to protect and promote the patient’s interests. The
health-care provider should avoid these conflicts at all times.
For example, there should be no financial incentive to evalu-
ating or providing care to a patient with wounds. Such an
example would include owning stock in the product or prod-
ucts that are recommended or prescribed for treatment. A con-
flict of interest would also exist if the health-care provider
referred the patient to him or herself or to anyone with whom
the provider has a financial or personal relationship. Practices
such as providing bonuses at the end of the fiscal year may
also be seen as a conflict of interest. Many health-care organi-
zations have developed firm policies about what is determined


Examples of conflicts of interests occur when the health-care
provider recommends that the patient purchases supplies from a
medical supply company for which a referral bonus is received for
patients referred to that vendor.

Ethical Considerations in Wound Evaluation 15

to be a conflict of interest; therefore, the health-care provider
needs to keep him- or herself updated continually regarding
these policies.


In respect to health care, confidentiality refers to the necessity
that each health-care provider hold in strict confidence infor-
mation that is discovered about the patient during the course of
the health-care practice. Generally, the patient has the right to
expect that any knowledge of his or her condition be discussed
or made available only to those health-care providers who will
need such information for care provision or reimbursement
purposes. The patient also has the right to expect that he or she
selects what health-care information and to whom that health-
care information may be released.

In some areas, under legislation, the patient’s rights are
superceded by the need to provide safety to the public. One
example is the requirement in many geographic locations to
inform a public health entity of communicable diseases. In most
cases such an example is uncommon in wound care.


It is the responsibility of each health-care provider to be aware
of current organizational policies or legislation concerning


Aside from autonomy, there is no bioethical concept quite as con-
troversial as justice. Originally, justice was a philosophical con-
cept that has been debated over the centuries. However, the
health-care provider confronted with a patient who needs wound

16 Nurse to Nurse

evaluation and care, does not want to be debating an esoteric
concept. Therefore in the field of wound care, the most common
type of justice that is encountered, is that of distributive justice.
The various theories of distributive justice strive to connect spe-
cific elements of the patient with distributions of benefits and
burdens that can be justified at that specific time and place.

Distributive justice seems to imply a fair and equal distribu-
tion of health-care resources; however, this would also imply
that there were enough resources available at any given time
for all who might require them. Obviously, this is not the cur-
rent situation found in the world at this time. Therefore, it
becomes the responsibility of each health-care provider to treat
each patient as equitably as possible within the organizational
structure and available resources. When this does not seem


An ethical dilemma occurs when one is confronted with a wound
that has been vigorously treated, but does not respond to a variety
of treatments. The wound may not heal at any time in the foresee-
able future therefore continuing to consume resources that may
not be plentiful. Include the entire wound team in discussions of
such situations and develop appropriate plans of care that include
counseling for the patient, family, and caregivers. These team
members must assist all other involved health-care providers to
critically evaluate:

1. What specifically can be done to resolve the wound?

2. What must be done to resolve the wound?

3. What must not be done to resolve the wound?

4. In what time frame and what manner should the wound be

Ethical Considerations in Wound Evaluation 17

likely, the health-care provider should ask for an ethics commit-
tee consultation or consult directly with an ethicist or a more
senior health-care provider.

In summary, a variety of bioethical concepts have been
defined and discussed relevant to providing evaluation and care
to individuals with wounds. It is important that all health-care
providers remain ever vigilant in recognizing situations and
applying these concepts.


The following Internet resources provide a variety of materials
to assist with ethics and ethical decision making:

• The University of Pennsylvania bioethics site

• The President’s Council on Bioethics (USA)

• The National Center for Ethics of the Veterans Health

• The Nuffield Council on Bioethics

• National Reference Center for Bioethics Literature, the
Kennedy Institute of Ethics

• American Medical Association bioethics site

• University of San Diego site has comprehensive informa-
tion on ethical theory and applied ethics

• National Institute of Health

18 Nurse to Nurse

• The Hastings Center

• The Center for Health Ethics and Law at the West Virginia
University Health ethical issues for professionals and non-

• Cardiff Centre for Ethics Law and Society (UK)

• University of Minnesota Center for Bioethics

• American Nurses Association Center for Ethics and
Human Rights


1. Beauchamp TL, Childress J F. Principles of Biomedical Ethics. New
York, NY: Oxford University Press; 2001.

2. Edge RS, Groves JR. Ethics of Health Care: A Guide for Clinical
Practice. 3rd ed. Clifton Park, NY: Thomson Delmar Learning;


American Nurses Association. Code of Ethics for Nurses with
Interpretive Statements. Washington, DC: Author; 2001.

American Nurses Association. Nursing’s Social Policy Statement. 2nd
ed. Washington, DC: Author; 2003.

Angelucci PA. Ethics in practice. Grasping the concept of medical
futility. Nursing Management. 2006; 37(2):12–14.

Austin W. Nursing ethics in an era of globalization. Advances in
Nursing Science. 2001;24(2):1–18.

The Belmont Report: Ethical Principles and Guidelines for the protec-
tion of human subjects of research. Available at: http://ohsr.od. Accessed January 02, 2006.

Ethical Considerations in Wound Evaluation 19

At least 25% of older adults will be uninsured at some point during
the years preceding eligibility for Medicare. Nursing Economics.
May/June 2006; 24(3):165 (journal article - brief item).

Breier-Mackie S. Patient autonomy and medical paternity: can
nurses help doctors listen to patients? Nursing Ethic.

Butts J, Rich K. Nursing Ethics: Across the Curriculum and Into
Practice. Boston, MA: Jones & Bartlett; 2005.

Chandra A, Willis W, Miller K. (2005). Patient-physician relation-
ships in the managed care environment—a comparative analysis
of various models. Hospital Topics. 2005;83(2): 36–39.

Cherry B, Jacob S. Contemporary Nursing: Issues, Trends, and
Management. 3rd ed. Philadelphia, PA: Mosby; 2005.

Davis AJ. Global influence of American nursing: some ethical
issues. Nursing Ethics. 1999;6(2):118–125.

Eldh A, Ekman I, Ehnfors M. Conditions for patient participation
and non-participation in health care. Nursing Ethics. 2006;13(5):

Erlen JA. When patients and families disagree. Orthopaedic Nursing.
2005;24(4): 279–282.

Fleck LM. The costs of caring: Who pays? Who profits? Who
panders? Hastings Center Report. May–June 2006: 13–16.

Gruskin S. Human rights and ethics in public health. American
Journal of Public Health. 2006;96(11): 1903–1905.

Hanssen I. An intercultural nursing perspective on autonomy.
Nursing Ethics. 2004;11(1):28–41.

Harper MG. Ethical multiculturalism: an evolutionary concept
analysis. Advances in Nursing Science. 2006;29(2): 110–124.

Hickman SE, Hammes BJ, Moss H, Tolle SW. Hope for the future:
achieving the original intent of advance directives. Hastings
Center Report. 2005;35(6):S26–S30.

Hyland D. An exploration of the relationship between patient
autonomy and patient advocacy: implications for nursing prac-
tice. Nursing Ethics. 2002;9(5):472–482.

Izumi S. Bridging western ethics and Japanese local ethics by lis-
tening to nurses’ concerns. Nursing Ethics. 2006);13(3):

20 Nurse to Nurse

Jacobs BB, Taylor C. Medical futility in the natural attitude.
Advances in Nursing Science. 2005;28(4):288–305.

Jonsdottir H, Litchfield M, Pharris MD. The relational core of nurs-
ing practice as partnership. Journal of Advanced Nursing.

Loewy EH, Loewy RS. Changing health care systems from ethical,
economic, and cross-cultural perspectives. New York, NY: Kluwer
Academic; 2002.

Loewy EH, Loewy RS. The ethics of terminal care: orchestrating the
end of life. New York, NY: Kluwer Academic; 2002.

McCabe C. Nurse-patient communication: an exploration of
patient’s experiences. Journal of Clinical Nursing. 2004;13: 41–49.

Monson MS. What to know about duty to report. Nursing
Management. 2005;36(5):14–16, 65.

Pelton LH. Getting what we deserve. Humanist. 2006;66(4): 14–17.
Peternelj-Taylor CA, Yonge O. Exploring boundaries in the Nurse-

Client relationship: professional roles and responsibilities.
Perspectives in Psychiatric Care. 2003;39(2):55–66.
Sire JW. The Universe Next Door: A Basic Worldview Catalogue.
Downer’s Grove, IL: InterVarsity Press ; 2004.
Starrs JM. The medical futility debate: treatment at any cost?
Journal of Gerontological Nursing. 2006;32(5):13–16.
Tarlier DS. Beyond caring: the moral and ethical bases of respon-
sive nurse-patient relationships. Nursing Philosophy. 2004;5(3):
Treadwell K, Cram N. Managed healthcare and federal health pro-
grams. Journal of Clinical Engineering. Jan/Mar 2004; 36–42.
Tsai F-C D. Eye on religion: Confucianism, autonomy, and patient
care. Southern Medical Journal. June 2006;99(6): 685–687.
United Nations: Universal Declaration of Human Rights. Available
at: Accessed January 02,
2006 January:
Von Bruck M. An ethics of justice in a cross-cultural context.
Buddhist-Christian Studies. 2006;26:61–77.
Woods DJ. Forty million uninsured: the ethics of public policy.
Public Integrity. 2006;8(2):149–164.

Chapter 2


— Definitions and Concepts
— Types of Wounds
— Wound Healing and Repair

• Superficial wound healing
• Primary intention and delayed primary wound healing
• Partial thickness wound healing
• Secondary intention wound healing
• Acute wound healing
• Chronic wound healing

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22 Nurse to Nurse


• Suggested bathing, soaps, and general skin care.
• Acne treatment rationale and common actions of over the counter

(OTC) and prescription therapies.
• Concepts for use in sun protection of the skin.
• Nutrition effective for skin care.
• Commonly used lotions and creams including rationale for use.
• Definitions and concepts of wound healing, repair, and types of wounds.


Following are effective measures to take for care of the skin of
both men and women on a daily basis.
• Bathing

— Avoid excessive washing; daily washing may not be nec-

— Use tepid water avoiding temperature extremes, especially
hot water

— Avoid overaggressive use of washcloths that may exfoliate
and remove stratum corneum

— Use a gentle, nondrying bar or liquid soap
Each individual should have his or her own soap, no
sharing of soap products
Antibacterial soap is not necessary unless prescribed
Moisturizing soaps such as Dove, Keri, Cetaphil, and
Basis are best
Pure Ivory Soap can be very drying and irritating
Axilla, groin, and perianal area may require soap; not
every body part requires soap

— Gently pat dry the skin and avoid abrasives and rubbing
— Apply a water-based lotion twice a day directly onto damp

skin and allow to air dry
— Exfoliants like a loofah are not necessary unless prescribed

Principles of Skin and Wound Care 23

— Use a gentle adult shampoo once every 7 days unless oth-
erwise indicated

Children’s shampoo is not effective for adults

Avoid hair products with alcohol, lead, and other toxins

• Acne skin care

— Acne is a disease of pilosebaceous units in the skin. The
sebaceous glands secrete sebum—an oily substance—
through the opening at the follicles (Figure 2-1). The most
common locations for acne outbreaks are the face, upper
chest, and back, due to the dense population of piloseba-
ceous units in these areas. Secreted sebum, the hair, and
keratinocytes in these pilosebaceous units form a plug,
which prohibits the sebum from reaching the skin’s surface.

Skin bacteria attract white blood cells resulting in
inflammation and the formation of a pimple.

These enlarged follicles, once plugged, form the acne
comedo or lesion. A white lesion is a closed comedo
while one that reaches the surface of the skin is an open
comedo. These surface lesions turn black as the sebum
is exposed to air.
º Some acne patients also experience papule(

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