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Wound Series Part 2b: Wound Care

2.5 Contact Hours
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Monday, April 1, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

≥ 92% of participants will know basic wound care.

Objectives

After completing this continuing education course, the participant will be able to meet the following objectives:

  1. Identify necessary wound care supplies.
  2. Define the TIME, DIMES, NERDS, and STONES mnemonics for wound care.
  3. Explain the rationale for why wet-to-dry dressings are no longer always recommended.
  4. Summarize the process of wound dressing changes.
  5. Determine important teaching points to provide patients and their families with regarding wound care.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Linda J. Cowan (PHD, ARNP, FNP-BC, CWS)

Introduction

This course provides specific information to help you approach common wounds from a nursing perspective, which focuses on the basic cleansing and dressing of wounds.

Ideally, care of a wound should begin with a "game plan." There is no strict 'recipe' that will fit all wounds. Still, the following are general measures and evidence-based recommendations that should be considered with all wound care (Goldberg & Diegelmann, 2020; Sibbald et al., 2021).

Wound Care Supplies

Common wound care supplies that are needed include (Sibbald et al., 2021; Doughty & McNichol, 2015):

  • Gloves (sterile or non-sterile/clean, according to the type of wound and your facility's policy)
  • 4" x4" gauze
  • Saline or non-cytotoxic wound cleanser
  • Disposable measuring tape
  • Skin prep wipes
  • Sterile or disinfected scissors
  • Primary dressing
  • Secondary or cover dressing (if needed)
  • Tape or securing device
  • Biological waste disposal bag
  • Drape(s)

Importance of Handwashing

Handwashing is more important than most of us think. Do not take hand washing for granted! You have heard that the most important infection control practice is hand washing. This is true. Proper handwashing prevents infection!

Wash with soap under running water for at least 15 seconds, with no shortcuts. When you perform wound care, wearing gloves is necessary in most cases unless it is a close family member or the patient is doing wound care for themselves. However, gloves are no substitute for handwashing (CDC, 2020).

Wound Care Mnemonics

Wound care has advanced tremendously with modern technology. This advancement is good news for patients but complicates things for healthcare providers. Forty years ago, there was only a small list of wound care products to choose from, and today there are thousands. However, clinicians need not fret about approaching wound care in modern healthcare. Clinicians need only to remember a few basic principles similar to the ABCs of CPR. The following sections include a few different mnemonics to help you remember components of wound care.

TIME

Think of this as the "TIME" for wound care. The wound bed preparation concept describes a systematic approach to addressing the wound bed's specific needs in full-thickness open wounds (Sibbald et al., 2021; Doughty & McNichol, 2015). Evidence-based literature describes this mnemonic, such as T-I-M-E or T-I-M-E-S, to help clinicians perform evidence-based wound care (Gupta et al., 2017).

T is for Tissue:

Tissue in the wound bed should be described and documented. This includes the appearance (color, consistency) of wound bed tissue and the presence and amount of any non-viable or necrotic tissue, as well as any hypergranulating tissue, hypertrophic scarring, or foreign bodies in the wound bed. Necrotic or non-viable tissue (including biofilm if detected) should be removed as appropriate or addressed. Hypergranulating tissue should be treated.

I is for Infection:

Signs of infection should be identified and documented. Determine if a critical infection is present. This wound may need systemic treatment versus non-critical chronic bacterial colonization that may require only local management by debridement and topical therapies.

M is for Moisture:

Moisture in the wound bed should be managed. A balance of moisture is important for wound healing. Topical wound care, especially dressings, are used to prevent the wound bed from drying out while eliminating excessive moisture in the wound bed. When excessive moisture in the wound exceeds the dressing's capabilities, it often causes moisture damage to the skin surrounding the open wound (maceration). Dressing selection is most important for addressing this specific need of the wound bed.

E is for the Edge of the wound:

Attention should be given to the wound edges. Rounded, "rolled" wound edges prevent epidermal cell migration, which may impair wound closure. Tracking or tunneling in the wound bed and undermining (a 'lip' or ledge under the wound edge) may impair healing. Undermining is often caused by shearing forces upon the wound area. It is frequently seen in pressure ulcers around the sacral area when the patient repeatedly slips down while sitting up in the bed.

DIMES

Other mnemonics are changing the T in T-I-M-E to D (for debridement), resulting in D-I-M-E, and adding an S to the anagram to address the skin and tissue surrounding the wound opening. In this case, S reminds us that the surrounding skin and tissue should be examined for the presence of or worsening of erythema (redness), edema (swelling), warmth, and skin lesions (blistering, rash, irritation, callus, or maceration).

NERDS

Additional publications have described algorithms for wound management or mnemonics to guide clinicians in deciding if local treatment is adequate or if systemic treatment may be advised. The following two mnemonics help to identify just that. Using the NERDS mnemonic, if three or more of the following symptoms are present, treat the wound topically:

  • Nonhealing wounds
  • Exudative wounds
  • Red and bleeding wound surface granulation tissue
  • Debris (yellow or black necrotic tissue) on the wound surface
  • Smell or unpleasant odor from the wound

STONES

Using the STONES mnemonic, if three or more of the following symptoms are present, treat the wound systemically:

  • Size is bigger
  • Temperature is increased
  • Os (probe to or exposed bone)
  • New or satellite areas of breakdown
  • Exudate has increased
  • Smell from the wound

Wet-to-Dry Dressings

Wound dressings are the most common component of wound care, providing a platform for a therapeutic or treatment modality. One aspect of dressings is essential: They should do no harm. That being said, why are we still using wet-to-dry dressings? There are now hundreds of commercially available wound care products in the United States. In clinical trials, numerous dressings or topical wound care applications have reported successful wound healing results. Yet, wet-to-dry dressings are still among frequently ordered wound care modalities in nearly all healthcare settings.

Wet-to-dry dressings are no longer evidence-based practice for wound care (Sibbald et al., 2021). As the name implies, a wet-to-dry dressing ultimately results in a dry wound bed (even if for limited amounts of time). Research demonstrates these dressings disrupt granulating tissue, impair epithelial cell migration, leave behind foreign bodies in the wound bed, increase the risk of infection, aerosolize bacteria, and cause severe pain upon removal (Sibbald et al., 2021).

Nevertheless, wet-to-dry dressings have been a standard, traditional, or 'default' dressing for decades. Modern wet-to-dry dressings are accomplished by moistening sterile cotton gauze with a solution (usually 0.9% normal saline) and placing it in the wound, allowing it to dry, then removing it dry from the wound bed (along with tissue that adheres to it), thus performing mechanical debridement (Goldberg & Diegelmann, 2020; Sibbald et al., 2021).

There are several reasons why this form of debridement may be detrimental to the wound bed and unnecessary, with so many other forms of wound debridement available today. Cost, compliance, pain, increased risk of infection, and re-injury to healthy granulating tissue are several reasons (Sibbald et al., 2021). Most healthcare providers have continued with wet-to-dry dressings more from misunderstood tradition than evidence-based wound care practices. Furthermore, the use of wet-to-dry dressings as a wound care modality (in most cases) is outdated and used with inappropriate frequency in today's health care arena (Goldberg & Diegelmann, 2020; Sibbald et al., 2021).

Then When, Where, What, Why, and How

If not wet-to-dry, then what? How do you select a moist wound dressing? There are so many from which to choose. What dressing has the most evidence supporting it? How often should you change the dressing?

Unfortunately, several systematic reviews have failed to produce strong evidence favoring one specific dressing type for all wounds to simplify the decision-making. Most clinicians who are not familiar with modern wound products just want to know, "if not wet-to-dry, then what one product can safely be used in its place?" The answer to this question should be, "it depends."

Wound experts now realize the "one size fits all" approach is not ideal for wound care or dressing product selection. Multiple wound treatment algorithms and guidelines exist to assist the clinician in selecting wound treatment approaches (Wounds Canada, 2017; Gupta et al., 2017; Sibbald et al., 2021).

Any dressing selection approach should agree with the principles of evidence-based practice (EBP). The principles of EBP affirm that health care should be delivered based on (Melnyk & Fineout-Overholt, 2019):

The strongest and most current research evidence

+

The clinician's experience & expertise

+

The patient's (and family's) preferences and values

Assessing the wound is only one small part of a whole person. Do not forget to assess and talk to the person attached to the wound in assessing the wound. Assess the person (physically as well as psychosocially). What are the preferences, personal needs, likes, dislikes of the patient (and their caregiver)? What are their feelings about wound/wound care? (Bates-Jensen, 2016; Melnyk & Fineout-Overholt, 2019). For a caregiver who gets sick and faints at the sight of blood, asking them to empty bloody drainage from a drainage tube may not be a good choice. As you assess the wound itself, identify its etiology and comorbid conditions affecting wound healing. Determine the goal of wound care for this person.

Is the Purpose of Wound Care Curative or to Heal the Wound

Is the goal of wound care temporary "maintenance" or to prevent further deterioration until the patient can tolerate more aggressive treatment?

This scenario may apply if a patient has a gangrenous toe or nonhealing/necrotic arterial foot ulcer. This patient is also in the ICU following a massive stroke and cannot tolerate any surgery until they are hemodynamically stable. In other words, the patient's condition needs to stabilize before aggressive approaches to wound healing can be safely deployed.

Is the Goal of Wound Care Palliative

This may be the case if you know the wound is not likely to heal (as at the end of life with multiple organ failure). Different products and approaches may be employed for wound care if the purpose of wound care is not to heal or close the wound but to provide pain relief, moisture management, or odor control and prevent or reduce the risk of spreading infection. This may frequently occur with malignant lesions in hospice patients, and these patients may present challenging situations. Still, rewarding outcomes may be possible to ease a person's suffering or improve quality at the end of life. (Gupta et al., 2017).

Wound Dressing Change Process

Typically, the process of wound dressing changes will look something like this:

  1. Verify current orders.
    1. If it appears inappropriate or non-evidence-based wound dressings/topical therapy has been ordered, question the order, and make more appropriate evidence-based recommendations.
  2. WASH YOUR HANDS!
  3. Gather supplies.
  4. Set up your workspace.
    1. There should be a clean drape to place all the supplies on, appropriate medical waste disposal containers handy, extra gloves, etc.
  5. Explain the procedure and ask if the patient has any questions or concerns.
  6. Make the patient comfortable.
    1. They will likely remain in the same position for 15-30 minutes, so the patient should not be standing or holding themselves in an uncomfortable or unnatural position for wound care.
    2. Consider pre-medicating the patient for pain 30 min before wound care with oral analgesics.
  7. Ensure that the person performing the wound care is also comfortable.
    1. Example: Raising the bed if necessary, so the person is not 'bent over' to do the wound care.
  8. WASH YOUR HANDS!
  9. Put on gloves and remove the old dressing.
    1. Discard the old dressing and your gloves in a biohazard or appropriate container.
  10. Assess the wound.
    1. Note the characteristics of the wound, wound exudates (drainage), and specific needs of the wound bed.
  11. WASH YOUR HANDS!
    1. Alcohol-based hand cleanser is alright for non-soiled hands in most cases unless C. Difficile is suspected in the patient (Centers for Disease Control and Prevention [CDC], 2020).
  12. Put on new gloves.
  13. Cleanse the wound with a non-toxic wound cleanser.
  14. Measure and photograph the wound if necessary.
    1. Wash hands before and after handling the camera and put on new gloves before touching the wound.
  15. Apply a new dressing and secure the dressing appropriately.
    1. Be mindful of the best way to secure the dressing to avoid trauma to the surrounding skin.
    2. Consider using a skin barrier wipe to the skin surrounding the wound where any adhesives will be applied.
  16. Discard gloves and used supplies inappropriate medical waste containers.
  17. WASH HANDS after wound care.
  18. Document the wound care, planned follow-up, and what education was provided.

Education

It is necessary to educate the patient, their families, and/or involved caregivers about (Doughty & McNichol, 2015):

  • The steps for wound care
  • Frequency of wound dressing changes
  • Next follow-up appointment if applicable
  • What to expect during wound healing
  • What to report to a healthcare provider

It is also helpful to demonstrate the wound dressing change for both patient and involved caregivers. You can use a simulation model while providing instruction. Written instructions are beneficial as well. As in learning any new skill, have the patient or caregiver repeat the demonstration of the dressing change to ensure complete understanding has taken place.

Case Study: Acute Wound Escalating to Nonhealing Wound

Scenario

You volunteer at a summer camp. Mike is a 23-year-old young man working at the camp as a counselor. He is 6ft tall and weighs 155 lbs. He was skateboarding with some of the teens at camp. He fell on a wooden ramp resulting in several superficial abrasions to the right forearm below the elbow and his right upper shin below the right knee.

As the camp health care provider, you would approach Mike like any other first-aid patient and determine if he needs more than simple first aid.

History

What should you know about Mike before you try to provide first aid to his wounds?

  1. Pertinent medical factors:
    1. Is he diabetic? (No)
    2. Does he have any blood clotting disorders? (No)
    3. Any allergies? (No known allergies)
    4. Autoimmune disorders or other medical history? (No)
    5. Is he on any medications? (No)
  2. Did anyone see the fall? (Yes, 3 other teens)
  3. What sort of protective gear was Mike wearing? (Helmet, both knee, and elbow pads)
  4. What did he fall against - Objects, flooring, ground, soft sand? (Fell against plywood ramp with right knee hitting first and then right elbow and forearm as he skids off into the dirt)
  5. Was the plywood rough or smooth? (Smooth on top but rough edges)
  6. What was the distance of the fall? (About 3 feet from the top of the ramp where he lost control)
  7. Did he hit anything else during his fall, such as his head? (No)
  8. Any reason to call 911? (Not obvious)

Assessment

Current symptoms:

  • What is his pain level on a scale of 0-10? (8-9 in right forearm and shin; 6-7 in the right knee, right elbow).
  • Does he have difficulty moving any extremity or joint? (His right elbow is sore to move, and he demonstrates about 90% range of motion; he also complains of pain in his right knee, although he can bear weight and walk on it with a limp).
  • Was he able to walk on his own to your first aid station? (Yes, with a limp).

Visible inspection:

  • Has the bleeding stopped? (Just some slight oozing from the right upper shin abrasion).
  • Visible edema, bruising/discoloration? (Redness to right knee extending down to right upper shin abrasion and some edema to right elbow and knee has started since he arrived in your first aid station).
  • Any visible contamination like dirt, clothing fabric, wood, etc.? (Yes, dirt and pieces of fabric, which you gently cleansed with saline).
  • Other injuries? (Nonvisible).

Right shin wound measures and description:

  • Right shin wound is an abrasion that starts 2 cm below the inferior edge of the patella/kneecap and extends to 5 cm below the knee.
  • It is a rough oval shape 3 cm long x 2 cm wide with shallow ~1mm depth.
  • Debris such as dirt and small wood splinters and some fabric threads were cleansed from the wound bed to reveal a 100% pale pink wound base after cleaning.
  • Slight erythema extends from the edges of the wound, approximately 0.5 cm.
  • Some slight edema of this area extending to the knee itself is noted.
  • Slight serosanguineous (blood-tinged clear amber fluid) oozing is still noted from the wound.

Right inferior forearm wound measures and description:

  • Superficial abrasion is noted over the lateral aspect of the right forearm that begins 3 cm distal to the elbow prominence and extends to 8 cm from the elbow prominence.
  • The wound measures 5 cm long by 3 cm wide at the widest axis x less than 1 mm deep.
  • The wound bed is jagged and rough, and dirt/debris was washed out of the wound with gentle irrigation with saline.
  • The wound bed is red, with a small amount of serosanguineous oozing noted.
  • The entire right elbow extending to the wound has some slight edema, warmth, and noted erythema.

Intervention

After a quick triage assessment, you determine that even though Mike wore knee and elbow protectors and the abrasion wounds are superficial, the nature of his fall to knee and elbow could entail a potential deeper injury (consider sending to the emergency room (ER) for x-rays to rule out fractures).

You are also aware that the forearm and shin wounds present potential complications. Why? The location (close to the joint) and thickness of the skin over these parts of the body make these superficial abrasions full-thickness wounds.

How will you perform first aid to Mike to send him to the ER for x-rays? Using universal precautions and clean or aseptic technique, gently cleanse the wounds with saline pat with gauze (Kent et al., 2018; Pickering & Marsden, 2015). Apply a wound hydrogel, or petrolatum impregnated gauze, cover with sterile gauze, secure in place with tubular gauze, cotton stockinette, or self-adherent wrap. This will be simple for ER providers to remove to inspect wounds and not interfere with x-rays. You note that you do not have any at camp. Still, if you had had a silicone interface self-adherent border dressing, this would have worked nicely too and would have been easily removed and reapplied (this could potentially be left in place for 3 days if only scant wound drainage).

Mike comes back to your station the next day for a dressing change. His x-rays of the knee and elbow were all within normal limits. The ER staff told him to rest and elevate the elbow and knee and ice them (10 min on and 30 min off) for 24 hours and continue daily wound care with you. They also told him to take 600mg of ibuprofen as needed every 6 to 8 hours.

Today, his right elbow/forearm self-reported pain level is 6-8, and his right knee/shin is 4-5. Using universal precautions and clean technique, you change the dressing, continuing to use a hydrogel wound gel or petrolatum impregnated gauze over the entire wound, secured in place by a secondary dressing and tubular netting. You also protected the wound edges using a skin protectant wipe applied to the skin immediately around the open wound. This approach maintains a moist wound bed, prevents the dressing from sticking to the wound, allows for continued extremity motion, and protects the surrounding skin.

You change this dressing daily for the next 5 days. You note the shin wound is healing as expected, and the knee joint edema is resolved, with some bruising now evident. However, the elbow area and forearm wound remain edematous, painful to touch, and movement. There is still a moderate amount of serosanguineous to yellow exudate (no unusual odor) as well as dark red erythema extending 0.7 cm from the proximal wound edges. This wound is not following the expected pathway to healing.

What are some possible reasons?

  1. He reinjured it yesterday (re-injury would certainly put the wound back to square one as far as an inflammatory state).
  2. He is still taking 600 mg of ibuprofen every 6 to 8 hours (non-steroidal anti-inflammatory medications can impair wound healing, but please note his shin is healing).
  3. He is constantly removing and reapplying the same dressing himself because it is uncomfortable (this certainly could impair wound healing if he is not using clean technique and introducing contamination, as well as disrupting the wound bed often, however, why is the wound so uncomfortable? (We need to ask Mike to describe this discomfort in more detail).
  4. He is not getting adequate nutrition (yes, this certainly could impair wound healing, but his shin wound is healing, so let us look to more local factors).

While any of these may interfere with wound healing, we should also consider other potential complications. The two biggest ones to consider in Mike's case are:

  1. A missed foreign body (especially a wood splinter from the edge of the ramp).
  2. An infection.

A missed wood splinter or organic foreign body may not have been detected by x-ray. Close examination of the wound and gentle probing with the wood end of a sterile cotton-tipped applicator reveals a hard embedded splinter that you can remove with forceps. It is a thin 0.7 cm long wood splinter at the proximal end of the forearm wound pointing deep into the wound towards the elbow. You note that it did not measure long enough to potentially invade the joint space, even fully embedded.

After it was removed, Mike states he felt some immediate pain relief. You decide to use an antimicrobial wound dressing for this wound while continuing the same petrolatum impregnated gauze dressing for the shin wound (though now you can change it 3 x per week along with the new dressing orders for his forearm). You also just happen to have a sample tube of Cadexomer Iodine gel you brought with you in your first aid kit.

Mike's new forearm wound dressing includes:

  1. Applying skin protectant wipe to the wound edges every dressing change.
  2. Applying Cadexomer iodine gel to the wound bed.
  3. Covering with gauze.
  4. Securing dressing with tubular gauze or self-adherent wrap.
  5. Changing dressing 3 times per week.

You follow Mike's wounds for wound care 3 x a week for the next 2 weeks, and the wounds close within 3 weeks.

Discussion of Outcomes

Mike's wounds should have both healed as expected. However, one did not. We have discussed that we should look to local factors within the wound itself for the impaired healing of the forearm wound (his other wound was healing as expected even though it was the most distal wound); this may (although not always) point to something more local within the forearm wound itself. When looking at wounds, remember to look at the whole person, not just the wound. It is also important to consider all the initial factors which led to the wound if things start to take a turn away from the anticipated pathway to healing.

Strengths and Weaknesses

Strengths:

  • A global, whole person assessment was conducted just after the injury.
  • You, the camp healthcare provider, decided to be conservative because of the nearness of the wounds to 2 joints where bones could have been easily broken or chipped and the nature of the fall.
  • Getting the extremities x-rayed was advantageous when the one wound was not healing because it answered the question of a possible broken bone or other non-organic foreign objects in the wounds.
  • You thought about the nature of the wound pain and began asking more questions and gently probing, which allowed you to discover the embedded wound splinter. If this were not found and removed, it would have continued to fester, possibly becoming infected, which could have put the joint at risk of spreading infection and had a very unpleasant ending.
  • Staying on top of symptoms and acting quickly when things did not go as expected.

Weaknesses:

  • The fact that this was a camp setting and there were a limited number of wound supplies on hand was a weakness.
  • We assume the camp healthcare provider had Cadexomer Iodine on hand, but that is unlikely in real life. A camp clinic would more likely have just the basics, so finding an antimicrobial solution could have been a lot more difficult and is a weakness of this case.
  • Instead, was manuka honey available? Could you make your own dilute Dakin's solution? In every situation, healthcare providers can think of what should be included in their first aid kits and on-hand clinic supplies and know enough about basic wound care and that basic options for the four main types of wounds are available:
    • Deep and dry wounds
    • Shallow and dry wounds
    • Deep and wet wounds
    • Shallow and wet wounds
  • Including antimicrobial options to be used in these situations can also be helpful. Still, you want to also take care to minimize the use of cytotoxic products.

Conclusion

This course covered an essentials list of necessary wound care supplies, a thorough review of several wound care mnemonics, an explanation of wet-to-dry dressing changes and what is currently most evidence-based in the literature, the full typical step-by-step process of wound dressing changes, as well as the important teaching points that patients and their families should be provided in reference to their wound care. For more information regarding wound bed cleansing and wound dressings, please continue forth within the wound care series to Wound Series Part 2c: Wound Bed Cleansing.

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References

  • Centers for Disease Control and Prevention. (CDC). (2020). Handwashing: Clean hands save lives. Retrieved Oct 22, 2021. Visit Source.
  • Doughty, D., McNichol, L. (2015). Wound Ostomy Continence Nurses Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer. Visit Source.
  • Goldberg, S. R., & Diegelmann, R. F. (2020). What makes wounds chronic. The surgical clinics of North America, 100(4), 681–693. Visit Source.
  • Kent, D. J., Scardillo, J. N., Dale, B., & Pike, C. (2018). Does the use of clean or sterile dressing technique affect the incidence of wound infection? Journal of Wound, Ostomy, and Continence Nursing: Official Publication of The Wound, Ostomy and Continence Nurses Society, 45(3), 265–269. Visit Source.
  • Melnyk, B., Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice, (4th ed.). Philadelphia, PA: Wolters Kluwer. Visit Source.
  • Pickering, D., & Marsden, J. (2015). Techniques for aseptic dressing and procedures. Community Eye Health, 28(89), 17. Visit Source.
  • Sibbald, R. G., Elliott, J. A., Persaud-Jaimangal, R., Goodman, L., Armstrong, D. G., Harley, C., Coelho, S., Xi, N., Evans, R., Mayer, D. O., Zhao, X., Heil, J., Kotru, B., Delmore, B., LeBlanc, K., Ayello, E. A., Smart, H., Tariq, G., Alavi, A., & Somayaji, R. (2021). Wound Bed Preparation 2021. Advances in Skin & Wound Care, 34(4), 183–195. Visit Source.
  • Wounds Canada. (2017). Wound dressing selection guide. Canadian Association of Wound Care. Retrieved Oct 22, 2021. Visit Source.