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How to Select Wound Care Products: A Review for the Podiatric

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How to Select
Wound Care
A Review for
the Podiatric
Here are some guidelines
to help choose the
appropriate treatment.
Goals and Objectives
Primary Goal: To help the podiatric
physician understand the factors involved in selecting an appropriate dressing for a particular wound. Further, to
address specific patient issues to provide
information regarding wound management. After reading this article, the podiatric physician should be able to:
1) Appreciate the history of wound
care dressings.
2) Recognize the stages of wound
healing and the factors that impede
wound healing.
3) Identify reasons for wound closure
failure as well as the podiatric treatment.
4) Describe wounds with regard to accepted definitions and classifications.
5) Be able to select the most appropriate wound healing product with regard
to a presenting wound type.
6) Recognize wound product dressing
considerations for lower extremity ulcers.
7) Be able to develop a wound care
product formulary for use in a clinical
8) Appreciate the clinical data regarding medicinal alternative wound care
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Following this article, an answer sheet and full set of instructions are provided (p. 198).—Editor
By Robert G. Smith, D.P.M., Msc, R.Ph., C.Ped
Literature reports have revealed
that 1.25 million people in the
United States suffer from burn
wounds yearly 1; while the prevalence of patients suffering from
chronic skin ulcers caused by either
pressure, venous stasis, or diabetic
etiology is astonishing.2,3 Therefore,
a podiatric physician, as a clinical
provider, may be asked to treat patients as well as offer suggestions to
Continued on page 184
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vented their healing. Although he
man discovered the multitude of
advocated that the majority of
wound coverings or ointments that
wounds be kept dry, moist wounds
were probably used. It can only be
other healthcare providers on
were covered with fat or oil-based
speculated that prehistoric man
the selection of the most approointments after being washed in
probably observed that a covered
priate lower extremity wound care
wine or vinegar. The most widely
wound bled less, and that applying
product. This selection is a
used ointments were honey, oil,
pressure to a more serious hemorthought-provoking one involving
and wine; wool boiled in water or
rhage could stop the bleeding.
many factors such as the wound
wine was considered a useful dressThere are three
environment, efing. Bandaging had become an art
major problems
fectiveness, paby the fifth century BC and surwith the presence
tient acceptabiliThroughout history,
geons knew that bandaging a limb
ty, and cost.
too tightly could cause gangrene.
wound: hemorCurrently, a
wounds have been
rhage, mechaniplethora
dressed in an
The Mystery of Infections
cal disruption of
wound care prodThe problem of infection was
tissues, and infecucts are available
attempt to prevent
considered a great mystery for
tion. Historical
for use. Thus, the
4,000 years due to its insidious narecords indicate
podiatric physicontamination,
ture. Wound redness, swelling with
that Samarians
cian is chalinfection, and
heat, and pain were described by
identified these
lenged with the
Celsus in De Medicinia in approxiproblems and set
task of selecting
mately 25 A.D. A dichotomy preforth the techthe most approsented itself to early physicians
niques of washing
priate product to
with regard to wound presentation.
wounds, bandagmeet the patienA patient usually survived a wound
ing wounds, and preparing of plast’s needs. Podiatric physicians
if it was localized with thick creamy
ters to treat these wounds.4
must understand that the essential
discharge; but then another would
goal of a wound care dressing is to
Also, other records indicate
die when the wound presented
provide an optimum healing envithat in Mesopotamia, wounds
with a thin watery, brown, foulronment. Further, they should unwere washed with water or milk
smelling discharge.4
derstand the principles involved
and then were dressed with honey
when formulating a wound care
or resin, conifer, myrrh and frankEarly accounts from 1650 BC
plan. This empowers them in unincense. It can be speculated that
describe the standard treatments
derstanding the factors involved
bandages could have been made
for wounds to include grease,
when selecting a particular wound
of wool or linen; however, nothhoney, and lint. The reason oil or
care product given a particular
ing is known of the ways that
grease were used was that they prewound type. A brief chronicled
bleeding was controlled during
vented sticking of the bandages to
perspective highlighting the evoluthis time.5
the wound and they did not spoil
tionary hallmarks of wound care
over time. Honey provided antibacBy 3000 B.C., minor hemorproducts should allow the podiaterial properties, while lint promotrhage was controlled by cauterizatric clinician to realize the pheed capillary action and packed the
tion. The practice of bandaging
nomenal progress that has taken
wounds to applace during the development of
both wine and
proximate diswound care products.
vinegar were used
rupted tissues, as
The problem of
Secondly, a vivid narrative debecause of their
well as taping of
scribing the wound healing process,
wounds to assist
infection was
wound type classification, and
properties. Variwith skin approxiwound assessment is offered to
ous metallic salts
mation, appears
considered a great
serve as a foundation for product
were used as anto be over 4,000
mystery for 4,000
selection. Finally, to enable the
cient topical anyears old. Other
podiatric physician to formulate a
tibacterial treatmeans of closing
years due to its
wound care product formulary,
wounds included
both a narrative section and deusing
The Egyptians
scriptive tables of specific product
classes are offered as easy, readable
clamps. Finally,
number of minerreferences.
the art of suturing
als to be used as
traumatic wounds is documented
treatment alternatives for infected
as early as the third and fourth cenwounds. For instance, green copper
Throughout history, wounds
tury B.C.4
pigment (obtained from malachite)
have been dressed in an attempt to
and chrysocolla had powerful asHippocrates advanced medicine
prevent contamination, infection,
tringent and antiseptic properties.
by describing diseases and their
and morbidity. Because of the lack
Mercury compounds were also used
natural history. He considered that
of records, it is understandably difby the Egyptians for their antibacwounds were diseases and thus, by
ficult to determine how prehistoric
analogy, a humoral imbalance preContinued on page 185
Wound Care...
terial properties.5 The Greeks introduced the use of verdigris as an antiseptic which showed to be more
powerful than either malachite or
During the middle ages, Paulus
Aegineta’s work set forth the treatment of many kind of wounds as
well as a variety of skin diseases.
During this time, treatment selection was based on the product’s
curative properties. First, copper
ore, cimolian chalk, cold water,
vinegar and wine were all used as
styptics. Secondly, myrrh, frankincense, egg-white, cooked honey, a
sponge or wool squeezed out in
wine or vinegar acted as astringents. Thirdly, verdigris, pine
resin, turpentine, radish or ray
honey were all used to cleanse
wounds. Finally, Alum brine,
chrysocolla, verdigris, red copper,
ox bile, bitter almonds or their oil
were used as erodents.5
Wound Sepsis
Joseph Lister addressed wound
sepsis, leading to the use of a specific chemical therapy in managing a
wound.4-7 Lister’s work was important in reducing both morbidity
and mortality from traumatic injuries. The importance of a moist
wound environment for healing
has become well established since
Winter’s observations in 1962.8
Podiatric physicians may be
overwhelmed by over-abundance of
wound care products to choose
from since Winter’s observations.
Therefore, it is essential that when
the podiatric physician selects a
wound care product the decision is
ground in science and not an arbitrary one.
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structures of fascia, muscle
and bone.9-11
Wound healing is a complex
biologic process that involves
chemotaxis and division of cells,
neovascularization, synthesis of extracellular matrix, proteins, and reThe Wound Healing Process
modeling of scar tissue. The process
Human skin is composed of two
of wound healing begins when disdistinct fused layruption of skin
ers, each with difintegrity occurs
ferent tissue cell
below the epiderHuman skin is
types which have
mis. Although
distinct functions
this process is a
composed of two
(Figure 1). Skin is
continuous comdistinct fused layers,
the largest organ
plex of interplay
of the body and is
between various
each with different
cell types found
10% of the body’s
in the resulting
weight.9-11 Epiderwound, it is comwhich have distinct
monly described
mis is the outeras occurring in
most layer of the
stages: inflammaskin and normally
tory, proliferaregenerates every
tive, and maturafour to six weeks.
tion. Findlay further subdivides this
It is avascular and develops from
process into four distinct phases:
ectodermal origin. It is the outerinflammatory/defensive, destrucmost layer of the skin and consists
tive/migratory, proliferative/granuof five cell types, also arranged in
lation, and maturation.12 Hunt’s relayers.
The dermis is composed of colview emphasizes both the contribulagen, elastic fibers, fibroblasts and
tions of coagulation and inflammais from mesodermal origin. It protion to the formidable eruption of
vides strength, support, blood, and
cell replication which is the founoxygen to the skin. It contains
dation of healing.13
blood vessels, hair follicles, lymphatic vessels, sebaceous glands, as
Tissue Injury
well as sweat glands. Thick bundles
Tissue injury causes the disrupof collagen anchor the dermis to
tion of blood vessels and extravasathe subcutaneous tissue and the
tion of blood constituents. A blood
clot forms, reestablishing homeostasis, and provides a provisional
extracellular matrix for cell migration.
Edema, erythema, heat, and
pain are characteristics of the inflammatory or first phase, which
begins at the time of the injury and
lasts four to six days. Macrophages
migrate into the wound area
around the fourth day to destroy
bacteria and clean the wound of
cellular debris.3,10,12-15
The Proliferative Phase
The proliferative phase, the second phase in the process, lasts from
four to 24 days. During this period,
red, beefy, shiny tissue with a granular appearance is generated. This
tissue consists of macrophages, fi-
Figure 1
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broblasts, immature collagen,
new blood vessels, and ground
type, nutritional status, vascular
status, and immunosuppression.10
The podiatric physician may
have a dramatic impact on a patient’s healing outcome by recognizing and preventing those factors
Maturation Phase
The third phase of wound repair
is the maturation phase, also
known as the remodeling phase,
lasting from 21 days to two years.
Collagen fibers change the red
granulation tissue to white vascular
tissue as vascularity decreases, resulting in a scar with maximum
tensile strength. Myofibroblast and
actin-rich fibronectin are responsible for wound contraction.3,10,12-15
Tissue injury
causes the disruption
of blood vessels
and extravasation
of blood
Factors That Impede Wound
A number of both local and systemic conditions may delay or impede wound healing. Some local
factors include: pressure of the area,
dry wound environment, wound
edema, repetitive trauma, local infection, and tissue necrosis. Systemic factors include age, body
that will impede wound healing.
Also, the podiatric physician may
be the one to identify possible
problems of patient’s nutritional
barriers, patient’s noncompliance,
local wound infection, or wound
trauma as the cause of impeded
wound healing.
Malnutrition has been shown to
be a major factor affecting wound
healing.16-20 Ongoing nutritional assessment is essential when managing the progress of a healing
wound. The roles of specific nutrients are discussed below with regard to wound healing.
Protein depletion impairs
wound healing by inhibiting angiogenesis, fibroblast proliferation,
and synthesis, accumulation, and
remodeling of collagen. 16,20 Glutamine has a central role in many
major metabolic pathways. It provides the substrate for the synthesis
of purines and pyrimidines for the
proliferating stimulated lymphocytes.21 Both carbohydrates and fats
supply cellular energy.
Additionally, fats supply esse nt ial f at t y acid s f o r ce llular
membrane manufacture and
prostaglandin production. Vitamin A moderates cell differentiation, controlling growth factors
and their receptors.22 It is responContinued on page 187
Recognized Reasons for Wound Closure Failures
Excessive Dry Wound Bed
Use a dressing that maintains moisture
(Hydrocolloid or hydrogel dressing)
Rolling Wound Skin Edges
Moisture-retentive dressing
White Skin Macerated Wound Edges
Protect Skin with Petrolatum ointment-Zinc oxide
Use a more absorptive dressing
Underminding or ecchymosis of surround skin
Protect the area
Protect the area from pressure
Inspect/Irrigate tunnel for foreign body
(suture or dressing material
Perform debridement if living tissue has adequate
No change in size and depth for 2 weeks
Reassess the patient for local and systemic
Increase in size or depth of wound bed
Reasses the patient for circulation and infection
facilitate wound closure, the podiatric physician should be able to
sible for collagen synthesis and
match the associated probable
epithelialization. Vitamin C is a
cause for the failure to thrive and
vital co-factor in the formation of
then select an appropriate intervenhydroxyproline residues in protion to expedite wound closure. 28
collagen, and its deficiency results
Probable causes for wound closure
in a decrease of collagen formafailure are pressure, dryness, moistion and a decrease in membrane
ture, ischemia, and infection.
If a wound shows no change in
its size or depth during a two-week
Pyridoxine, riboflavin, and thitime period, then the causes may
amine are important co-factors that
be pressure or trauma to the area,
may stimulate antibody and white
infection, or patient issues that inblood cell formation. They have
clude poor circuroles as co-factors
lation, poor nuin cellular develtrition, poor conopment and protrol of disease
mote enzyme acMalnutrition
processes, and intivity.
has been shown
adequate hydraIron is a cotion.28
factor in the hyto be a major factor
drolyzation of the
If a wound
amino acids lypresents with inaffecting wound
sine and proline,
creased size or
which are essendepth the causes
tial for collagen
may be excess
synthesis. Also,
pressure, poor ciriron enhances
culation, or infecleucocyte bacterial activity.
tion.28 When a tunnel presents, it
Zinc supplementation may
may be caused by pressure over
speed wound healing, but only in
bony prominences, the presence of
the presence of zinc deficiency. 24
a foreign body, or the presence of a
deep infection. 28 Excess shearing
Zinc acts as a co-factor for enzymes
during cell proliferation. Copper is
force to the wound area will reveal
a co-factor in a number of enzymes
undermining or ecchymosis of the
involved in wound healing, the
surrounding skin.
most notable being lysyl oxidase,
When a wound presents as dry
which catalyzes the cross-linkage of
or with rolled skin edges, the explacollagen.20
nation may be inadequate hydration. 28 White skin or macerated
wound edges may be caused by exMedications
cessive moisture, while increase in
Medications are known to affect
drainage or a change in nature of
wound healing. Inhibition of
drainage as in color from clear to
wound healing has been reported
purulent may be autolytic or enzywith the use of glucocorticosteroid,
matic debridement or an infection
anti-inflammatory drugs and antiof the wound bed.28
neoplastic agents. Exogenous glucocorticosteroids inhibit wound contraction, collagen synthesis, and
Necrosis of the Wound Bed
connective tissue formation. Both
Necrosis of the wound bed may
nonsteroidal anti-inflammatory
be caused by ischemia and wound
agents and antineoplastic agents
edges that appear red, hot, tenhave been studied in animal moddered, and indurated may be exels to demonstrate impaired wound
plained by inflammation due to exhealing.25-27
cess pressure or infection.28 Table 1
summarizes wound bed conditions
and interventions that may be seFailure Causes
lected by the podiatric physician to
One of the key elements the
treat the corresponding cause for a
podiatric physician should master
wound’s failure to thrive.
when treating wounds of the lower
Finally, essentially all facets of
extremity is to recognize the most
wound healing have been reported
common signs involved when a
to decrease with age. Decreases in
wound does not thrive. In order to
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wound healing processes
that are directly related to
increased age include: glucose
metabolism, oxygen consumption, inflammatory cell infiltrate,
macrophage function, fibroblast
function, capillary growth, collagen
remodeling, contraction rate, and
re-epithelialization rate.29
The podiatric physician should advise elderly patients that even superficial wounds heal at a slower
Wound Types
Wounds may be classified as
acute or chronic.30,31 Risk factors associated with chronic wounds include excessive pressure, diabetes
mellitus, poor circulation, immunodeficiency, and infection. The
most common chronic, cutaneous
wounds include venous leg ulcers,
arterial leg ulcers, neuropathic ulcers, and pressure ulcers.10,28
Venous leg ulcers, in which the
efficient return of blood to the
heart is impeded by lost valve function in central veins, are the most
common ulcers of the lower extremities. Venous leg ulcers can be
quite large and usually occur on the
medial side of the ankle. They always present as a dark-brown stain.
The wound edges are shallow and
diffuse. Venous ulcers produce large
amounts of fluid (Figure 2).10,28
Arterial leg ulcers can occur on
any part of the leg, but are commonly found below the ankle.
Continued on page 188
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Trauma is often a precipitating event. Usually, patients experience pain at rest and when the
leg is elevated. These ulcers generally have well-defined borders, are
dry or necrotic, and are deeper and
smaller than venous ulcers. The
wound floor is described as deep
with a cliff edge.10,28
Diabetic Ulcers
A diabetic foot ulcer is caused by
neuropathy and vascular disease related to diabetes mellitus. These ulcers are usually small and deep
with steep edges and are often sur-
rounded by calluses. Callus often
surrounds the ulcer floor. 28 The
ulcer floor is often dry and necrotic
with localized edema (Figure 3).
Pressure Ulcers
Pressure ulcers also called decubitus ulcers, bedsores, and pressure
sores. They are lesions caused by
unrelieved pressure, resulting in
damage to underlying tissue. They
occur almost exclusively on the tissue located over a bony prominence.10,28
Wound Assessment
Assessment of any wound
should begin with the extent of the
wound, and include tissue level involved, the wound dimensions, and
its effect on the patient.10,28,32 Each
ulcer should be classified by wound
morphology, severity, and location.
Common terms used in connection
with a healing wound include exudate, necrosis, slough, fistula, sinus
tract, and tunneling 2,10,28
Exudute is material composed
of serum, fibrin, and white blood
cells that escape from blood vessels
into a superficial lesion or area of
inflammation. Necrosis is death of
living tissue due to lost blood supply, corrosion, local injury, or burning. Slough is dead tissue that has
Continued on page 189
Wound Product Classes
Carrasyn gel
Curasol gel
Elta hydrogel
Rehydrate wound bed
Reduce pain
Facilitate autolytic
Intrasite gel
Periwound area
Some require
Second dressing
Hollister wound
Draining collector
Collect and contain
Skin Sealants
Allkare Protective
Hollister skin gel
Sween prep
Skin Protectant
Avoid contact with
Patient's eyes
Skin Substitutes
Support Wound Closure
3M Transpore
Curity Standard Porous
Durapore Surgical
Micropore Tape 3M
Secure Dressings
Direct use on
Open wounds
Polyskin II
Facilitate autolytic
Reduce friction
May adhere to
Some wounds
wounds anatomically by the tissue
layers involved.10
Pressure ulcers are classified into
separated from healthy tissue.
four stages using criteria established
A fistula is an abnormal pasby the National Pressure Ulcer Adsage leading from an abscess or
visory Panel Consensus Develophollow organ to the body surface,
ment Conference and the Wound
permitting the passage of fluids or
Ostomy and Continence Nurses
secretions. A sinus tract is a narSociety.2,10,33
row, elongated
path extending
Staging classifrom a focus of
fication may be
suppuration to
useful when seEssentially
the skin’s surface
lecting a wound
all facets of wound
and often discare
charges pus. TunStage
inhealing have been
neling is a term
nonused to describe
blanchable eryreported to
tissue destruction
thema of intact
decrease with age.
underlying intact
skin with discolskin. Finally, the
oration, warmth
term wound buror hardness. Stage
den is the extent
II ulcers are suof the wound and its attributes,
perficial lesions similar to abrawhile wound severity reflects
sions, blisters, shallow craters with
wound burden, host factors, and
partial thickness skin loss involving
the epidermis, dermis, or both.
Stage III ulcers are full-thickness,
skin loss involving damage or
Classification Systems
necrosis to subcutaneous tissue that
Several classification systems
may extend to the underlying fasidentify wounds with regard to
cia. It presents clinically as a deep
stages. The podiatric physician
crater with or without undermining
should be familiar with the followadjacent tissue. Stage IV ulcers ining classification systems: Meggitt’s
volve full-thickness, skin loss with
surgical management of the diabetextensive destruction, tissue necroic foot, Wagner’s the dysvascular
sis, and damage to muscle, tendon,
foot, the University of Texas, San
joint capsule, or bone. Stage IV
Antonio classification, and the
wounds frequently present with
S(AD) SAD classification.
tunneling characteristics and sinus
The podiatric physician must
Wound Dressings
then be able to apply clinimeterics
The principle function of a
to these classification systems to
wound dressing is to provide an opensure that their validity can be
timum healing environment. It is
readily applied to clinical pracessential for the podiatric physician
tice. 33,34 Staging systems identify
to understand the primary goals of
topically managing a wound which
should include: keeping the local
environment moist, keeping the
wound clean from debris and bacteria, and preventing further disruption to the wound from trauma.
Also, the podiatric physician must
understand that no one wound care
product is appropriate for all
The choice of a wound dressing
is dependent on the cause, presence
of infection, wound type and size,
stage of wound healing, cost, and
patient acceptability.12
According to Lawrence,35 dressFigure 3
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ing materials should be
sterile, strong, absorbent,
protective, inexpensive, and
conform to the contours of the
body. A dressing should be reasonably strong, to provide mechanical
protection to the wound, but not
so rigid that the lower limb’s movement is impaired, or so abrasive
that movement irritates the wound.
It should be nontoxic and should
not sensitize the skin.
Further, a dressing material
needs to be free of particulate or fibrous material that may shed into
the wound. It needs to be easy to
remove and not adhere to the
wound. A dressing should be free of
bacteria, preventing the wound
from acquiring bacteria from the
environment and preventing any
wound bacteria from being dispersed into the environment.
Dressings should be compatible
with therapeutic agents that might
be used with them. Finally, a dressing should have an acceptable appearance to patients, nursing staff,
and others.36
Primary vs. Secondary
All wound dressings can be
classed as either primary or sec-
Arterial leg
ulcers can occur
on any part of the leg,
but are commonly
found below
the ankle.
ondary. Primary dressings are
placed directly over the wound.10,3640
They provide protection, support, absorption, prevent desiccation, infection, and serve as an adhesive base for the secondary
dressing. Secondary dressings provide additional support, absorption, further protection, compression, and occlusion.10,36-40 Often the
secondary dressing serves as a pressure dressing.
Secondary dressings absorb
moisture and exudate that are not
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absorbed by the primary
dressing. The selection of materials for primary or secondary
dressings is governed by the particular application.
Goals of Topical Therapy
Podiatric physicians should be
familiar with the essential goals of
topical therapy when selecting a
product. These wound care products must provide adequate oxygen
and circulation to the tissues, insulate and protect the healing
wound, eliminate clinical infection
by removing excess exudate from
the wound, maintain a clean and
moist environment, and obtain
complete wound closure. There-
Several classifications
systems identify
wounds with regard
to stages.
fore, an ideal wound care dressing
promotes healing without toxicity
by acting as a barrier between the
wound and the environment. Sev-
eral different types of products
may be needed as the wound progresses through the stages of healing. There are numerous categories
and classifications of wound dressing products. Table 2 presents
wound dressings products and
wound types.10,28,36-40
These products are produced
from naturally occurring calcium
and sodium salts of alginic acid
found in a family of brown seaweed
(Phaeophyceae). They are soft, nonwoven fibers twisted in a rope fashion or shaped in fibrous mats. AlgiContinued on page 191
Dressings Considerations for the
Lower Extremity Ulcers
Not Indicated
Not Indicated
Use for Copious Drainage
Wet Ulcers
Tunneling Ulcers
Deep Ulcers
Bleeding Ulcers
Protect Ulcer
Use for dry gangrene
Use for moisture with
Revascularized Ulcer
Protect Ulcer
Absorb drainage
Protect Ulcer
Use under Compression
Wet Ulcers
Protect Ulcer
Maintain wound
for dry gangrene
Use for absorption
or as Padding
Use for absorption
Protect Ulcer
Use for autolytic
Do not use on
Ischemic Tissue
Protect skin
Promote Epithelialization
Do not use withCopious
Drainage or cellulitis
Promote Granulation
Pain Management
Do not use with Copious
Necrotic Ulcer
Shallow Ulcer
Use to Debride
Use to maintain
moist wound
Use to Debride
Pain Management
Do not use with Copious
Necrotic Ulcer
Tunneling Ulcers
Dry Ulcer
Use after ulcer
Use to protect fragile
Not to be used
in presents
of cellulitis
Not indicated
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Composites are manufactured
Foam dressings are
nates are rich in either mannuronic
as a single product that combines
manufactured as either a
acid or guluronic acid; the relative
the physical products of different
polyurethane or silcone foam
amount of each influence the
dressing types. For example, one
with either hydrophilic or hyamount of exuduate absorbed and
product may include an absorptive
drophobic properties. They transthe shape the dressing will retain.
layer, a bacterial barrier, and a
mit moisture vapor and oxygen and
provide thermal insulation to the
conform to the
property. Comwound bed. Foams are indicated for
wound’s shape
posites are used
partial to full thickness wounds
Alginates form
and are approfor both partial
with minimal to heavy amounts of
priate for partial
and full thickness
drainage. A principle advantage is
a soft gel and
and full-thickwounds as either
being non-adherent, which preness, moderately
secvents injury to the surrounding
absorb up to 20 times
to heavily drainondary dressings.
their weight of
ing sinus tract,
They are effective
Another advantage of a foam
cavity, or tunnel
for wounds with
product is its ability to contain exuexudate.
wounds, with or
date. Some foam products require a
without infecheavy exudate,
cover dressing and tape; others are
tion. While in
healthy granular
waterproof with an adhesive border
contact with the
wounds, necrotic
and may be used under compreswound, alginates form a soft gel
tissue with slough or eschar, or any
sion. They are not recommended
and absorb up to 20 times their
mixed wound. One disadvantage is
for wounds with no exudate or
weight of exudate.
that their adhesive borders may
wounds with dry eschar.
Alignate dressings are primary
limit their use on fragile skin.
dressings and can be left in the
wound for up to seven days. A secEnzymatic Debriders
These cotton products have a
ondary dressing can be applied
These products are proteolytic,
relatively wide weave through
over the alginate dressing to facilichemical agents that break down
which new tissue can grow. Gauze
tate absorbency. Major contraindidevitalized tissue. Enzymatic dedressings are manufactured in
cations to their use are the presbriders are used as a non-surgical
many forms. Impregnated gauze
ence of dry eschar, third degree
method of debridement for fullwith petrolatum prevents it from
burns, and surgical implantation.
thickness necrotic wounds, pressure
adhering to the wound. Gauze can
Disadvantages of using alginates
ulcers, dermal ulbe used on draininclude possible dehydration of
cers, and infected
the wound bed, a foul odor from
wounds. Their
necrotic wounds,
Enzymatic debriders
the gel, and the need for a secprinciple disadand
ondary dressing.
vantage is that
wounds and may
are used as a
they are inactivatbe used as packCleansers
ed by soaps, deing materials for
non-surgical method
These solutions are indicated to
tergents, acidic
dead shape, tunof debridement
be used on superficial, partial-thicksolutions, and
nels, and sinus
ness, and some full-thickness
tracts. Their prifor full-thickness
wounds. Their chemical properties
Some enzymatic
mary advantage is
adjust wound pH and create a
agents can damtheir widespread
necrotic wounds,
moist environment. These agents
age healthy tisavailability and
pressure ulcers,
are not recommended for infected
cost effectiveness.
Their disadvandermal ulcers, and
tages include the
tendency to tear
infected wounds.
Collagen dressings stimulate
This class of
away new skin on
cellular migration and contribute to
products funcremoval and shed
new tissue development. Collagen
tions by absorblint on to the
is a body protein that stimulates
ing five times their weight of exuwound. Therefore, a non-adhering
wound debridement. They are abdate. An exudate absorber conforms
dressing should be applied first and
sorbent, non-adherent, and conto the wound’s surface, thus elimithen gauze should be used as a secform to the wound’s surface. They
nating dead space and maintaining
ondary dressing.
should not be used and not recoma moist wound environment. This
mended for necrotic wounds.
allows for an eschar to soften as
Collagen is contraindicated in
well as allow for slough to liquefy.
Hydrocolloids are hydrophilic
third degree burns. Their use is also
They should be used on full thickcolloid particles (sodium
contraindicated in patients with
ness wounds with necrotic tissue
caroboxymethlycellulose, gelatin,
bovine product sensitivities.
and moderate to heavy exudate.
Continued on page 192
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pectin, elastomers, and adhesives) bound to polyurethane
foams that are impermeable to bacteria and facilitate wound debridement. Cross-linkage of the material
used influences the viscosity of the
gel under the dressing.
A new dressing should be applied when the accumulation of
wound fluid causes separation of
the dressing from the wound. They
are occlusive and come in many
sizes, shapes, and forms. Hydrocolloids should be used on superficial
or partial thickness wounds with
light to moderate exudate. They
may be used under compression
and may be left in place for three to
seven days.
Although they are comfortable to wear, particularly when
placed on high friction sites, they
may be difficult to remove. The
principle disadvantage is their
opaque nature, making wound
evaluation difficult. They are
contraindicated for use in full
thickness wounds, infected
wounds or in the presence of
sinus tracts. Surrounding fragile
skin may be torn with removal of
this product. Patients must be
warned of the rather malodorous
characteristic of yellow-brown
draining fluid under some of
these dressings.
Hydrogel products are non-adherent, water-based, or glycerinbased amorphous, cross-linked
polymer gels. Due to their chemical
nature and high water content (8099%), they are non-absorbent and
therefore are not recommended for
wounds with heavy exudates. Hydrogel dressings are complex lattices in which the dispersion medium is trapped. They are indicated
to be used on light exudate, partial
and full-thickness wounds with
depth, burns, and tissue damage by
Hydrogels can help reduce
pain, decrease wound temperature,
and reduce inflammation. These
products soften and loosen necrotic tissue as well as fill wound dead
space. If used alone, they do not
keep bacteria out of the wound.
They are not recommended for
wounds with moderate to heavy
exudate or where there is evidence
of gangrenous tissue that should
be kept dry to reduce the risk of
Pouches are to be used on
wounds that drain more than 50 cc.
per day and wounds with highly
excoriating exudate. These dressings do not need to be changed as
often as other dressing types. They
protect the surrounding skin and
provide a means to measure wound
exudate production during a fixed
period of time. Their only disadvantage is that it may be time consuming to apply them.
Skin Sealants
These products are film barriers
that create a plastic-like coating on
gauze with
petrolatum prevents
it from adhering
to the wound.
the skin that protects the injury
from mechanical epidermal stripping or maceration. They are to be
used on intact skin surrounding the
wound. Skin sealants contain alcohol that may cause pain and denude skin.
Skin Substitutes
Skin substitutes are derived
from human origin tissue or are
bio-engineered. They are used to
support wound closure and serve as
a replacement for skin and surgical
grafting. A bio-engineered skin
substitute closely resembles human
skin in structure, function, and
handling; and may provide both
epidermal and dermal components. They are indicated for the
treatment of partial and full-thickness skin ulcers due to venous insufficiency of greater than one
month’s duration, which have not
adequately responded to conventional ulcer therapy.
Skin substitutes are also indicated for the treatment of full thickness diabetic foot ulcers. The podiatric physician should check the expiration date to ensure product viability and follow manufacturer’s instructions for use and application.
Tapes are used to secure wound
care products, pouches, tubes, and
drains in place when the surrounding skin is healthy. Their composition, widths, adhesive properties
and hypoallergenic qualities are
variable. Cloth or clear tape should
be used where strength is needed;
and paper tape when gentleness is
Tape placement should be rotated with each dressing change to
minimize skin irritation. Tapes may
cause epidermal stripping if applied
inappropriately or removed from
fragile skin. Tapes do not stretch to
accommodate swelling.
Therapeutic Moisturizers
Collectively these products include creams, gels, liquids, or
ointment preparations used to
soothe, soften and moisturize the
skin. Moisturizers should be applied after cleansing with a gentle
agent and when the skin is dry.
The ingredients for these agents
vary based each particular manufacturer’s formation generally containing water, humectants, emollients, and vitamins. Some products also may include an antimicrobial ingredient. Therapeutic
moisturizers are the second step in
the prevention of skin breakdown.
The process consists of cleaning,
moisturizing, and protecting the
Transparent Films
Transparent films have either a
sterile semi-permeable polyurethane membrane or a co-polymer
membrane with a porous adhesive
layer that allows for wound visualization. They are water-proof, permit oxygen and water vapor to
cross the membrane barrier, and
therefore are not absorbent. They
are impermeable to bacteria and
Transparent films are indicated
for partial thickness wounds, superContinued on page 193
ficial burns, and skin graft donor
sites. They retain moisture while facilitating autolysis, and do not require a secondary dressing. Films
are very flexible and are good for
wounds on difficult anatomical
sites, particularly over joints.
They are not recommended for
use in infected wounds with moderate to heavy exudate or with fragile skin edges. Due to their highly
adhesive nature, they are difficult
to apply and may not stay in place
on high friction areas. Untimely
dressing removal can potentially
strip away new skin growth.
contaminate the wound.
For this reason, an antibiotic
ointment or cream should be used
before any bandages are applied. A
topical antimicrobial agent should
inhibit pathogenic microorganisms
in wounds without slowing the
normal rate of tissue repair.98
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Co ical
Wound Care...
polymyxin B may be
quinolone and an antimycotic agent providing broad antimicrobial activity and faster healing rates.53
Alternative Treatment
The history of wound care is reNo Ideal Agent
plete with examples of alternate
The ideal topical antimicrobial
practices. Numerous case reports in
agent does not exist. Topical anthe literature, for
timicrobial agents
example, describe
have the potential
wound treatment
to affect the
Hydrogels can
with various subrate of healing
stances such as
through a number
help reduce pain,
honey, sugar, ioof possible mechadine, and meat
nisms. These posdecrease wound
Topical Antimicrobial
tenderizer. Podiasibilities include
Educational Interventions
tric physicians
the antimicrobial
An opportunity for the podiamay be faced
effect of these
and reduce
tric physician to intervene on bewith
half of a patient’s wound healing
who are demandalter the wound’s
process and ensure a positive outing more inforenvironment and
come is to clarify the appropriatemation, more opany other effect,
ness for the use of a topical antibitions, and greater
whether it be biootic on a wound during its healing.
ability to participate in their treatchemical, metabolic, or physical
Researchers have shown that a
ment decisions.
caused by the vehicles or the active
wound heals faster and with less inOver time, people have innoagents themselves. By more effecflammation if it is allowed to heal
vated with creative topical dresstively eradicating bacteria, topical
without a scab.
ings to treat wounds: aloe vera,
antibiotics may produce a faster rate
Normally, a wound left to run
antacids, vegetable shortening,
of healing in some cutaneous infecits course will form a scab. In this
honey, baby powder, gentian viotions than a placebo or no treatenvironment, where a relative loss
let, and golden seal, inappropriate
of hydration occurs, resistance to
unmonitored applications of heat,
Geronemus and associates comepidermal cell migration increases
urea of chloroform, sugar and povipared four commonly used topical
due to obstruction by dead and
done-iodine, and the use of legend
antimicrobial agents on the rate of
crusty tissue. If the surface tissue is
drugs off-label as wound healing
re-epithelialization of clean wounds
excessively dehydrated and has a
in white domestic pigs.45
thick wound crust or a scab, epiderNeomycin-Bacitracin-Polymixin
Few of these treatment modalimal cells may
ties have beneficial properties, and
have to burrow to
healing by 25%
there are no research studies to supa deeper plane bewhile its vehicle
port their use in wound healing.
neath the scab to
accelerated healPodiatric physicians should educate
Tape placement
reach moist, live
ing by only 9%;
themselves about the myths about
should be rotated
cells where they
when compared
topical treatments for wounds and
can migrate and
treatapply evidence-based medicine to
with each dressing
ment. Silver sulfadetermine if these wound care
diazine also protreatment myths are valid.
change to minimize
duced a 28% inTherefore, the
skin irritation.
Aloe Vera
crease, but the
podiatric physirate was not sigThe effects of aloe vera on the
cian must advise
nificantly differskin has met with much controa patient to keep
ent from the veversy. Historically, reports of its
healing wounds
hicle’s improvement of 21%.
beneficial effects are found in the
covered despite the long term myth
Mertz et al., demonstrated that
writings of Hippocrates and
of leaving wounds open. A wound
mupirocin accelerated healing by
Alexander the Great. In most
should be kept covered with a ban8% and its vehicle retarded healing
cases, the distribution of aloe
dage to ensure a moist healing enby 5% compared to wounds exproducts often are accompanied
vironment; however, the same
with misinformation and claims
posed to air.50
moist environment that encourages
that promote skepticism.
healing also encourages the overBoyce and colleagues suggest
growth of any bacteria that may
that neomycin, mupirocin, and
Continued on page 194
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Wound Care...
gram-positive organisms. Its antibiReports of the use of a comotic properties are attributed to its
pounded mixture of sugar and
low pH, a thermolabile substance
povidone-iodine have been cited to
Antacid Products
called inhibine, and its hygroscopic
show enhanced wound healing in
The topical application of an
properties. 63 Honey also contains
both animal and human subantacid product to protect a wound
jects.61,62 Knutson et al., documenthas been utilized for many years.55
enzymes such as catalase which aid
in the healing properties.
ed the use of sugar and povidoneThe pH of the skin is acidic, acting
iodine to enhance wound healing
as a natural antibiotic and preventMolan summarized the cliniover a five year period when treating the growth of bacteria normally
cally-based evidence supporting
ing 605 patients
found residing on the skin. Applythe use of honey
ing an antacid to protect a wound
as a wound dressburns, and ulcers
and its surrounding skin will ining.64 This review
The use of honey
with granulated
crease this acidic pH, thus allowing
reported the findsugar and povibacteria to grow and increase the
ings of 17 ranfor decubitus ulcers
chance of infection. Also, the applidomized, conand burns has been
Their compoundcation of an antacid to the wound
trolled trials ined mixture was
base or surrounding skin will dry
volving 1965 pardocumented in the
prepared in a
out the wound and delay the healticipants, as well
ratio of 3 to 4
ing process.54
as five clinical triliterature.
parts sugar to 1
als of other forms
part povidone-ioinvolving 97 parHoney
dine ointment,
ticipants treated
The use of honey for decubitus
with the addition of 60 to 80 ml of
with honey. The wound types
ulcers and burns has been docupovidone-iodine solution per
treated with honey during these
mented in the literature.56-60 Subrahkilogram.
control trials were either superfimanyam reported that a total of
Rapid healing ensued, due to a
cial burns, partial thickness
104 cases of superficial burn inreduction in bacterial contaminawounds, moderate burns, third dejuries were studied to assess effition, rapid debridement of eschar,
gree burns, chronic leg ulcers,
ciency of honey as a dressing in
probable nourishment of surface
pressure ulcers, and surgical
comparison with silver sulfadiazine
cells, filling of defects with granulawounds.64
gauze dressing. In the 52 patients
tion tissue, and covering of granutreated with honey, 91% of the
These studies compared honey
lation tissue with epithelium. These
wounds were rendered sterile in
to either silver sulfadiazine, amniinvestigators further discovered
seven days. Of the 52 patients treatotic membrane, Vaseline gauze, an
that the requirements for skin grafted with silver sulfadiazine, 7%
occlusive dressing, mupirocin,
ing and antibiotics were greatly reshowed control of infection in
povidone-iodine, or a boiled potato
duced, as were hospital costs for
seven days. Of the wounds treated
peel. 64 Molan comments on the
wound care.62
with honey, 87% healed within 15
very large amount of evidence as
days as compared to 10% in the silwell as the clinical observations
ver sulfadiazine group. Allergy and
demonstrating honey has signifiDeveloping a Wound Care
side effects were not observed in
cant anti-inflammatory activity.64
Product Formulary
the group who
There are many wound care
This review
was exposed to
dressing products available for the
presents a large
the honey applipodiatric physician to select when
body of evidence
treating a lower extremity wound;
supporting the
however, clear, robust evidence of
use of honey as a
S u b r a h films are indicated for
the comparative effectiveness of
wound dressing
these products is limited. There is
for a wide range
compared the use
partial thickness
a lack of evidence from well-conof wounds beof honey impregwounds, superficial
trolled, randomized trials evaluatcause its antibacnated gauze verus
ing the clinical and cost-effectivet
polyurethane film
burns, and skin graft
ness of wound care products. On
rapidly clears in(Opsite В® ) in the
donor sites.
the other hand, there is some relifection and protreatment
able clinical evidence on the mantects the wound,
burns as a proagement of leg ulcers that the podand it provides a
spective randomiatric physician can use when demoist healing
ized study. He
veloping a wound care product
environment without the risk of
demonstrated that honey impregformulary.
bacterial growth occurring. Also,
nated gauze dressing wounds
The podiatric physician must
honey rapidly debrides wounds
showed earlier healing as compared
begin the process of development
and removes malodor, its anti-into Opsite В® (10.8 days versus 15.3
of a formulary by first reviewing
flammatory activity reduces
the literature of all wound care
edema and exudates, and preHoney consists of simple sugars
products available. Available revents or minimizes hypertrophic
and is both sterile and inhibits
growth of both gram-negative and
Continued on page 195
sources must be used in the most
efficient way possible to avoid selecting products that may not
meet the needs of the podiatric
physician’s patients. Then a shortlist of two or three products from
various wound care classification
(depending on how they will be
dispensed and stored) should be
The podiatric physician should
evaluate each product from the list
either by clinical or non-clinical
means. 65 Effective clinical evaluation of a product relies on using expert opinions from the literature or
from colleagues to ensure the product selected is the most appropriate
one to represent a particular class of
products. Once each product has
been evaluated, a final product inclusion list should be formulated
and published.65
Product Cost
Product cost must play a role in
formulating a wound care formulary.65,66 The price of products used in
the treatment process is a relatively
minor part of the overall cost.66 The
podiatric physician should consider
that the lowest priced product is
not necessarily the most cost-effective choice because the dominant
There is a lack
of evidence from
randomized trials
evaluating the clinical
and cost-effectiveness
of wound care
element of a product is the cost of
the provider’s time.
Other Considerations
Other elements the podiatric
physician should consider when
formulating a list of products is to
reflect upon patient acceptability,
safety, ease of use, availability, and
type of storage required.65
The podiatric physician should
not only use current compendiums
to determine if clinical evidence is
available for each product, but also
The lowest priced
product is not
necessarily the most
cost-effective choice
because the dominant
element of a product
is the cost of the
provider’s time.
search out wound care resources on
the Internet.67
Fikar and Delinois have complied a comprehensive list of
URLs for Internet sites providing
information on wound and ulcer
care that the podiatric physician
can utilize during the development of their wound care product
New products are being introduced to the healthcare market frequently and podiatric physicians
should have a fundamental knowledge of their indications and the
process of wound healing. Once
they have mastered the principles
of wound healing and have become
familiar with each category of
wound care products, they can
have a profound effect as members
of the wound care team.
Numerous products exist, and
at times it may be difficult to assess
the most appropriate wound care
product necessary to facilitate patient healing. The podiatric physician, as an active member of the
wound care team, should assist in
the selection of an appropriate
dressing for a particular wound.
Some variables to be considered
by the podiatric physician when
making this selection are the etiology of the wound, the amount of exudate present, the location of the
wound, the presence of infection,
the dressing’s cost, and the long-
ng io
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Co ical
Wound Care...
term goals set for the patient by the wound care
team. The ability to assess the
wound clinically and recommend an appropriate dressing is essential when providing podiatric
care to patients with lower extremity wounds. в– References
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Subrahmanyam M. Honey impregnated gauze versus polyurethane film (Opsite R) in the treatment of burns-a prospective randomized study. Br J Surg
Bergman A, Yanai J, Weiss J, et al.
Acceleration of wound healing by topical
application of honey: an animal model.
Am J Surg 1983; 145:374-376.
Archer HG, Barnett S, Irving S, et al.
A controlled model of moist wound healing: comparison between semi-permeable
film, antiseptics and sugar paste. J Exp
Path 1990; 71:155-170.
Knutson RA, Merbitz LA, Creekmore MA, et al. Use of sugar and povidone-iodine to enhance wound healing:
five years experience. S Med J 1981;
White JW, Subers MH, Schepartz AI.
The identification of inhibine, the antibacterial factor in honey, as hydrogen peroxide and its orgin in a honey glucose-oxidase system. Biochem. Biophys. Acta 1963;
Molan PC. The evidence supporting
the use honey as a wound dressing. Lower
extremity wounds 5(1) 2006 40-54.
Preece J. Development of a woundmanagement formulary for use in clinical
practice. Professional Nurse 2004 20 (3) 2729.
Posnett J. Making cost effectiveness
the bassis of product selection. J of Wound
Care 2006 15 (1) S14-S15.
Fikar CR and Delinosi BD. Woundcare resources on the Internet: a second
update. JAPMA 2006 96 (3) 264-268.
Dr. Smith is in
private practice
Beach, Florida
and is a Fellow
of the American
Wound Care
Association. His
E-mail is Robert.
See answer sheet on page 199.
1) All the following products function as skin substitutes to support
wound closure, except
A) ApilgrafВ®
B) DermagraftВ®
C) Collagenase SantylВ®
D) TranscyteВ®
2) The podiatric physician must
begin the process of development of
a wound care product formulary by
A) Creating a long list of 300 to
500 products from one wound
care class.
B) Not evaluating any wound
care products by clinical or nonclinical means.
C) Purchasing an entire line of
products from several manufacturers, regardless of cost.
D) Reviewing the literature of all
wound care products available.
3) Which statement regarding nutrition and the wound healing process
is true?
A) Glutamine has a minor to
non-active role in many metabolic pathways.
B) Vitamin C is a vital co-factor in
formation of hydroxycarbolic
acid residues in mini-collagen.
C) Iron peroxide is a co-factor in
hydrolyzation of amino-acids
glutamine and serine.
D) Zinc acts as a co-factor for enzymes during cell proliferation
4) With regard to the National Pressure Ulcer Staging System, which
statement is correct?
A) Stage one is a superficial lesion of full thickness depth.
B) Stage three lesions may extend to underlying fascia structures.
C) Stage two lesions are nonblanchable lesions.
D) Stage five lesions result in entire foot amputations.
5) Which statement is correct with
regard to wound care products?
A) The principle function of a
wound dressing is to provide an
optimum healing environment.
B) The most expensive product is
always the most appropriate
C) Wounds should be allowed to
dry out, and dressing should be
avoided until the scar is present.
D) There is no benefit for the
podiatric physician to develop a
wound care product formulary.
6) A 46 year old male diabetic patient
presents with a deep, wet, tunneling
foot ulcers. Please select the most appropriate dressing with the correctly
matched class for this patient?
A) Scarlet Red Ointment : Enzymatic Debrider
B) Lyofoam : Cleanser
C) Accuzyme : Composites
D) Sorbsan : Alginates
7) Identify the true statement about
the following wound care products.
A) Alginates form a soft gel and
absorb up to 20 times their
weight in exudate.
B) Enzymatic debriders are used
as surgical-sharp methods of debridement.
C) Foams are recommended for
non-draining wounds.
D) Cleansers are recommended
for infected wounds.
8) Which statement is not correct
concerning wound care products ?
A) Enzymatic debriders are inactivated by soap detergents.
B) Foams are described as
being semipermeable, with either hydrophilic or hydrophobic
C) Hydrocolloids are described as
being hydrophillic colloid particles bound to polyurethane
D) Alginates are recommended
for both arterial and lymphatic
lower extremity ulcers
9) Select the wound care product
that is correctly matched with its
A) Micropore : Hydrocolloids
B) Sween Prep : Skin Sealant
C) OpSite : Hydrocolloids
D) Xerofoam Gauze: Pouches
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10) Which statement is true concerning Hydrogel products?
A) Hydrogels cause increased
pain at the wound site.
B) Hydrogels can be left in
place for periods of one to
three months without being
C) Hydrogels are not recommended for wounds with moderate to heavy exudates.
D) Hydrogels often harden and
lead to wound necrosis.
11) Identify the false statement concerning wound care products.
A) Tapes do not stretch to accommodate swelling.
B) Transparent films have semipermeable membranes either of
polyurethane or co-polymer.
C) Skin sealants create a plasticlike coating on the skin.
D) Patients should not be
warned of the rather malodorous characteristic of yellowbrown draining fluid under some
of hydrocolloid dressings.
12) Identify the correct statement
concerning honey as a wound care
A) Inhibine is a thermolabile substance in honey responsible for
its antibiotic properties.
B) Honey has not been utilized
as a topical wound care dressing
C) Honey consists of complex
sugars that inhibit fungal and
yeast organisms only.
D) Honey contains catalase,
which does not aid in wound
13) Which of the following statements regarding alternative approaches to wound care is supported by clinical study?
A) Antacids, when applied to the
skin, act as natural antibiotics decreasing bacterial growth.
B) Literature reports identify that
a compounded mixture of sugar
and povidone-iodine facilitates
enhancing wound healing in
Continued on page 198
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both animals and human subjects.
C) Topical applied heat is always indicated to dry
up a wound bed to remove exudate.
D) Aloe vera is universally accepted as a topical
wound product.
14) Which wound care product selection is correctly
matched with its appropriate ulcer type?
A) Transparent Film: Venous Ulcer
B) Alginate: Arterial Ulcer
C) Hydrogel: Venous with Copious Drainage
D) Foam: Arterial Revascular Ulcer
15) Which wound product is correctly matched with
its most appropriate purpose (indication)?
A) Tapes: Secure dressings
B) Gauze: Rehydrate wound beds
C) Enzyme Debriders : To secure wound sites
D) Hydrocolloids : Non-surgical method of
16) All of the following products inactivate enzymatic
debriders, except?
A) Metallic ions
B) Acidic solution
C) Water
D) Soaps
17) According to Lawrence, dressing materials should
possess all the following qualities, except:
A) Protective
B) Sterile and strong
C) Inexpensive
D) Nonconforming
18) Findlay subdivides wound healing into how many
distinct phases?
A) three
B) four
C) five
D) six
19) Identify the wound care product that is not indicated for patients allergic or sensitive to bovine products?
A) Algicell
B) Carrafilm
C) Amerigel
D) Collagen
20) Which of the following is not one of the phases of
wound healing?
A) Proliferative
B) Maturation
C) Inflammatory
D) Transition
See answer sheet on page 199.
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Over, please
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EXAM #1/07
Selecting Wound Care Products
(R. Smith)
1. A B
11. A B
2. A B
12. A B
3. A B
13. A B
4. A B
14. A B
5. A B
15. A B
6. A B
16. A B
7. A B
17. A B
8. A B
18. A B
9. A B
19. A B
10. A B
20. A B
Please indicate the date you completed this exam
How much time did it take you to complete the lesson?
______ hours ______minutes
How well did this lesson achieve its educational
_______Very well
__________Not at all
What overall grade would you assign this lesson?
Additional comments and suggestions for future exams:
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