Author Archive

Educate Patients about Effects of Smoking on the Wound Healing Process

Wednesday, November 7th, 2018

Editor’s note: The name and specific patient details were changed for privacy.

Smoking is known to hinder wound healing, yet most wound care practitioners fail to document any smoking cessation discussion or education.

The daughter of Mrs. Bradley* was barely able to contain herself while giving her deposition. She was sobbing from a place deep in her heart as she retold the story of how her mother lost her leg partly due to the effects of smoking on the wound healing process.

Her mother started limping, and they realized she had an “opening” in the skin on the bottom of her foot.

Despite treatment, the wound grew in size and became infected. It soon became apparent that she was facing an amputation.


Sacral Wounds and Diarrhea Don’t Mix

Wednesday, September 12th, 2018

Frequent bouts of diarrhea make it difficult to care for wounds on the sacrum or coccyx, and healing often is impeded because of fecal contamination.

Many patients, particularly those with mobility issues, have pressure injuries on the sacrum or coccyx. Frequent bouts of diarrhea make it difficult to care for these wounds, which affects healing. If frequent, loose, and watery stools contaminate the wound, it can make the healing process more challenging. The first step is to identify the cause of the diarrhea in order to begin the appropriate nutritional, medical, and pharmaceutical treatment plan.

Causes of Diarrhea

Diarrhea is a symptom of many diseases and disorders. Here are just a few to consider.

Food intolerance/allergies: These include lactose and gluten intolerance or excessive intake of sorbitol, mannitol, or xylitol.

Protein energy malnutrition: Hypoproteinemia (albumin levels < 2.6 g/dL) is associated with intestinal edema, which negatively affects luminal absorption and may result in diarrhea.

Bacterial contamination: Contaminated food or water may lead to Campylobacter, Salmonella, Shigella, Clostridium difficile, or Escherichia coli.

Viral infections: Rotavirus, Norwalk virus, cytomegalovirus, herpes simplex virus, or viral hepatitis may all cause diarrhea.

Enteral tube feedings: Hypertonic formulas, refeeding syndrome, contamination, bolus feedings into the small intestine, and lack of fiber in the formula are all reasons that some patients may experience diarrhea.

Parasites: Giardia lamblia, Entamoeba histolytica, or Cryptosporidium can enter the body through food or water and settle in the digestive tract.

Drug reactions: Laxatives, diuretics, cholinergic drugs, antibiotics, prostaglandins, liquid medications containing sugar alcohols, warfarin, thyroid preparations, anti-epileptics, and many other drugs can cause diarrhea.

Gastrointestinal disease: Inflammatory bowel disease, short gut syndrome, HIV/AIDS, Crohn’s disease, chronic ulcerative colitis, bowel resection, and malabsorption syndrome all have diarrhea as a symptom of the disease.

Fecal impaction: Impacted feces prevent the passage of normal stool. Only watery stool is able to pass the point of impaction.

Types of Diarrhea

The list of possible causes of diarrhea is lengthy, and it sometimes is difficult to pinpoint the cause. It may help to classify the diarrhea in one of the three common categories—watery, fatty, or small volume.

Watery diarrhea occurs when the amount of water and electrolytes moving into the intestinal mucosa exceeds the amount absorbed into the bloodstream. Watery diarrhea is further classified into two subtypes—osmotic or secretory. Osmotic diarrhea abates with fasting, while secretory does not. Watery osmotic diarrhea usually accompanies lactose intolerance, dumping syndromes, and enteral feeding intolerances. Watery secretory diarrhea is often a sign of bacterial enterotoxins and viruses.

Fatty diarrhea, or steatorrhea, usually accompanies conditions associated with malabsorption, such as chronic pancreatitis or short bowel syndrome.

Small volume diarrhea may accompany diverticulitis of the colon.

Bloody or black tarry stools may indicate a more serious condition—this is not common diarrhea. Black tarry stools, or melena, usually indicates that blood is coming from the upper part of the gastrointestinal tract. Maroon or red, bloody stools, called hematochezia, usually suggests that blood is coming from the large intestine or rectum. These conditions warrant prompt medical attention and testing.

Occasionally, the ingestion of black licorice, lead, iron supplements, or even blueberries can cause black stools or false melena. A fecal occult blood test can rule our false melena.

Medical Record Documentation

Always document diarrhea, including the frequency, odor, color, presence of blood, abdominal pain, bloating, and fever. Also document what you suspect are the possible causes and type of diarrhea because this information will form the basis for the treatment plan.

Detailed records describing what is occurring with the patient provide essential information to the entire care team. These types of wounds may take longer to heal or present challenges. Therefore, thorough documentation also is needed in case any future legal or care questions arise.

Medical Treatment

The first step is to obtain a detailed medical and nutritional history. A nutritional history should include questions about the use of dietetic food products. Many patients with diabetes replace sugary foods with dietetic foods containing the sugar alcohols sorbitol, mannitol, and xylitol. These products frequently cause diarrhea, making it necessary to eliminate them from the diet if they are not well tolerated. Many medications also contain sugar alcohols, so the pharmacist should review the medication list and recommend appropriate substitutes. Magnesium-containing medications and supplements also may cause diarrhea, so the pharmacist should monitor this as well.

A stool culture sometimes is ordered to identify parasites, bacteria, or other signs of infections. In addition, sometimes stools are examined for fecal white blood cells and Clostridium difficile toxin. Blood tests can rule out or confirm the presence of certain diseases such as human immunodeficiency virus. A fasting or elimination test can confirm if diarrhea is caused by a food allergy or intolerance. Finally, a sigmoidoscopy or colonoscopy sometimes is performed.

Preventing Dehydration

The main goal of treatment for diarrhea is to prevent dehydration and electrolyte imbalance. It is necessary to correct losses of potassium and sodium as soon as possible by oral rehydration therapy (ORT). ORT is simply the provision of a proper oral rehydration solution. Water does not contain the necessary electrolytes for ORT, and sugary juices such as apple juice may worsen diarrhea. Limiting of caffeinated and alcoholic beverages is recommended.

Proper homemade and commercially produced oral rehydration solutions are both used. Commercially available products include Pedialyte® (Abbott Nutrition, Columbus, OH) and CeraLyte® (Cera Products Inc, Hilton Head Island, SC). Sports drinks such as Gatorade® (Pepsi-Co, Harrison, NY) also help. While many patients can rehydrate orally, individuals with symptoms of severe dehydration should stay in a healthcare facility so they can receive intravenous fluids.

Careful laboratory monitoring of sodium, potassium, chloride, BUN/creatinine ratio, and albumin also is necessary. Monitoring of patients with a history of hypertension or heart failure is recommended when giving high-sodium solutions.

Medical Nutrition Therapy

Medical nutrition therapy (MNT) is determined by the specific cause of the diarrhea. However, some general recommendations apply in most situations. In acute cases, it sometimes is necessary to begin treatment by having the patient NPO for 12 hours. Intravenous fluids sometimes are ordered if dehydration is present. Oral fluids are started as soon as tolerated.

The initial oral diet should consist of broth, tea, and toast with additional foods added as tolerated. High sugar foods are not recommended.


  • Consider using foods containing probiotics, such as yogurt with live cultures, especially for patients taking antibiotics
  • Serve small, frequent meals throughout the day because they are best tolerated
  • Reintroduce dairy products and wheat products slowly
  • Avoid foods high in roughage, such as raw fruits and vegetables
  • Add soluble fiber, which dissolves in water, to the diet as tolerated (soluble fiber, including pectin is found in oatmeal, apples, bananas, beans, and psyllium)
  • Prescribe a lactose-free diet if lactose intolerance is present
  • Replace fat-soluble vitamins with a vitamin supplement if steatorrhea is present
  • Order pharmaceuticals such as Imodium®, Pepto-Bismol®, Kaopectate®, or Lomotil® as needed
  • Provide total parenteral nutrition if complete bowel rest is needed

Wound Healing

Most cases of diarrhea will resolve with time and a multifaceted treatment plan involving a history and physical exam, medical work-up, MNT, and pharmaceuticals. Unfortunately, some patients may fail to improve despite all of these approaches. When treating the wound, use techniques to minimize contamination from stools. For some patients, a fecal incontinence pouch or operative diversion is necessary until the wound heals. It is important to document all interventions, and if one approach does not work, keep trying another idea or product.

Wound Care Education Institute® provides online and onsite courses in Skin & WoundDiabetic and Ostomy Management. Eligible clinicians may sit for the prestigious WCC®, DWC®, OMS and NWCC™ national board certification exams through the National Alliance of Wound Care and Ostomy®(NAWCO®). For details, see

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

What Would You Do if Your Patient Chokes?

Friday, August 31st, 2018

Every minute counts when a patient chokes, so you must react confidently and have a plan in place to handle this emergency situation.

John Quiñones stars in the ABC television show What Would You . The program features actors cast in scenes of conflict or illegal activity in public settings, while hidden cameras record the situation. The focus of the show is to see whether ordinary people intervene or just pass by and how they react. For example, a recent episode featured a young girl’s nanny berating her in public and calling her stupid. Several passersby asked the nanny to cool it, while others just squirmed and silently hurried by. The point of the show is that we never really know how we will react to a situation until we are actually in it, and then each of us has to make a choice.


The Head to Toe Search for Wounds

Tuesday, June 12th, 2018

A comprehensive skin assessment should look for more than just wounds because many medical problems have telltale signs that are easy to see if you know what to look for.

POA. These three little letters have become very important in wound care because we must document any wounds present on admission (POA). By doing so, we are saying that these wounds began somewhere else—maybe at home, maybe in another care setting, but definitely not while under the present facility’s care. This distinction of origin has great implications both financially and legally.


Nutrition Tips for Wound Patients With Cancer

Friday, May 11th, 2018

Patients with wounds usually have multiple medical problems, and often the other diagnoses make meeting the nutritional plan difficult, such as when the wound patient also has cancer.

I often discuss the increased nutritional requirements to fuel wound healing. Patients need extra calories and protein each day, plus an adequate amount of fluids, the right mix of vitamins and minerals, and any adjuvant treatments, such as targeted amino acids. A question that I often am asked is how you accomplish this when the patient has an additional diagnosis that impedes or supersedes the recommended nutritional plan. For example, what should you do when treating wound patients with cancer? It is rare that a patient presents with only a single medical problem, and sometimes the other problems pose challenges to the nutritional plan.


Helping Wounds Heal With Amino Acids

Friday, April 6th, 2018

The use of targeted amino acids is becoming more common as a strategy to help heal a variety of conditions, including wounds, because of the role key amino acids have in rebuilding tissue.

Chronic wounds, meaning those that have not healed in 12 weeks, affect approximately 6.5 million patients in the United States annually at a cost of $25 billion.1 The term chronic wound refers to various types of skin integrity problems, such as pressure injuries, diabetic foot ulcers, venous ulcers, arterial ulcers, burns, and traumatic wounds to name a few.

The Role of Nutrition

Nutrition often is not the first thing you think of when talking about wounds, but it is important to understand the link between poor nutrition and wound healing. Essentially, when a body has a wound, it has competition for the nutrients it needs. Wound healing is very energy dependent; energy is another word for calories. If your patient is not eating well and not meeting his or her caloric and protein goals every day, weight loss typically occurs.

When nutritional substrate is in short supply, the body decides whether to use the available substrate to build new tissue for the wound or to use it to keep its vital organs functioning. If weight loss continues unchecked, wound healing is impaired and eventually it will cease altogether in favor of the body’s vital organs.2


Stinging. Burning. Painful. Wounds Hurt!

Saturday, March 10th, 2018

Wound pain is sometimes difficult to quantify, but if a patient complains of pain, this requires effective and timely pain management. In the midst of the war on narcotics, that might mean looking for alternative pain management techniques and learning new approaches.

Several months ago, I was attacked by the most venomous scorpion in North America, the Arizona bark scorpion. This stealth attack happened while I slept in my own bed at home in our southern Nevada desert home. I woke up with a jolt knowing that something was terribly wrong with me, but not quite sure what was happening. I felt a fiery tingling pain in both my hands and my abdomen, yet at the same time I also had a total loss of feeling in those areas. I remember yelling to my family that I was paralyzed, but they were confused because I was running around and frantically waving my arms obviously not paralyzed at all. We only figured out what had happened when I tried to crawl back into bed and saw the scorpion on my pillow.

My scorpion stings were an indescribable sensation and unlike any type of pain I had ever experienced. Even today, I am struggling to find the words to tell you what it felt like. All I knew was that it hurt and was unlike any pain I had previously experienced or could even compare it to. For the record, I did some research afterward—people describe it as feeling quite similar to being electrocuted. Luckily, I can say that I was never electrocuted, but that is how people describe it.

Just as luckily, I have never had a pressure injury or a diabetic foot ulcer, so I am not really sure what those feel like either. My patients tell me they hurt. Some patients seem like they are in extreme pain, while others seem to have only mild pain. How do we quantify wound pain, and more importantly, how do we manage it effectively?


Discover the Benefits of Wound Care Nutrition Certification

Friday, February 9th, 2018

Whether you are looking to increase your wound care nutrition knowledge or advance your career, a new wound care certification course for Registered Dietitians (RD) and Registered Dietitian Nutritionists (RDN) will help you meet your goals, while improving outcomes for your wound care patients.

I often get funny reactions when I tell people I specialize in wounds. Lay people always assume I mean bullet wounds. I notice them nodding with confusion when I go on to explain that I do not see many bullet wounds, but treat plenty of pressure injuries and diabetic foot ulcers.

When I have the same conversation with nurses, patient care assistants, and other healthcare providers who do not specialize in wounds, they seem to nod with a similar amount of confusion. They immediately think of topical care and turning and repositioning—all important to wound healing—but they overlook the fact that in order to build new tissue it is necessary to have adequate nutritional substrate onboard.

Clearing up this confusion is one of the reasons I am so excited to share the new nutrition certification available from the National Alliance of Wound Care and Ostomy® (NAWCO®). Hopefully every skin and wound care team will soon have a certified nutrition member to help heal wounds from the inside out!


8 Reasons to Get Diabetes Under Control Now!

Friday, January 12th, 2018

Patients with diabetes are more likely to suffer many serious health issues besides foot wounds and amputations. This makes it imperative that they resolve to get their blood glucose levels under control.

All of the lawsuits I review have a common theme. The plaintiff suffers from a chronic wound and some degree of malnutrition and/or dehydration. I have started to notice that in addition to these problems, the plaintiff also quite often has diabetes. This trifecta of problems leads to pain, suffering, disability, and discontent.

People with diabetes are 10 to 20 times more likely to have a lower extremity amputation than those without diabetes.1 This is a scary statistic compounded by the fact that people with diabetes may not even notice a foot wound developing because they cannot feel it because of neuropathy. A foot ulcer is the initial event in more than 85% of major amputations that are performed on people with diabetes.2 Knowing this should provide enough motivation for patients to get their diabetes under control, but some people need even more reasons. Here are eight more consequences you can discuss with your patients. Hopefully, one will hit home.


Can You Use Job Burnout as a Legal Defense?

Friday, November 10th, 2017

Wound care is a stressful profession, and sometimes your empathy bucket becomes empty, but job burnout is not a proper professional or legal defense.

A group of my professional friends were having lunch together and catching up when one friend disclosed that she was taking a month off of work. We all looked at her agape and at the same time exclaimed “a month?” We had a dozen questions for her. Was she ill? How did she arrange this? What did her supervisor say? Would she still have her job at the end of the month? And most importantly, why was she taking a month off?

She replied that she was burnt-out and needed a break. You can imagine that this response elicited just another round of questions. Does someone get a month off because they are tired? Was that what she was saying? In retrospect, it is clear that she was more than tired. She was nearing personal and professional exhaustion and not treating her patients with her usual caring nature. She was a good practitioner, but had to take care of a few things for herself before she could get back to caring for others. She had obtained a doctor’s note for a mental health break and was cleared for this by her employer because she was indeed a valuable employee. But is her case the exception or the rule?

Putting a Name to It

No one likes to admit they are suffering from job burnout, that is until they are in front of a courtroom and need to offer some sort of plausible explanation for the poor care reflected in the medical record. In that instance, it seems that feeling overwhelmed by the job is a rational thing to admit. No one pointedly says they have burnout. They use euphemisms—such as the word overwhelmed—to explain why a patient slipped through the cracks, or the patient’s turning schedule went awry, or a dressing change was not done on time. And maybe they were truly overwhelmed, but is that a suitable defense?

A Recent Case

In a recent legal case, a wound care nurse testified that she was feeling stressed out by both her job and her home life. She explained that her patients were not listening to her, just as her children were not listening to her. Her patience was thin, and yes, she was tired but she was doing the best that she could. She admitted that she was questioning her role in the long-term care facility as the wound care nurse and wondered if perhaps there was something “better” suited for her.

She certainly had a lot on her plate and seemed genuine in both her distress and her efforts to get everything done properly. The plaintiff attorney pointed out that the bottom line was that everything was not done properly and the patient’s wounds worsened. The defense attorney was quick to counter that the wound would have worsened no matter what because of the patient’s medical condition, but because we don’t have a crystal ball, we will never know for sure.

 Digging a Little Deeper

This scenario is seen in every healthcare facility in the country in some form today. We don’t need a courtroom or attorneys to recognize that some of our co-workers, or even ourselves, are angry, frustrated, bored, irritable, uninterested, or just plain drained. We may commiserate with each other over our lunch break, but nothing substantive really happens. Until a lawsuit is filed, that is. This is why we need to change the conversation and have real solutions instead of platitudes for colleagues who need a mental health break or some time to recharge.

Questions to Ask

According to the Mayo Clinic, job burnout is a special type of job stress—a state of physical, emotional, or mental exhaustion combined with doubts about your competence and the value of your work.

Could you be experiencing job burnout? Ask yourself the following questions:

  • Have you become cynical or critical at work?
  • Do you drag yourself to work and have trouble getting started once you arrive?
  • Have you become irritable or impatient with co-workers, customers, or clients?
  • Do you lack the energy to stay consistently productive?
  • Do you lack satisfaction from your achievements?
  • Do you feel disillusioned about your job?
  • Are you using food, drugs, or alcohol to feel better or to simply not feel?
  • Have your sleep habits or appetite changed?
  • Are you troubled by unexplained headaches, backaches, or other physical complaints?

If you answered “yes” to any of these questions, you might have burnout and may need some intervention.

Handling Burnout

Burnout occurs for a wide variety of reasons, and finding the underlying reason is the key to addressing it effectively. The answer is not always so deep and complicated. Some people really are not well suited for wound care. Others may have an undiscovered medical problem, such a thyroid disorder. Many others may have a home-work imbalance that they need to address. It might mean that more sleep, exercise, or downtime is needed.

From the facility’s leadership point of view, it is important to create an environment where employees can take a mental health break without repercussions. Frustration often comes from feeling a lack of control. Giving employees a say in how to best get the job done always is appreciated rather than micromanaging them. Mentoring and adequate training also helps, as well as creating an environment where job rotation is possible. No one likes to do exactly the same thing every single day for months on end.

Take Action

The bottom line is that the time to explain that you are feeling job burnout is not after a lawsuit is filed when you are called on the carpet. That does not justify poor care or incomplete medical record documentation. It does not make the patient’s loved ones feel sorry for you. All it does is tarnish both your and your facility’s reputation. Deal with it now. You will be glad you did.