WA26 • Washington Nurses 2026

Table of Contents

WA26 • Washington Nurses 2026

How to Receive Credit

NetCE 2 Hour Course #97431 • Cultural Competence: An Overview

97431 • Cultural Competence: An Overview

1. INTRODUCTION

2. DEFINITIONS

3. BIAS: IMPLICIT AND EXPLICIT

4. SOCIAL DETERMINANTS OF HEALTH

5. BARRIERS TO PROVIDING CARE

6. BEST PRACTICES FOR CULTURALLY RESPONSIVE CARE

7. PROMOTING CULTURALLY SENSITIVE COMMUNICATION

8. CULTURALLY SENSITIVE ASSESSMENT GUIDELINES

9. A WELCOMING AND SAFE ENVIRONMENT

10. CONCLUSION

Works Cited

NetCE 1 Hour Course #31840 • Nurses' Knowledge, Beliefs, and Exercise Habits: A Focus on Cardiovascular Disease

31840 • Nurses' Knowledge, Beliefs, and Exercise Habits: A Focus on Cardiovascular Disease

1. INTRODUCTION

2. NURSES AND PERSONAL HEALTH

3. NURSES AS ROLE MODELS FOR PROMOTING HEALTHY BEHAVIORS

4. THE ROLE OF ONGOING EDUCATION AND PROFESSIONAL DEVELOPMENT

5. EVALUATION AND IMPLEMENTATION STRATEGIES

6. CASE STUDY

7. CONCLUSION

Works Cited

NetCE 5 Hour Course #34574 • Treating Pressure Injuries and Chronic Wounds

34574 • Treating Pressure Injuries and Chronic Wounds

1. INTRODUCTION

2. AN OVERVIEW OF PRESSURE INJURIES

3. PATIENT ASSESSMENT

4. WOUND ASSESSMENT

5. AN OVERVIEW OF WOUND HEALING

6. WOUND CLEANING

7. PAIN MANAGEMENT

8. WOUND DEBRIDEMENT

9. WOUND DRESSINGS

10. WOUND MONITORING

11. PREVENTION OF PRESSURE INJURIES

12. PROGNOSIS

13. CONCLUSION

14. RESOURCES

Works Cited

Evidence-Based Practice Recommendations Citations

WA26 • Washington Nurses 2026

Alice Yick Flanagan, PhD, MSW

Tina Schmidt-McNulty, DHSc, MS, ACSM-CEP, RN

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

WA26 • Washington Nurses 2026

Expiration Date: 02/28/2027

How to Receive Credit

To complete this Special Offer for continuing education credit please go to http://www.netce.com/specials in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

97431 • Cultural Competence: An Overview

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2025 NetCE, All rights reserved.

Culture serves as a lens through which patients and practitioners filter their experiences and perceptions. Patients will bring their unique life stories and concerns to the practitioner, and their cultural values and belief systems will inevitably shape how the problem is defined and their beliefs about what is effective in solving the problem. However, the cultural backgrounds and values of patients are not necessarily scripts that define behavior, and when practitioners view culture as a strength and not a pathology, practitioners will be able to more effectively join with patients to mobilize change.

Table of Contents

97431 • Cultural Competence: An Overview

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. DEFINITIONS

CULTURAL COMPETENCE

CULTURAL HUMILITY

DISCRIMINATION

DIVERSITY

INTERSECTIONALITY

PREJUDICE

RACISM

3. BIAS: IMPLICIT AND EXPLICIT

ROLE OF INTERPROFESSIONAL COLLABORATION AND PRACTICE

4. SOCIAL DETERMINANTS OF HEALTH

5. BARRIERS TO PROVIDING CARE

6. BEST PRACTICES FOR CULTURALLY RESPONSIVE CARE

RACIAL BACKGROUNDS

RELIGIOUS, CULTURAL, AND ETHNIC BACKGROUNDS

GENDER

GENDER AND SEXUAL MINORITY POPULATIONS

AGE

PERSONS WITH MENTAL OR PHYSICAL DISABILITY

VETERANS

7. PROMOTING CULTURALLY SENSITIVE COMMUNICATION

8. CULTURALLY SENSITIVE ASSESSMENT GUIDELINES

9. A WELCOMING AND SAFE ENVIRONMENT

10. CONCLUSION

Works Cited

97431 • Cultural Competence: An Overview

Education Category. Ethics - Human Rights

Release Date. 03/01/2025

Expiration Date. 02/29/2028

Course Overview

Culture serves as a lens through which patients and practitioners filter their experiences and perceptions. Patients will bring their unique life stories and concerns to the practitioner, and their cultural values and belief systems will inevitably shape how the problem is defined and their beliefs about what is effective in solving the problem. However, the cultural backgrounds and values of patients are not necessarily scripts that define behavior, and when practitioners view culture as a strength and not a pathology, practitioners will be able to more effectively join with patients to mobilize change.

Audience

This course is designed for all members of the interprofessional healthcare team.

Accreditations & Approvals

In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 2 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this enduring material for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NetCE designates this continuing education activity for 2 ANCC contact hour(s). NetCE designates this continuing education activity for 2.4 hours for Alabama nurses. Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 2 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. NetCE designates this activity for 2 ACPE credit(s). ACPE Universal Activity Number: JA4008164-0000-25-019-H04-P. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and/or Self-Assessment requirements of the American Board of Surgery's Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. This activity has been approved for the American Board of Anesthesiology’s® (ABA) requirements for Part II: Lifelong Learning and Self-Assessment of the American Board of Anesthesiology’s (ABA) redesigned Maintenance of Certification in Anesthesiology Program® (MOCA®), known as MOCA 2.0®. Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements. Maintenance of Certification in Anesthesiology Program® and MOCA® are registered certification marks of the American Board of Anesthesiology®. MOCA 2.0® is a trademark of the American Board of Anesthesiology®. Successful completion of this CME activity, which includes participation in the activity with individual assessments of the participant and feedback to the participant, enables the participant to earn 2 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. This activity has been designated for 2 Lifelong Learning (Part II) credits for the American Board of Pathology Continuing Certification Program. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME's "CME in Support of MOC" program in Section 3 of the Royal College's MOC Program. NetCE is authorized by IACET to offer 0.2 CEU(s) for this program. AACN Synergy CERP Category B.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353 (valid through July 30, 2029); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2027; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Special Approvals

This course has been approved by the Nevada State Board of Nursing to meet the requirement for cultural competency education. This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.

Course Objective

The purpose of this course is to provide members of the interprofessional healthcare team with the knowledge, skills, and strategies necessary to provide culturally competent and responsive care to all patients.

Learning Objectives

Upon completion of this course, you should be able to:

1. Define cultural competence, implicit bias, and related terminology.

2. Outline social determinants of health and barriers to providing care.

3. Discuss best practices for providing culturally competent care to various patient populations.

4. Discuss key aspects of creating a welcoming and safe environment, including avoidance of discriminatory language and behaviors.

Faculty

Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.

Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.

Faculty Disclosure

Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

John M. Leonard, MD

Mary Franks, MSN, APRN, FNP-C

Randall L. Allen, PharmD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Culturally competent care has been defined as "care that takes into account issues related to diversity, marginalization, and vulnerability due to culture, race, gender, and sexual orientation" [1]. A culturally competent person is someone who is aware of how being different from the norm can be marginalizing and how this marginalization may affect seeking or receiving health care [1]. To be effective cross-culturally with any diverse group, healthcare professionals must have awareness, sensitivity, and knowledge about the culture involved, enhanced by the use of cross-cultural communication skills [2].

Healthcare professionals are accustomed to working to promote the healthy physical and psychosocial development and well-being of individuals within the context of the greater community. For years, these same professionals have been identifying at-risk populations and developing programs or making referrals to resources to promote the health and safety of at-risk groups. But, because of general assumptions, persistent stereotypes, and implicit and explicit biases, culture-related healthcare disparities persist [2]. In the increasingly diverse landscape of the United States, assessing and addressing culture-related barriers to care are a necessary part of health care. This includes seeking to improve one's cultural competence and identifying blind spots and biases.

2. DEFINITIONS

CULTURAL COMPETENCE

In healthcare, cultural competence is broadly defined as practitioners' knowledge of and ability to apply cultural information and appreciation of a different group's cultural and belief systems to their work [4]. It is a dynamic process, meaning that there is no endpoint to the journey to becoming culturally aware, sensitive, and competent. Some have argued that cultural curiosity is a vital aspect of this approach.

CULTURAL HUMILITY

Cultural humility refers to an attitude of humbleness, acknowledging one's limitations in the cultural knowledge of groups. Practitioners who apply cultural humility readily concede that they are not experts in others' cultures and that there are aspects of culture and social experiences that they do not know. From this perspective, patients are considered teachers of the cultural norms, beliefs, and value systems of their group, while practitioners are the learners [5]. Cultural humility is a lifelong process involving reflexivity, self-evaluation, and self-critique [6].

DISCRIMINATION

Discrimination has traditionally been viewed as the outcome of prejudice [7]. It encompasses overt or hidden actions, behaviors, or practices of members in a dominant group against members of a subordinate group [8]. Discrimination has also been further categorized as lifetime, which consists of major discreet discriminatory events, or everyday, which is subtle, continual, and part of day-to-day life and can have a cumulate effect on individuals [9].

DIVERSITY

Diversity "encompasses differences in and among societal groups based on race, ethnicity, gender, age, physical/mental abilities, religion, sexual orientation, and other distinguishing characteristics" [10]. Diversity is often incorrectly conceptualized into singular dimensions as opposed to multiple and intersecting diversity factors [11].

INTERSECTIONALITY

Intersectionality is a term to describe the multiple facets of identity, including race, gender, sexual orientation, religion, sex, and age. These facets are not mutually exclusive, and the meanings that are ascribed to these identities are inter-related and interact to create a whole [12]. This term also encompasses the ways that different types and systems of oppression intersect and affect individuals.

PREJUDICE

Prejudice is a generally negative feeling, attitude, or stereotype against members of a group [13]. It is important not to equate prejudice and racism, although the two concepts are related. All humans have prejudices, but not all individuals are racist. The popular definition is that "prejudice plus power equals racism" [13]. Prejudice stems from the process of ascribing every member of a group with the same attributes [14].

RACISM

Racism is the "systematic subordination of members of targeted racial groups who have relatively little social power…by members of the agent racial group who have relatively more social power" [15]. Racism is perpetuated and reinforced by social values, norms, and institutions.

There is some controversy regarding whether unconscious (implicit) racism exists. Experts assert that images embedded in our unconscious are the result of socialization and personal observations, and negative attributes may be unconsciously applied to racial minority groups [16]. These implicit attributes affect individuals' thoughts and behaviors without a conscious awareness.

Structural racism refers to the laws, policies, and institutional norms and ideologies that systematically reinforce inequities, resulting in differential access to services such as health care, education, employment, and housing for racial and ethnic minorities [17,18].

3. BIAS: IMPLICIT AND EXPLICIT

In a sociocultural context, biases are generally defined as negative evaluations of a particular social group relative to another group. Explicit biases are conscious, whereby an individual is fully aware of his/her attitudes and there may be intentional behaviors related to these attitudes [19]. For example, an individual may openly endorse a belief that women are weak and men are strong. This bias is fully conscious and is made explicitly known. The individual's ideas may then be reflected in his/her work as a manager.

FitzGerald and Hurst assert that there are cases in which implicit cognitive processes are involved in biases and conscious availability, controllability, and mental resources are not [20]. The term "implicit bias" refers to the unconscious attitudes and evaluations held by individuals. These individuals do not necessarily endorse the bias, but the embedded beliefs/attitudes can negatively affect their behaviors [21,22,23,24]. Some have asserted that the cognitive processes that dictate implicit and explicit biases are separate and independent [24].

Implicit biases can start as early as 3 years of age. As children age, they may begin to become more egalitarian in what they explicitly endorse, but their implicit biases may not necessarily change in accordance to these outward expressions [25]. Because implicit biases occur on the subconscious or unconscious level, particular social attributes (e.g., skin color) can quietly and insidiously affect perceptions and behaviors [26]. According to Georgetown University's National Center on Cultural Competency, social characteristics that can trigger implicit biases include [27]:

- Age

- Disability

- Education

- English language proficiency and fluency

- Ethnicity

- Health status

- Disease/diagnosis (e.g., human immunodeficiency virus [HIV])

- Insurance

- Obesity

- Race

- Socioeconomic status

- Sexual orientation, gender identity, or gender expression

- Skin tone

- Substance use

An alternative way of conceptualizing implicit bias is that an unconscious evaluation is only negative if it has further adverse consequences on a group that is already disadvantaged or produces inequities [20,28]. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages [28].

When the concept of implicit bias was introduced in the 1990s, it was thought that implicit biases could be directly linked to behavior. Despite the decades of empirical research, many questions, controversies, and debates remain about the dynamics and pathways of implicit biases [21].

Specific conditions or environmental risk factors have been associated with an increased risk for certain implicit biases, including [104,105]:

- Stressful emotional states (e.g., anger, frustration)

- Uncertainty

- Low-effort cognitive processing

- Time pressure

- Lack of feedback

- Feeling behind with work

- Lack of guidance

- Long hours

- Overcrowding

- High-crises environments

- Mentally taxing tasks

- Juggling competing tasks

ROLE OF INTERPROFESSIONAL COLLABORATION AND PRACTICE

The study of implicit bias is appropriately interdisciplinary, representing social psychology, medicine, health psychology, neuroscience, counseling, mental health, gerontology, gender/sexuality studies, religious studies, and disability studies [28]. Therefore, implicit bias empirical research and curricula training development lends itself well to interprofessional collaboration and practice (ICP).

The main characteristics of IPC allow for implicit and explicit biases to be addressed by the interprofessional team. One of the core features of IPC is sharing—professionals from different disciplines share their philosophies, values, perspectives, data, and strategies for planning of interventions [29]. IPC also involves the sharing of roles, responsibilities, decision making, and power [30]. Everyone on the team employs their expertise, knowledge, and skills, working collectively on a shared, patient-centered goal or outcome [30,31].

Another feature of IPC is interdependency. Instead of working in an autonomous manner, each team member's contributions are valued and maximized, which ultimately leads to synergy [29]. At the heart of this are two other key features: mutual trust/respect and communication [31]. In order to share responsibilities, the differing roles and expertise are respected.

Experts have recommended that a structural or critical theoretical perspective be integrated into core competencies in healthcare education to teach students about implicit bias, racism, and health disparities. This includes [32]:

- Values/ethics: The ethical duty for health professionals to partner and collaborate to advocate for the elimination of policies that promote the perpetuation of implicit bias, racism, and health disparities among marginalized populations.

- Roles/responsibilities: One of the primary roles and responsibilities of health professionals is to analyze how institutional and organizational factors promote racism and implicit bias and how these factors contribute to health disparities. This analysis should extend to include one's own position in this structure.

- Interprofessional communication: Ongoing discussions of implicit bias, perspective taking, and counter-stereotypical dialogues should be woven into day-to-day practice with colleagues from diverse disciplines.

- Teams/teamwork: Health professionals should develop meaningful contacts with marginalized communities in order to better understand whom they are serving.

Adopting approaches from the fields of education, gender studies, sociology, psychology, and race/ethnic studies can help build curricula that represent a variety of disciplines [33]. Students can learn about and discuss implicit bias and its impact, not simply from a health outcomes perspective but holistically. Skills in problem-solving, communication, leadership, and teamwork should be included [33].

4. SOCIAL DETERMINANTS OF HEALTH

Social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. Healthy People 2030 groups social determinants of health into five categories [34]:

- Economic stability

- Education access and quality

- Health care access and quality

- Social and community context

- Neighborhood and built environment

These factors have a major impact on people's health, well-being, and quality of life. Examples of social determinants of health include [34]:

- Safe housing, transportation, and neighborhoods

- Racism, discrimination, and violence

- Education, job opportunities, and income

- Access to nutritious foods and physical activity opportunities

- Polluted air and water

- Language and literacy skills

Social determinants of health also contribute to wide health disparities and inequities. For example, people who lack access to grocery stores with healthy foods are less likely to have good nutrition, which raises the risk of heart disease, diabetes, and obesity and lowers life expectancy compared with those who have easier access to healthy foods [34].

Promoting healthy choices will not eliminate these and other health disparities. Instead, public health organizations and their partners must take action to improve the conditions in people's environments. Healthcare providers play a role by identifying factors affecting the health of their patients, providing resources (when appropriate), and advocating for healthy environments.

5. BARRIERS TO PROVIDING CARE

Culturally diverse patients experience a variety of barriers when seeking health and mental health care, including:

- Immigration status

- Lower socioeconomic status

- Language barriers

- Cultural differences

- Lack of or poor health insurance coverage

- Fear of or experiences with provider discrimination

- Mistrust of healthcare systems

Such obstacles can interfere with or prevent access to treatment and services, compromise appropriate referrals, affect compliance with recommendations, and result in poor outcomes. Culturally competent providers build and maintain rich referral resources to meet patients' diverse needs.

Encountering discrimination when seeking health or mental health services is a barrier to optimal care and contributor to poorer outcomes in under-represented groups. Some providers will not treat patients because of moral objections, which can affect all groups, but particularly those who are gender and/or sexual minorities, religious minorities, and/or immigrants. Since the mid-2010s, several states have passed laws allowing individual health providers to refuse to provide services if doing so would violate their morals or religious beliefs [35]. However, it is important to remember that providers are obligated to act within their profession's code of ethics and to ensure patients receive the best possible care.

6. BEST PRACTICES FOR CULTURALLY RESPONSIVE CARE

The U.S. Department of Health and Human Services has outlined steps important to incorporate in evaluation and treatment planning processes to ensure culturally competent clinical and programmatic decisions and skills [36].

The first step is to engage patients. In nonemergent situations, it is important to establish rapport before asking a series of assessment questions or delving deeply into history taking. Providers should use simple gestures as culturally appropriate (e.g., handshakes, facial expressions, greetings) to help establish a first impression. The intent is that all patients feel understood and seen following each interaction. Culturally responsive interview behaviors and paperwork should be used at all times [36].

When engaging in any patient teaching, remember that individuals may be new to the specific language or jargon and expectations of the diagnosis and care process. Patients should be encouraged to collaborate in every step of their care. This consists of seeking the patient's input and interpretation and establishing ways they can seek clarification. Patient feedback can then be used to help identify cultural issues and specific needs. If appropriate, collaboration should extend to include family and community members.

Assessment should incorporate culturally relevant themes to gain a better understanding of patients and identify their cultural strengths and challenges. Themes include [36]:

- Immigration history

- Cultural identity and acculturation

- Membership in a subculture

- Beliefs about health, healing, and help-seeking

- Trauma and loss

In some cases, it may be appropriate and beneficial to obtain culturally relevant collateral information, with the patient's permission, from sources other than the patient (e.g., family or community members) to better understand beliefs and practices that shape the patient's cultural identity and understanding of the world.

Practitioners should work to identify screening and assessment tools that have been translated into or adapted for other languages and have been validated for their particular population group(s). An instrument's cultural applicability to the population being served should be assessed, keeping in mind that research is limited on the cross-cultural applicability of specific test items or questions, diagnostic criteria, and concepts in evaluative and diagnostic processes [36].

Typically, culturally responsive care includes holistic treatment goals that aim to improve physical health and spiritual strength; utilize strengths-based strategies that fortify cultural heritage, identity, and resiliency; and recognize that treatment planning is a dynamic process that evolves along with an understanding of patient history and treatment needs.

In addition to these general approaches, specific considerations may be appropriate for specific populations. While discussion of every possible patient subgroup is outside of the scope of this course, an overview of some of the most commonly marginalized populations are outlined in the following sections [36].

RACIAL BACKGROUNDS

Race and color impact the ways in which individuals interact with their environments and are perceived and treated by others. Race is defined as groups of humans divided on the basis of inherited physical and behavioral differences. As part of the cultural competence process and as a reflection of cultural humility, practitioners should strive to learn as much as possible about the specific racial/ethnic populations they serve [37]. However, considerable diversity exists within any specific culture, race, or ethnicity [37]. Cultural beliefs, traditions, and practices change over time, both through generations and within an individual's lifetime. It is also possible for the differences between two members of the same racial/ethnic group to be greater than the differences between two people from different racial/ethnic groups. Within-group variations in how individuals interact with their environments and specific social contexts are also often present.

As with all patients, it is vital to actively listen and critically evaluate patient relationships. All practitioners should seek to educate themselves regarding the experiences of patients who are members of a community that differs from their own. Resources and opportunities to collaborate may be available from community organizations and leaders.

Finally, preferred language and immigration/migration status, if the patient is comfortable providing the information, should be considered. Interpreters should be used when appropriate, with adherence to best practices for the use of interpretation services. Stressing confidentiality and privacy is particularly important for undocumented workers or recent immigrants, who may be fearful of deportation.

Black Patients

"Black" or "African American" is a classification that serves as a descriptor; it has sociopolitical and self-identification ramifications. The U.S. Census Bureau defines Black or African American as "a person having origins in any of the Black racial groups of Africa" [38].

According to the Pew Research Center, in 2023 an estimated 48.3 million individuals self-identified as Black or African American, including more than 5 million self-identified Black individuals that indicated being born in a country other than the United States [39]. This group tends to be young; 30% of the Black or African American population in the United States is younger than 20 years of age. In 2023, the median age for this group was 32.6 years, compared with the general U.S. population median age of 38.2 years [39]. In terms of educational attainment, 90.1% of Black or African American individuals had a high school diploma or equivalent and 27.6% had a bachelor's degree [40]. Geographically, more than 56% of the United States Black or African American population lives in the South, with the largest population of individuals residing in Texas (3.7 million), Florida (4.0 million), and Georgia (3.7 million) [39].

Historical adversity and institutional racism contribute to health disparities in this group. For the Black population, patient assessment and treatment planning should be framed in a context that recognizes the totality of life experiences faced by patients. In many cases, particularly in the provision of mental health care, equality is sought in the provider-patient relationship, with less distance and more disclosing. Practitioners should assess whether their practices connect with core values of Black culture, such as family, kinship, community, and spirituality. Generalized or Eurocentric treatment approaches may not easily align with these components of the Black community [42]. Providers should also consider the impact of racial discrimination on health and mental health among Black patients. Reports indicate that expressions of emotion by Black patients tend to be negatively misunderstood or dismissed; this reflects implicit or explicit biases.

Asian Patients

"Asian" is a single term widely used to describe individuals who have kinship and identity ties to Asia, including the Far East, Southeast Asia, and the Indian subcontinent. This encompasses countries such as China, Japan, Korea, Vietnam, Cambodia, Thailand, India, Pakistan, and the Philippines. Native Hawaiian and Pacific Islander are often combined with Asian American in census data. The Pacific Islands include Hawaii, Guam, Samoa, Fiji, and many others. There are more than 25 Asian/Pacific Islander groups, each with a different migration history and widely varying sociopolitical environments in their homelands [38].

As of 2022, 24.7 million individuals in the United States identified as Asian [43]. Individuals of Chinese (excluding Taiwanese) descent represent the largest Asian subgroup in the United States (5.5 million), followed by Asian Indian (4.9 million), Filipino (4.5 million), Vietnamese (2.3 million), Korean (2.1 million), and Japanese (1.6 million) [43]. In terms of educational attainment, 92.3% of Asian individuals in the United States had a high school diploma or equivalency, and 59.3% had a bachelor's degree in 2022 [40,43]. Geographically, individuals of Asian descent live in all regions of the United States, although the majority of individuals (55%) were located within just five states in 2019. Among Asian individuals in the United States, 6.7 million (30%) reside in California, followed by New York (1.9 million), Texas (1.6 million), New Jersey (958,000), and Washington (852,000) [44].

Asian American groups have differing levels of acculturation, lengths of residency in the United States, languages, English-speaking proficiency, education attainment, socioeconomic statuses, and religions. For example, there are approximately 32 different languages spoken among Asian individuals, and within each Asian subgroup (e.g., Chinese), multiple dialects may be present [36].

Recommended best practices when caring for Asian American patients include:

- Create an advisory committee using representatives from the community.

- Incorporate cultural knowledge and maintain flexible attitudes.

- Provide services in the patients' primary language.

- Develop culturally specific questionnaires for intake to capture information that may be missed by standard questionnaires.

- Emphasize traditional values and incorporate traditional practices (e.g., acupuncture) into treatment plans, when appropriate and desired.

- Explore patient coping mechanisms that draw upon cultural strengths.

Latino/a/x or Hispanic Patients

In 2022, the Hispanic population in the United States included 63.7 million individuals, or 19.1% of the U.S. population [45]. In 2021, 37.2 million individuals in the U.S. Hispanic population group identified as being of Mexican descent (58.4%), followed by Puerto Rican (9.1%), Salvadoran (3.9%), Dominican (3.8%), and Cuban (3.8%) [46]. They are a young group, with a median age of 30.7 years [45]. In terms of educational attainment, 75.2% of Hispanic individuals in the United States had a high school diploma or equivalency, and 20.9% had a bachelor's degree in 2022 [46]. Geographically, among the 63.7 million Hispanic individuals in the United States, 25% reside in California, followed by Texas (19%), Florida (9%), New York (6%), and Arizona (4%) [47].

When involved in the care of Latinx/Hispanic individuals, practitioners should strive to employ personalismo (warm, genuine communication) and recognize the importance of familismo (the centrality of the family). More flexible scheduling strategies may be more successful with this group, if possible, and some patients may benefit from culturally specific treatment and ethnic and gender matching with providers. Aspects of Latino culture can be assets in treatment: strength, perseverance, flexibility, and an ability to survive [36].

American Indian/Alaska Natives (AI/AN)

The American Indian/Alaska Native (AI/AN) population is extremely diverse. According to the U.S. Census, the terms "American Indian" or "Alaskan Native" refer to individuals who identify themselves with tribal attachment to indigenous groups of North and South America. Other terms used include "Native American" or "Native," although individual preference on how a person or group would like to be identified should be taken into consideration [38,40]. In the United States, there are 574 federally recognized tribal governments and 324 federally recognized reservations [57].

In 2020, it was reported that there were 9.7 million AI/AN individuals in the United States. In general, this group is young, with a median age of 31 years, compared with the general median age of 38.2 years [57]. In terms of education attainment, 74% of AI/AN individuals in the United States had a high school diploma or equivalency, and 16.8% had a bachelor's degree in 2023 [40,41]. As of 2020, the states with the greatest number of residents identifying as American Indian are California (11.7%), Oklahoma (11.7%), Arizona (9.5%), New Mexico (9.1%), , and Texas (5.9%). Alaska Native individuals make up 67.1% of the population in Alaska [58].

Listening is an important aspect of rapport building with AI/AN patients, and practitioners should use active listening and reflective responses. Assessments and histories may include information regarding patients' stories, experiences, dreams, and rituals and their relevance. Interruptions and excessive questioning should be avoided if at all possible. Extended periods of silence may occur, and time should be allowed for patients to adjust and process information. Practitioners should avoid asking about family or personal matters unrelated to presenting issues without first asking permission to inquire about these areas. Native American/Alaska Native patients often respond best when they are given suggestions and options rather than directions [36].

White American Patients

In 2023, 75.3% of the U.S. population identified as White alone [48]. The U.S. Census Bureau defines White race as person having origins in any of the original peoples of Europe, the Middle East, or North Africa [38]. The White population in the United States is diverse in its religious, cultural, and social composition. The greatest proportion of this group reports a English ancestry (25.5 million), followed by Irish (10.9 million), German (15.4 million), and Italian (6.6 million) [49]. The median age of White individuals is 44 years. In terms of education attainment, 95.2% of White-only individuals in the United States had a high school diploma or equivalency, and 41.8% had a bachelor's degree in 2022 [40]

Providers can assume that most well-accepted treatment approaches and interventions have been tested and evaluated with White American individuals, particularly men. However, approaches may need modification to suit class, ethnic, religious, and other factors [36].

Providers should establish not only the patient's ethnic background, but also how strongly the person identifies with that background. It is also important to be sensitive to multiracial/multiethnic heritage, if present, and how this might affect family relationships and social experiences. Assumption of White race should be avoided, as White-passing persons of color have their own unique needs [36].

RELIGIOUS, CULTURAL, AND ETHNIC BACKGROUNDS

Religion, culture, beliefs, and ethnic customs can influence how patients understand health concepts, how they take care of their health, and how they make decisions related to their health. Without proper training, clinicians may deliver medical advice without understanding how health beliefs and cultural practices influence the way that advice is received. Asking about patients' religions, cultures, and ethnic customs can help clinicians engage patients so that, together, they can devise treatment plans that are consistent with the patients' values [37].

Respectfully ask patients about their health beliefs and customs and note their responses in their medical records. Address patients' cultural values specifically in the context of their health care. For example, one may ask [37]:

- "Is there anything I should know about your culture, beliefs, or religious practices that would help me take better care of you?"

- "Do you have any dietary restrictions that we should consider as we develop a food plan to help you lose weight?"

- "Your condition is very serious. Some people like to know everything that is going on with their illness, whereas others may want to know what is most important but not necessarily all the details. How much do you want to know? Is there anyone else you would like me to talk to about your condition?"

- "What do you call your illness and what do you think caused it?"

- "Do any traditional healers advise you about your health?"

Practitioners should avoid stereotyping based on religious or cultural background. Each person is an individual and may or may not adhere to certain cultural beliefs or practices common in his or her culture. Asking patients about their beliefs and way of life is the best way to be sure you know how their values may impact their care [37].

GENDER

The term "gender" refers to the established and expected norms, behaviors, and roles associated with being a girl, boy, woman, or man. Because gender is a social construct, the definition of gender is unique to any given society and/or collective group and changes over time. Gender is hierarchical and produces inequalities that often intersect with one or more social and/or economic inequalities. Other important terms related to gender include [50,51]:

Gender identity: A person's internal identification and experience of gender, which may or may not correspond to physiology or designated sex at birth. Gender identities include cisgender (identify as sex assigned at birth), transgender (identify as a different sex than assigned at birth), and non-binary (do not identify as either male or female), among others.

Gender expression: The way in which an individual expresses gender outwardly through appearance (e.g., clothing, make up, physical features), behaviors, and personality styles, often culturally defined as masculine or feminine. Gender expression can, but does not always, reflect the person's gender identity; individual preference, comfortability, culture, and societal and sociopolitical acceptance can influence gender expression.

Gender role: A set of societal expectations about how someone should behave based on their gender, often categorized as masculine or feminine.

Sex: The biological and physiological characteristics that differentiate male and female, such as chromosomes, hormones, and reproductive organs. The terms "sex" and "gender" are often incorrectly used interchangeably; however, it is important to differentiate between the two and be able to identify that sex is biological and gender is a social construct.

Gender traits and roles common for men in Western societies are often related to views of masculinity, and include an emphasis on strength, courage, leadership, independence, dominance, and assertiveness. Issues related to male gender identity, including inadequate help-seeking, denial of pain and weakness, and not showing emotion, have several important implications for health. Research has shown that male gender identity has been associated with risky behavior and an increased risk for negative health consequences, including injury, disease, and death [53,54,55].

Gender roles among women are related to femininity and include being polite, accommodating, nurturing, passive, and helpful. Women are often viewed as caregivers and tend to prioritize the needs of others above personal needs. In addition, providing gender-sensitive care to women involves overcoming the limitations imposed by the dominant medical model in women's health, improving advocacy for oneself [53].

In addition, the concept of masculinity may lead to inadequate help- and information-seeking behavior and a reduced likelihood of engaging in behavior to promote health. These behaviors appear to be rooted in a decreased likelihood for men to perceive themselves as being ill or at risk for illness, injury, or death [53,54,55]. Although men are more likely than women to lack a regular healthcare provider and to avoid seeking help or information, women are more likely to have a chronic condition requiring regular monitoring and are more likely to have forgone necessary health care and/or medication due to the cost [53].

Men's beliefs about masculinity and traditional male roles affect health communication and literacy, and healthcare practitioners should consider male-specific beliefs and perceptions when communicating with male patients. For example, because men tend to focus on present rather than future health, concepts of fear, wellness, and longevity often do not work well in health messages. Instead, healthcare practitioners should focus more on "masculine" concepts, such as strength, safety, and performance, all of which tie into men's perceptions of their roles as providers and protectors [54,55]. Women tend to have a higher level of health literacy but should still be involved and active participant with their own healthcare and/or treatment plans [53].

GENDER AND SEXUAL MINORITY POPULATIONS

The gender and sexual minority (GSM) population, also referred to as the transgender and gender nonconforming population, is a diverse group that can be defined as a subculture, accounting for 7.6% of the U.S. population in 2023 [3]. This group includes gay men, lesbian women, bisexual persons, transgender individuals, and those questioning their sexual identity, among others. The GSM population is diverse, representing all ages and all socioeconomic, ethnic, educational, and religious backgrounds. The population has been described as "hidden and invisible," "marginalized," and "stigmatized." As a result, the unique health and safety needs of the population have often been overlooked or ignored. Clear definitions of the concepts related to sexual identity will be helpful. The following is a glossary of terms used in discussions of this group [50,51,52]:

Asexual/aromantic: An individual who does not experience sexual attraction. There is considerable diversity in individuals' desire (or lack thereof) for romantic or other relationships.

Bisexual: An adjective that refers to people who relate sexually and affectionately to both women and men.

Coming-out process: A process by which an individual, in the face of societal stigma, moves from denial to acknowledging his/her sexual orientation. Successful resolution leads to self-acceptance. Coming out is a lifelong process for lesbian, gay, bisexual, and transgender persons and their families and friends as they begin to tell others at work, in school, at church, and in their communities.

Gay: The umbrella term for GSM persons, although it most specifically refers to men who are attracted to and love men. It is equally acceptable and more accurate to refer to gay women as "lesbians."

Gender and sexual minorities (GSM): A term meant to encompass lesbian, gay, bisexual, trans, queer/questioning, intersex/intergender, asexual/ally (LGBTQIA+) people as well as less well-recognized groups, including aromantic, two-spirited, and gender-fluid persons.

Heterosexism: An institutional and societal reinforcement of heterosexuality as the privileged and powerful norm.

Heterosexuality: Erotic feelings, attitudes, values, attraction, arousal, and/or physical contact with partners of the opposite gender.

Homophobia: A negative attitude or fear of non-straight sexuality or GSM individuals. This may be internalized in the form of negative feelings toward oneself and self-hatred. Called "internalized homophobia," it may be manifested by fear of discovery, denial, or discomfort with being LGBTQIA+, low self-esteem, or aggression against other lesbians and gay men.

Homosexuality: The "persistent sexual and emotional attraction to members of one's own gender" as part of the continuum of sexual expression. Typically not used to describe people.

Intersex/intergender: Encompasses a diverse set of congenital differences relating to gonads, chromosomes, and genitals that fall outside the typical parameters of male or female sex. Although intersex falls under the umbrella of LGBTQIA+, many do not identify with that label.

LGBTQIA+: An acronym used to refer to the lesbian, gay, bisexual, transgender/transsexual, queer/questioning, intersex/intergender, asexual/ally community. In some cases, the acronym may be shortened for ease of use, although a + usually always follows to represent other identities not included in the other letters.

Queer: An umbrella term to describe persons with a spectrum of identities and orientations that are outside of the heteronormative standard.

Sexual identity: The inner sense of oneself as a sexual being, including how one identifies in terms of gender and sexual orientation.

Sexual orientation: An enduring emotional, romantic, sexual, and/or affectionate attraction to another person. Individuals may experience this attraction to someone of the same gender, the opposite gender, both genders, or gender-nonconforming.

Transgender: An umbrella term describing a number of distinct gender positions and identities, including crossdressing, transsexual, non-binary, and intersex.

One's intrapersonal acceptance or rejection of societal stereotypes and prejudices, the acceptance of one's self-identity as a sexual minority, and how much one affiliates with other members of the GSM community varies greatly among individuals. Some authors stress the diversity within the GSM community by discussing "GSM populations." For example, it is understandable that a GSM population living in rural areas of the United States would have little in common with a GSM population living in urban areas or "gay-friendly" neighborhoods. Additionally, mental health experts have suggested that "GSM community" symbolizes a single group of individuals who express their sexuality differently than the majority of heterosexual individuals. However, many distinct communities have been identified, including lesbian, gay, bisexual, and transgender. Each community is different from the other as well as different from the heterosexual community. A culturally competent healthcare provider should keep this diversity in mind so that vital differences among these smaller groups are not lost when thinking of the GSM population in general [50,51,56].

Commonalities exist among the GSM communities as well. For example, many adolescents, whether gay, lesbian, bisexual, transgender, or questioning their sexual identity, lack sexual minority role models to assist with successful psychosocial development [51,56].

The subtle and pervasive ways that discomfort with GSM individuals may be manifested have been examined and, in some instances, categorized as "cultural heterosexism," which is characterized by the stigmatization in thinking and actions found in our nation's cultural institutions, such as the educational and legal systems. "Cultural heterosexism fosters individual antigay attitudes by providing a ready-made system of values and stereotypical beliefs that justify such prejudice as natural" [59]. Perhaps the paucity of information about the GSM community in basic professional education has been a reflection of cultural heterosexism. Writers, funding sources, and publishers have been exposed to the same cultural institutions for many years [56].

Individuals generally begin to absorb these institutional attitudes as children and may consequently develop "psychological heterosexism," which may also manifest as antigay prejudice. Many individuals, as children, have little contact with someone who is openly gay and, as a result, may not be able to associate homosexuality with an actual person. Instead, they may associate it with concepts such as "sin," "sickness," "predator," "outsider," or some other negative characteristic from which the individual wants to maintain distance [59]. Psychological heterosexism involves (among other factors) considering sexual identity and determining that one does not want to think further about it. The direction of this thinking is undeniably negative, resulting in an environment that allows antigay hostility [59]. The impact of antigay prejudice on the physical and mental health of members of the LGBTQIA+ community and their families should not be underestimated.

Sexual minority individuals also are not immune to societal attitudes and may internalize negative aspects of the antigay prejudice experience. Anxiety, depression, social withdrawal, and other reactions may result. While the study of psychological heterosexism, both blatant and subtle, is in the early stages of research, it has had a measurable impact on the mental health of the GSM community [2,51,56,69,70].

Examples of the range of manifestations of heterosexism and/or homophobia in our society are readily available. Without difficulty, each example presented here may be conceptualized as related to the emotional or physical health of a GSM individual or family member:

- A kindergarten student calls another child an LGBTQIA+ slur but does not really know what he is saying.

- A teenage girl allows herself to become pregnant, "proving" her heterosexuality to herself, her family, and her friends.

- A parent worries that her 12-year-old daughter is still a "tomboy."

- An office employee decides to place a photo of an old boyfriend in her office rather than a photo of her gender-nonconforming partner of five years.

- A college student buries himself in his studies in an effort to ignore his same-sex feelings and replace feelings of isolation.

- Two teenage girls, thought by peers to be transgender individuals, are assaulted and killed while sitting together in an automobile.

- A female patient is told by a healthcare provider that her haircut makes her look like a lesbian and is examined roughly.

- A gay man chooses not to reveal his sexual identity to his healthcare provider out of fear of a reduction or withdrawal of healthcare services.

The manifestations of heterosexism have inhibited our learning about the LGBTQIA+ population and its needs. Gay patients have feared open discussion about their health needs because of potential negative reactions to their self-disclosure. Prejudice has impacted research efforts by limiting available funding. All of these factors emphasize that the healthcare education system has failed to educate providers and researchers about the unique aspects of LGBTQIA+ health [56].

Common Myths

Many myths surround homosexuality; a few are outlined below. The origin of these myths may be better understood after examining the history of homosexuality as well as the attitudes toward human sexuality in general. The history of the development of societal norms related to homosexuality includes misconceptions developed during times when research was not available on which to build a scientific knowledge base [71,72,73].

Myth: Sexual orientation is a choice.

Fact: No consensus exists among scientists about the reasons that an individual develops his/her sexual orientation. Some research has shown that the bodies and brains of gay men and women differ subtly in structure and function from their heterosexual counterparts; however, no findings have conclusively shown that sexual orientation is determined by any particular factor or set of factors. Many people confuse sexual orientation with sexual identity. The reader may consider reviewing the definitions of these terms when further considering this myth.

Myth: Gay men and lesbians can be easily identified because they have distinctive characteristics.

Fact: Most gay and lesbian individuals conform to the majority of society in the way they dress and act. Further, a person's appearance is not necessarily an indication of sexual or romantic interests.

Myth: Gay people want to come into our schools and recruit our children to their "lifestyle."

Fact: Efforts to bring issues related to LGBTQIA+ history and rights into schools are not efforts to "convert," just as education on European history is not an effort to glamorize or "convert" to European identity. The intent has been to teach a more complete history of the world and to prevent children from mistreating LGBTQIA+ who are often the subjects of harassment and physical attacks. There is no evidence that people could be "recruited" to a gay sexual orientation, even if someone wanted to do this.

AGE

Elderly patients should be routinely screened for health and mental health conditions using tools specifically developed for this population, despite some practitioners' discomfort with asking questions about sensitive topics. These population-appropriate assessments may be included in other health screening tools.

An emphasis on wellness and purpose is important when working with older adults. In the past, aging was associated with disability, loss, decline, and a separation from occupational productivity. Although patient growth and positive change and development are values that practitioners embrace, the unconscious acceptance of societal myths and stereotypes of aging may prevent practitioners from promoting these values in elderly individuals [74,77].

Common Myths of Aging

Society holds several myths about the elderly. Many of these myths may be easily disputed based on existing demographic survey data and other studies.

Myth: Most older adults live alone and are isolated.

Fact: In 2023, 68% of men and 47% of women 65 years and older were married. An estimated 28% lived alone [75]. In 2021, an estimated 18% of the U.S. population lived in multigenerational household, compared with 7% in the early 1970s. Several factors have contributed to this trend, including growing racial and ethnic diversity, financial reasons, and caregiving Individuals 65 years and older comprise nearly 20% of individuals living in multigenerational households [76].

Myth: Most older adults engage in very minimal productive activity.

Fact: In 2023, 19% of persons 65 years and older were employed or actively looking for work, representing approximately 7% of all wages and salaries paid by U.S. employers. The elderly are more engaged in self-employed activities than younger persons. In 2023, 23% of those 65 years of age and older were self-employed, compared with an average of 10% of those 25 years to 64 years of age [78].

Myth: Life satisfaction is low among the elderly.

Fact: Data from a 2024 survey conducted by the AARP indicate that 9 out of 10 individuals 50 years of age and older are at least somewhat optimistic about their future, with half (49%) being extremely or very optimistic. Approximately 25% of respondents 65 years of age and older reported being very happy, compared to 17% in those 50 to 64 years of age. Most of the factors that predict happiness for the young, such as good health and financial stability, also apply to the elderly. Older adults tend to report higher levels of well-being in part due to the quality of their social relationships; 28% indicate their relationships with friends and family have improved in the last five years, and 45% feel they will continue to get better [79].

PERSONS WITH MENTAL OR PHYSICAL DISABILITY

Americans with disabilities represent a large and heterogeneous segment of the population. The prevalence of disability varies by age group and definition. Based on the U.S. Census Bureau's 2023 American Community Survey (ACS), which describes disability in terms of functional limitations, 13.6% of the civilian U.S. noninstitutionalized population has a disability, defined as difficulty in hearing or vision, cognitive function, ambulation, self-care, or independent living [80]. Among individuals 3 to 21 years of age in the 2022–2023 school year, 15% of those enrolled in public school had a disability (defined as specific learning disabilities, speech or language impairments, intellectual disability, emotional disturbance, hearing impairments, orthopedic impairments, other health impairments, visual impairments, multiple disabilities, deaf-blindness, autism, traumatic brain injury, or developmental delay) [81].

People with disabilities experience many health disparities. Some documented disparities include poorer self-rated health; higher rates of obesity, smoking, and inactivity; fewer cancer screenings (particularly mammography and Pap tests); fewer breast-conserving surgeries when breast cancer is diagnosed; and higher rates of death from breast or lung cancer [82].

Disability cultural competence requires appreciation of social model precepts, which recognize patients' rights to seek care that meets their expectations and values. The social model of disability has been characterized as centering disability as a social creation rather than an attribute of the patient. As such, disability requires a social/political response in order to improve environmental factors affecting access and acceptance [83]. This involves adoption of person-first language, acknowledgement of social and environmental factors impacting persons abilities, and confronting disability-associated stigma.

VETERANS

The effects of military service and deployment to military combat on the individual and the family system are wide-reaching. According to the U.S. Department of Defense, there were 3.4 million current military personnel in 2023 and 15.8 million veterans in 2023 [106,107]. The Army has the largest number of active-duty members, followed by the Navy, Air Force, and Marine Corps [106]. Military service presents its own set of risk and protective factors for a variety of mental health issues, including post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), depression and suicide, substance abuse, and interpersonal violence. In particular, transitioning from combat back to home life can be particularly trying for veterans and their families.

As the number of military conflicts and deployments has increased since 2001, the need to identify and provide better treatment for veterans and their families has become a greater priority. The first step in providing optimal care is the identification of veterans and veteran families during initial assessments, with an acknowledgement that veterans may be any sex/gender and are present in all adult age groups.

Unfortunately, veterans and military families often do not voluntarily report their military service in healthcare appointments. In 2015, the American Medical Association updated its recommendations for social history taking to include military history and veteran status [108]. In addition, the American Academy of Nursing has designed the Have You Ever Served? Initiative to encourage health and mental health professionals to ask their patients about military service and related areas of concern [109]. This program provides pocket cards, posters, and resource links for professionals working with veterans and their families. Recommended questions for intake include [109]:

- Have you or has someone close to you ever served in the military?

- When did you serve?

- Which branch?

- What did you do while you were in the military?

- Were you assigned to a hostile or combative area?

- Did you experience enemy fire, see combat, or witness casualties?

- Were you wounded, injured, or hospitalized?

- Did you participate in any experimental projects or tests?

- Were you exposed to noise, chemicals, gases, demolition of munitions, pesticides, or other hazardous substances?

7. PROMOTING CULTURALLY SENSITIVE COMMUNICATION

Communication, the process of sending a message from one party to another, consists of both verbal and nonverbal components. Verbal and nonverbal communications are embedded within the culture of the parties disseminating the information and within the culture of the parties receiving the information. Communication is complex and multilayered because it involves unstated, implicit rules about a variety of factors, including physical distance between parties, tone of voice, acceptable topics of discussion, physical contact, and amount of eye contact [84]. Each of these variables is influenced by the perception of the level of formality/informality of the situation. Frequently, misunderstandings occur because the decoding and interpretation of these nonverbal cues are not accurate.

The verbal component of communication is just as complicated. Certainly, similarity in language shared by both parties enhances communication, but assuming that both parties in a conversation speak the same language, how the information is interpreted is still influenced by a host of factors. Linguists have posited that approximately 14,000 different meanings and interpretations can be extracted from the 500 most common English words [85]. Consequently, practitioners must be aware of the different communication styles held by diverse ethnic minority patients, as the clinical communication process is the primary vehicle by which problems and solutions are identified and conveyed [86].

Styles of communication can be classified from high- to low-context [87]. High-context cultures are those cultures that disseminate information relying on shared experience, implicit messages, nonverbal cues, and the relationship between the two parties [85,88]. Members of these cultural groups tend to listen with their eyes and focus on how something was said or conveyed [84,87]. On the other hand, low-context cultures rely on verbal communication or what is explicitly stated in the conversation [85]. Consequently, low-context communicators listen with their ears and focus on what is being said [84,87,88]. Western culture, including the United States, can be classified as a low-context culture. On the other hand, groups from collectivistic cultures, such as Asian/Pacific Islander, Hispanic, AI/AN, and Black and African American, are from high-context cultures [87].

Communicators from high-context cultures generally display the following characteristics [84,85,88]:

- Use of indirect modes of communication

- Use of vague descriptions

- Less talk and less eye contact

- Interpersonal sensitivity

- Use of feelings to facilitate behavior

- Assumed recollection of shared experiences

- Reliance on nonverbal cues such as gestures, tone of voice, posture, voice level, rhythm of speaking, emotions, and pace and timing of speech

- Assimilation of the "whole" picture, including visual and auditory cues

- Emotional speech

- Use of silence

- Use of more formal language, emphasizing hierarchy between parties

On the other hand, low-context communicators can typically be described as [84,85,88]:

- Employing direct patterns of communication

- Using explicit descriptions and terms

- Assuming meanings are described explicitly

- Utilizing and relying minimally on nonverbal cues

- Speaking more and often raising their voices (more animated, dramatic)

- Often being impatient to get to the point of the discussion

- Using more informal language; less emphasis on hierarchy, more equality between parties (more friendly)

- Being more comfortable with fluidness and change

- Uncomfortable using long pauses and storytelling as a means of communicating

Understanding the distinctions between individuals who come from high- and low-context cultures can promote cultural sensitivity. However, it is vital that practitioners take heed of several words of caution. First, it is important not to assume that two individuals sharing the same culture (e.g., low-context culture) will automatically have a shared script for communicating. Second, it is important to not immediately classify an individual into a low- or high-context culture because of their ethnicity. A Chinese American man may not necessarily be a high-context communicator because he is Asian. A host of factors, such as level of acculturation, upbringing and socialization, education, and family immigration history, will all play a role in how one learns to communicate. Third, a major criticism of the discussion of low-/high-context cultures is that they reinforce dualism and ultimately oversimplify the complexities and nuances of communication [89].

Learning to communicate effectively also requires an understanding of how different conversational traits influence the communication process, or how information is conveyed and interpreted. Again, the goal of this section is not to simply dichotomize individuals' conversational styles into categories, but rather to understand the factors that play a role in how someone makes a decision on how to communicate [84].

As long as there are two parties involved in a conversation, nonverbal communication is inevitable, and it becomes salient particularly when it is processed from one culture to another. Nonverbal communication is any behavior (including gestures, posture, eye contact, facial expressions, and body positions) that transcends verbal or written forms of communication [90]. Nonverbal communication can enhance or reinforce what is said verbally, and conversely, it can completely contradict the message communicated verbally. It can also end up replacing what was verbally communicated if both parties do not share a native language [91].

In Western culture, communication is more direct and eye contact is highly valued. When eye contact is not maintained, many Westerners assume that the party is hiding pertinent information. However, in some cultures, reducing eye contact is a sign of respect [86]. Conversely, patients may interpret direct and indirect gazes differently. For example, in one study, Japanese individuals tended to rate faces with a direct gaze as angry and less pleasant compared with Finnish participants [92].

The amount of social space or distance between two communicating parties is culturally charged as well. Depending upon the social context, Westerners tend to maintain a distance of about three feet, or an arm's length, in conversations [85]. In a public setting, where both parties are engaged in a neutral, nonpersonal topic, Westerners will feel encroached upon and uncomfortable if an individual maintains a closer conversational distance. However, in other cultures, such as Latino and Middle Eastern, a closer distance would be the norm [85]. Chung recommends that in a clinical setting the practitioner allow patients to set the tone and social distance [93]. The practitioner can sit first and permit the patient to select where they want to sit.

Cross-cultural communication is by no means simple, and there is no set of rules to merely abide by. Instead, promoting culturally sensitive communication is an art that requires practitioners to self-reflect, be self-aware, and be willing to learn. Therefore, as practitioners become skilled in noticing nonverbal behaviors and how they relate to their own behaviors and emotions, they will be more able to understand their own level of discomfort and comprehend behavior from a cultural perspective [84].

8. CULTURALLY SENSITIVE ASSESSMENT GUIDELINES

Practitioners may be categorized as either disease-centric or patient-centric [94]. Disease-centered practitioners are concerned with sign/symptom observation and, ultimately, diagnosis. On the other hand, patient-centered practitioners focus more on the patient's experience of the illness, subjective descriptions, and personal beliefs [94]. Patient-centered practice involves culturally sensitive assessment. It allows practitioners to move assessment and practice away from a pathology-oriented model and instead acknowledge the complex transactions of the individual's movement within, among, and between various systems [95].

Practitioners who engage in culturally sensitive assessment nonjudgmentally obtain information related to the patient's cultural beliefs, overall perspective, and specific health beliefs [96]. They also allow the patient to control the timing [97].

The goal is to avoid the tendency to misinterpret health concerns of ethnic minority patients. Panos and Panos have developed a qualitative culturally sensitive assessment process that focuses on several domains [96]. Each domain includes several questions a practitioner may address in order to ensure that he or she is providing culturally responsive care.

Alternatively, Kleinman suggests that the practitioner ask the patient what he or she thinks is the nature of the problem. He highlights the following types of questions that may be posed to the patient [98]:

- Why has the illness/problem affected you?

- Why has the illness had its onset now?

- What course do you think the illness will follow?

- How does the illness affect you?

- What do you think is the best or appropriate treatment? What treatment do you want?

- What do you fear most about the illness and its treatment?

Similar to Kleinman's culturally sensitive assessment questions, Galanti has proposed the 4 Cs of Culture [99]:

- What do you call the problem?

- What do you think caused it?

- How do you cope with the problem?

- What questions or concerns do you have about the problem or treatment?

Pachter proposed a dynamic model that involves several tiers and transactions, similar to Panos and Panos' model [100]. The first component of Pachter's model calls for the practitioner to take responsibility for cultural awareness and knowledge. The professional must be willing to acknowledge that they do not possess enough or adequate knowledge in health beliefs and practices among the different ethnic and cultural groups they come in contact with. Reading and becoming familiar with medical anthropology is a good first step.

The second component emphasizes the need for specifically tailored assessment [100]. Pachter advocates the notion that there is tremendous diversity within groups. Often, there are many intersecting variables, such as level of acculturation, age at immigration, educational level, and socioeconomic status, that influence health ideologies. Finally, the third component involves a negotiation process between the patient and the professional [100]. The negotiation consists of a dialogue that involves a genuine respect of beliefs. The professional might recommend a combination of alternative and Western treatments.

Beckerman and Corbett further recommend that recently immigrated families be assessed for [101]:

- Coping and adaptation strengths

- Issues of loss and adaptation

- The structure of the family in terms of boundaries and hierarchies after immigration

- Specific emotional needs

- Acculturative stress and conflict for each family member

Practitioners should seek to understand the sociopolitical context of the origin country. A migration narrative is also recommended, whereby an individual provides a story of their migration history. Asking about how long the family has been in the United States, who immigrated first, who was left behind, and what support networks are lacking gives the practitioner an overview of the individual's present situation. The theme of loss is very important to explore. Types of losses may include family and friends left behind, social status, social identity, financial resources, and familiarity. For refugees and newly immigrated individuals and families, assessment of basic needs (e.g., food, housing, transportation) is necessary [102,103].

Culturally sensitive assessment involves a dynamic framework whereby the practitioner engages in a continual process of questioning. Practitioners should work to recognize that there are a host of factors that contribute to patients' multiple identities (e.g., race, gender, socioeconomic status, religion) [36,37,82].

9. A WELCOMING AND SAFE ENVIRONMENT

Improving access to care can be facilitated, in part, by providing a welcoming environment. The basis of establishing a safe and welcoming environment for all patients is security, which begins with inclusive practice and good clinician-patient rapport. Shared respect is critical to a patient's feeling of psychological well-being. Security can also be fostered by a positive and safe physical setting. For patients who are acutely ill, both the illness experience and treatment process can produce trauma. This is particularly true if involuntary detainment or hospitalization is necessary, but exposure to other individuals' narratives of experienced trauma or observing atypical behaviors from individuals presenting as violent, disorganized, or harmful to themselves can also be traumatic. As such, care environments should be controlled in a way to minimize traumatic stress responses. Providers should keep this in mind when structuring the environment (e.g., lighting, arrangement of space), creating processes (e.g., layout of appointments or care systems, forms), and providing staff guidance (e.g., nonverbal communication, intonation, communication patterns). During each encounter, the patient's perception of safety is impacted by caretakers and ancillary staff [36,82].

Experts recommend the adoption and posting of a nondiscrimination policy that signals to both healthcare providers and patients that all persons will be treated with dignity and respect. Also, checklists and records should include options for the patient defining their race/ethnicity, preferred language, gender expression, and pronouns; this can help to better capture information about patients and be a sign of acceptance to that person. If appropriate, providers should admit their lack of experience with patient subgroups and seek guidance from patients regarding their expectations of the visit [36,51,53].

Front office staff should avoid discriminatory language and behaviors. For example, staff should avoid using gender-based pronouns, both on the phone and in person. Instead of asking, "How may I help you, sir?" the staff person could simply ask, "How may I help you?" Offices that utilize electronic health records should have a system to track and record the gender, name, and pronoun of all patients. This can be accomplished by standardizing the notes field to document a preferred name and pronoun for all patients. Some persons who identify as non-binary (i.e., neither or both genders) may prefer that plural pronouns (e.g., they) be used [36,51].

Questions should be framed in ways that do not make assumptions about a patient's culture, gender identity, sexual orientation, or behavior. Language should be inclusive, allowing the patient to decide when and what to disclose. Assurance of confidentiality should be stressed to the patient to allow for a more open discussion, and confidentiality should be ensured if a patient is being referred to a different healthcare provider. Asking open-ended questions can be helpful during a history and physical [36,51,82].

The FACT acronym may be helpful for healthcare providers. Providers should:

- Focus on those health issues for which the individual seeks care

- Avoid intrusive behavior

- Consider people as individuals

- Treat individuals according to their gender

Training office staff to increase their knowledge and sensitivity toward persons will also help facilitate a positive experience for patients.

10. CONCLUSION

Culture serves as a lens through which patients and practitioners filter their experiences and perceptions. Patients will bring their unique life stories and concerns to the practitioner, and their cultural values and belief systems will inevitably shape how the problem is defined and their beliefs about what is effective in solving the problem. However, the cultural backgrounds and values of patients are not necessarily scripts that define behavior, and when practitioners view culture as a strength and not a pathology, practitioners will be able to more effectively join with patients to mobilize change.

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31840 • Nurses' Knowledge, Beliefs, and Exercise Habits: A Focus on Cardiovascular Disease

Tina Schmidt-McNulty, DHSc, MS, ACSM-CEP, RN

www.netce.com

Copyright © 2025 NetCE, All rights reserved.

Nurses are crucial in educating patients on preventing and managing CVD. However, the demanding nature of their profession places them at greater risk for health issues, including CVD. Despite understanding that regular physical activity is essential in reducing risks for CVD, many nurses do not exercise enough, which negatively affects their health and potentially the quality of patient care.

Table of Contents

31840 • Nurses' Knowledge, Beliefs, and Exercise Habits: A Focus on Cardiovascular Disease

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. NURSES AND PERSONAL HEALTH

IMPACT OF NURSES' HEALTH BEHAVIORS ON PATIENT CARE

BARRIERS TO HEALTHY BEHAVIORS AMONG NURSES

LITERATURE REVIEW

3. NURSES AS ROLE MODELS FOR PROMOTING HEALTHY BEHAVIORS

4. THE ROLE OF ONGOING EDUCATION AND PROFESSIONAL DEVELOPMENT

5. EVALUATION AND IMPLEMENTATION STRATEGIES

6. CASE STUDY

7. CONCLUSION

Works Cited

31840 • Nurses' Knowledge, Beliefs, and Exercise Habits: A Focus on Cardiovascular Disease

Education Category. Community Health

Release Date. 09/01/2025

Expiration Date. 08/31/2028

Course Overview

Nurses are crucial in educating patients on preventing and managing CVD. However, the demanding nature of their profession places them at greater risk for health issues, including CVD. Despite understanding that regular physical activity is essential in reducing risks for CVD, many nurses do not exercise enough, which negatively affects their health and potentially the quality of patient care.

Audience

This course is designed for nurses in all practice settings whose attention to self-care and cardiovascular disease prevention may impact their ability to live healthily and provide optimal patient care.

Accreditations & Approvals

In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

NetCE designates this continuing education activity for 1 ANCC contact hour(s). NetCE designates this continuing education activity for 1.2 hours for Alabama nurses. NetCE is authorized by IACET to offer 0.1 CEU(s) for this program. AACN Synergy CERP Category B.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353 (valid through July 30, 2029); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2027; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Course Objective

The purpose of this course is to highlight the relationship between nurses' health beliefs and self-care and their recommendations and teachings to patients, with the goal of supporting interventions to better support nurses' healthy lifestyle choices, self-care, and patient teaching.

Learning Objectives

Upon completion of this course, you should be able to:

1. Outline the role of nurses in promoting and modeling health and wellness for patients.

2. Relate the importance of nurses' health to performance and patient care.

3. Discuss strategies for nurses to incorporate healthier lifestyle choices.

Faculty

Tina Schmidt-McNulty, DHSc, MS, ACSM-CEP, RN, is an instructor in the Department of Kinesiology and Nutrition at the University of Illinois Chicago. Her academic foundation in health, exercise instruction/programming, and nursing is strengthened by specialized certifications in clinical exercise physiology and group fitness. Her professional background includes clinical nursing experience in cardiovascular care and cardiac rehabilitation, as well as coaching at the high school level, where she developed seasonal training programs. She is also an active member of the Exercise is Medicine Clinical Practice Committee.

With more than 30 years in the fitness industry as a presenter, author, coach, and instructor, Dr. Schmidt-McNulty has published numerous articles on special populations and health risk factors, and has led initiatives promoting fitness and wellness in corporate, hospital, and university settings. Her work reflects a commitment to bridging academic knowledge with practical application, encouraging student engagement, and building a strong foundation for lifelong learning in health and exercise sciences.

Faculty Disclosure

Contributing faculty, Tina Schmidt-McNulty, DHSc, MS, ACSM-CEP, RN, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Mary Franks, MSN, APRN, FNP-C

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Florence Nightingale, a pioneer in nursing, emphasized the necessity of personal health and self-care to prevent illness and promote wellness [1]. She believed self-care was essential for nurses to provide quality patient care, a relevant principle today. Nurses often face numerous challenges undermining their health and wellness, such as family responsibilities, demanding work schedules, and burnout [2]. Research has linked poor health behaviors, particularly insufficient physical activity, to increased risks of chronic diseases, making self-care even more crucial [3].

2. NURSES AND PERSONAL HEALTH

Despite possessing knowledge of prevention strategies and understanding the benefits of physical activity, many nurses do not follow these recommendations. This contributes to the increased prevalence of hypertension, obesity, and related health conditions within the nursing profession [4,5]. As noted, common barriers include time constraints, stress, and fatigue, making it challenging for nurses to engage in regular self-care, including physical activity [6]. These challenges not only affect nurses' health but can also impact the quality of care they provide.

IMPACT OF NURSES' HEALTH BEHAVIORS ON PATIENT CARE

Nurses, as health promoters, play a crucial role in influencing patients to adopt healthy behaviors. Those who maintain healthy lifestyles are more likely to inspire patients to follow suit, thereby demonstrating the significant impact of nurses on health promotion [7,8]. Conversely, patients may be less inclined to trust health advice from nurses who do not practice these behaviors themselves [9,10]. Thus, nurses should prioritize their health to effectively serve as role models, reinforcing the connection between their personal habits and patient outcomes.

BARRIERS TO HEALTHY BEHAVIORS AMONG NURSES

Awareness of personal health risks can significantly influence engagement in self-care practices. Greater recognition of these risks has been linked to improved self-care habits [11,12]. However, despite access to health knowledge and resources, many nurses need help prioritizing their health [13]. Psychological and environmental barriers, such as lack of time, energy, and support, hinder the adoption of healthy behaviors [6]. Understanding these barriers is critical to developing effective programs that support nurses in overcoming these challenges.

LITERATURE REVIEW

Nurses face unique challenges that place them at increased risk for chronic diseases, including cardiovascular disease (CVD). Long shifts, high stress levels, and the physical demands of patient care often lead to poor health practices, such as insufficient physical activity, inadequate sleep, and unhealthy dietary habits [14]. Studies highlight that nurses experience higher rates of obesity, hypertension, and hyperlipidemia compared with the general population [15,16].

The American Heart Association (AHA) and the World Health Organization (WHO) emphasize the critical role of nurses in reducing the global burden of heart disease. Effective patient education on risk factors—such as poor diet, inactivity, and smoking—relies on nursing professionals [17]. However, the demanding nature of the profession can impede their ability to model healthy behaviors, complicating efforts to promote personal and professional wellness.

Emerging research suggests that a proper understanding of personal risk is essential for engaging in preventive health behaviors. Research indicates that nurses who assess their risk are likely to adopt health-promoting practices [12]. Unfortunately, many underestimate their vulnerability, leading to complacency and a reluctance to implement lifestyle changes [18]. Misplaced optimism, whereby nurses perceive their risk to be lower than it is, can impede motivation for self-care [19].

3. NURSES AS ROLE MODELS FOR PROMOTING HEALTHY BEHAVIORS

Given their crucial role in patient education, nurses must stay informed about CVD prevention, guidelines, and treatment. Nurses who maintain healthy lifestyles are more likely to influence patients to adopt similar behaviors, reinforcing the importance of their role as health advocates [7,20]. Research demonstrates that patients are more inclined to adopt recommended changes, such as increasing physical activity, when advised by healthcare professionals who practice these behaviors themselves [7].

However, nurses frequently encounter obstacles in maintaining healthy behaviors, particularly sustaining regular physical activity. Challenges such as fatigue, heavy workloads, and lack of time due to extended shifts often hinder their ability to engage in recommended exercise routines [21]. Addressing these barriers through targeted professional development and wellness initiatives can empower nurses to enhance their health and better support their patients.

4. THE ROLE OF ONGOING EDUCATION AND PROFESSIONAL DEVELOPMENT

To provide high-quality, evidence-based care, nurses should prioritize ongoing professional development. Nurses are expected to stay informed on evidence-based recommendations for disease prevention and health promotion [13]. This requires support from unit managers and hospital administrators, who are critical in fostering a culture that encourages continuous learning and professional growth [5,22].

Integrating evidence-based physical activity guidelines into education programs can improve nurses' ability to translate these recommendations into practice. Nurses with current knowledge are more effective in promoting lifestyle modifications to their patients [23,24]. However, many nurses would benefit from up-to-date knowledge, reinforcing the need for ongoing professional development opportunities that focus on applying these guidelines to personal and professional settings [8].

5. EVALUATION AND IMPLEMENTATION STRATEGIES

The Health Belief Model (HBM) offers a useful framework for understanding the health behaviors of nurses, particularly those related to physical activity [25]. The model suggests that an individual's perception of their disease risk, the severity of the condition, and the perceived benefits and barriers to behavior change all shape their actions [26]. Nurses' perceptions of their health risks can influence their willingness to engage in physical activity and counsel patients on similar behaviors [12]. By recognizing these factors, healthcare institutions can design initiatives that better support nurses adopting healthy lifestyles, enhancing their well-being and patient care quality.

Wellness initiatives in healthcare settings can be effectively implemented through a structured approach that addresses organizational and individual needs. Conducting a needs assessment through surveys can help identify critical wellness needs, barriers to maintaining a healthy lifestyle, and prevalent risk factors (e.g., work-related stress, cardiovascular risks) [27]. Based on this assessment, priorities for intervention, such as stress reduction, physical activity, healthy eating, mental health support, and sleep hygiene, can be set [12].

Tailored wellness programs can then be designed. Physical activity initiatives may include on-site fitness options, group classes like yoga and aerobics, and active breaks during shifts to reduce physical and mental strain [7]. Nutrition initiatives should ensure access to healthy meals and snacks, promote water consumption, and offer dietary counseling [28]. Mental health support is another essential component, with offerings such as mindfulness training, meditation sessions, and access to counseling services to help manage workplace stress [29].

Leadership and peer support play critical roles in promoting wellness. Appointing wellness champions within the nursing staff can create role models for healthy behaviors, while active management involvement demonstrates the organization's commitment to employee well-being [7]. Ensuring flexibility and accessibility is also important. Wellness activities should be adaptable to the shift schedules of healthcare staff, allowing participation regardless of working hours [26].

Finally, wellness programs should be evaluated and adapted over time. Monitoring outcomes, such as participation rates and health improvements, and collecting feedback can help refine initiatives to ensure they remain relevant and practical. By aligning wellness initiatives with the unique needs of nursing staff and embedding them into the organizational culture, healthcare facilities can significantly improve staff well-being and patient care quality [13,29]. As Florence Nightingale emphasized, nurses should "teach not by preaching but by setting an example through their actions" [7]. By prioritizing their health and well-being, nurses can effectively promote healthy behaviors among patients, contributing to improved health outcomes and a more robust healthcare system.

6. CASE STUDY

A cross-sectional study explored cardiovascular nurses' self-perceived cardiovascular risk factors, attitudes, perceived barriers toward physical activity, and their practices in promoting a healthy lifestyle by recommending physical activity to patients [30]. A convenience sample of full-time, part-time, and PRN nurses working consistently in U.S. cardiovascular units was recruited. Using validated instruments, data were collected via an online survey that assessed demographics, self-perceived CVD risk, physical activity habits, and health promotion practices.

Results revealed that a significant portion of the nurses in this case study (74.2%) had low self-perceived CVD risk, while 25.8% had higher risk scores. Most nurses (87.1%) fell below recommended physical activity levels, emphasizing the need for targeted interventions to promote exercise within the nursing community. The study found that nurses with higher CVD knowledge scores were three times more likely to recommend exercise to patients. These findings indicate that enhancing nurses' CVD knowledge and addressing skill-related barriers may support greater health promotion practices.

The study highlights the importance of understanding the relationship between nurses' perceived health risks, knowledge of CVD, and health promotion behaviors. Many nurses perceive themselves as knowledgeable about CVD risk reduction, yet their physical activity habits do not align with this knowledge. Factors such as workplace environment, job type, and fatigue can hinder the application of this knowledge to personal health practices [5,22]. This understanding can enlighten healthcare professionals and guide the development of effective interventions to promote nurses' health and well-being.

This particular study found that the majority of nurses did not meet the recommended minimum 150 minutes of moderate physical activity per week [31,32]. While some nurses engaged in light-to-moderate activities, it was often insufficient to provide the health benefits associated with regular exercise. Nurses working in highly demanding environments may overestimate their activity levels due to the physical nature of their work shifts [21]. Occupational activities such as walking during shifts were not continuous or vigorous enough to meet recommended guidelines, highlighting the need for targeted strategies to encourage leisure-time physical activity [8,15,33].

Accurate perception of personal CVD risk is essential for motivating health behavior change. Previous studies have shown a positive correlation between individual or family history of CVD and perceived risk, but this does not always translate into healthier behaviors [12,18]. The current study found no significant differences between high-risk and low-risk groups regarding knowledge, perceived risk, or intention to change behaviors.

Perceived barriers, such as a lack of energy and time, were frequently reported among this sample, consistent with other research indicating that long work hours, high stress, and external responsibilities can impede nurses' engagement in physical activity [5,22]. Addressing these barriers through targeted interventions is crucial to support nurses' health and their ability to effectively counsel patients on adopting healthy lifestyles.

7. CONCLUSION

Nurses are crucial in educating patients on preventing and managing CVD. However, the demanding nature of their profession places them at greater risk for health issues, including CVD [3]. Despite understanding that regular physical activity is essential in reducing risks for CVD, many nurses do not exercise enough, which negatively affects their health and potentially the quality of patient care [28,34].

Educational interventions based on the Health Belief Model could motivate nurses to prioritize their health by addressing perceived barriers and enhancing self-efficacy [13,35]. Integrating wellness initiatives and continuous CVD education can support nurses in making lasting changes and improving patient care [29,35]. These efforts will ultimately benefit nurses and their patients, contributing to a healthier workforce and improved patient outcomes.

Works Cited

1. 1. Olshansky EF. Self-care: an imperative for nurses. Nurs Forum. 2011;46(1):55-65.

2. Willis TM, Gambrell DJ, Douthit JD. Nurses' health promotion behaviors correlate with their metabolic syndrome risk. Nurs Res. 2019;68(6):435-442.

3. Jahromi MK, Ramezanli S, Taheri L. Effect of a self-care education program on quality of life in patients with chronic heart failure: a randomized controlled trial. Appl Nurs Res. 2017;37:11-18.

4. Avraham R, Shani M, Rosenne H. Physical activity and health behaviors among nurses: a cross-sectional study. Nurs Health Sci. 2020;22(2):323-330.

5. Gould L, Carpenter H, Farmer DR, Holland D, Dawson JM. Healthy Nurse, Healthy Nation (HNHN): background and first year results. Appl Nurs Res. 2019;49:64-69.

6. Waksmanska W, Witczak I, Leja-Szpak A, Kulik H. Barriers to physical activity among nurses and nursing students. Med Stud. 2018;34(2):123-128.

7. Priano SM, Hong O, Chen JL. Lifestyles and health-related outcomes of U.S. hospital nurses: a systematic review. Nurs Outlook. 2018;66(1):66-76.

8. Ross A, Yang L, Wehrlen L, Perez A, Farmer N, Bevans M. Nurses and health-promoting self-care: do we practice what we preach? J Nurs Manag. 2019;27(5):1097-1104.

9. Heidke P, Howie S, Ferdous T. Use of health coaching to improve health outcomes for people with chronic diseases: an integrative review. Patient Educ Couns. 2020;103(5):930-943.

10. Kelly M, Wills J, Sykes S. Do nurses' personal health behaviours impact on their health promotion practice? A systematic review. Int J Nurs Stud. 2017;76:62-77.

11. Deasy C, Doody O, Tuohy D. Nurses' physical activity behaviour and recommendations to patients. J Clin Nurs. 2016;25(1-2):203-212.

12. Gujral H, Sproat T, Richmond N, Friend M. Nurses' knowledge of cardiovascular risk factors and risk perception: a cross-sectional study. J Nurs Manag. 2020;28(6):1445-1452.

13. Wu SH, Yau SY, Liao HY, Chen RL. Nurses' health-promoting lifestyles and related factors in southern Taiwan. J Clin Nurs. 2011;20(9-10):1519-1527.

14. Roskoden FC, Krüger J, Vogt LJ, et al. Physical activity, energy expenditure, nutritional habits, quality of sleep and stress levels in shift-working health care personnel. PLoS One. 2017;12(1):e0169983.

15. Reed SA, Prince MA. Obesity in nursing: the implications for the profession. J Nurs Manag. 2018;26(1):1-3.

16. Wills J, Kelly M, Frampton C. Nurses' health-related behaviors: do they practice what they preach? J Nurs Educ. 2019;58(2):96-100.

17. Lin PC, Lee SH, Tsai YC, Lin YM. The prevalence of cardiovascular disease risk factors and their associations with job stress and health-promoting lifestyle among hospital nurses in Taiwan: a cross-sectional study. J Occup Health. 2017;59(1):23-31.

18. Imes CC, Lewis FM. Family history of cardiovascular disease, perceived cardiovascular disease risk, and health-related behavior: a review of the literature. J Cardiovasc Nurs. 2014;29(2):108-129.

19. Webster R, Heeley E. Perceptions of risk: understanding cardiovascular disease. Risk Manag Healthc Policy. 2010;3:49-60.

20. Esposito EM, Fitzpatrick JJ. Registered nurses' beliefs of the benefits of exercise, their exercise behavior, and their patient teaching regarding exercise. Int J Nurs Pract. 2011;17(4):351-356.

21. Essen M, Brown LM. Physical activity levels and perceived barriers to exercise among nurses in a community hospital. J Nurs Adm. 2020;50(6):328-334.

22. Letvak S. Nurses' health: the influence of work and non-work factors. Nurs Outlook. 2013;61(5):303-310.

23. Lin PC, Lin YM, Lee SH. Nurses' knowledge, attitudes, and implementation of health promotion activities: relationships between self-evaluations and actual performances. J Clin Nurs. 2018;27(13-14):2853-2861.

24. van Hell-Cromwijk M, Huisman-de Waal G, Schoonhoven L, van Achterberg T. Nurses' self-efficacy, outcome expectations, and knowledge regarding physical activity for hospitalized patients: a cross-sectional survey. J Clin Nurs. 2021;30(1-2):270-280.

25. Champion VL, Skinner CS. The health belief model. In: Glanz K, Rimer BK, Viswanath K (eds). Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. New York, NY: Jossey-Bass; 2008: 45-65.

26. Glanz K, Rimer BK, Viswanath K (eds). Health Behavior: Theory, Research, and Practice. 5th ed. New York, NY: Jossey-Bass; 2015.

27. Blake H, Bermingham F, Johnson G, Tabner A. Health of nurses and midwives: the results of a UK survey. Occup Med. 2017;67(8):683-690.

28. Keele R. To role model or not? Nurses' challenges in promoting a healthy lifestyle. Workplace Health Saf. 2019;67(12):584-591.

29. Hosseini M, Ashktorab T, Taghdisi MH. Health promotion lifestyle in nursing students: a systematic review. JHPM. 2013;2(1):66-79.

30. Schmidt-McNulty TA. How Well Do Cardiovascular Nurses Estimate Their CVD Risk and Their Likelihood of Recommending Exercise to Their Patients? [dissertation]. Indianapolis, IN: University of Indianapolis; 2020.

31. American Heart Association. American Heart Association Recommendations for Physical Activity in Adults and Kids. Available at https://www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-in-adults. Last accessed August 11, 2025.

32. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 12th ed. New York, NY: Wolters Kluwer; 2025.

33. McCarthy VJ, Power S, Greaney ML. Factors influencing nurses' adherence to physical activity recommendations. J Clin Nurs. 2018;27(19-20):3584-3593.

34. Riegel B, Jaarsma T, Stromberg A. A middle-range theory of self-care of chronic illness. Adv Nurs Sci. 2017;40(3):226-245.

35. Amraei K, Hashemian M, Jalili M, Mohajer S. The effect of educational intervention based on health belief model on promoting physical activity among nurses. J Nurs Midwifery Sci. 2020;7(3):158-164.

34574 • Treating Pressure Injuries and Chronic Wounds

Maryam Mamou, BSN, RN, CRRN, CWOCN

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

Implementation of early, state-of-the-art treatment is the key to effectively treating pressure injuries and chronic wounds. However, this treatment must be holistic in its approach and take into consideration the patient's medical condition and the patient's/family's long-term goals. In this team effort, nursing staff of all levels play an important and decisive role in pressure injury treatment. This course will discuss how nurses can treat various types of pressure injuries and wounds effectively and completely and will provide the information necessary to respond to patient and/or family queries about treatments used in wound care.

Table of Contents

34574 • Treating Pressure Injuries and Chronic Wounds

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. AN OVERVIEW OF PRESSURE INJURIES

NPIAP PRESSURE INJURY STAGING

3. PATIENT ASSESSMENT

PATIENT HISTORY AND DATA COLLECTION

PHYSICAL EXAMINATION

NUTRITIONAL ASSESSMENT

OTHER COMORBIDITIES

ESTABLISHING APPROPRIATE GOALS

4. WOUND ASSESSMENT

HISTORY OF THE WOUND

WOUND PHOTOGRAPHY

WOUND MEASUREMENT

TUNNELING AND UNDERMINING

WOUND BED

SURROUNDING SKIN

WOUND PAIN

5. AN OVERVIEW OF WOUND HEALING

HEMOSTASIS

INFLAMMATION

PROLIFERATION

MATURATION/REMODELING

6. WOUND CLEANING

7. PAIN MANAGEMENT

8. WOUND DEBRIDEMENT

AUTOLYTIC DEBRIDEMENT

ENZYMATIC DEBRIDEMENT

MECHANICAL DEBRIDEMENT

CHEMICAL DEBRIDEMENT

9. WOUND DRESSINGS

HYDROCOLLOIDS

HYDROGEL

FOAM DRESSINGS

SILVER-IMPREGNATED DRESSINGS

CADEXOMER IODINE DRESSINGS

CALCIUM ALGINATE DRESSINGS

HYDROCOLLOID FIBER DRESSINGS

GAUZE

COMPOSITE DRESSINGS

COLLAGEN DRESSINGS

SPECIAL CONSIDERATIONS

10. WOUND MONITORING

DOCUMENTATION

11. PREVENTION OF PRESSURE INJURIES

12. PROGNOSIS

13. CONCLUSION

14. RESOURCES

Works Cited

Evidence-Based Practice Recommendations Citations

34574 • Treating Pressure Injuries and Chronic Wounds

Education Category. Infection Control / Internal Medicine

Release Date. 08/01/2024

Expiration Date. 07/31/2027

Course Overview

Implementation of early, state-of-the-art treatment is the key to effectively treating pressure injuries and chronic wounds. However, this treatment must be holistic in its approach and take into consideration the patient's medical condition and the patient's/family's long-term goals. In this team effort, nursing staff of all levels play an important and decisive role in pressure injury treatment. This course will discuss how nurses can treat various types of pressure injuries and wounds effectively and completely and will provide the information necessary to respond to patient and/or family queries about treatments used in wound care.

Audience

This course is designed for nurses in all care settings who may care for patients with pressure injuries or chronic wounds.

Accreditations & Approvals

In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 5 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this continuing education activity for 5 ANCC contact hour(s). NetCE designates this continuing education activity for 1 pharmacotherapeutic/pharmacology contact hour(s). NetCE designates this continuing education activity for 6 hours for Alabama nurses. AACN Synergy CERP Category A. NetCE is authorized by IACET to offer 0.5 CEU(s) for this program.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353 (valid through July 30, 2029); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2027; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Course Objective

The purpose of this course is to provide nurses with information about the process of wound healing and interventions that may advance or hinder it in order to support the use of evidence-based practice and improve patient health.

Learning Objectives

Upon completion of this course, you should be able to:

1. Describe pressure injuries and ulcers and how they develop.

2. Accurately identify pressure injury stages.

3. List key points of patient history and physical examination, and describe how the different body systems impact pressure injury development and healing.

4. Perform a comprehensive wound assessment.

5. Discuss the stages of wound healing.

6. Describe the different approaches to wound debridement and cleansing.

7. List the different types of dressing materials available for wound care.

8. Outline the necessary components of evaluating and monitoring wound healing.

Faculty

Maryam Mamou, BSN, RN, CRRN, CWOCN, is an Irish-trained RN who has lived and worked in the United States for 20 years. During her career, she has completed a BSN and went on to become a certified rehabilitation nurse, a certified life care planner, and more recently a certified wound ostomy and continence nurse. She is a graduate of the wound ostomy and continence program at Emory University in Atlanta, Georgia, and is nationally certified in these areas.

Ms. Mamou has worked in various rehabilitation settings and has first-hand experience of how pressure ulcers impact patients' recovery and quality of life. She has held positions as staff nurse, unit coordinator, educator, and director of nursing in home health care. She has been involved in developing and implementing several staff education programs in a variety of settings. She was most recently employed as a wound ostomy and continence nurse at East Alabama Medical Center in Opelika, Alabama.

Faculty Disclosure

Contributing faculty, Maryam Mamou, BSN, RN, CRRN, CWOCN, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Mary Franks, MSN, APRN, FNP-C

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Implementation of early, state-of-the-art treatment is the key to effectively treating pressure ulcers and chronic wounds. However, this treatment must be holistic in its approach and take into consideration the patient's medical condition and the patient's/family's long-term goals. Pressure injury management should incorporate comprehensive, holistic care so that all factors that contribute to the development and progress or lack of progress of the wound are equally addressed. The diagnosis and management of the wound should be seen in the context of the whole person.

Studies have shown that the most effective model for wound care management is a multidisciplinary team approach. Ideally, the team should include all disciplines with a role in promoting wound healing, including physicians, certified wound care nurses, nursing staff, physical therapists, dieticians, occupational therapists, social workers, utilization review specialists, and speech therapists[1]. In this team effort, nursing staff of all levels play an important and decisive role in wound treatment. However, it can be a daunting task for any nurse to be part of the decision-making process responsible for determining the wound care modality best suited to meet the needs of the patient. This course will provide the information necessary to properly treat various types of pressure ulcers and wounds effectively and completely.

As a result of the National Pressure Ulcer Advisory Panel (NPUAP) 2016 Staging Consensus Conference, the terminology changed from "pressure ulcer" to "pressure injury" to more accurately describe pressure injuries to both intact and ulcerated skin [2]. The staging system for pressure ulcers was also updated to clarify the definitions of various stages and reduce confusion [3]. In 2019, the Advisory Panel announced a name change from NPUAP to National Pressure Injury Advisory Panel (NPIAP) to adopt the internationally preferred term of "pressure injury" in place of "pressure ulcer" [4]. For the purpose of this course, the terms "pressure ulcer" and "pressure injury" are used interchangeably, except in defining and staging injury.

2. AN OVERVIEW OF PRESSURE INJURIES

According to the 2019 NPIAP guideline, pressure injuries are localized areas of injury to the skin or underlying soft tissue caused by sustained pressure or pressure in combination with shear or friction, including those related to a medical or other device. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities, and condition of the tissue. The injury can present as intact skin or an open ulcer and may be painful. Pressure injuries commonly develop in association with debilitating illness and injury that lead to immobility and gravity-dependent pressure over boney prominences, such as the sacrum, hip, heel, or ankle [1,3].

A pressure ulcer may also be referred to as a pressure injury, pressure sore, a bed sore, a dermal ulcer, or a decubitus ulcer. The ulceration is caused by compression of the soft tissue between two hard surfaces—the bone surface internally and the rigid surface of a bed, chair, or splint externally. According to the Centers for Medicare and Medicaid Services (CMS) guideline, a pressure ulcer can develop in at-risk patients within two to six hours of the onset of pressure [5]. Pressure ulcers can occur in all healthcare settings and affect all age groups. No healthcare specialty is immune from having a patient who will develop pressure ulcers [6]. The skin is the largest organ in the body, and preserving its integrity depends on the other organ systems for circulation, nutrition, and immune function.

The study of pressure ulcers began in recent times, although historical evidence suggests that wound problems have existed throughout humanity [7]. The oldest written documentation of wound management is from around 1500 B.C.E., in studies of ancient Egyptian medicine. These scripts show that Egyptians used oiled frog skins, honey, lint, and animal grease for wound care [7]. Attention to pressure ulcer prevention and treatment has grown in recent years, starting in the 1990s. Historically, pressure ulcers were regarded as a nursing problem, but they are now recognized to be the result of deficits at multiple points of care [7].

An estimated 95% of pressure injuries occur on the lower part of the body, with approximately 70% in the hip and buttocks area and 15% to 25% in the lower extremities [8]. There is a two to six times greater mortality risk for patients who develop pressure ulcers [8,9]. In acute care hospitals, patient risk for acquiring a pressure injury is estimated to range from 2.7% to 29% [1,8].

Pressure injuries are one of the most recurrent medical complications of spinal cord injuries (SCIs). According to the 2023 report of the National Spinal Cord Injury Statistical Center, 25.2% of patients with SCI reported pressure injury in the first year since discharge from rehabilitation, 30% reported pressure injury in the 20 years following SCI, and 36% reported pressure injury in the 40 years following SCI [10].

The recurrence rate, or the number of patients who have had a pressure ulcer and develop another one, is highly debatable due to a lack of standardized nomenclature. One estimate for pressure ulcer recurrence ranges between 5% and 41%; another source indicates recurrence rates between 40% and 80%. Although rates are considered highly variable, all patients with existing pressure ulcers are considered at high risk for developing additional ulcers, regardless of the clinical setting [11].

NPIAP PRESSURE INJURY STAGING

In 2014, the NPUAP (now the NPIAP) and the European Pressure Ulcer Advisory Panel (EPUAP) developed a common international definition and description system for pressure ulcers. As noted, the NPUAP further revised some of these definitions and staging efforts to reduce confusion and clarify terminology in 2019. The revised NPIAP guidelines for staging a pressure injury are [2,6]:

- Stage 1 Pressure Injury—Nonblanchable erythema of intact skin: Intact skin with a localized area of nonblanchable erythema. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include maroon or purple discoloration, as this may indicate deep pressure injury. Changes may appear differently in darkly pigmented skin.

- Stage 2 Pressure Injury—Partial-thickness skin loss with exposed dermis: The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage, including incontinence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds (e.g., skin tears, burns, abrasions).

- Stage 3 Pressure Injury—Full-thickness skin loss: These wounds display full-thickness skin loss with adipose visible in the ulcer and granulation tissue and epibole (rolled wound edges) often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomic location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, it is considered an unstageable pressure injury.

- Stage 4 Pressure Injury—Full-thickness skin and tissue loss: Wounds of this stage have full-thickness skin and tissue loss, with exposed or directly palpable fascia, tendon, muscle, ligament, cartilage, or bone, often with sloughing or eschar on the wound bed and epibole, undermining, tunneling, and fistula formation. Depth varies by anatomic location. If slough or eschar obscures the extent of tissue loss, it is considered an unstageable pressure injury.

- Unstageable Pressure Injury—Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is completely covered by slough and/or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

- Deep Tissue Pressure Injury—Persistent non-blanchable deep red, maroon, or purple discoloration: This wound is characterized by intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, stage 3, or stage 4). This term does not describe vascular, traumatic, neuropathic, or dermatologic conditions.

In addition to the revised staging definitions, the NPIAP Consensus Conference members agreed upon two new pressure injury definitions [2]:

- Medical device-related pressure injury: Medical device-related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. This term refers to etiology; the injury should be staged using the staging system.

- Mucosal membrane pressure injury: Mucosal membrane pressure injuries are found on mucous membranes with a history of a medical device use at the anatomic location. Due to the anatomy of the tissue, these injuries cannot be staged.

3. PATIENT ASSESSMENT

Assessment is the first and most critical step in wound care. It is important to keep in mind that treatment plans are based on the findings from the assessment, and one of the major goals is to prevent undirected and inappropriate care [9].

The two parts of the assessment are the physical examination and data collection, which includes past and present medical history, social environment, educational needs, and cultural norms [8,9]. These two components will enable the clinician to obtain an overall view of the patient's current health status [12].

PATIENT HISTORY AND DATA COLLECTION

A detailed history is usually gathered during an interview with the patient, significant others, family, caregivers, and other healthcare professionals involved in the patient's care. If a patient is admitted from another facility, it may be necessary to speak with the nursing staff at that facility in addition to reviewing the medical record.

The patient interview should be conducted in a private, quiet area and in an unhurried manner. One goal of the interview process is to begin to develop the therapeutic relationship with patients and those who are important in their care. The interview should not be merely a series of questions but should also include active listening and observation [9].

Health habits should be evaluated, including determination of how active the patient is, daily routines, diet, and sleep habits. Smoking, alcohol use, and illicit drug abuse can impair tissue profusion and delay wound healing [8,9].

A medication profile should be obtained, including prescription and over-the-counter medications. Certain medications will interfere with wound healing or interact with wound treatments [8,9]. For example, anti-inflammatory drugs can prolong the inflammatory phase of wound healing [12].

It is important to include a list of allergies in the medical history. For patients with latex allergy, wound care products that contain latex cannot be used. Sulfonamide antibiotics are common allergens, and silver sulfadiazine is a frequently used topical wound application. Before attempting any pharmacotherapy, the clinician must be aware of the patient's allergy history [9].

Social Environment

The patient should be evaluated within the context of his or her support system [8,9]. The strength or weakness of the support system will help determine the structure of the ongoing wound care plan. For example, is there someone who is willing to learn how to change dressings and perform procedures if the patient is discharged home? Is there someone available to take the patient to an outpatient wound treatment center after discharge? It is vital to determine which type of wound care is the safest, most efficient, and most cost effective for the patient and family and to evaluate the optimum environment in which to deliver this care [13].

Consequences of the wound for the patient and significant other/family must also be assessed. Pressure ulcers have profound effects on the quality of life for patients and many times for caregivers also. Studies show that the psychologic impact of ulcers is greater among younger patients [13].

Caregiver guilt associated with the development of a pressure ulcer is common, and healthcare professionals should be aware of their own preconceptions related to pressure ulcers. Nonverbal responses, such as facial expressions, may be more important than the words that are said. Patient and family reports suggest that, in many instances, healthcare professionals regard pressure ulcers as a sign of neglect. In reality, most caregivers are family members willing to take on the responsibility but with little or no training or preparation for the role. The emotional response of the patient and family to a pressure ulcer may range from anger, embarrassment, and shame to guilt and powerlessness [13].

The physical environment in the home setting must also be considered, especially if the patient will require the services of home health care to continue wound treatment postdischarge. Part of the assessment should include discussion of where the patient lives and if all the basic services are available to them after discharge, such as running water. If there is a lack of service for utilities and electricity, a social worker is an invaluable resource. It is important to recognize that these are issues that must be addressed from the moment of admission and not left until discharge is imminent. A patient with a poor or nonexistent support network or a challenging living environment will require a more in-depth discharge plan to ensure that the goals of wound treatment are met [9].

Educational Needs

Ascertaining the patient's educational status and ability to learn and retain new information is essential to the plan of care. Most of this information can be gathered by direct, nonthreatening questions, such as "What grade did you complete in school?" This simple question can elicit a direct answer and further information about the patient's level of education, literacy level, and language preferences. Knowledge of the significant other's/caregiver's level of education and comprehension is also important, especially for cognitively impaired or dependent patients.

In the clinical setting, the questions most frequently asked by patients and their families regarding wound care are [13]:

- Will the wound heal?

- How long will it take to heal?

- Will the treatment cause pain?

Both the patient's and the family's learning style should be assessed, including current understanding of wound prevention and wound care. Misconceptions may be addressed in a nonconfrontational manner. Many beliefs about appropriate wound care interventions are rooted in treatment modalities that were popular in the past. The clinician should be aware of current evidence-based practices and be able to explain them in simple, clear terms.

Finally, the patient's cognitive status should be assessed, including comorbidities that would adversely affect the patient's ability to care for him- or herself. For example, a patient who has experienced a cerebrovascular accident may have difficulties processing and retaining new information. The patient's coping patterns and willingness or ability to comply with treatment should be taken into consideration. Common issues that should be addressed are feelings of hopelessness, despair, depression, and anger. If any of these factors are present, referral to a mental health professional is advised.

Cultural Norms

In our multicultural society, patients have diverse healthcare beliefs, lifestyles, and practices. Respect for these differences is necessary for all healthcare providers. During the patient history, information should be gathered regarding the patient's and family's beliefs about health and wellness. If these beliefs are unknown, goals may be set that are not in keeping with the patient's priorities.

PHYSICAL EXAMINATION

The physical examination will include a systems review, and the clinician must assess how impairments in any body system will impact wound healing and help shape the plan of care [8]. Comorbid conditions play a part in this assessment. Diabetes and obesity, specifically, affect a large number of patients and can result in devastating impairment in wound healing.

Respiratory System

Many respiratory problems can lead to wound development, slow the process of wound healing, and require special wound care interventions. The respiratory system is partially responsible for delivering oxygen and nutrients to the tissues, both of which are necessary for wound healing.

Many patients with asthma require steroid therapy to control and relieve symptoms, and it is not unusual for individuals with asthma to have a prolonged history of steroid use [9]. While steroids are effective in suppressing the inflammation responsible for asthma attacks, they also block the inflammatory phase of wound healing, which is essential to wound resolution [9]. Oral or topical vitamin A may be used to decrease the anti-inflammatory effects of steroids; consultation with the treating physician on an individual basis for the possible use of vitamin A in the wound treatment plan of care is recommended [14].

Cardiovascular System

Patients with heart disease tend to have impaired pumping capacity, and all body tissues will suffer as a result of this. In patients with any cardiovascular disease, such as congestive heart failure and coronary artery disease, wound healing will be problematic [9].

Musculoskeletal and Neurologic Systems

Patients who have impaired movement in any part of their body are at high risk for pressure ulcer development [9]. This includes those with cerebrovascular accident, spinal cord injuries, multiple sclerosis, Parkinson disease, and arthritis [8,9]. These conditions can severely limit mobility (a risk factor for wound development) and make positioning for wound care difficult.

Gastrointestinal System

Gastrointestinal diseases that lead to poor digestion and malabsorption of nutrients will have a negative impact on wound healing [9]. Patients receiving enteral feedings via gastrostomy tubes frequently have loose stools, which can cause wound contamination. A dietician can make recommendations for altering the consistency of the existing formula or changing to another product. A key consideration for patients with diarrhea is the use of dressings that protect the wound from fecal contamination [9].

Genitourinary System

Approximately 10 to 13 million Americans are troubled with either transient or chronic urinary incontinence [15]. Urinary incontinence will lead to maceration (water logging) of the skin, potentiating the risk for further skin breakdown and contamination of existing wounds [9].

NUTRITIONAL ASSESSMENT

A full nutritional assessment and plan, preferably in consultation with a nutritionist, is an important part of wound care, as nutritionally compromised patients have greater difficulty achieving wound healing. The goal is to characterize the patient's current nutritional state, identify changes that have occurred in recent months or weeks, and predict the impact on the patient's overall functional level and prognosis for healing. This assessment should include protein and calorie intake, hydration status, and the measure of serum albumin and/or proalbumin. Dehydration impairs wound healing by decreasing the blood volume available to transport oxygen and nutrients to healing wounds [9].

Once the patient's nutritional needs and functional status have been clarified, an appropriate plan of care can be devised to ensure adequate nutritional and fluid intake. For some patients with late-stage pressure ulcers and documented nutritional deficiencies, a brief period of enteral or parenteral supplementation may be advisable, keeping in mind that the patient's and family's preferences play an important role in establishing a diet plan.

OTHER COMORBIDITIES

Diabetes

It is estimated that 11.6% of the American population has diabetes [16]. In these patients, elevated glucose levels can impair wound healing and negatively affect the immune system's ability to control infection. Wound healing in patients with diabetes is characterized by a decreased production and deposition of collagen and decreased strength of the healed tissue [1]. In addition, many patients with diabetes, particularly those whose disease is poorly controlled, will develop neuropathy, making the development of ulcers more likely and delaying healing.

Obesity

The number of individuals with morbid obesity continues to rise, and this in turn raises problems for wound healing [17]. Adipose tissue is poorly vascularized, placing these patients at risk for prolonged healing [1].

ESTABLISHING APPROPRIATE GOALS

At the end of the interview and physical examination of the wound(s), it should be possible to formulate goals and develop a plan of care as a team, including the patient and family [9]. Clinicians should be aware that a completely healed wound may not be an attainable goal for all patients. For example, an appropriate goal for a hospice patient might be for the wound to remain stable and for wound pain and odor to be adequately controlled.

It may also be necessary to set separate short-term and long-term goals for wound care. The short-term goals are those that would be implemented immediately in the acute care setting, while long-term goals would continue after discharge [9].

4. WOUND ASSESSMENT

Evidence Based Practice Recommendation

The National Pressure Injury Advisory Panel, the European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance, recommend selecting a uniform, consistent method for measuring pressure injury size and surface area to facilitate meaningful comparisons of wound measurements across time.

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Last Accessed: July 18, 2024

Level of Evidence: B2 (The recommendation is supported by level 2 studies of low quality providing direct evidence or level 3 or 4 studies providing direct evidence.)

All wounds must be thoroughly assessed. Most facilities have their own guidelines regarding minimum frequency of wound assessments, but they should occur at least once a week. Documentation of the cause of the wound is important, if this information can be obtained [13].

The wound assessment includes identifying the location of the wound; its size, shape, and depth; the condition of the wound edges; and the presence or absence of tunneling or undermining [13]. Assessment findings should also note the condition of the wound bed and how visible it is. For example, the entire surface of the wound may be visible or part or all of it may be obscured by necrotic tissue [9]. The location of the wound should be stated in a manner that is clearly understood. Anatomical markings should be used, such as the sacrum or right or left ischium [12].

It is important to remember that an ulcer cannot be staged until the complete wound bed can be seen [12]. If necrotic tissue is present, determine its defining characteristics, including color (black, brown, yellow, or some combination) and density (hard and leathery or soft to the touch). Necrotic tissue may be attached to the wound bed, like a second skin, or it can be loosely adhered. Even if necrosis is present, visible wound size, length, and width must still be measured and documented.

It is necessary also to evaluate any exudate in the wound and again describe it; it may be clear, bloody, serosanguineous, thick yellow, or greenish. Note whether an odor is present [9].

HISTORY OF THE WOUND

Aside from the physical condition of the wound, information about the history of the wound should be obtained. How the wound started and how long it has been present must be documented. Treatments used and the patient's wound response to these interventions should also be noted [9]. If noncompliance with treatments has been an issue, the underlying cause(s) must be ascertained. Lack of communication between the involved parties may have led to a misunderstanding on the part of the patient and/or caregiver(s) as to their role in wound care. For example, a bedbound patient in the home may require daily dressing changes by the designated family caretaker, with the home health agency monitoring wound progress on a weekly basis. To prevent inadequate care, the caretaker should be appropriately trained in the dressing technique and should understand the importance of completing the dressing changes on a daily basis. Economic strain can also contribute to noncompliance. Patients may not have the financial resources necessary to purchase dressing supplies.

WOUND PHOTOGRAPHY

With the growing awareness of the possibility of litigation in wound care, many facilities have instigated a policy of photo documentation. Wounds present on admission are photographed. In addition, some facilities require serial photographs to track wound progress and status at the time of discharge. Signed consent is required before wound photographs can be taken, and in most instances, the photographs become a permanent part of the patient's medical record. Approximately 75% of home health agencies in the United States now include wound photography as part of the patient's medical record [9]. The American Health Information Management Association recommends that consent for photography be included in the consent for treatment when photography is routinely used. The Health Insurance Portability and Accountability Act (HIPAA) guidelines require that patients are adequately informed of the use of photography [18].

WOUND MEASUREMENT

Accurate measurement of the wound is probably the most important feature of wound assessment [9]. It provides information on the initial size and progression or non-progression of healing, allowing for valuable feedback on the effectiveness of clinical interventions. Decreasing wound size is generally regarded as a sign of wound healing [13].

Wounds should always be measured in centimeters, using a plastic or paper ruler. Wound length is measured from head to toe; width is measured from hip to hip. The depth of the wound can be obtained by gently inserting a sterile cotton-tipped applicator into the wound bed and marking it at skin level. The applicator is then measured using a metric ruler [1].

TUNNELING AND UNDERMINING

Sinus tracts and undermining impair healing, and it is important to immediately identify their presence. A sinus tract is a tunnel that extends from any part of the wound and can bore through subcutaneous tissue and muscle. This tunnel creates dead space, which can result in abscess formation and further impede the healing process. A sinus tract can be measured using a sterile cotton swab [13].

Undermining is defined as destruction of the tissue under the skin around the edges of the wound. This frequently occurs in pressure ulcers that have been subjected to shear force as well as pressure. It is important to document the location and extent of undermining.

The easiest way to measure and describe undermining is by using the face of the clock. With the patient's head representing 12 o'clock, sweep the area of undermining or probe the tunneling to ascertain the depth. For example, undermining along the right border would be recorded as extending from 1 o'clock to 5 o'clock with a depth of 4 cm [13]. It is important to check around the entire perimeter of the wound, as undermining can occur in more than one location.

WOUND BED

It is also vital to assess and document the appearance of the wound bed. If the wound bed has a mixture of tissue in it, this should be documented by an approximate percentage (e.g., the wound base is 75% granulation tissue and 25% slough). Granulation results in "beefy" red tissue with a shiny, moist granular appearance, while necrotic tissue is gray, brown, or black. Eschars are typically gray to black and dry or leathery in appearance [19]. Slough tissue is yellow/white to gray in color. It may be stringy or thick and appear as a layer over the wound bed [19]. Epithelial tissue will often begin to grow in from the edges over the wound surface. This tissue is generally pink and shiny. As a quick reference color guide, red is associated with normal healing, yellow indicates slough or dead tissue, and black is necrosis [13].

SURROUNDING SKIN

The condition of the surrounding skin surface up to 4 cm from the edge of the wound circumferentially must also be assessed and documented. Its characteristics should be noted, particularly color and integrity [14]. Maceration from excessive drainage may indicate that the dressing used is not appropriate and a different product is needed. Circumferential redness up to 2 cm from the wound is indicative of cellulitis.

WOUND PAIN

According to the NPIAP, pressure injuries cause considerable pain and suffering [3]. Pressure ulcer pain has been described as ranging from sore to excruciating. In one study, 75% of patients rated their pain as mild, discomforting, or distressing; 18% rated their pain as horrible or excruciating [20]. Another study ranked pain according to stage of pressure ulcer and found that 50% of patients with stage 2 pressure ulcers indicated their pain was discomforting. All patients with stage 3 ulcers indicated pain was distressing, and 100% of patients with stage 4 injuries rated pain as horrible [21]. Pain and odor control are a major concern for patients, and studies have shown that patients rank pain control as more important than healing [13]. The level of pressure ulcer pain depends both on the stage of the ulcer and on manipulation of the area (e.g., if a dressing change is done at the time of assessment). The majority of patients report pressure ulcer pain at rest as well as with dressing changes. Pressure ulcer pain may be due to tissue trauma, inflammation, damaged nerve endings, infection, procedures such as debridement, and dressing changes [21].

The criterion standard for assessing pain intensity is self-report using standard pain intensity instruments. Two of the most widely used pain assessment scales are the numeric pain intensity scale and the Wong-Baker Faces Pain Rating Scale [22]. The numeric pain intensity scale consists of ratings from 0 (no pain) to 10 (worst possible pain). This scale can be used for pain assessment with adults and children older than 7 years of age [6]. Visual presentation of the numeric pain intensity scale is helpful with hearing impaired patients, and the scale has been translated into many languages.

The Wong-Baker Faces Pain Rating Scale consists of six faces ranging from a happy smiling face (no pain), to a crying, frowning face (worst pain). The patient is asked to choose the face that best reflects his or her pain. The Faces Pain Rating Scale is the preferred scale for use with children and may also be used with the geriatric population. It can also be used with cognitively impaired patients and those for whom English is a second language.

After the initial pain assessment has been completed, reassessment should be done at regular intervals. As noted, pain intensity should be rated by the patient, not a healthcare professional. The following questions may be used to help determine patients' pain levels:

- What kind of pain are you experiencing?

- What word(s) would you use to best describe it (e.g., burning, aching, shooting)?

- What makes the pain better?

- What makes it worse?

- Where is the pain located?

- Does the pain radiate?

- Would you describe your pain as none, mild, moderate, severe, or excruciating?

- How would you rate your pain on a scale of 0 to 10, with 0 representing no pain and 10 being the worst imaginable pain?

- What is the pain intensity at its worst, best, and now?

- Is the pain better or worse at any particular time of the day or night?

- When does it start and when does it stop?

5. AN OVERVIEW OF WOUND HEALING

Wounds heal by two possible mechanisms: regeneration or scar tissue formation. The depth of the wound (i.e., the number of tissue layers involved) will determine whether the wound will heal by regeneration or by scar tissue formation [14].

Wounds can also be described as healing by primary or secondary intention. Wounds resolved by primary intention are surgically closed. With secondary intention, wounds are left open and heal via the process of granulation, contraction, and epithelialization. Pressure injuries are an example of a wound that heals by secondary intention. A third classification, wounds that heal by tertiary intention, includes cases in which healing starts by secondary intention but the wound is then surgically closed [14]. Wound healing can be conceptualized as a cascade of events, and the process will differ depending on many different factors, particularly whether the wound is partial thickness or full thickness [14]. A partial thickness wound involves loss of the epidermis and usually part of the dermis [1]. These wounds are shallow, superficial, and painful. Healing of a partial thickness wound is usually a straight-forward process involving a brief inflammatory phase, cell migration, and re-establishment of normal skin layers [14]. The most important consideration with partial thickness wounds is to keep the area moist and clean. It is important to remember that a dry cell is a dead cell.

Full thickness wounds occur when there is destruction of the epidermis and the complete dermis. At the base of the wound, subcutaneous tissue, fascia, muscle, or bone may be visible [14]. Healing of full thickness wounds occurs in four stages: hemostasis, inflammation, proliferation, and remodeling, with considerable overlap occurring among the stages. The time frame for repair of a full thickness wound is considerably longer than that of a partial thickness wound [1]. Regardless of the cause, this biologic process of repair is the same for all acute wounds [9].

HEMOSTASIS

Hemostasis begins soon after a wound develops. This stage involves fibrin clot formation to stem blood loss and to protect the wound from bacterial infection. Studies have shown that substandard clot formation leads to poor wound healing, and individuals with impaired clotting have impaired healing [1,14]. Clotting activates degranulation of the platelets, which causes the release of growth factors called polypeptides into the wound [9]. Growth factors begin the process of wound repair by recruiting neutrophils and macrophages to the wound bed [14].

INFLAMMATION

The standard signs and symptoms of localized inflammation are erythema, swelling, warmth, and tenderness. In normal healing, these signs are only minimally noticeable. During the inflammatory phase of wound healing, they are considered a normal response [9].

After hemostasis is established, the next stage in the process of natural healing is inflammation, which should result in the establishment of a clean wound bed. During this phase, damaged tissue is broken down and, along with excessive bacteria, removed from the wound by white blood cells [1]. The two most important cells involved in the inflammatory phase are neutrophils and macrophages [13].

Neutrophils arrive in the wound immediately after injury, usually within the first hour. For the first few days they lead the wound clean-up process [1]. They target the bacteria and debris in the wound, which is removed by the process of phagocytosis. Neutrophils have a very short life span, and around the third day after injury, they begin to disappear from the wound and are replaced by macrophages [13].

Macrophages perform multiple functions in wound repair and have been referred to as the regulators of wound repair. They are essential to the process of moving wound healing from the inflammatory phase to the proliferative phase [9]. Studies have shown that wound repair is limited or non-existent in the absence of macrophages [14].

When caring for a wound in the inflammatory phase, the goals are debridement and infection control. These wounds usually have a great deal of drainage, so absorptive dressings are normally used [14]. The end result of the inflammatory phase is a clean wound bed [1].

PROLIFERATION

The proliferative phase of wound healing overlaps and follows the inflammatory phase. During this process, the wound bed is filled with new granulation tissue and the wound is resurfaced with new epithelial tissue [14]. This stage can last for several weeks [9].

In full thickness wounds, the process of re-epithelialization occurs only from the wound edges [14]. Margin basal cells attached to the dermis eventually loosen and start migrating across the wound. The horizontal movement comes to a halt when the cells meet [9]. This is called contact inhibition. Wound contraction is the final part of the proliferative phase. Fibers in the wound contract to bring the wound edges closer together.

MATURATION/REMODELING

Maturation and remodeling of the wound involves rearranging collagen fibers and increasing the tensile strength of the scar tissue. Scar tissue regains about 80% of normal tissue strength within three months, but it is important to note that it never achieves the full strength of the original tissue [14]. Therefore, the healed site of an old wound is vulnerable to further breakdown.

6. WOUND CLEANING

The Institute for Clinical Systems Improvement (ICSI) recommends that all pressure ulcers be cleaned when first diagnosed and then with every dressing change [23,24]. The purpose of wound cleaning is to remove nonadherent debris from the wound bed in order to promote healing and make the wound less susceptible to bacterial overgrowth and infection [13]. While cleaning the wound, it is necessary to minimize trauma to the wound bed and healthy tissue [13]. Choosing the correct product for cleaning the wound is very important. Most wounds can be effectively cleaned with normal saline, a nontoxic and inexpensive product [9,24]. If used, saline must be applied to the wound with sufficient force to remove surface debris and contaminants while also minimizing trauma to the wound [1]. Normal saline used for wound cleansing should be room temperature and should be discarded within 24 to 48 hours after opening [9].

The most frequently used method for wound cleansing is irrigation [1]. Studies of the optimal irrigation pressure for effective wound cleaning have found that pressures less than 4 pounds per square inch do not remove wound debris and pressures greater than 15 pounds per square inch force the debris into the wound tissue rather than removing it [1]. The goal is to obtain pressures in the range of 8 to 15 pounds [14]. Irrigation should be done gently using a 35-cc syringe and a 19-gauge needle [14]. An angiocatheter can be used instead of a needle to decrease the risks of finger sticks [1].

If a large amount of debris is present in the wound, use of a commercial cleaning agent may be necessary. Wound cleansers with surfactants in their composition are helpful when the wound is heavily burdened with surface debris. These cleansers break the chemical bonds that attach the wound debris and cause it to loosen from the wound bed [13].

Antimicrobial agents have usually been discouraged for wound cleansing, and they are not required for cleaning healthy, noninfected wounds [9,25]. However, research has shown that antiseptic agents such as sodium hypochlorite and povidone iodine (both at the strength of 0.25%) are safe to use in wound care for short periods of time (four to seven days) to decrease the bacterial burden [9,25]. Sodium hypochlorite should be used for no longer than 10 days due to cytotoxicity of healthy cells and granulating tissues surround the wound [25,26,27]. Some studies show that infection rates using povidone iodine are similar to those when saline was used; saline may be as effective as and safer to use than povidone iodine [26,27]. The benefits of these products should be weighed against the possible risk of bacterial resistance. Skin cleansers (e.g., those used to remove feces from the skin) are much more toxic than wound cleansers and should not be used for wound care [13].

7. PAIN MANAGEMENT

The goals of pain management in the pressure ulcer patient are to provide analgesic relief and to eliminate the cause of pain. There are several interventions and practice modifications that can prevent or manage wound-associated pain.

Skin care and assessments should be performed at a time of day when the patient is least fatigued [12]. All procedures should be thoroughly explained before they are performed. If a patient has questions, this should be addressed, and healthcare professionals should be encouraging and provide positive reinforcement. It is important to avoid trauma (e.g., shearing, tear injuries) to fragile skin during transferring, positioning, or holding a patient. If necessary, adjunctive medications may be administered to improve sleep and reduce anxiety, which can contribute to experiences of pain.

Dressing changes are often very painful. An analgesic may be administered 30 minutes before dressing changes, and if possible, the number of daily dressing changes should be kept to a minimum. Tape should always be avoided on fragile skin. If patients are able, they should be allowed to remove their own dressings or set the pace of dressing changes. All patients should be assessed for pain before, during, and after dressing changes, and these findings must be documented [13].

Physical therapy and occupational therapy may be helpful to decrease contractures and muscle spasm. Of course, ensuring proper seating and positioning can improve pain scores and decrease the risk for further pressure injuries.

8. WOUND DEBRIDEMENT

Necrotic tissue compromises wound healing and can be a source of bacterial overgrowth [9]. It stalls wound healing in the inflammatory phase and prevents the natural progression of healing [14]. For a wound to heal, it must be free of nonviable tissue, and this is commonly achieved by debridement [13].

Evidence Based Practice Recommendation

According to the National Pressure Injury Advisory Panel, the European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance, pressure injuries should be debrided of devitalized tissue and suspected or confirmed biofilm, with maintenance debridement performed until the wound bed is free of devitalized tissue and covered with granulation tissue.

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Last Accessed: July 18, 2024

Level of Evidence: B2 (The recommendation is supported by level 2 studies of low quality providing direct evidence or level 3 or 4 studies providing direct evidence.)

Necrotic tissue adheres to the wound bed more when the moisture level in the wound drops and the amount of tissue damage increases [9]. It can present in different forms, though most necrotic tissue is firm and dry. Beneath the dry necrotic tissue is slough, the moist, soft, dead tissue often found loosely attached to the wound bed. Slough has a stringy appearance and may be brown, yellow, or gray in color [1].

In addition to helping move the wound through the stages of healing, debridement is often necessary to visualize the wound bed and stage the wound; a wound covered with necrotic tissue cannot be staged [13]. An exception is eschar on the heels, which acts as a natural biologic cover, and should not be removed unless infection is present.

The method of debridement used depends on the amount of necrotic tissue present, the location of the wound, and the patient's overall condition [9]. By definition, stage 1 pressure injury does not require debridement. The wound should simply be covered with transparent film for protection and preventive measures taken to limit progression and reduce the risk for additional pressure injury elsewhere. Stage 2 and early stage 3 wounds can often be debrided effectively with autolytic and/or enzymatic debridement technique, as discussed in detail later in this section. Patients with stage 3 or 4 pressure ulcers who have undermining and/or tunneling or extensive necrotic tissue should have a surgical evaluation for possible surgical debridement of the wound, if this is consistent with their condition and the goals of care [2,6]. Infected wounds may require systemic antibiotic treatment and immediate surgical debridement [13]. Maintenance debridement should be continued until there is a covering of granulation tissue in the wound bed and the wound is free of necrotic tissue [6].

AUTOLYTIC DEBRIDEMENT

The body's own physiologic processes to remove necrotic tissue are referred to as autolytic debridement [9]. Studies have shown that autolytic wound debridement is more effective than wet-to-dry dressings because it removes only necrotic tissue and leaves healthy tissue intact [9]. For autolytic debridement to be successful there must be a moist environment and sufficient white blood cells available to the wound [1]. A layer of wound exudate should be kept in contact with the surface of the wound [14]. A moisture-retaining dressing may be used to keep the wound bed moist [9,13]. This allows fluid to accumulate in the wound, rehydrating necrotic tissue and making it possible for enzymes in the wound to digest the dead tissue [9]. For a wound covered with dry eschar, it is appropriate to crosshatch the eschar, as this allows a faster build-up of moisture in the wound [9]. In their clinical practice guidelines for pressure ulcer treatment, the ICSI recommends autolytic and enzymatic debridement as the preferred approach for patients in long-term care and home care and for patients who cannot tolerate other methods of debridement [9,23].

Choosing the correct product and dressing material for autolytic debridement is important to successful healing; a semi-occlusive or occlusive dressing should be used [13]. In addition, amorphous hydrogels are effective in digesting necrotic tissue in wounds and may be used as an adjunct [9].

Transparent film dressings are the best choices for debriding dry eschar, as they are non-absorptive. These dressings establish a fluid environment. For moist wounds with necrotic tissue, hydrocolloids are a good choice. Hydrocolloids have the ability to absorb a certain amount of drainage while maintaining a moist wound environment [9].

There are several advantages to autolytic debridement. It is relatively inexpensive and harmless to healthy tissue. Wound progress is usually seen within six days, and it can be used in combination with other debridement methods for enhanced effect [9]. It is generally a good option for patients whose condition does not permit surgical intervention.

The disadvantage of the autolytic approach is that lack of familiarity with the process can cause problems. The breakdown of dead tissue and the subsequent odor and accumulation of exudate may cause clinicians/family members to wrongly infer that the wound is either infected or worsening [1].

Nursing staff and caregivers should understand that the accumulated fluid in the wound contains essential factors necessary for debriding the wound and promoting wound repair [1]. Education should also note that the wound will initially become larger with debridement, but this is not a sign that the wound is deteriorating [13].

ENZYMATIC DEBRIDEMENT

Enzymatic debridement is a safe and effective method that involves the application of a concentrated, commercially prepared enzyme to the surface of the necrotic tissue [13]. It is recommended when surgical debridement is not an option and the patient is not considered a good candidate for autolytic debridement [9,23].

Enzymatic debridement is a selective method that will not adversely affect healthy tissue [9]. Applied enzymes liquefy the necrotic tissue and destroy the bonds that attach it to the wound bed [12]. The advantages of enzymatic debridement are that it does not harm healthy tissue in the wound and can be effectively used in combination with other methods of debridement [9]. Eschar present in the wound should be crosshatched before application of enzymatic therapy to improve efficacy, as enzymes are not active on a dry surface [9].

Wound progress should be seen in 48 to 72 hours. However, complete debridement of the wound may be a long process; therefore, whenever possible this method is used in conjunction with autolytic debridement and conservative surgical wound debridement (i.e., bedside removal of loosely adherent necrotic tissue) [14]. Conservative surgical wound debridement is completed by a physician or a wound care nurse.

Enzyme formulations available for debridement include collagenase (Santyl), papain (enzymes derived from papaya), and trypsin (Granulex, Vasolex, Xemaderm); only collagenase is available in the United States [12]. Collagenase is a derivative of Clostridium bacteria and acts by liquefying the collagen bonds that fasten necrotic tissue to the underlying wound bed. The time to effect ranges from several days to weeks.

Enzymatic debridement can be used in conjunction with most other dressings; however, it should not be used with silver or cadexomer iodine dressings. Silver dressings reduce the efficacy of collagenase by more than 50%; cadexomer iodine reduces its efficacy by 90% [28].

Studies indicate that enzymatic debridement is cost-effective, but it requires daily or twice daily dressing changes and the application of a secondary cover dressing, which should be factored into the cost [28]. When the wound bed is free from necrotic tissue and slough, the use of enzymatic debridement should be discontinued.

Enzymatic debridement is not generally indicated for the treatment of infected wounds due to the extended length of time required to achieve a clean wound. If necessary, enzymes may be used in cases of infected wounds if antibiotic therapy has already been initiated [14].

MECHANICAL DEBRIDEMENT

Mechanical debridement is achieved by applying outside force to remove necrotic tissue in a wound [9,23]. One long-standing and widely used form of mechanical debridement is wet-to-dry gauze dressings, usually with normal saline. Although it is a commonly used treatment, the advantages of familiarity and simplicity of use are outweighed by the disadvantages. Studies indicate that wet-to-dry dressings remove healthy viable tissue as well as necrotic tissue [9]. In addition, the standard time frame for dressing changes, every eight hours, increases the associated costs of labor and supplies. The dry, adherent dressings are painful to remove, and seepage of moisture from the dressing can lead to maceration of periwound tissue. As such, the AHRQ advises cautious use of this method of debridement [9].

Whirlpool therapy is another form of mechanical debridement. It is most frequently used with larger wounds to remove debris and bacteria from the wound bed. However, it does not remove dry eschar from the wound, and there are concerns about the likelihood of cross-contamination between patients [1].

The use of ultrasound waves to debride wounds has also been explored. With this technique, low-frequency ultrasound creates small bubbles in the wound that implode, causing the necrotic tissue to liquefy [12]. This method is generally less painful and less traumatic than traditional methods, with faster healing rates compared to other methods of mechanical debridement [29,30]. Studies show that low-frequency ultrasound is most effective when used three times per week [30]. However, further comparative evidence and large-scale studies are necessary before it can be recommended as a replacement for established treatment modalities [30,31].

Maggot Debridement Therapy

Maggot debridement therapy (MDT), an approach popular at the early 20th century, is finding a renewed place in wound care debridement [13,32]. Much of this interest is centered on the ability of maggots to ingest and destroy micro-organisms without inducing resistance among bacterial organisms. It is believed that the larvae secrete enzymes, including collagenase, that break down the necrotic tissue; they also ingest and destroy micro-organisms [1]. Maggots have the ability to access moist tissue throughout the wound bed and clean small areas without harming healthy tissue [33]. The process involves the application of sterilized larvae from the green-bottle fly maggots to the wound bed every two to three days. The maggots can be applied to the wound directly or in a containment pouch [13]. The most appropriate dressing for wounds treated with maggots is one that keeps the larvae in place, allows for a flow of oxygen, and is suitable for the characteristics of the wound [9].

MDT is indicated for pressure ulcers with necrotic tissue with or without infection [33]. It has also been shown to be an effective treatment of diabetic wounds [34]. Maggots work well in wounds in which moisture and oxygen are readily available and the pH is fairly stable [9]. The therapy is considered mainly for the treatment of wounds for which other forms of treatment are either not appropriate or not successful [14]. MDT is contraindicated in patients who have bleeding abnormalities or deep tunneled wounds [13]. Because there is no benefit in continuing MDT past one week, another type of dressing should be used after two or three applications of MDT [35].

Precautions should be taken to prevent the larvae from coming in contact with healthy skin, as there is a possibility of enzymatic damage. Otherwise, there are no reported side effects from maggot therapy. However, some patients complain of a crawling or tingling feeling [1]. Maggot therapy may also cause psychologic distress for many patients, and its use should be discussed thoroughly with the patient and/or family prior to commencing therapy [13]. This therapy should only be used with appropriately informed consent.

CHEMICAL DEBRIDEMENT

Chemical debridement utilizes nonenzymatic solutions to break down necrotic tissue in wounds [14]. The most widely used are sodium hypochlorite (bleach) solutions, including Dakin's solution, and oxychlorosene (Clorpactin WCS-90) [14,36,37]. Dakin's solution at the strength of 0.25% is nontoxic to healthy tissue, and gauze dressings soaked in Dakin's solution help to dissolve necrotic tissue and decrease the bacterial burden in the wound [14]. Regardless of the chemical used, the dressings must be changed every 12 hours. The periwound area should be protected from contact with the dressing, either with petrolatum ointment or strips of solid skin barrier around the edges of the wound [14].

Dakin's solution is normally stored in clear containers. It loses its potency in 24 to 48 hours and must be replaced at least every other day. When first opened, containers should be labeled with the date and time. After the wound is free from necrotic tissue, the use of sodium hypochlorite or oxychlorosene should be discontinued [14].

9. WOUND DRESSINGS

Wound dressings are a pivotal aspect of wound care [6]. Dressings insulate the wound from the external environment, provide a barrier to prevent bacterial infection, maintain a moist environment, wick fluid from areas of tunneling, and absorb drainage [14]. Ideally, a wound dressing should also provide for gaseous exchange, allowing oxygen, carbon dioxide, and water vapor to pass in and out through the dressing [9].

When choosing a wound dressing, one of the most important factors to consider is the type of tissue in the wound bed—granulating or slick looking, moist or dry. Also consider the depth of the wound, whether tunneling or tracking is present, and the amount of drainage [14]. The condition of the skin surrounding the ulcer must also be determined [6].

Wound dressings can be divided into two main categories: those placed inside the wound in contact with the wound bed and those placed on top of the wound as a cover. Shallow wounds with little drainage may only require a cover dressing. However, wounds with a depth greater than 0.5 cm and/or with tunneling or undermining often require both an internal and a cover dressing [14]. As the wound changes, the type of dressing may also need to be changed [6].

Dressings can also be categorized according to their ability to introduce or wick moisture. Dressings that add moisture to the wound bed are referred to as hydrating; dressings that remove excess exudates from the wound surface are absorptive [14].

HYDROCOLLOIDS

Evidence Based Practice Recommendation

The National Pressure Injury Advisory Panel, the European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance recommend using hydrocolloid dressings for non-infected category/stage 2 pressure injuries, as indicated by the clinical condition of the pressure injury.

https://static1.squarespace.com/static/6479484083027f25a6246fcb/t/6553d3440e18d57a550c4e7e/1699992399539/CPG2019edition-digital-Nov2023version.pdf

Last Accessed: July 18, 2024

Level of Evidence: B1 (The recommendation is supported by level 1 studies of moderate or low quality providing direct evidence or level 2 studies of high or moderate quality providing direct evidence.)

Hydrocolloids are excellent dressings for the prevention of secondary infections [14]. In the past, hydrocolloids were considered occlusive dressings, but more recent versions have a backing of a semiocclusive film layer that is impermeable to fluids and bacteria but semipermeable to gas and water vapor [1]. Hydrocolloids can accommodate only moderate amounts of wound drainage and are therefore not used for heavily draining wounds [14].

These dressings can produce an odor upon removal. In the absence of other signs of clinical infection, this is not an abnormal finding and should be explained to concerned patients and staff [13]. Hydrocolloids may also leave a residual in the wound bed, which should be gently irrigated out at dressing change. Hydrocolloids lose their effectiveness if they are changed too frequently and should not be used for wounds that need to be monitored daily [1].

HYDROGEL

Hydrogel dressings are used with shallow wounds with minimal amounts of drainage and are also a good option for painful ulcers [6]. Hydrogel dressings are usually hydrating and are either glycerin- or water-based [1]. These dressings are appropriate for use with topical medications and antibacterial agents [13].

Amorphous hydrogel dressings are especially useful for wounds with depth and contours [6]. However, these dressings provide only minimal absorption and should be used in wounds with small amounts of exudate [14]. Amorphous hydrogel dressings vary widely in their level of viscosity and are available in sheet dressing, tube, spray bottle, and ribbon gauze [1].

FOAM DRESSINGS

Foam dressings are a good choice for stage 2 and shallow stage 3 injuries with drainage and for painful pressure injuries. Foam dressings protect wounds at risk of further damage from shear and can be used along with topical treatments [6,13]. Foam dressings impregnated with ionic silver are available to reduce the risk of infection. These dressings can also be used along with alginates to improve management of wound drainage [1]. Foam provides for thermal insulation, conforms to body shape, and leaves no residual in the wound [9]. Clinicians must be careful to place the correct side of the foam dressing in contact with the wound surface [13].

SILVER-IMPREGNATED DRESSINGS

Silver-impregnated dressings are a treatment option for infected or heavily colonized wounds or wounds that are at increased risk for infection. Silver has an antimicrobial effect on a broad spectrum of organisms and has been shown to reduce the bacterial count in wounds, except for highly exuding wounds where the cytotoxic properties of silver may offset these advantages [1,38]. Sustained-release silver dressings are toxic to bacteria and fungi but do not adversely affect healthy wound tissue [14]. However, silver-resistant organisms do exist, and the judicious use of silver is advised, similar to the approach adopted with antibiotics [1,38]. It is recommended that the use of silver dressings be limited to a two- to four-week period [1].

CADEXOMER IODINE DRESSINGS

Cadexomer iodine dressings are used for wounds with moderate-to-high amounts of drainage. They should not be used for patients who are sensitive to iodine or individuals with thyroid disease [39]. Cadexomer iodine dressings are antimicrobial and help fight bacteria while maintaining a moist environment for wound healing [13]. Although these dressings are capable of reducing bacterial counts in wounds, they do not replace the need for systemic antibiotic therapy and are regarded as an adjunct in the treatment of wound infections [13]. One systematic review found no clear difference between cadexomer iodine and standard care [40].

CALCIUM ALGINATE DRESSINGS

Calcium alginate dressings are highly absorptive dressings made from lightweight seaweed. They can absorb up to 20 times their weight in wound drainage, which makes them an excellent choice for heavily draining wounds [13]. There are two types of alginates: one that becomes a gel after coming in contact with the wound drainage and one that retains its original shape while absorbing exudates [14]. In addition to their absorptive abilities, calcium alginate dressings can aid in hemostasis, making them a good choice for bleeding wounds. They also have been found to be effective against both Gram-positive and Gram-negative bacteria [41]. Wounds treated with alginate dressings made from seaweed may smell fishy or like "low tide" [13].

HYDROCOLLOID FIBER DRESSINGS

Hydrocolloid fiber dressings are used only in wounds with large amounts of drainage. They are placed in the wound dry and transform into a gel after absorbing exudate [14]. These dressings are comfortable and easy to remove, but they usually require a secondary dressing to hold them in place [13].

GAUZE

Gauze packing was used frequently in the past, but it is now regarded as less effective in coping with wound drainage than calcium alginate or hydrocolloid fiber dressings. Gauze dressings do not provide a barrier against bacteria, do not lower wound temperature, and can pull healthy granulating tissue out of the wound on removal [14]. Gauze dressings are also labor intensive, requiring several dressing changes daily, which adds to the cost of the overall care [13].

COMPOSITE DRESSINGS

Composite dressings are a combination of more than one material used to fulfill several important functions in the wound. They provide an effective barrier to bacterial contamination of the wound and include an absorptive layer and foam, hydrocolloid, or hydrogel. Composite dressings can have either a semi-adherent or non-adherent surface placed in contact with the wound bed [13]. Composite dressings are comfortable and are available in various shapes and sizes [1]. These dressings should not be cut, as this compromises the structure of the dressing [13].

COLLAGEN DRESSINGS

Some dressings incorporate collagen, which is an important protein involved in wound healing and repair [1]. The dressings can be 100% collagen or combined with other products, such as alginates. They provide a high level of absorption while keeping the wound bed moist and are easily removed [13]. For wounds with very little drainage, collagen gel can be applied in a layer one-quarter inch thick [1]. Collagen used in most wound dressings is derived from cowhide. Therefore, it should not be used in patients who are allergic to bovine products [13].

SPECIAL CONSIDERATIONS

Tunneling and Undermining

An occlusive dressing should not be placed over wounds with tunneling and undermining due to the danger of anaerobic micro-organism growth [13]. Ribbon gauze should be used to fill areas of narrow tunneling, with the end of the gauze placed securely in the wound base to allow for easy retrieval [12].

Wound Packing and Filling

Wounds are packed to fill dead space and eliminate the possibility of abscess formation caused by premature closure of the wound. The materials used for packing should conform to the base and sides of the wound. Wound packing material should be fluffed and placed loosely into the wound using a cotton swab [1]. It is important to ensure that the dressing material is in contact with all wound surfaces but also that the wound is not overpacked.

Wound fillers come in hydrated form, usually paste or gels, or dry form, which includes powder, granules, beads, and rope. Wound fillers can contain collagen, alginate, foam, or hydrogel. They are non-adherent and require a secondary dressing to hold them in place. Dressing changes of packed wounds are normally done on at least a daily basis [1].

Frequency of Dressing Changes

The frequency with which a dressing will be changed depends on several factors, including the manufacturer's guidelines, the condition of the wound, and the amount of drainage present. Daily or every other day dressing changes are usually better for the patient, being less painful and more cost effective than dressings that must be changed two to three times per day [14]. This should be taken into consideration when selecting wound dressings.

10. WOUND MONITORING

Routine evaluation of wound treatments and wound progression is essential, and wounds should be assessed at each dressing change [1]. Clinical signs of improvement are expected to appear within two to four weeks [14]. When evaluating the wound, the most important factor to consider is whether the wound is progressing toward the goals established at the onset of treatment. If the wound is not progressing, further assessment and adjustment of the treatment approach are warranted [1].

For nonhealing wounds, the first factor to evaluate is the quality of wound care. This includes determining if dressing changes are being carried out at the recommended intervals, if the dressings are applied appropriately, and if the manufacturer's instructions for product use are being followed [1]. Factors affecting the patient's condition should be taken into consideration and addressed appropriately. Failure of a wound to improve is often due to systemic factors, such as ischemia, infection, or malnutrition, or continuation of the causative factors. These issues must be addressed first to achieve optimum wound healing. A change in the dressing treatment is indicated if any of the following problems occur [14]:

- Maceration of the surrounding skin

- Inadequate control of wound drainage

- A change in the amount of drainage or the depth of the wound

Reverse staging of pressure injuries is not an acceptable approach to gauging the level of wound healing. Healed pressure injuries do not replace lost muscle, subcutaneous fat, or dermis [6]. Tools that do appropriately measure degrees of healing include the Bates-Jensen Wound Assessment Tool and the Pressure Ulcer Scale for Healing (PUSH) Tool [13,42]. The Bates-Jensen Wound Assessment Tool has thirteen variables that provide a composite picture of the status of the wound [13]. The PUSH tool uses scores in three domains (i.e., size, exudate amount, and tissue type) to indicate improvement or deterioration of the ulcer. A score of 0 on the PUSH tool indicates the wound has healed, whereas the highest score of 17 indicates wound degeneration [13].

DOCUMENTATION

Wound care documentation should be concise and frequent [13]. It should be based on nationally recognized standards of care; shortcuts should not be used, and only approved abbreviations should be included in the documentation [12]. Problems arise when there are numerous and different descriptions of a pressure injury [1]. If present, all wounds should be documented on admission to provide a baseline comparison for future assessments [13]. Subsequent wound care provided must be recorded, including accurate dates and times and the name of the clinician providing the care. All statements should be substantiated by objective clinical findings. The condition of the wound on discharge should be thoroughly documented and reported to the agency providing follow-up care. As noted, photography is becoming increasingly commonplace.

11. PREVENTION OF PRESSURE INJURIES

All persons who are bedfast or chairfast should be considered at risk of developing pressure injuries. Specific potential risk factors include conditions that limit mobility, such as stroke, debilitating illness, frail elderly, and injuries that require external medical devices (e.g., fracture casting).

The 2019 NPIAP/EPUAP guideline and the 2016 prevention points advocate attention to the following principles of preventive skin care for at-risk persons and for patients with an established pressure injury [6,43]:

- Skin should be examined within eight hours of admission, and a structured risk assessment (e.g., the Braden Scale) should be conducted as close to eight hours after admission to identify individuals at risk of pressure injury.

- Avoid positioning the individual on an area of skin redness whenever possible.

- Keep the skin clean and dry.

- Do not massage or vigorously rub skin zones at risk (i.e., over bony prominences).

- Develop and implement an individualized continence management plan.

- Protect at-risk zones of skin from excessive moisture with a barrier product.

- Consider prophylactic dressings, such as polyurethane foam dressing, to protect skin over boney prominences (e.g. back, sacrum) or in direct contact with medical devices.

Patients with any degree of pressure-induced skin injury/ulcer should be positioned and repositioned at frequent, regular intervals throughout the day, making use of foam mattresses or protective overlays designed to reduce pressure and avoid friction/shear.

12. PROGNOSIS

With appropriate care (i.e., careful and through assessment), treatment of comorbidities, diligent wound management, and maintenance of nutrition, the prognosis for complete healing of pressure injuries is very good, especially if intervention occurs before late stage 3 progression. A two-year observational study of 1,626 patients with stage 2 through 4 pressure ulcers admitted to 51 nursing homes in all parts of the country found that with standard care, 74% of stage 2, 60% of stage 3, and 33% of stage 4 injuries had healed completely at six months [44]. Of surviving patients at one year of therapy, 87%, 80%, and 60% respectively had healed.

13. CONCLUSION

Wound care is an exciting and ever-evolving practice, and a coordinated team effort can bring about remarkable results. Healthcare professionals must keep abreast of the growing scientific research in this area, as newer or re-discovered treatments can impact nursing practice and expected patient outcomes. An improved knowledge and appreciation of wound development and healing will enhance patient care and ultimately quality of life.

14. RESOURCES

National Pressure Injury Advisory Panel (NPUAP)

Educational and Clinical Resources

https://npiap.com/page/resources

European Pressure Ulcer Advisory Panel (EPUAP)

Pressure Ulcer Guidelines

https://epuap.org/pu-guideline

Agency for Healthcare Research and Quality (AHRQ)

Preventing Pressure Ulcers in Hospitals

https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/index.html

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