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The purpose of this educational module is to present an overview of wound care for most chronic wounds. This is not meant to be an extensive or all inclusive course which details advanced wound therapies for the wound care specialist. Rather, it is to help the typical nurse or clinician (in any setting) to become more familiar with principles of good wound healing and provide a guide to wound dressings, thereby answering the age old question, what should I put on the wound? This module will also include pain management for wounds - an under-addressed clinical problem.
A Health Technology Assessment (HTA) related to wound care management (Bradley, Cullum, & Sheldon, 1999) estimated the worldwide prevalence of wounds includes 40 to 50 million non-healing surgical wound, 8 to 10 million leg ulcers, 7 to 8 million pressure ulcers, and 7-10 million burn wounds. These numbers reflect that more people throughout the world have chronic, complex or non-healing wounds than the total US population with cardiovascular disease (approximately 15 million), asthma (18 million), or diabetes (10 million) (CDC - 2011 National Estimates - 2011 National Diabetes Fact Sheet - Publications - Diabetes DDT, n.d.). Chronic, complex or non-healing wounds represent a major health problem and a growing economic concern. To improve wound healing outcomes and decrease the number of chronic or non-healing wounds worldwide, evidence-based wound prevention and treatment strategies are necessary.
When an alteration in skin integrity occurs, such as when a teenager falls from a skateboard and scrapes his/her knee, it results in a wound. If the wound extends only through the epidermis and perhaps involves part of the dermis (but does not involve subcutaneous tissue or underlying structures), it is considered a partial thickness wound. We expect this type of wound will heal by re-epithelialization, and likely will not scar. If the wound extends through the epidermis and the dermis, and includes subcutaneous tissue or underlying structures, it is considered a full thickness wound. We expect this type of wound to heal by a complex process resulting in scar tissue formation. The location of the wound determines the depth of tissue loss required to establish if a wound is a partial or full thickness wound. Some parts of the body (over the anterior shin, the knuckles of the hands, bridge of the nose, etc.) have very thin skin and do not have a significant amount of subcutaneous fat/tissue. A shallow wound over these areas would be a full-thickness wound though they may only extend 2mm deep (or less). Alternatively, wounds over the buttocks or fleshy parts of the body may be the same 2mm depth and yet remain partial thickness wounds, because they do not extend into subcutaneous tissue. Areas of the body such as the ears and bridge of the nose have cartilage directly covered by dermis and epidermis. Any wound that involves cartilage is a full thickness wound, even if it appears very superficial.
Wounds are said to be healing by primary intention if a linear wound (such as a surgical incision) is re-approximated (edges pulled together) and sutured, stapled, glued or taped together (without gaps). These wounds will typically form a healing ridge by post-operative day 5 in healthy individuals (Sussman & Bates-Jensen, 2007). This healing ridge is evidence of collagen deposition knitting the two separate wounded edges together resulting in a healed surgical site. In such a case, the skin at the wounded site should have the same tensile strength as surrounding tissue after healing has fully occurred. This point is important to remember as we move on to discuss wounds that heal by secondary intention.
Wounds are described as healing by secondary intention if they are left open to heal or fill in with new granulation tissue and finally close by re-epithelialization. Scar tissue in full thickness wounds that heal by secondary intention (or scar tissue formation) will continue to mature 12-18 months after complete closure of the wound opening. The tensile strength of the resulting scar tissue in the area of a wound healed by secondary intention will never reach more than 80% of the tensile strength of the surrounding tissue. Therefore, this will always be a weak spot, prone to breakdown before the surrounding tissue. Therefore, a full thickness pressure ulcer in a location likely exposed to repeated pressure such as the ischia or coccyx, which healed by secondary intention instead of flap closure, will be at greater risk of recurrence. This is one reason that surgeons prefer to create surgical skin flaps to close certain wounds such as clean, uncomplicated full thickness pressure ulcers in relatively healthy individuals (with the best chance of surgical healing), instead of leaving these wounds open to heal by secondary intention (Bryant & Nix, 2007).
On the other hand, full thickness wounds which are initially sutured closed, then re-opened (or left open at the start) for awhile and finally sutured, stapled, glued or taped closed again, are said to be closed by tertiary closure. These wounds heal by a combination of scar tissue formation and surgical wound healing. Therefore, their suture lines may or may not reach the tensile strength of the surrounding tissue, depending on the amount of scar tissue formation (Bryant & Nix, 2007; Sussman & Bates-Jensen, 2007).
As discussed above, full thickness wounds healing by secondary intention actually heal by scar tissue formation. The wounded human body sets into motion a cascade of processes that results in the production of new collagen to fill the open defect of a full thickness wound in the skin/tissue. If the skateboarder is young and healthy, his/her knee will bleed for a few seconds and clotting factors and fibrin will start clotting the blood. Chemical signals (cytokines) will be initiated which will result in localized edema, redness at the area, slight warmth and pain. The localized pain, edema, warmth and redness will typically resolve in 3-7 days (inflammatory phase of wound healing). If the wound bed is not kept moist, the wound will dry out and a scab will form. Next, the body will produce enzymes (matrix metalloproteinases or MMPs) under the scab to help lift it, especially at the edges. The wound bed under the scab will be moist to promote cellular communication, proliferation and movement (Bryant & Nix, 2007). The skateboarder will likely pick the scab off of the wound, especially if it feels tight or itchy. However, the scab will form again, smaller this time, as the wound contracts. If all goes as expected, the wound will completely close (re-epithelialize) in a few weeks. As described, this is an acute wound. Interestingly, George Winter (Winter, 1962) demonstrated that open wounds (not sutured surgical wounds), which are kept continuously moist actually heal almost 50% faster than those allowed to dry out and scab over. The skateboarders scenario demonstrates uncomplicated acute wound healing. The typical needs of acute wounds versus chronic wounds are described below.
The typical needs of the uncomplicated ACUTE wound are:
In contrast to acute wounds, any wound that does not follow the expected pathway to healing is a chronic wound. Chronic wounds most often get stuck in the inflammatory phase of healing, resulting in delayed wound healing, and often, persistent edema, redness and pain (Baranoski & Ayello, 2004; Bryant & Nix, 2007; Schultz et al., 2003; Sussman & Bates-Jensen, 2007).
Inflammation in chronic wounds typically starts as it does in acute wounds: wounding bleeding → clotting cascade → release of cytokines → edema, warmth, redness, pain. However, unlike acute wounds, in a chronic, complex or recalcitrant wound, the expected pathway to healing stops here and never progresses out of a chronic inflammatory state. The presence of biofilm, or overwhelming infection; malnutrition; immune suppression; certain medications and a variety of other factors can contribute to a wound remaining in a chronic inflammatory state. Chronic wounds get stuck in the inflammatory phase of wound healing.
The typical needs of the CHRONIC wound are similar to the acute wound with one exception:
More advanced chronic wound treatments and adjunctive therapies will be discussed in a future course.
This section seeks to provide specific information to help you approach the wound from a nursing or caregiver perspective, which focuses on the cleansing and dressing of wounds.
Ideally, care of a wound should begin with a game plan. There is no strict recipe that will fit all wounds, but the following are general measures and recommendations (Baranoski & Ayello, 2004; Hess, 2005; Sussman & Bates-Jensen, 2007) that should be considered with all wound care. Typically, the process of wound dressing changes will look something like this:
|Common wound care supplies: gloves (sterile or non-sterile/clean), 4x4 gauze, saline or wound cleanser, paper measuring tape, skin prep wipes, disinfected scissors, primary dressing, secondary or cover dressing (if needed), tape or securing device, biological waste disposal bag, drape(s).
Now we will attempt to break this down into individual considerations. Gathering supplies, selecting the appropriate materials, setting up your workspace, and making the patient and caregiver comfortable are self-explanatory.
Do not take hand washing for granted! You have heard it said that the most important infection control practice is hand washing. This is true. Proper hand washing prevents infection: Wash with soap under running water for at least 15 seconds. No short cuts. Wearing gloves when you perform wound care is necessary in most cases, unless it is a close family member or the patient is doing wound care for themselves. However, wearing gloves is no substitute for hand washing (CDC, 2012)!
Wound care has advanced tremendously with modern technology. This is good news for patients, but complicates things for health care providers. Forty years ago, there was only a small list of wound care products to choose from and today there are thousands. However, clinicians need not fret about approaching wound care in modern healthcare. Clinicians need only to remember a few basic principles similar to the ABCs of CPR. Think of this as the TIME for wound care. Schultz et al. (Carville, 2006; Schultz et al., 2003, 2004a) wrote a pivotal article on wound bed preparation which describes a systematic approach to addressing specific needs of the wound bed in full thickness open wounds. In their article they describe the anagram T-I-M-E to assist clinicians in performing evidence-based wound care.
Many experts agree it is necessary to cleanse wounds at each dressing change to remove wound exudates, cellular waste, debris, bacteria, etc. However, caution is warranted regarding antimicrobial wound cleansers. Several studies report on the cytotoxicity of various common wound cleansers. Cytotoxicity relates to the substance being toxic to human tissue cells. Cytotoxic wound cleansers will not only kill germs but also kill healthy cells such as the fibroblasts (white cells that manufacture collagen/new tissue) or epidermal keratinocytes (important skin cells). (Baranoski & Ayello, 2004; Krasner, Rodeheaver, Sibbald, & Woo, 2012; Rabenberg, Ingersoll, Sandrey, & Johnson, 2002; Wilson, Mills, Prather, & Dimitrijevich, 2005).
In addition, many of these cleansers are antimitotic (prevent cellular mitosis and regeneration), which is how some chemotherapy agents function to prevent cancer cell growth. While that may be a desirable trait for cancer treatment, it may not be as desirable for a wound cleanser!
Wilson et al. (2005) reported on the cellular toxicity of common skin and wound cleansers such as dilute Acetic acid (0.25% vinegar), Cara-Klens, Dermal Wound Cleanser, Dial Liquid Antimicrobial Soap, Hibiclens, Hydrogen peroxide (3%), diluted Dakins solution (0.025% sodium hypochlorite/bleach), Povidone Iodine (10%), Puriclens, Restore Wound Cleanser, SAF-Clens, Saline (0.9% sodium chloride), Shur-Clens, Biolox, Techni-Care, etc. Their study revealed that only Shur-Clens, SAF-Clens and Saline were non-cytotoxic to fibroblasts (Toxicity index 0) without being diluted. Only Biolox, Shur-Clens and Techni-Care were non-cytotoxic to epidermal keratinocytes (Toxicity index 0) without being diluted. Some cleansers had higher toxicity indices such as 10 (need to dilute 10 times to reach a non-cytotoxic strength), 100, 1000, 10,000 or 100,000 (need to dilute 100,000 times to reach a non-cytotoxic strength). The higher the index, the more cytotoxic the cleanser. The cleansers which had the highest toxicity index against fibroblasts included Hibiclens (10,000), Dial Antibacterial Soap (100,000) and Ivory Liqui-Gel (100,000). The cleansers which had the highest toxicity index (100,000) against epidermal keratinocytes included Hydrogen peroxide, Povidone Iodine, and Dakins Solution.
Many clinicians are badly informed concerning Dakins solution, when to use and not to use, storage, documentation and strengths. Here are some things every clinician should know about Dakins:
Dakins solution is a 0.5% sodium hypochlorite solution and is often diluted because of its high cytotoxic properties. RECORD the correct strength!!!The following is a chart which describes the different dilutions of sodium hypochlorite solution.
|Industry Term
|Percent of Sodium Hypochlorite
|Active: Total
|NaOCl Parts per Million
|Dilution of Bleach
|50,000 ppm
|Dakin's Full Strength *
|5,000 ppm
|Dakin's Half Strength *
|2,500 ppm
|Dakin's Quarter Strength *
|1,250 ppm
|Diluted Sodium Hypochlorite
|250 ppm
|Di-Dak-Sol *
|125 ppm
Ohio State University Medical Center (OSUMC) Department of Inpatient Nursing (2002) published a nice patient education pamphlet, How to Make Dakins Solution. This pamphlet describes diluting 3 ounces of common (unscented) household bleach (5.25% sodium hypochlorite solution) with 32 ounces of clean, boiled water (buffered with teaspoon baking soda/sodium bicarbonate) to make a full strength Dakins solution (0.5% sodium Hypochlorite solution).
To make strength Dakins solution (0.25% sodium hypochlorite), use only 3 tablespoons (48ml) bleach mixed with the same amount of water (32 ounces) and baking soda (1/2 tsp.). OSUMC reports tightly sealed jars of these solutions may be stored at room temperature up to one month (in a dark jar), but once opened, any unused solution should be discarded within 48 hours. University of Virginia Health System also created a similar document.
In most cases, wound experts recommend using water or saline to cleanse the wound (Fernandez, Griffiths, & Ussia, 2007). Some articles suggest tap water may be appropriate to cleanse a chronic wound. However, a Cochrane systematic review of research exploring this tap water question concluded, The decision to use tap water to cleanse wounds should take into account the quality of water, nature of wounds and the patients general condition, including the presence of co-morbid conditions (Fernandez et al., 2007). They also point out that for tap water to be considered for wound cleansing, it must be potable. Caution may be warranted for several reasons when considering tap water. Most of the studies in the systematic review were small and did not have adequate sample sizes to determine significant differences between groups. It is not known if the water used for wound cleansing vs. normal saline was tested for bacterial, cysts, fungi or presence of any other contaminants. Tap water if obtained from a well may contain contaminants such as bacteria or other contaminants, undetectable to the human eye. Alternatively, city water is typically chlorinated at around 3 parts per million or 0.3mg/L and also typically contains fluoride (0.5mg/L to 1.0mg/L) - it is unknown what effect this may have on cellular activity in the wound bed, and this was not reported on by the studies included in the Cochrane systematic review. Therefore, the author recommends using primarily saline or a proven non-cytotoxic wound cleanser.
An exception to using cytotoxic wound cleansers is when the benefits outweigh the risks. For instance, in the case of localized bacterial invasion in which the host is unable to overcome the bioburden of the infecting organism(s) with its own immune defenses (such as pseudomona aeruginosa infection resulting in further wound deterioration), the fibroblasts and epidermal keratinocytes are not likely to survive this hostile wound environment anyway. Therefore, it may justify using a short-term application of cytotoxic wound cleanser such as a dilute Dakins solution (sodium hypochlorite) just long enough to eradicate the infecting organisms. Yes, this is likely to impair cellular function temporarily but the infecting organisms would do far worse if you did not address/control them. Once you have cleaned up the wound (perhaps a few weeks), you should return to non-cytotoxic moist wound healing principles for wound care.
Cleansing the wound should not only address washing or rinsing a wound but also includes debridement or addressing removal of non-viable (necrotic) tissue from the wound bed. Necrotic tissue is a breeding ground for bacteria and impairs wound healing (Schultz et al., 2003). Removing this unhealthy tissue (debridement) may be achieved by a variety of means: Sharp debridement, either selective or non-selective (with scalpel, scissors, curette); enzymatic (collagenase ointment or similar); autolytic (promoting the body's own enzymatic activities); mechanical (rough friction or wet-to-dry) and larval debridement (maggots) (Schultz & Dowsett, 2012; Schultz et al., 2003).
Necrotic tissue in the wound bed provides a breeding ground for bacteria, impairs optimal cellular communication and proliferation, and acts as a physiological barrier to new tissue deposition and wound contraction (Schultz & Dowsett, 2012; Schultz et al., 2003; Sussman & Bates-Jensen, 2007). In almost all cases, necrotic tissue should be removed when safely possible. This includes slough (white, yellow, grey chicken fat appearing tissue), fibrin (adherent, white yellow or grey fibrous non-viable tissue), and eschar (typically thick, brown to black, leathery dead tissue). There are a few exceptions to this rule. One very important exception is in the case of intact, hard, black eschar on the heel of the foot. There is no way to determine the depth of tissue damage underneath this eschar, so removing it may expose bone and predispose the patient to infection and osteomyelitis. Intact is the key word here. If this eschar is dry, and NOT soft or boggy or fluctuant, and does not have any lifting at any of the wound edges or drainage, then it may actually be beneficial to leave this eschar alone. Of course, pressure should be off-loaded from the area, and the eschar should be kept clean and dry. Cover the eschar with dry gauze for protection and paint it daily with a small amount of Betadine solution (letting it air dry thoroughly before applying dry gauze for protection and padding). With this tissue in place, it may act as a protective body bandage keeping bacteria and contaminants out of the wound. The wound healing process under this eschar may continue if other wound healing impediments are addressed (offloading pressure, adequate nutrition & blood flow, adequate immune function and tissue perfusion). If the wound under the eschar follows a healing trajectory, the eschar may lift itself after several weeks and display newly epithelialized skin underneath. In some cases, it may lift prematurely at an edge or starts feeling boggy or fluctuant underneath the eschar and may start draining. In this case, it may be best to remove the eschar (Bryant & Nix, 2007).
Typical methods of debridement include sharp debridement, mechanical, autolytic, enzymatic and larval debridement. Sharp debridement is usually performed with a scalpel, curette, and/or scissors. This may occur in a surgical suite by a surgeon or at the bedside by a physician, PA, ARNP, or certified wound specialist if allowed by state board scope of practice limitations. Enzymatic debridement is typically achieved by applying ointment (collagenase) to the wound bed. Mechanical debridement may be accomplished by wet-to-dry dressings, by rubbing/friction while cleansing the wound, or by pulsed water jets & hydrotherapy (pulsed lavage, whirlpool). Autolytic debridement occurs by promoting natural enzymes in wound fluid to degrade non-viable tissues usually by placing an occlusive or semi-occlusive dressing over the non-viable tissue. In addition, autolytic debridement may be accomplished by osmotic wound products such as medical grade honey or gauze saturated with a hypertonic sodium chloride since these products draw fluid from wound bed tissues into the wound product and loosen necrotic tissue. Larval debridement is performed by allowing sterile maggots to remove non-viable tissue (Baranoski & Ayello, 2004; Bradley et al., 1999; Bryant & Nix, 2007; Schultz & Dowsett, 2012; Schultz et al., 2003; Sussman & Bates-Jensen, 2007).
Maggots are the unsung heroes of wound healing. Maggot(s) or larval debridement therapy (MDT or LDT) has been utilized for medical purposes for hundreds or thousands of years. Mayan Native Americans and other ancient cultures have documented reports of maggots being used in certain medical treatments, especially for wound care. Larvae of certain fly species, such as Phaenicia sericata (blow fly); remove only dead tissue while promoting healthy tissue in the wound bed, helping wounds heal faster.
An American Civil War surgeon, Dr. John Zacharias (1837-1901), is one of the first healthcare providers in the US who intentionally utilized maggots in the debridement of wounds. He noted that maggots cleansed opened wounds of necrotic tissue better and more rapidly than any other method at his disposal. In WWI, an orthopedic surgeon named Dr. William Baer recognized the efficacy of maggots to clean up compound fractures and large open flesh wounds when he discovered them in several untended war wounds from the battlefield. Dr. Baer and Dr Zacharias both credited the blow fly larvae with preventing sepsis and saving many soldiers lives in these battlefield cases. Dr Baer was very impressed with the usefulness of fly larvae/maggots as a medical treatment. After the war, Dr. Baer worked as a medical practitioner and researcher at Johns Hopkins Hospital, where he started to conduct research using blow fly larvae in 1929. Initially he used live larvae/maggots he found in the neighborhood or those he grew on a windowsill. One patient died after contracting tetanus from contaminated maggots, so Dr. Baer developed sterile maggot growing procedures. He is well known for his research using sterile maggots in 21 individuals with wounds infected with chronic osteomyelitis not responsive to other treatment. All of these wounds completely healed within six weeks and confirmed that maggots were effective at rapid wound debridement of necrotic tissue as well as reducing the presence of bacteria in wounds. In addition, wounds treated with larval therapy demonstrate reduced wound odor and a wound bed which tends to become more normalized to an alkaline ph environment (Baer, 2011; Schultz & Dowsett, 2012; Sherman, 2009).
Regrettably, with the development of antibiotics in the 1940's and various skin and wound antiseptics, the use of LDT declined. Systemic and topical antibiotics became more a standard of care and more antiseptics were utilized in skin and wound care. Maggot therapy was essentially abandoned in favor of more modern or easier methods, not because they were no longer effective, but largely because of negative reactions of patients, their caregivers and clinicians, who found it distasteful to apply small squirming worms that could crawl out of a wound.
The Food and Drug Administration (FDA) cleared medicinal maggots (Phaenicia or Lucilia sericata) for debriding non-healing necrotic skin and soft tissue wounds in the 1980s, after a renewed interest in larval debridement therapy due to increasing drug sensitivities and the exponential growth of antibiotic resistant organisms. Medical maggots were approved by the FDA as a medical device in the US, and are processed under controlled laboratory conditions. They are germ-free and disease-free as well as unable to reproduce (sterile in both cases). Interestingly, in Europe, Canada and Japan maggots are classified as medicinal drugs. The reason for this is because maggots debride non-viable tissue partly by secreting proteolytic digestive enzymes, which liquefy the necrotic tissue that the larvae then suck up and remove (along with bacteria and biofilm) from the wound bed. In addition, research suggests maggots are very effective at eliminating drug resistant organisms such as MRSA (methicillin resistant staphylococcus aureus), they do not excrete bacteria into the wound, and they are a most efficient way to debride a wound without the typical pain or bleeding associated with other forms of debridement such as sharp debridement (Sherman, 2009).
In many cases, wound inflammation is often mistaken for wound infection, since the signs of inflammation are warmth, edema, pain, and localized redness. Patients with these symptoms are often placed on antimicrobial treatment regimes without the benefit of microbiological studies to guide them (no quantitative tissue cultures from the wound). This may be one contributing factor in the development of drug resistant organisms. There has been much written about wound infection and other authors can address this better than this brief wound care review (Baranoski & Ayello, 2004; Bryant & Nix, 2007; Schultz, Davidson, Kirsner, Bornstein, & Herman, 2011; Schultz & Dowsett, 2012; Sussman & Bates-Jensen, 2007; Wolcott et al., 2010) Nevertheless, it is one of the most requested topics of wound care courses (to know when to treat and when not to treat infection). Therefore, we will quickly summarize some important facts and helpful tips regarding wound infection:
|Levine technique for obtaining swab culture (when a quantitative tissue sample is not an option):
Rinse the wound bed once with sterile saline (non-bacteriostatic and preservative- free). Moisten the sterile culture swab with sterile non-bacteriostatic and preservative-free saline and rotate the swab completely over a 1cm2 area in the wound bed where it is free of necrotic tissue. Press down slightly to illicit fresh wound fluid. Take your time to allow adequate time for fluid collection. Place in appropriate culture media transport tube and take care that the sample does not sit at room temperature longer than the lab recommends (Bryant & Nix, 2007). Note: A wound culture left on the desk overnight will likely need to be repeated. Check your labs policy on this!
As a general rule of thumb, the wound care provider who is ordering the wound care should re-evaluate the wound for progress at least 2 weeks after the initial wound orders are placed. If the wound is stable, the topical wound treatment is performing as anticipated, and the wound is progressing as expected, the wound treatment may be continued and the follow up could be extended to once every 2 to 4 weeks. If the wound has not improved after the initial 2 weeks, but the wound has not worsened, the clinician should make a decision if a change of wound treatment is in order or if there are other factors which need to be addressed which may be impairing wound healing (nutrition, medications, glycemic control, infection, etc.). After addressing these factors, have the patient return to the clinic in another week or two to re-evaluate progress with the current treatment. If no progress is noted, or the wound worsens at all, a change in treatment may be warranted (Baranoski & Ayello, 2004; Bryant & Nix, 2007; Sussman & Bates-Jensen, 2007).
Measuring the wound is an essential component of wound monitoring and documentation. Wounds may be measured using a variety of techniques but the two most common techniques are the clock method and the longest axis method. The measurement method used should be performed consistently by all care providers. Only one method should be used for all wound measurement documentation for the entire facility to minimize confusion and inconsistency in the patients charts. The clock method consists of imagining the top of the patients head to be at the 12 o'clock position of a clock and the soles of the feet to be at the 6 o'clock position of an imaginary clock. All wounds are measured with length being the measure of the wound along the 6 to 12 o'clock axis and the width being the measure of the wound opening along the 3 to 9 o'clock axis. This works well to get the same measures no matter what position the patient is lying or sitting in. The longest axis method consist of taking the wound opening measurements along the longest axis of the wound as the length and the width measurement as the measurement of the wound opening along the perpendicular axis. Wound depth is measured the same way for both of these methods. Using the blunt end of a cotton tipped applicator, hold the stick lightly resting upon the deepest portion of the wound and using a gloved hand, grasp the stick at the wound edge and measure the straight depth of the wound at the deepest portion of the wound and record this as straight depth. Tunnels or tracking in the wound or undermining (lip under the inner aspect of the wound edge) should be measured at most shallow and deepest points. It should also be noted if tunneling or tracking connects two wounds or connects with any joint space or underlying structures (Baranoski & Ayello, 2004; Bryant & Nix, 2007; Sussman & Bates-Jensen, 2007).
Photographing the wound (if desired) as an additional component of wound monitoring includes establishing a routine frequency of photographic documentation, a consistent camera and distance from the wound for all photographs, and a measuring ruler in the frame next to the wound for size reference. It is imperative that you consider who is taking the photos. If another person is taking the pictures, make sure they follow infection control practices and do not touch the patient with the camera or anything in the patients room, especially if they will be taking the camera back to a central work area or other patients room. If it is the same clinician performing the dressing change, care should be taken to follow strict infection control protocols concerning handling the camera and where it is stored during wound care. For example, it should not be laid on the patients bed or bedside table without a clean barrier under it. It should not be handled after touching the patient, the wound dressing or wound care supplies without first washing your hands. Hands should be washed again after handling the camera. The camera should not be in close proximity to the wound during dressing changes if at all possible. During dressing changes, bacteria may be aerosolized and could contaminate the camera. The camera should not be taken from one patients room to another for other photos without first using some kind of disinfecting wipe or changing camera covers if disposable covers are used.
If photographs are to be used in the electronic health record, the author recommends that a photo of the patients ID bracelet be taken, followed by a photo of the wound, then the ID bracelet again, so that this sequence of photos may be uploaded into the appropriate electronic health record, and minimize the chance of the picture being uploaded to the wrong patients chart. In most cases, identifiers such as patient name, initials, date, etc. should not be included in any photo that may be used for educational purposes. However, follow your facility's protocols for taking and uploading wound photographs.
One of the main functions of a wound dressing or wound therapy is moisture management. Specifically, to maintain a moist wound bed while also eliminating excessive wound drainage. Since George Winters seminal work in 1962, demonstrating open wounds treated with dressings which maintained a moist environment healed almost 50% faster than wounds allowed to dry out, no published studies have been able to refute the effectiveness of moist wound healing. In fact, current scientific investigations not only support what has been known about moist wound healing, but serve to further explain the role of a moist wound bed in relation to the local cellular activity associated with wound healing (cytokine signaling, fibroblast cell proliferation, collagen and matrix synthesis, epithelial cell migration, etc).
There are hundreds of commercially available wound care products in the United States. Numerous dressings or topical wound care applications have reported successful wound healing results in clinical trials, yet wet-to-dry dressings are still one of the most frequently ordered wound care modalities in nearly all healthcare settings (Cowan & Stechmiller, 2009; Fleck, 2009). Wet-to-dry dressings are no longer evidenced-based practice for wound care. As the name implies, a wet-to-dry dressing ultimately results in a dry wound bed (even if for limited amounts of time). Research demonstrates these dressings disrupt granulating tissue, impair epithelial cell migration, leaves behind foreign bodies in the wound bed, increase the risk of infection, aerosolize bacteria, and cause severe pain upon removal (Cowan & Stechmiller, 2009; Fleck, 2009). Nevertheless, wet-to-dry dressings have been a standard, traditional or default dressing for decades (Bryant & Nix, 2007; Cowan & Stechmiller, 2009; Mulder, 1995). Modern wet-to-dry dressings are accomplished by moistening sterile cotton gauze with a solution (usually 0.9% normal saline) and placing it in the wound, allowing it to dry, then removing it dry from the wound bed (along with tissue that adheres to it), thus performing mechanical debridement. There are several reasons why this form of debridement may be detrimental to the wound bed, and unnecessary with so many other forms of wound debridement available today. Cost, compliance, pain, increased risk of infection and re-injury to healthy granulating tissue are several of these reasons (Bryant & Nix, 2007; Cowan & Stechmiller, 2009; Mulder, 1995).
It is the authors belief that most health care providers have continued with wet-to-dry dressings more out of misunderstood tradition rather than evidence-based wound care practices. Furthermore, the use of wet-to-dry dressings as a wound care modality may be outdated and used with inappropriate frequency in todays health care arena (Cowan & Stechmiller, 2009).
If not wet-to dry, then what how do you select a moist wound dressing? There are so many to choose from. What dressing has the most evidence supporting it? How often should you change the dressing? Unfortunately, several systematic reviews have failed to produce strong evidence in favor of one specific dressing type for all wounds. Most clinicians who are not very familiar with modern wound products just want to know, if not wet-to-dry, then what one product can safely be used in its place? The answer to this question should be, it depends.
Wound experts now realize the one size fits all approach is not ideal for wound care or dressing product selection. Multiple EBP wound treatment algorithms exist to assist the clinician in selecting wound treatment approaches. Krasner, Sibbald & Woo (2012) developed a Conceptual Framework for Wound Dressing Product Selection. This model reminds health care providers that wound care should be delivered using a Holistic, Interprofessional, and Patient-Centered Approach. This approach should also be in agreement with the principles of evidence based practice (EBP). The principles of EBP affirm that health care should be delivered based on the strongest and most current research evidence + the clinicians experience & expertise + the patients (and familys) preferences and values (Sackett, 1999; Sackett et al., 2000; Titler, 2008).
Before you can determine anything about the wound, you must assess the wound. However, the wound is only one small part of a person. In assessing the wound, dont forget to assess and talk to the person attached to the wound. Assess the person (physically as well as psychosocially). What are the preferences, personal needs, likes, dislikes of the patient (as well as their caregiver)? What are their feelings about the wound/wound care? For a caregiver who gets sick and faints at the sight of blood, asking them to empty bloody drainage from a drainage tube may not be a good choice. As you assess the wound itself, identify the etiology of the wound and co-morbid conditions which may affect wound healing. In Krasner, Sibbald & Woos model (2012), they suggest approaching wound care with one of 3 options or goals in mind.
Probably the most effective and economical substitute for saline moistened gauze (wet-to-dry) dressings are wound gel moistened or impregnated gauze dressings. However, there are now a myriad of evidence-supported wound dressings to address specific needs of various types of wounds. This section is an introduction to some common dressings which have at least moderately strong evidence supporting their use. Please see Table 1 for list of common wound dressings and suggestions for frequency of dressing changes. Resources for all of this information were obtained from 5 main sources: (Baranoski & Ayello, 2004; Bryant & Nix, 2007; Hess, 2005; Krasner et al., 2012; Sussman & Bates-Jensen, 2007). In addition, the Agency for Healthcare Research & Quality (AHRQ) has several evidence synthesis summaries and technical assessments published or currently in progress (such as a review of skin substitutes for chronic wounds) which may be pertinent to wound care.
The ideal dressing should promote the best environment in the wound bed to promote wound healing. In other words, it should maintain a moist wound bed, be thermally insulating, protective to the wound, free of particles that could remain in the wound and become foreign bodies in the wound, be vapor permeable, hypoallergenic, non-toxic, comfortable, and cost effective (Carville, 2006; Hess, 2005; Jones, Grey, & Harding, 2006; Mulder, 1995). Health care providers should consider patient and/or caregiver cognitive and physical limitations/abilities when ordering a wound dressing, if the patient or caregiver will be expected to do the wound care. In addition, if at all possible, the wound dressing should also be aesthetically acceptable to the patient/caregiver (taking their preferences into account) and promote the patient continuing as many activities of daily living as possible (within the limits of his co-morbid conditions) (Krasner et al., 2012). The average health care provider or medical clinic should have at least a familiarity with the following products, and probably have at least one of each type of dressing on hand/in stock:
Gauze comes in a plethora of forms, sizes, shapes, and layered products. The most common gauze products are sterile or aseptic (packaged individually, in packages of 2 or in bulk packages of 50 or 200 cotton, woven, 8 or 12 layered, 4 x 4 or 2 x 2 sizes. Telfa is gauze which is coated with a plastic film to help render it non-adhesive. Gauze also comes in larger bulk dressings such as abdominal dressings. These dressings are commonly made today with bulky absorptive layers of cotton batting and woven gauze in larger sizes such as 5 x 9 or 8 x 10. Gauze dressings are also manufactured in woven gauze of one rolled length (roll gauze) in a variety of widths (such as 2 of 4 or 6 widths). Gauze may be impregnated with other substances such as calamine, petrolatum, wound gels, silver, etc. In addition, combination products may have layers of gauze combined with layers of other wound products such as charcoal, alginates, adhesive backings or borders. Gauze pads are typically latex-free, however, not all gauze rolls are latex-free check packaging!
Whereas, wet to dry dressings are moistened with saline and allowed to dry out, wound gels are a good alternative that effectively maintains a moist wound bed. The clinician may moisten gauze with a wound gel, or use a pre-packaged gel impregnated gauze. Typically, this only needs to be changed once a day instead of 2-3 times per day. Wound gel dressing changes would be less painful than wet-to-dry. Wound gels come in amorphous gels (in tubes) or in sheets of flexible semisolid gel. Wound gels are commonly made of organic polymers that maintain moisture in the wound bed but also swell with water or wound drainage. In addition, wound gel may contain silicone, water, glycerine, polyethylene oxide, alginate or collagen. Common brand names of these wound gels include (this is not meant to be all-inclusive): Saf-Gel, Vigilon, Elastogel, Curasol, Solugel, Intrasite Gel, Purulon Gel, DuoDERM gel, Nu-gel, Stimulen collagen gel, etc. Some gel sheets such as Vigilon come with polyethylene film covers on each side that should be removed before placing gel sheet on wound (this will allow more vapor permeability). Gel products may absorb up to 5 or more times their body weight in wound drainage yet will not dry out or dissolve. Typically the gel product is placed in the wound bed and covered with a secondary dressing to secure in place (such as gauze or foam). These products are normally changed daily, though gel sheets on certain wounds such as superficial wounds and skin tears may be left on for 1 week if the skin tear is clean (non-infected) with a well approximated flap and is not heavily exudating. Wound gel sheets that come with adhesive borders may be changed 3 times per week. Wound gels are appropriate for full thickness, shallow or deep wounds with scant to small amounts of drainage or varying amounts of drainage where the wound bed may dry out at times. Silicone gel sheets may also be useful in preventing or treating wound scarring (keyloids) for up to one year after wound closure.
Care should be taken to manage moisture so that excessive moisture is not allowed to seep out over the surrounding wound edges causing maceration. Skin Barrier wipes, powders or creams may be useful to protect periwound skin from adhesives (barrier wipes) or excessive moisture (barrier creams such as zinc oxide, or dimethicone). These are applied at each dressing change.
Another simple dressing to use is impregnated gauze. Pre-packaged impregnated gauze products are typically impregnated with petrolatum, hydrogel, Bismuth Tribromophenate, hypertonic sodium chloride, zinc, or crystalline iodine compound (iodoform). Common brand names of these dressings include (this is not meant to be all-inclusive): Vaseline Gauze, Adaptic, Xeroform, Curasalt, Mesalt, etc. The most basic and inexpensive of the petrolatum impregnated gauze may average $40 or less per box of 50. These dressings are conforming and may be good choice when filling tunnels or tracking as long as one piece and not multiple pieces are packed loosely into the tunnel. These dressings provide non-drying and moisture retaining wound interface, they conform to the wound bed, and petrolatum impregnated products may help protect periwound skin if they are shallow abrasions, so may be placed on the wound overlapping the edges. Normally these dressings are changed daily, and covered with a secondary dressing such as gauze pads or roll gauze, foam, bandage / wraps.
Hydrocolloid dressings are typically opaque, self adherent patch type dressings made of sodium carboxymethylcellulose, pectin and gelatin mixed with polymers and adhesives. They also have a semipermeable film or foam sheet covering which makes them generally waterproof. However, waterproof does not mean it can be submersed such as in a bathtub or pool. These dressings are flexible wafers of differing sizes, thicknesses and shapes (some may be cut to desired size and shape). They can conform to many areas of the body. Common brand names of these dressings include (this is not meant to be all-inclusive): Restore, DuoDERM, DuoDERM CGF, Tegasorb, Comfeel, Granuflex, and 3M Tegaderm hydrocolloid thin. When exposed to exudate (wound drainage), the polysaccharides & other polymers absorb water and swell but remain contained in the adhesive matrix. Some have marks to tell you when the wound drainage is exceeding the dressing's limit and it is time to change. Most hydrocolloid dressings are Latex-free. Most if cut to size, should be cut larger than wound. These dressings are typically changed every 2-5 days and it is best to use a skin barrier wipe applied to the periwound skin before application of the hydrocolloid.
Alginates are super absorbent fibers typically composed of calcium alginate manufactured from brown seaweed that becomes gel-like when exposed to sodium-rich wound exudates. It resembles angle hair and is manufactured from brown seaweed. They may absorb up to 20 times their weight in wound exudates. This makes them a good choice for highly exudating wounds. However, they are not recommended for dry or only slightly moist wound beds, as they will not remain a gel without the presence of moisture from the wound bed. Thus, they may dehydrate the wound bed, or allow the wound bed to dry out. Alginates may be available as sheets or pads and ropes and also are known for some hemostatic properties, making them a good choice for a wound bed that may be oozing a small amount of blood after sharp debridement. In addition, some alginates may have silver incorporated into the fibers as an antimicrobial agent. Alginates typically require a secondary cover dressing such as gauze or ABD pad and are changed daily or as necessary to manage wound exudates.
Hydrofiber dressings are non-wicking, absorptive primary dressings made of sodium carboxymethyl-cellulose fibers that absorb wound drainage and turn into a gel sheet. They may also keep the wound bed moist if the wound is sometimes dry (you would moisten them with saline or water). Hydrofibers act somewhat like an alginate but will not promote hemostasis like alginates. Some hydrofiber dressings include 1.2% silver as an antimicrobial component (usually delineated by the silver element symbol AG in the hydrofiber name). They are appropriate for full thickness wounds with minimal to moderately amounts of drainage. They are typically changed once every 1 to 3 days and require a secondary cover dressing.
Foam dressings are typically a thick both absorptive and protective. They may be selected to provide conforming padding and may be used in combination with other products (such as alginates or hydrofibers) if needed; Foams may be used as a packing material in large wounds to fill dead space. Not all foam dressings are appropriate for infected wounds. Check manufacturer guidelines if infection is an issue. Some foam dressings are impregnated with silver or other antimicrobial material (such as Methylene Blue and Gentian Violet or polyhexamethylene biguanide/PHMB) or coated with a silicone interface. Some foam dressings may be self-adhesive or have an adhesive border. Most foam dressings are latex-free and made of polyurethane foam coated with a waterproof outer surface. Change frequency may vary from daily to up to every 7 days for some products, depending on wound drainage amounts. Check manufacturer recommendations.
Silver ions may be incorporated in wound gels, woven fabric dressings, foam, rope, alginates or hydrofiber dressings. Most silver fabric dressings are not very absorbant; they are used primarily to deliver silver ions to wound bed for the silvers antimicrobial effects. However, silver alginates, hydrofibers, foams, or composite dressings are absorbent. Silver ions are activated by wound exudates or water; some silver products (Acticoat 3 day or 7 day) should not be moistened with sodium chloride (saline). Most silver products should not be mixed with hydrogen peroxide or sodium hypochlorite (Dakins or DiDaksol) solutions because the ions will inactivate each other. Silver products should not be combined with iodine products for the same reason. Silver dressings may need secondary dressings and may be changed daily up to every 7 days, depending on the product.
In general, povidone iodine should not be used in chronic wound care due to its cytotoxic properties. However, cadexomer iodine is available which is antimicrobial while remaining non-cytotoxic to the wound bed. Cadexomer iodine is available in a wound gel (thick paste) or a flexible pad which is typically applied to the wound bed with a secondary dressing on top and left in the wound bed for 3 days, or until the color changes from a orange-brown to a grey-brown. They are used for antimicrobial effects on infected room and are effective against most bacteria including pseudomonas, staphylococcus aureus and streptococcus as well as fungus.
Compression dressings or bandage wraps are primarily used for lower extremity venous insufficiency. Compression garments are also appropriate for extremities effected by lymphedema (such as after mastectomies with axillary lymph node removal) or burns. Short-stretch compression is typically used for lymphedema (these are NOT ace bandages). Long-stretch compression (multilayer wraps and ace-type bandage) is also the typical treatment venous leg wounds. It is important to verify arterial perfusion to affected limb before applying compression. Compression may be applied in 2 to 4 layers, with a therapeutic layer such as zinc-oxide or calamine impregnated strips applied first, an absorptive layer next, possibly a bandage layer and/or Coban layer on top. These dressings may be applied every few days to weekly, depending upon amount of wound exudates. Once edema is under control and wounds healed, lifelong compression stockings should be worn by the patient (apply daily first thing in the morning before ambulating and remove at night just before retiring to bed).
Composite dressings are combination dressings of various sizes that are made up of two or more separate materials to address unique needs of certain wounds. These dressings tend to be layered with a contact layer (may be non-adhesive), an absorptive layer, and possibly an antimicrobial layer or odor absorbing layer (such as charcoal). They also may have an adhesive border to secure them to the wound site.
Tissue engineered skin substitutes, matrix dressings, collagen products and negative pressure wound therapy are some of the advanced wound therapies to be discussed in a future article.
|Type of product
|Examples *Brands/Names
|Types of wounds
|Petrolatum or Hydrogel Impregnated gauze
|Vaseline Gauze, Adaptic, Xeroform; Skintegrity, Elta, Restore, Dermagauze, Curafil
|Shallow and dry wounds; abrasions, skin tears, etc.
|Provides non-drying and moisture retaining wound interface, conforms to the wound bed, petrolatum impregnated products may help protect periwound skin if shallow abrasions. Typically changed daily, though may be left in place over well-approximated, non-infected skin tears up to 1 week.
|Wound Gels/Hydrogels
|Saf-Gel, Vigilon, Elastogel, Curasol, Solugel, Intrasite Gel, Purulon Gel, DuoDERM gel, Nu-gel, Stimulen collagen gel
|Dry to minimally draining wounds; partial and full thickness depth, 2nd degree burns, exposed tendons
|Organic polymers that maintain moisture in the wound bed but also swell with water/drainage (some can absorb up to 5x their own weight in exudate). These gels typically will not dry out or dissolve. May be changed daily, though some gel sheets such as on skin tears may be left on for 1 week if a well approximated flap. Some gel sheets may also be used over scars to reduce hyperkeratosis (keyloid formation).
|Restore, DuoDERM, DuoDERM CGF, Tegasorb, Comfeel, Granuflex, 3M Tegaderm hydrocolloid thin
|Partial and full thickness wounds; minimal to moderate drainage
|Typically a flexible wafer of differing sizes, thicknesses and shapes (some may be cut to desired size and shape); forms an Impermeable barrier (most are waterproof); self-adhesive; may contain gelatin, pectin and carboxy-methylcellulose together with other polymers and adhesives. When exposed to exudate (wound drainage), the polysaccharides & other polymers absorb water and swell but remain contained in the adhesive matrix. May be changed every 3-5 days.
|Transparent films
|Op-Site, 3M Tegaderm, PolySkin, Suresite, Blisterfilm, Argomed and Argomed plus TPU films, Mefilm, Uniflex, AcuDerm
|Partial thickness or shallow wounds with minimal to small drainage
|Most are polyurethane films; provide moisture retention and may provide skin protection. May also assist with autolytic debridement. Most are oxygen or vapor permeable (not 100% occlusive). Sometimes used to "waterproof" a wound
|Aquacel, Aquacel AG
|mostly shallow; partial to full thickness; minimal to moderate drainage
|Non-wicking, absorptive dressing made of sodium carboxymethyl-cellulose fibers that absorb wound drainage and turn into a gel sheet. They may also keep wound bed moist if wound is sometimes dry (moisten with saline or water). Act somewhat like an alginate but will not promote hemostasis like alginates. Typically changed 1-3 days.
|Non-adherent polyurethane foam or Silicone interfaced foam;
|Optifoam, Mepilex, Mepilex Border, Mepilex Transfer, Allevyn, PolyMem, Lyofoam, Hydrasorb
|shallow wounds to those with some depth; partial to full tickness; minimal to heavy drainage
|Absorptive & protective - provides conforming padding and may be used in combination with other products (such as alginates or hydrofibers) if needed; Some have self-adhesive borders. Foams that have a silicone contact layer may be useful in reducing hypertrophic (keyloid) scarring. Some have multiple layers (such as polyurethane foam+ polyacrylate fibers + waterproof film in Mepilex). Typically changed 1-3 days.
|Calcium Alginate
|CalciCare, AlgiSite M, Maxsorb
|Moderate to heavily draining wounds with no necrotic tissue
|Highly absorptive fiber (rope or pad) product made from brown seaweed. Turns to gel when moistened with wound drainage. Change daily.
|Optifoam, Mepilex, Hydrasorb
|Deeper, full tickness; moderate to heavy drainage
|Absorptive and protective - provides conforming padding and may be used in combination with other products (such as alginates or hydrofibers) if needed; Foams may be used as a packing material in large wounds to fill dead space.
|Mepitel, Elastogel, etc.
|Dry to exudating wounds or delicate wound beds (exposed tendons, etc.); or over newly closed wounds with high risk of scarring
|Some are fenestrated (have holes in them such as Mepitel) and may be applied directly to wound bed under negative pressure wound therapy or other dressing as a non-stick primary dressing. Some are thicker and used over shallow wounds or newly closed wounds to prevent hypertrophic (keyloid) scarring. May be changed every 2-7 days.
|Roll Gauze
|Deeper, full tickness; moderate to heavy drainage
|Absorptive and may be used to fill dead space; may also be used in combination with other products (such as alginates or hydrofibers) if needed; Kerlix not recommended due to loose fibers
|Antimicrobial silver impregnated woven fabric
|Acticoat Burn (3day), 7day, flex, surgical site dressings
|Not for very dry wounds
|Not very absorbant - used primarily to deliver silver ions to wound bed for antimicrobial effects. Silver ions are activated by wound exudates or water; some silver products should not be moistened with sodium chloride (saline) or sodium hypochlorite (Dakins or DiDaksol) solutions because the ions will inactivate each other. Silver products should not be combined with iodine products.
|Other silver products
|silver wound gels; Silver gel sheets (Silvasorb), silver alginate; silver hydrofiber, silver foam
|Application varies by type of base product
|Use silver gels as you would other wound gels, use silver alginates you would other alginates, silver foams as you would other foam dressings, etc.
|Profore, Profore lite, Unna Boots (with zinc oxide or calamine impregnated contact layer) or multilayer (2-4 layer) wraps, ace wraps,
|for lower extremity venous wounds
|Long-stretch compression (multilayer wraps and ace bandage) is typical treatment of choice for venous insufficiency and venous leg wounds. Verify arterial perfusion to affected limb first!
|Silver Nitrate sticks
|see notes
|Applied directly to rolled wound edges, hypergranulating tissue in wound bed; chemically cauterizes acute bleeding
|Collagenase ointment
|wounds with necrotic tissue in wound bed
|only FDA approved active enzymatic ointment to help remove necrotic tissue from wound bed
|Antifungal skin products
|2% miconazole nitrate in powder, spray, cream, lotion, or ointment. Aloe Vesta Antifungal; Monistat 1, Neosporin AF, Baza Antifungal; Carrington Antifungal; Fungoid; Lotrimin AF, etc.
|Skin with fungal rash
|Generally for fungal rash affecting skin around wound. Typically apply small amount, gently rubbing into skin so it is no longer visible. Powder may be applied with a light dusting, then gently rub onto affected skin (and may blot with skin barrier liquid to seal in, if excessive moisture is present or under ostomy appliance).
Pain management includes an accurate assessment and documentation of wound pain. The gold standard for an accurate assessment of the patients pain is the patients self reported pain level. Whether a pain scale of 0 (no pain) to 10 (excruciating pain) is used, or smiling faces/grimacing faces, the level of pain should be documented exactly as the patient reports it (Hess, 2005). The quality of pain (stabbing, shooting, throbbing, sharp, dull, constant or intermittent) along with what factors relieve the pain or make the pain worse (walking, standing, elevating the leg, etc.) should be ascertained and documented. Worsening wound pain is one hallmark of a deteriorating wound and may be more indicative of infection than other observable signs such as edema, warmth and erythema surrounding chronic wounds (Baranoski & Ayello, 2004).
Pain with dressing changes may be managed by topical anesthetic products such as 2% or 4% topical Lidocaine Jelly, or EMLA cream, or systemic medications such as NSAIDS or opioids. Topical anesthetics (Lidocaine, Prilocaine, etc.) should be applied with enough time prior to dressing change or debridement for the medication to take effect (approximately 10 min). Similarly, systemic pain medication should also be administered with enough time for pain relief (at least 30 minutes) (Bryant & Nix, 2007; Sussman & Bates-Jensen, 2007).
Addressing the pain when infection is suspected would include addressing the infection. Certain wound products may assist with pain management in specific types of wounds. Matrix applications using small intestine submucosa (SIS) technology (typically porcine) have been successful in relieving some wound pain, particularly over donor sites from split thickness skin grafts. Glycerine or silicone based gel sheets as well as hydrogel sheets (cross-linked polyethylene oxide and water) such as Vigilon may be cool and soothing to partial thickness wounds such as second degree burns and silicone is helpful in reducing scarring after wound closure (Hess, 2005; Sussman & Bates-Jensen, 2007).
Be on the alert for new, different (especially worsening), or persistent pain associated with chronic wounds. Persistent pain in a neuropathic extremity with a chronic wound, as well as may be associated with osteomyelitis (Bryant & Nix, 2007; Krasner et al., 2012; Schultz & Dowsett, 2012).
Baer, W. S. (2011). The classic: The treatment of chronic osteomyelitis with the maggot (larva of the blow fly). 1931. Clinical orthopaedics and related research, 469(4), 920944. doi:10.1007/s11999-010-1416-3
Baranoski, S., & Ayello, E. A. (2004). Wound Care Essentials: Practice Principles. Lippincott Williams & Wilkins.
Bradley, M., Cullum, N., & Sheldon, T. (1999). The debridement of chronic wounds: a systematic review. Core Research.
Bryant, R., & Nix, D. (2007). Acute and Chronic Wounds (3rd ed.). Mosby.
Carville, K. (2006). Which dressing should I use? It all depends on the TIMEING. Australian family physician, 35(7), 486489.
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CDC, C.-C. for D. C. and. (2012). CDC - Hygiene and Handwashing - Water-related Emergencies and Outbreaks - Healthy Water. Prevention. Retrieved January 1, 2013, from (Visit Source).
Century Pharmaceuticals, Inc. (2011) Retrieved 1/3/13 from (Visit Source).
Cowan, L. J., & Stechmiller, J. (2009). Prevalence of wet-to-dry dressings in wound care. Advances in skin & wound care, 22(12), 567573. doi:10.1097/01.ASW.0000363469.25740.74.
Fernandez, R. S., Griffiths, R., & Ussia, C. (2007). Water for wound cleansing. International journal of evidence-based healthcare, 5(3), 305323. doi:10.1111/j.1479-6988.2007.00068.x
Fleck, C. A. (2009). Why Wet to Dry? The Journal of the American College of Certified Wound Specialists, 1(4), 109113. doi:10.1016/j.jcws.2009.09.003
Hess, C. T. (2005). Wound Care: Clinical Guide. Lippincott Williams & Wilkins.
Jones, V., Grey, J. E., & Harding, K. G. (2006). Wound dressings. BMJ (Clinical research ed.), 332(7544), 777780. doi:10.1136/bmj.332.7544.777
Krasner, D. L., Ed, Rodeheaver, G. T., Sibbald, R. G., & Woo, K. Y. (Eds.). (2012). Chronic Wound Care: A Clinical Source Book for Healthcare Professionals (5th ed., Vol. I). Malvern, PA: HMP Communications, LLC.
Mulder, G. D. (1995). Cost-effective managed care: gel versus wet-to-dry for debridement. Ostomy/wound management, 41(2), 6870, 72, 74 passim.
Rabenberg, V. S., Ingersoll, C. D., Sandrey, M. A., & Johnson, M. T. (2002). The Bactericidal And Cytotoxic Effects Of Antimicrobial Wound Cleansers. Journal of Athletic Training, 37(1), 5154.
Schultz, G. S., Barillo, D. J., Mozingo, D. W., & Chin, G. A. (2004a). Wound bed preparation and a brief history of TIME. International wound journal, 1(1), 1932. doi:10.1111/j.1742-481x.2004.00008.x
Schultz, G. S., Barillo, D. J., Mozingo, D. W., & Chin, G. A. (2004b). Wound bed preparation and a brief history of TIME. International Wound Journal, 1(1), 1932. doi:10.1111/j.1742-481x.2004.00008.x
Schultz, G. S., Davidson, J. M., Kirsner, R. S., Bornstein, P., & Herman, I. M. (2011). Dynamic reciprocity in the wound microenvironment. Wound repair and regeneration: official publication of the Wound Healing
Society [and] the European Tissue Repair Society, 19(2), 134148. doi:10.1111/j.1524-475X.2011.00673.x
Schultz, G. S., & Dowsett, C. (2012). Wound bed preparation revisited. Wounds International, 3(1), 2529.
Schultz, G. S., Sibbald, R. G., Falanga, V., Ayello, E. A., Dowsett, C., Harding, K., Vanscheidt, W. (2003). Wound bed preparation: a systematic approach to wound management. Wound repair and regeneration: official publication of the Wound Healing Society [and] the European Tissue Repair Society, 11 Suppl 1, S128.
Sherman, R. A. (2009). Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. Journal of diabetes science and technology, 3(2), 336344.
Sussman, C., & Bates-Jensen, B. M. (2007). Wound Care: A Collaborative Practice Manual. Lippincott Williams & Wilkins.
Wilson, J., Mills, J., Prather, I., & Dimitrijevich, S. D. (2005). A toxicity index of skin and wound cleansers used on in vitro fibroblasts and keratinocytes. Advances in Skin and Wound Care, 18(7), 373378.
Winter, G. D. (1962). Formation of the Scab and the Rate of Epithelization of Superficial Wounds in the Skin of the Young Domestic Pig. , Published online: 20 January 1962; | doi:10.1038/193293a0, 193(4812), 293294. doi:10.1038/193293a0.
Wolcott, R. D., Rumbaugh, K. P., James, G., Schultz, G., Phillips, P., Yang, Q., Dowd, S. E. (2010). Biofilm maturity studies indicate sharp debridement opens a time- dependent therapeutic window. Journal of wound care, 19(8), 320328.
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)
Advance Practice Nurse Pharmacology Credit, CPD: Practice Effectively, Geriatrics, Wound care


text:
Storm in a Teacup
By Cobra Mobile Limited
Open iTunes to buy and download apps.
Take Storm on a wonderful adventure in his magical teacup. Storm's brother Cloud has created an amazing dream-like world for you to explore! Solve puzzles, avoid pitfalls and beat the bad guys in this imaginative and unique platformer!
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Follow Cobra Mobile on Twitter at: twitter.com/cobramobile
What's New in Version 1.7
● Support for iOS 8
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Thanks for playing.
Customer Reviews
This game is a classic on my iDevices. The update, while the graphics aren't as crisp on my Air as I'd like them to be, is a welcome fit on the latest iOS. Hopefully, the graphics will be amped up soon in the next iteration.
- $2.99
- Category: Games
- Updated: Dec 14, 2014
- Version: 1.7
- Size: 19.4 MB
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- Seller: Cobra Mobile Limited
- © Cobra Mobile
Compatibility: Requires iOS 6.0 or later. Compatible with iPhone, iPad, and iPod touch.
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subset: commoncrawl


text:
MANDATORY for all U0/U1s, and U2s who have not attended
There are ways to ensure marketers are not fumbling in the dark when it comes to getting the most out of using emotion in their marketing campaigns. From billboards and adverts to their company website, my research shows that emotions such as shame and guilt can be used to create a favourable response from consumers.
The Social Business Academia Report 2014 gives a comprehensive overview about many of the social business initiatives that take place at universities around the world. Social businesses aim to solve social problems in a financially self-sustainable way.
... Robert J. David is Associate Professor of Strategy & Organization and the Cleghorn Faculty Scholar at the Desautels Faculty of Management, McGill University. He is also Director of the Centre for Strategy Studies in Organization at McGill.
This is Karl Moore of the Desautels Faculty of Management at McGill University, talking management for The Globe and Mail. Today, I am delighted to speak to Andrew Shipilov from [international business school] Insead, just outside of Paris.
When you look at alliances, trust is really important. Tell us more about this.
Read full article: The Globe and Mail, December 9, 2014
Joanna Klimczak doesn't want to support poverty-reduction, she wants to end it.
And, she's going to England to further her cause.
... The 23-year-old student in the faculty of management at McGill University applied for the prestigious scholarship last summer and learned on the weekend that she'd earned one of the coveted spots.
Read full article: St. Catharines Standard, December 3, 2014
Many people strive to be leaders in their society so they can make a difference in the world and improve people's lives. As many of us know, it takes just one person to create even the most significant of changes around us — this thought alone should push everyone to develop their inner leader, no matter what their personality may be.
This is Karl Moore of the Desautels Faculty of Management at McGill University with Talking Management for The Globe and Mail. Today I am delighted to speak to Michael Jacobites from the London Business School.
Michael, tell us about value migration.
Read full article: The Globe and Mail, December 2, 2014
Shame and guilt have different effects on consumer buying habits, new research from the Desautels Faculty of Management in Canada finds.
... Professor DaHee Han says:
"To get the best response, a fitness club could produce an ad that induces shame and highlights the bigger picture, such as 'Are you overweight? How ashamed do you feel? Stop overeating, join our fitness programme and feel healthy all the time'.
The Board of Directors of Andrew Peller Limited (TSX: ADW.A)(TSX: ADW.B) ("APL" or the "Company") is pleased to announce that Mr. Brian D. Athaide has been appointed Chief Financial Officer and Executive Vice President Human Resources and Information Technologies of the Company effective January 5, 2015. In conjunction with this appointment Mr. Peter Patchet, Chief Financial Officer CFO and Executive Vice President Human Resources, will be retiring January 5, 2015.
Kelowna, British Columbia: Decisive Dividend Corporation (TSX-V: DE.P) (the "Corporation"), a capital pool company listed on the TSX Venture Exchange (the "Exchange"), is pleased to announce that it has entered into a share purchase agreement dated November 26, 2014 (the "Share Purchase Agreement") with each of Patrick C. Turner of Penticton, British Columbia, Leslie Gray Cameron of Peachland, British Columbia and Ronald Sutcliffe of Penticton, British Columbia (the "Vendors"), being all of the shareholders of PGR Ventures Inc.


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Update on ElenaElena is an experienced entrepreneur in her chosen occupation. For the past 15 years, she has been selling yarn at one of the markets in her home city of Melitopol. She has her own retail location and a group of regular clients who trust her. Elena plans to purchase a good lot of quality yarn worth 10,000 hryvnia she hopes to receive from Kiva, and to continue gradual development of her business.
Елена планирует закупить хорошую партию качественной пряжи на сумму в 10 000 гривен, полученную от КИВА и продолжать последовательно развивать свой бизнес.
Previous Loan DetailsElena is married and has two children. She has her own business. She sells yarn at the city's central market and has her own retail outlet. Elena has 14 years of work experience. She is hardworking and responsible. Elena wants to develop her business in order to improve the family's welfare.... More from Elena's previous loan »
Additional Information
About HOPE UkraineHOPE International, a Christian faith-based non-profit organization, has been operating in Ukraine since 1997. HOPE Ukraine was the organization's first international venture. In addition to its core microfinance activities, HOPE also supports an active children's ministry in Ukraine in the form of "Tomorrow Clubs," after-school programs that teach children the gospel through games, skits and songs.
Concurrent and Successive Loans
Our Field Partners often work with borrowers over a series of loans as the borrowers build credit, take out bigger loans, and expand their businesses. In order to make it easier for our Field Partners to post loans for borrowers who have been listed on Kiva before, we allow them to post successive and concurrent loans for their Kiva borrowers. This means that our Field Partners are able to post a borrower's second, third, etc., loan on Kiva without having to re-enter all of the borrower's information.
This borrower has been listed on Kiva before, so you'll see an updated loan description, as well as excerpts of the original descriptions from earlier loans. Most borrowers take out loans consecutively, meaning that they receive a second loan after having repaid the first. However, sometimes our Field Partners give out concurrent loans, allowing borrowers to take out one primary loan and a secondary "add-on" loan along with it. These "add-on" loans are typically smaller than the borrower's primary loan and serve a different purpose. Because Field Partners can now post loans as successive and concurrent loans, you will be able to track borrower progress over time and see the various ways a borrower is working with our Field Partners through funds from Kiva's lenders.
About Ukraine
5View loans »
Success!! The loan was 100% repaid
- Repayment Term
- 8 months (Additional Information)
- Repayment Schedule
- Monthly
- Pre-Disbursed:
- Jan 11, 2013
- Listed
- Jan 29, 2013
- Currency Exchange Loss:
- Possible
- Ended:
- Jun 17, 2013


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There's Bacon in my Peanut Butter....
Bacon in peanut brittle...bacon in my ice cream...even bacon to top a cake? Slashfood.com and Gratefulpalate.com are up on the bacon trend sweeping America by offering these...and more. Surprise guests and become the favorite person to your bacon-loving family members.
And if that wasn't enough...check out 50 MORE ways to use bacon
Saved to


text:
- Differential Diagnosis
- Diseases
- Drugs
- More
- Try building your search one term at a time, and be as specific as you can! Search term example: "chronic cough".
- Do not enter multiple findings such as "anemia, chronic cough, weight loss, vomiting" all at the same time.
- After selecting your term from the search results a list of possible diagnoses will be generated. If the list is too long, you will be able to narrow it down by entering additional terms.
- Do not enter values such as "heart rhythm 110" or "sodium 125", instead use "tachycardia" or "hyponatremia".
Sign-in (or register) to check out the new features we've just launched!
Differential Diagnosis For Ciliary injection/perilimbal (cicumcorneal)
Available only to registered users.
- Suggest
- 14 possible diagnoses found
- Infectious Disorders (Specific Agent)
- Leptospiral meningitis
- Leptospirosis/severe (Weils) type
- Leptospiral disease
- Leptospirosis Ictohemorrhagica
- Infected organ, Abscesses
- Keratitis
- Allergic, Collagen, Auto-Immune Disorders
- Iritis
- Uveitis
- Ankylosing spondylitis (Marie-Strumple)
- Arthritis of inflammatory bowel disease
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- Synonyms
- Ciliary hyperaemia, Ciliary hyperemia
- Definition
- Be the first to add a definition for Ciliary injection/perilimbal (cicumcorneal)
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text:
Sara's Mecha Wyvern Transformation by AkuOreoWatch
©2012-2016 AkuOreo
Another shaded sketch of Sara, this time mid-transformation into a mechanical wyvern. While I can't ink or color, I can still draw and shade, but Wraith has to upload them for me.
yay tfs
are you going to do a full series with this?
another piece of art that makes me wish my writing/drawing hand never got that weird lump that bled so easily wen i was writing, playing on my ps2 (back then) or drawing due to muscle moving and opening it. found wen i had it off i cant draw short straight lines up to an inch in length at an angle. if u want proof its very hard to distinguish between one of my Vs and a R wen i write stuff
Something robotic XD is it megagodzilla
neat mostly i know you for that weird plant elf transformation thingie
Transformation and roboticization are two themes that should collaborate more often. <3
Very cool.
looks so very painful
COOOL! can't wait to see the finished product. (both the end of the TF and the coloring!)
Great Job


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..::*Best of February Issue 2*::..Journal Entry: Wed Feb 15, 2012, 10:13 AM
Welcome to the second issue of #TwC February's features!! Hope you enjoy!!
:thumb284442205: :thumb284655236: :thumb268111136:
Previous Months
All of 2014
All of 2013
All of 2012
All of 2011
All of 2010
your founder
Thank you so much for featuring my artwork among these beautiful pieces!
Thank you very much for the feature! Beautiful collection
Awesome selection!
Just beautiful!!!
Thanks so much for being featured with these amazing works. I am happy.
Wow! Thanks for featuring my picture Grandfather Tree. And what a great feature.
Again a beautiful feature
Very lovely feature


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Brian Foley Blog for brfoley https://blogs.oracle.com/brfoley/feed/entries/atom 2007-09-02T22:35:31+00:00 Apache Roller https://blogs.oracle.com/brfoley/entry/display_grid_or_display_grid DISPLAY grid or display GRID? brfoley 2005-06-16T07:20:51+00:00 2005-06-16T14:20:49+00:00

Most grid uses these days are "compute" grids. As we start to look at some other interesting concepts of "grid" usage one that has been mentioned has been the "display grid". However, as I think about this it seems that the term really spans a continuum of possibilities.

 Is it a DISPLAY grid ... or a display GRID?

 DISPLAY grid to me implies that the primary usage/focus is around the concept of "display". Whether that is a web browser based environment to a single/few selected apps to a fully blown desktop environment. The focus is on the interactive usage. The grid portion than gets brought into the concept in two ways. First, the architecture used to deliver the display functionality could/may be based upon common grid architectures. Second is that there is a desire to use unused cpu cycles to do "tradional" grid computing tasks. This scenario would be typified by things like ... delivery of web based kiosks or "simple" web based vertical solutions.

 display GRID than is the total opposite of the first scenario. The primary usage/focus is around the grid computing aspects and that secondary to the grid computing might be the display of the results of the grid computing tasks. This scenario would be typified by things like ... animation rendering, molecular modeling, dna sequencing etc... You might want to be able to display from the grid simply because the volume of the date is such that moving it would be tedious, or, it's a very iterative/interactive process that the user is involved in.

 That's my thoughts... what do you think? https://blogs.oracle.com/brfoley/entry/home_bandwidth_comsumption_part_2 Home Bandwidth Comsumption - Part 2 brfoley 2005-06-13T07:50:48+00:00 2005-06-13T17:58:09+00:00
 I finally started my "bandwidth monitoring" test from home. While I'm accumulating the statistics I thought people might be interested on how I'm gathering the stats.

 Look back at my earlier blog about "Home networking gone wild" and you'll see a diagram of my home network. The goal of this test is to measure my inbound & outbound internet traffic and not the traffic that's local to the home network. The biggest "challenge" is that virtually all of todays "hubs" are really "switches". And the issue with switches is that you cannot view the traffic on all the ports from a single port.

 So the solution is to track down an old ethernet hub. That is a real hub that does shared traffic across all the port. Fortunately a compatriot in my office had one stashed away and was willing to lend it to me for a little while.

 With that accomplished I could now "instrument" my internet connection as follows.

 With the Solaris 10 laptop plugged into the ethernet hub I can than run the open source tool called "ethereal" to snarf all the traffic between the internet and my home router.

 I'm only a few days into gathering statistics when will report back what I find out. https://blogs.oracle.com/brfoley/entry/display_grid_coming_to_a Display Grid ... Coming to a home near you? brfoley 2005-06-10T10:20:27+00:00 2005-06-10T17:25:38+00:00
Maybe you've heard Scott McNealy mention the idea of a "Display Grid" in relationship to both the current Sun Grid projects and Sun Ray / Tarantella.

 For the past year now I've been running a project where we've placed a Sun Ray server infrastructure externally to Sun's corp network. With it we've been doing demos and setting up executive level contacts to experience first hand how Sun Rays work in a wide area network setting (WAN), using of course the worlds largest WAN... the internet. From some of this work we've been garnering ideas and use cases that may be used to develop some initial "Display Grid" ideas.

 How well does this model work?

 Here's  a blog written by one of our test users you might find interesting.

 I've had test users running Sun Rays from across the Atlantic with very good performance. The fact that Sun Rays run blazingly fast across a WAN has huge potentials in my opinion to change how companies deploy desktop computing. Even if you don't need to do it across the internet, think about the benefits within your own company network of being able to easily deploy and support desktops from a more centralized compute facility. (It's back to the future, mainframe computing, done with a much nicer, multimedia, more flexible display device).

 https://blogs.oracle.com/brfoley/entry/home_bandwidth_consumption Home Bandwidth Consumption brfoley 2005-05-23T12:31:25+00:00 2005-05-23T19:37:20+00:00 In a previous blog I wrote about my home network. That started me thinking about how much bandwidth am I using, what protocols, what systems etc.. In particular I'm interested in the bandwidth used by my Sun Rays in a wide area deployment scenario. To that end, I'm going to setup this week a monitoring capability and measure my bandwidth usage. I'll gather stats for a least a week than do some analysis and report back here on my findings. https://blogs.oracle.com/brfoley/entry/make_a_sun_ray_wireless Make a Sun Ray Wireless (Or any other wired device) brfoley 2005-05-18T14:33:10+00:00 2005-05-18T21:46:01+00:00 Some of my friends and colleagues claim that I'm a gadget guy. I think a lot of other people are much more gadget aquire'ers but I do my fair share of getting neat devices to make my life better, or come up with a way to use something else in a fresh manner.
 One of the things that I've needed to do in the last year for some demos and proof of concepts is show a wireless Sun Ray. I also often see posted on our internal email aliases questions by other people on how to do the same thing. So, for what it's worth, here's what I've been using and recommending to people.
 Check out the D-Link DWL-G730AP
 This is a sweet little device that actually has 3 different modes of operation. It's about the size of a credit card, but thicker, it can be powered by wall power or better yet via USB. The 3 modes are Access Point mode, Access Point/Router mode, and Wireless Bridge mode.
 I actually use and take this with me when I travel because you just don't know when you might need to turn a conference room in to a wireless network!
 For the Sun Ray, I simply configure it as a wireless bridge, connect it's ethernet to the ethernet on the Sun Ray, tap into the USB on the Sun Ray for power and voila! you're running wireless!
 https://blogs.oracle.com/brfoley/entry/home_networking_gone_wild Home networking gone wild brfoley 2005-05-17T06:50:52+00:00 2005-05-17T13:41:49+00:00 As my first real post I'd like to introduce you to my home network. See, I've been working from home mostly now for the past year (Sun has great technology for flexible work locations) and I finally got around to looking at what I've got and was quite surprised at how much my home network has grown over the last year.
 Here's a drawing of the network.

 As you can see the left side is pretty normal. The 3 Windows XP laptops and the Windos XP desktop systems are used by my family,3 college age kids all have the laptops and my wife uses the desktop PC. It's interesting to note though that the desktop PC is really quite old, it's a 400Mhz PIII that's used for wordprocesssing, email and web. And works quite nicely at that. Haven't had to "upgrade" it at all.
 The right side is my "home office" network.
 The Netra T1 is running Solaris 10 and I use it for a lot of things, but mostly as one of my Solaris learning/experimentation/prototyping systems for projects that I'm working on.
 The Apple Xserve is one of the two "stable" systems in my network. By stable I mean I don't "experiment" with it. I've put a graphics card in it and use it as a desktop system. I split my time between this system and my Solaris 10 laptop (Toshiba M2). I must admit that until Solaris 10 my primary tool was my Apple Powerbook. However the Xserve has supplanted the Powerbook and when I need a mobile system I take my Solaris 10 laptop.
 As I've already mentioned, the next in line is the Toshiba M2 laptop running Solaris 10. It's setup to also dual boot WIndows XP but I find I haven't had to do that for quite some time now  . This is my other "stable" system. I don't do a lot of "experimenting" with it because I depend on it daily for use. Most often I have it "VPN'ed" into Sun's internal network so I can access files/information there.
 Next is the Sun Ray 170. This is Sun's newest Sun Ray. It's a beautiful design with a 17" LCD monitor built in. Being that it's an ultra thin client it needs to connect to a server someplace to drive it. I boot it from a number of different servers depending on my needs, however, most often it's connected to a set of servers that I work with that is part of Sun's Sun Grid project. (More about this in a future blog  ) At this point let me just say that even though the servers that I'm connecting to are hundreds of miles away performance is as good as if it were in my basement! If you haven't seen what the Sun Ray can do in a "low-bandwidth" situation you really should. It's very impressive!
 The Sun Ray 1G is connected to a Cisco 831 VPN/Router. The Cisco builts a VPN tunnel into Sun's internal network and the 1G runs from a server within the corportate network. This is part of our Sun Ray@Home inititive. What's really cool about this is that I can be working on this Sun Ray at home, pull out the smartcard, go into any Sun office, insert my smartcard the viola! everything that was being displayed at home has now followed me to my Sun office!
 For phone access for a long time I've just been using my cell phone. However, my office is in my basement and coverage isn't the best there. I've managed to get by with that though. Just recently though I've added my latest piece of network stuff. A Vonage VoIP solution. So now I do all my phoning via the Vonage service.
 Finally, there's the old Powerbook. I still use it, but mostly when I'm in other places in the house and need access. Otherwise it sits around waiting to be used.
 To make it easier to use all of this equipment I have the 2 Sun Rays, the Toshiba and the Xserve all using a single keyboard/mouse via a USB KVM switch. However, I have 3 monitors setup so I can see all the time what's on them all. Well, one monitor has to be switched since I only have 3 monitors for 4 systems.
 Of course, this is only the equipment that is always in the network. I often need to build up testing/prototyping environements and for that I have other gear ( a Sun V20z Opteron server, various X86 & SPARC laptops, and other Sun Rays) for whatever project that I'm currently working on. And of course I'm working on various servers on the Sun Grid projects.
 Finally, here's a photo of "command central" as I like to call it. If you look closly at the picture over my desk you'll be able to see Duke hanging out with me also  .
  https://blogs.oracle.com/brfoley/entry/introduction Introduction brfoley 2005-05-16T07:31:43+00:00 2005-05-16T14:37:18+00:00 Well, I've been wrestling with this whole blogging thing for a while and have finally decided to give it a whirl. Just a quick blurb about me. I've been with Sun almost 15 years, almost all that time working in what we call the "field". Working with customers etc... out in a sales office as some form of Systems Engineer/Technologist. I'm located in out Southfield, MI office however lately I've been working from my home office more and more (a few blogs about technology enablement etc... to come). These days I'm part of our Sun Grid team with a particular interest in desktop/user experiences. Which will of course lead me to writing about Sun Rays also.


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While most women in the Greek world are kept in seclusion and forbidden to learn any kind of skill in sports, riding or hunting, Spartan women by contrast were brought up from girlhood to excel at these things and to disdain household chores. One such woman by the name of Cynisca took the Greek world by storm when she won the four-horse chariot race this past month. Cynisca embodies royalty, fortitude and resilience, and it is for these assets that society, both male and female, has welcomed her with open arms.
What's it like to be the first women ever to win an event at the Olympics?
Honestly, it's immensely overwhelming. In a sense I've achieved something no other has been able accomplish. I've broken through boundaries that I never thought I'd be able to conquer. It's the best feeling to know that you've reached the top, the pinnacle.
Does it feel even better knowing that these barriers you've surmounted have been created through the power of men?
Of course it does. The Greek world, especially Athens, has been ruled and controlled by men for such a long time and now, with one achievement, I've allowed other women to follow my footsteps. Ultimately this could lead to more respect and equality given to women in Greece. I'm amazed to think that I created a new and exciting future for the female generations to come.
And all Greeks will know you created this future. There is an inscription on the base of your statue which Apelleas kindly built, what does this inscription read?
The inscription says, 'Kings of Sparta were my forefathers and my brothers. Victorious Cynisca with her chariot drawn by swift-footed horses erected this statue. I assert that I am the only women in all Greece who has won this crown'. I guess it's there to remind people that I was the first women in all of Greece to achieve sporting greatness. I know it's a little over the top but my dear friend, Apelleas, insisted it be excessive.
Do you intend to...


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Man wanted in Philly killing found in Vt.
COLCHESTER The U.S. Marshals Service says a Pennsylvania man arrested in Vermont is awaiting extradition back to Philadelphia to face charges of murder and sexual assault on a minor.
Authorities say Clifford Murdah Moore was arrested Friday in a cab while on his way to the Burlington International Airport, from where he is believed to have been planning to leave the country.
The 34-year-old Moore was awaiting trial in Philadelphia after being charged with murder in 2010. While out on bail, he was charged with unlawful contact with a minor, statutory sexual assault, intimidation of a witness, corruption of a minor and making terrorist threats.
Authorities say Moore failed to appear for his trial, and a warrant was issued for him in November.MORE IN Central Vermont
CAMBRIDGE — Gov. Full Story
A Navy sailor from Arlington has pleaded guilty to charges alleging that he... Full StoryPolice dogs killed
on duty honored
Four police dogs killed in the line of duty,... Full Story
- Most Popular
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text:
the Cordis TEMPO® AQUA® Diagnostic Catheter is an angiographic catheter providing excellent flow rates and optimal contrast delivery and vessel opacification.
TEMPO® AQUA® Catheters offer:
- Precise control and sturdy support. High-strength nylon construction and braided shaft design give strength and flexibility for superb torque response and maximum tactile control.
- Enhanced tip radiopacity. An extended, tungsten-filled NEON® tip, with superb visualization for rapid and precise catheter placement. Less need for contrast injection.
- Flexible tip. Patented soft design and long non-braided distal end increases tip flexibility, helps reduce risk of vessel trauma and promotes patient comfort.
- Microcatheter compatibility. Compatible with Codman Neurovascular RAPIDTRANSIT® and PROWLER® Microcatheters, as well as REGATTA® Steerable Guidewire.
- Smoother delivery. Hydrophilic SLX® Coating minimizes friction between the catheter and the vessel wall for rapid and smooth vessel engagement.


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Randall Kennedy: If Obama Loses, Then What?
Barack Obama has already broken countless racial barriers in his historic run for America's highest office. In this installment of Talk of the Nation's "This American Moment" series, Randall Kennedy talks about what it would mean if Obama lost the election.
Kennedy, a Harvard law professor, weighed in on this prospect in his Washington Post article, "The Big 'What If.'"
"The hopes of black America ride on his shoulders," Kennedy writes, "But the outcome's way up in the air."
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Not sure if such a thing exists but is there any freely available data from things like an army exercise with the MILES system that tracks the gun's location and the direction of the rounds fired, hits recorded? Like how the Ace Combat games show the path of all planes and missiles in your debriefing after each mission. Even data from a multiplayer FPS would be useful.
Shooting range or MILES data?
Started by Mr Butlertron , 20 Mar 2012 14:44
1 reply to this topic
Posted 21 March 2012 - 05:11 #2
Pretty sure I've seen something similar on Arma before...................... will get back to you if I remember where.
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CQB-M: For all your Close Quarter Battle needs!


text:
IPROC, Panasonic Corporation
|IPROC, Panasonic Corporation Patent applications
|Patent application number
|SWITCH AND SWITCH DEVICE USING SAME - Regarding a switch used for various controls of a motor vehicle in particular and a switch device using the switch, it becomes possible to simplify the configuration and to perform reliable detection of trouble. A first detector is disposed on a surface opposing to a magnet fitted to an actuator, and a second detector is disposed thereunder. A controller detects magnetism of the magnet by using the first detector and the second detector. In case one of the detectors is out of order, it can also be detected from ON/OFF signal from the first detector and the second detector.


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Designs with two master suites gain popularity in upscale homes in Oklahoma
Two master suites? Why not three?
That's what Judy Barton and her daughter Beth Sapp were looking for seven years ago: a home not only large enough, but designed, for two separate master suites — plus a third living area for teenage Rachel, Beth's daughter and Judy's grandaughter.
"I met with Judy and Beth, and they both wanted their own space, and Beth's daughter wanted her own space," recalled Mike Gilles of Savannah Builders, who custom-built the home on NW 130 Terrace in the Canyon Lakes neighborhood, southeast of Memorial and Council roads.
"So this house was created to have a kitchen-family area where everybody could come together, great space. Then, each one would have their own suite," he said. "Judy has her own suite with a little library, and Beth had her own suite, and the daughter had the whole upstairs, which is a game room and her own suite.
"We just worked as a team and created this fantastic property. Sorry to see Judy leave, but life changes, and it's way too big for one person."
Beth moved on. Rachel is in college. The 3,446-square-foot home is too big for Judy. So the home with the unusual design — not that common in Oklahoma City, at least — is on the market.
It will appeal to a certain niche buyer, said Realtor Chad Neathery of Paradigm AdvantEdge Real Estate, who has it listed.
Couples who need to sleep apart — so each can sleep — are turning to two-master homes, he said. Maybe one snores, or uses a CPAP machine, for continuous positive airway pressure, a ventilation therapy.
"Mainly it's retired people. It's an older generation. The people I've seen are in their 60s, 70s," Neathery said. "It's also for aging parents, someone in their 50s that has a parent in their 70s or 80s ... a separate room, private, for their aging parents."
The design isn't new. Having two master suites was thought to be a hot trend just before the Great Recession turned housing on its head and set homebuilding back nationally. Seven years ago, the design couldn't be found in Oklahoma City, Neathery said.
New to metro
"It is new to Oklahoma City," he said. Neathery said that when the owners first approached him and Gilles, "There wasn't anything on the market like what she wanted, so she custom-designed it."
Two-master designs have grown in popularity and will continue to do so, especially in higher-end homes, said Brent Gibson, of Brent Gibson Classic Home Design in Edmond.
"We do quite a few of them," Gibson said, mostly for people in their 40s or older. "It's designed so if one of the spouses has problems sleeping, or has sleep apnea or snores."
College graduates returning to live with their parents for awhile have some families turning to separate master suites complete with living areas, kitchenettes and separate garages and entrances, he said. Families with housekeepers or full-time caregivers also turn to double master suites.
Upscale homes
The trend seems to be limited to upscale homes and house plans.
Steven Carey of Preferred Plans Inc. in Norman said demand for double vanities, two walk-in closets, "even two different toilets," is strong, as are aging-in-place features like wider-than-usual doorways and hallways. But double masters not so much, he said, for people trying to stretch dollars.
Gilles said he's seeing more interest from his custom-build customers.
"It's not real common in Oklahoma City," he said. "We've done more and more of them, as some people, as parents, are building a nice home but they're going to have adult kids come and stay with them, maybe for vacations, and so we're doing a lot of houses that have individual suites — some even with individual kitchenettes, like an apartment pod."
The home in Canyon Lakes is a model for what Gilles sees as a big trend for families with multiple generations living together or with a full-time, live-in caregiver.
"The bedrooms are completely separated, but you can't tell any difference when you walk in. It's just a luxurious, open family space," he said. "If you have adult kids, they can be upstairs. If you have a mother-in-law, if you have a caregiver that needs to be in — everybody has their own space."
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