Radiofrecuencia en la cicatrización de heridas crónicas. Una revisión en hospital de media estancia / Radiofrequency in the healing process in chronic wounds. A review in a half-stay hospital

Las heridas crónicas son un problema de salud significativo. Parece que la estimulación eléctrica produce una reducción significativamente mayor en el área de superficie y cicatrización más completa de las úlceras de difícil cicatrización y de evolución tórpida en comparación con la terapia habitual, sin vendaje compresivo. OBJETIVOS: Evaluar el efecto que la radiofrecuencia a baja intensidad y con efectos no térmicos tiene sobre los diferentes componentes del mecanismo del proceso de cicatrización. METODOLOGÍA: Para el tratamiento, se utilizó un dispositivo de tecarterapia (CAPENERGY C200). Se aplicaron un total de 10 sesiones de radiofrecuencia con una periodicidad de 1 vez a la semana con una potencia del 60% y una frecuencia de 1,2 MHz durante 30 minutos. RESULTADOS: La presencia de edema, observada en todos los pacientes en la región de la extremidad inferior, desapareció en 30 de los 36 pacientes (Wilcoxon p = 0,004). Este resultado fue confirmado por ultrasonido. El edema celular subcutáneo medio disminuyó en 1,73 cm (Friedman p = 0,000). La temperatura del área tomada antes y después del tratamiento se incrementó en un promedio de 1,4 °C. Estas diferencias son estadísticamente significativas (Wilcoxon p = 0,000). CONCLUSIONES: La radiofrecuencia parece que puede reducir el largo proceso de cicatrización de las lesiones de evolución tórpida, y nos encontramos con unas diferencias significativas a lo largo del tratamiento y con una reducción progresiva en las mediciones de las lesiones y mayor rapidez en la cicatrización de las heridas complejas

Chronic wounds are a significant health problem. Electrical stimulation seems to produce a significantly greater reduction in surface area and more complete healing of difficult-to-heal and poorly healing ulcers compared to standard therapy without compressive bandaging. OBJECTIVES: To evaluate the effect that radiofrequency at low intensity and with non-thermal effects has on the different components of the mechanism of the healing process. METHODOLOGY: A tecartherapy device (CAPENERGY C200) was used for the treatment. A total of 10 radiofrequency sessions were applied once a week with a power of 60% and a frequency of 1.2 MHz for 30 minutes. RESULTS: The presence of oedema, observed in all patients in the lower extremity region, disappeared in 30 of the 36 patients (Wilcoxon p = 0.004). This result was confirmed by ultrasound. The mean subcutaneous cellular oedema decreased by 1.73 cm (Friedman p = 0.000). The temperature of the area taken before and after treatment increased by an average of °C. These differences are statistically significant (Wilcoxon p = 0.000). CONCLUSIONS: Radiofrequency appears to be able to reduce the long healing process of torpidly evolving lesions, and we found significant differences throughout the treatment and a progressive reduction in lesion measurements and faster healing of complex wounds

Perfil de portadores de feridas crônicas sob a ótica da enfermagem assistencial / Profile of patients with chronic wounds under nursing care / Perfil de los portadores de heridas crónicas desde la perspectiva de asistencia de enfermería

Introdução: Feridas crônicas demandam tempo de tratamento, podem levar a amputações e prejudicar a qualidade de vida, embora sejam preveníveis por meio de ações assistenciais bem direcionadas. Objetivo: Identificar o perfil de portadores de feridas crônicas atendidos em Unidades Básicas de Saúde do interior do Paraná. Material e Método: Estudo transversal realizado através de inquérito domiciliar. A análise descritiva foi realizada por meio da distribuição de frequências de variáveis categóricas e para análise de associação utilizou-se o teste de Qui-quadrado. Resultados: Entre os participantes (N=100), predominou o sexo feminino, sem companheiro, idosos, com baixa escolaridade e renda. A úlcera vasculogênica prevaleceu (n=51;51%) e o tratamento mais utilizado foi com ácido graxo essencial (n=43;28,6%). Em análise de associação, houve relação entre estar acamado e a presença de úlcera por pressão (p<0,001). Doenças crônicas como a hipertensão arterial e diabetes relacionaram-se com os tipos de úlcera (p=0,039). Conclusão: Verificou-se que o perfil de portadores de doença crônica teve maior prevalência no sexo feminino, em pessoas que não possuíam companheiro, que concluíram o ensino fundamental e com renda mensal de um a dois salários mínimos. A maioria tinha úlceras vasculogênicas. Necessária a implantação de um conjunto de ações assistenciais com abrangência em aspectos biopsicossociais.(AU)

Introduction: Chronic wounds require time of treatment, can lead to amputations and impair the quality of life, although they are preventable through well targeted care actions. Objective: To identify the profile of patients with chronic wounds treated in Basic Health Units in the interior of Paraná. Material and Method: Cross-sectional study conducted through household survey. The descriptive analysis was performed by means of frequency distribution of categorical variables and for association analysis the chi-square test was used. Results: Among the participants (N=100), the female sex predominated, without a partner, elderly, with low schooling and income. Vasculogenic ulcer prevailed (n=51;51%) and the most commonly used treatment was essential fatty acid (n=43;28.6%). In an association analysis, there was a relationship between being bedridden and the presence of pressure ulcers (P0,001). Chronic diseases such as hypertension and diabetes were related to the types of ulcers (p=0.039). Conclusion: It was verified that the profile of patients with chronic disease had higher prevalence in females, in people who did not have a partner, who completed elementary school and with monthly income of one to two minimum wages. Most of them had vasculogenic ulcers. It was necessary to implement a set of care actions with coverage in biopsychosocial aspects.(AU)

Introducción: Las heridas crónicas requieren tiempo de tratamiento, pueden conducir a amputaciones y deteriorar la calidad de vida, aunque son prevenibles mediante acciones asistenciales bien focalizadas. Objetivo: Identificar el perfil de pacientes con heridas crónicas atendidos en Unidades Básicas de Salud del interior de Paraná. Material y Método: Estudio transversal realizado a través de una encuesta de hogares. El análisis descriptivo se realizó mediante la distribución de frecuencias de variables categóricas y para el análisis de asociación se utilizó la prueba de Chi-cuadrado. Resultados: Entre los participantes (n = 100), predominó el género femenino, sin pareja, ancianos, con baja escolaridad e ingresos. Predominaron las úlceras...(AU)

Prevención de úlceras iatrogénicas por inmovilización terapéutica en niños con férula. Ensayo clínico / Prevention of iatrogenic ulcers produced by therapeutic immobilization with a lower limb splint in children. Clinical trial

INTRODUCCIÓN: La inmovilización con férula de yeso en miembro inferior es un procedimiento frecuente para niños en los servicios de urgencias, el cual no está exento de riesgos relacionados con la inmovilidad y presión, sobre estos factores los enfermeros tienen que adoptar cuidados preventivos. OBJETIVO: Comprobar la eficacia del parche-talonera polimérico en la prevención de úlceras iatrogénicas en niños inmovilizados con férula de yeso en miembro inferior. MATERIAL Y MÉTODO: Ensayo clínico aleatorio preventivo sobre pacientes pediátricos de 0 a 14 años que precisen inmovilización con férula de yeso en miembro inferior. Se realizó muestreo consecutivo no probabilístico simple ciego. Análisis estadístico descriptivo de las variables y test de la X 2 con las variables aplicación del parche y aparición de úlceras. RESULTADOS: Se obtuvo una muestra de n=74 pacientes. Se objetivó úlcera en 21.7% de pacientes, piel íntegra (48.2%) y eritema que palidece 30.1%. Se aplicó el test de la X2 para las variables aplicación de parche polimérico y aparición de úlcera, obteniendo X 2=0.135 con p = 0.713, y por tanto, no existe significación estadística entre estas dos variables. CONCLUSIONES: No existe relación directa entre la prevención de úlceras por presión en niños inmovilizados con férula de yeso y la aplicación de parche protector polimérico. Es fundamental que los enfermeros/as ofrezcan una educación sanitaria de calidad en los cuidados y mantenimiento de la férula para evitar complicaciones

INTRODUCTION: Immobilization with plaster cast in lower limb is a frequent procedure for children in the emergency services, which is not without risks related to immobility and pressure, on these factors nurses have to adopt preventive care. OBJECTIVE: To verify the efficacy of the polymeric heel patch in the prevention of iatrogenic ulcers in children immobilized with a plaster splint in the lower limb. MATERIAL AND METHOD: Preventive randomized clinical trial on pediatric patients aged 0 to 14 years who require immobilization with a lower limb cast cast. Simple blind non-probabilistic consecutive sampling was performed. Descriptive statistical analysis of the variables and X2 test with the application variables of the patch and the appearance of ulcers. RESULTS: A total sample of n = 74 patients was obtained. Ulcer was observed in 21.7% of patients, whole skin (48.2%) and erythema that pales 30.1%. The X2 test was applied for the application of polymer patch and ulcer appearance variables, obtaining X2 = 0.135 with p = 0.713, and therefore, there is no statistical significance between these two variables. CONCLUSIONS: There is no direct relationship between the prevention of pressure ulcers in children immobilized with plaster splint and the application of polymeric protective patch. It is very important that nurses offer a quality health education in the care and maintenance of the splint to avoid complications

Punch grafting for pain reduction in hard-to-heal ulcers.

OBJECTIVE: Punch-grafting is a traditional technique to enhance wound healing, which has been associated with significant pain reduction. There are few studies measuring pain reduction after punch grafting, our study was designed to measure this outcome. METHOD: Patients with hard-to-heal wounds treated with punch grafting were included in a single centre prospective study. Wound pain intensity was measured using a Visual Analogue Scale (VAS) at baseline (before the procedure) and at three time points after the procedure. Punch grafting was performed in an outpatient setting. Patient demographic data, wound aetiology and percentage of graft take were recorded. RESULTS: A total of 136 patients were included (62 men and 74 women). Mean age was 60±35 years and 51 (38%) had venous leg ulcers (VLU), 29 (21%) had postoperative wounds, 15 (11%) Martorell ulcers, 15 (11%) traumatic wounds, four (3%) arterial ulcers and 22 (16%) 'other' ulcers. Of the patients, 38 (28%) did not present with painful ulcers and, after punch grafting, all of them remained painless; 29 (21%) patients obtained >70% pain reduction, whereas 73 (54%) patients achieved pain suppression. Pain suppression did not depend on the percentage of graft take. CONCLUSION: Punch-grafting is a simple, technique that not only promotes wound healing but also reduces pain. It can also be performed on an outpatient basis. Further studies should be performed to achieve a better understanding of this beneficial finding. Declaration of interest: The authors have no conflicts of interest to declare.

Evaluation of a superabsorbent wound dressing, patient and clinician perspective: a case series.

OBJECTIVE: The primary objective of this study was to evaluate the fluid management capabilities of a superabsorbent wound dressing (Zetuvit Plus Silicone), with secondary objectives related to parameters that support whether the dressing enables undisturbed healing. METHOD: This study was an open labelled non-comparative study. Patients included in the study were selected by the clinical investigator(s) according to whether the patient required a dressing for the management of moderately to highly exuding wounds. RESULTS: A total of 50 patients were included in the study. Results related to the primary objective demonstrated that the superabsorbent wound dressing was able to absorb all levels of exudate across the range (low to high). At each assessment time point these results show that in 98% of assessments the superabsorbent dressing was rated as 'very good' (91%) or 'good' (7%) at exudate management. Secondary objectives relating to wound bed preparation, healing and management of pain were also positive. Additionally, at the end of each patient treatment, the dressing's fluid management capabilities were rated overall as 'excellent' (100% of cases). There was little pain associated with the wound or at dressing change throughout the study and its flexibility/conformability allowed for comfort and patient satisfaction aligned with increased quality of life. Additionally, inclusion of a silicone adhesive layer allowed painless and atraumatic removal of the dressing, increasing patient comfort, both during wear and at dressing removal, and supported the description of enabling undisturbed wound healing. CONCLUSION: The superabsorbent wound dressing achieved the primary objective relating to wound exudate management in all the assessments undertaken in this study. In addition, the silicone interface allowed for undisturbed healing as evidenced by little or no adherence of the dressing to underlying tissue, preventing damage to periwound skin. Overall, the superabsorbent wound dressing with the addition of the silicone interface could offer advantages over other superabsorbent polymer dressings (that might adhere to the wound surface) or silicone wound dressings (that might not have the absorbent properties of this type of dressing).

Resultados clinicos de las enfermeras de practica avanzada en heridas cronicas complejas en Andalucia / Clinical results of the nurses of advanced practice in complex chronic wounds in Andalucia

OBJETIVO: Describir y analizar el rol clínico de la enfermera de práctica avanzada en heridas crónicas complejas (EPA-HCC) en Andalucía, en cuanto al seguimiento de pacientes con heridas crónicas. MÉTODOS: Estudio descriptivo transversal en los distritos Poniente de Almería, del A. G. C. Jaén Norte-Nordeste, A. G. S. Serranía de Málaga y Distrito Metropolitano de Granada entre junio del 2015 y junio del 2018, midiendo variables descriptivas como: diagnóstico etiológico de las heridas crónicas, tiempo de evolución antes de ser remitidos a EPA-HCC, tasas de cicatrización, mejoría, empeoramiento, total de heridas crónicas, tasas de derivación desde EPA-HCC a hospitales. RESULTADOS: Se realizó seguimiento de un total de 767 personas con heridas crónicas, donde el 70% de todas ellas fueron úlceras por presión, úlceras venosas y lesiones de pie diabético, con una media de evolución de todas las lesiones de 21 meses y cuya derivación por parte de las EPA-HCC hacia los especialistas hospitalarios fue del 13,82%, siendo más del 86,18% (n = 661) de los pacientes gestionados de forma eficaz por las EPA-HCC. La derivación directa de los pacientes a consulta de especialistas médicos desde la implantación de la figura fue tan solo del 5%, con el importante ahorro en coste que esto supuso; además, las EPA-HCC atendieron a casi una de cada 4 heridas crónicas, datos estos que solo hicieron referencia a la atención directa, no de consultoría. CONCLUSIONES: El rol clínico y coordinación que desempeñaron las EPA-HCC en los pacientes con heridas crónicas es efectiva en la mejora de los cuidados

OBJECTIVE: To describe and to analyze the clinical role performed by the advanced practice nurse in complex chronic wounds (APN-CCW) in Andalusia, regarding the follow-up of patients with chronic wounds. METHODS: Cross-sectional descriptive study in the Poniente of Almería Districts, of the H. M. A. Jaén North-Northeast, H. M. A. Serranía de Málaga and the Metropolitan District of Granada between June 2015 and June 2018, measuring descriptive variables such as: etiological diagnosis of chronic wounds, evolution time before referring to APN-CCW, healing, improvement, worsening and deaths rates, total of chronic wounds, referral rates from APN-CCW to hospitals. RESULTS: A total of 767 people with chronic wounds were followed up, and 70% of all of them were pressure ulcers, venous ulcers and diabetic feet, with an average of 21 months- evolution of all injuries and whose derivation from APN-CCW to hospital specialists was 13.82%, with more than a 86.18% (n=661) of patients effectively managed by APN-CCW. The direct derivation of patients to the medical specialists office since the implementation of the figure was only 5%, with the significant cost savings that this supposed, besides, the APN-CCW attended almost one in every 4 chronic wounds, no consulting. CONCLUSIONS: The clinical role and coordination of the APN-CCW in patients with chronic wounds is effective in improving care

TIMERS: undertaking wound assessment in the community.

Community nurses regularly treat patients with chronic wounds (those persisting over 6 weeks); with the complexity of both the patients' health needs and the wound itself, this often becomes a highly time-consuming task for the nurse. Wound assessment tools are designed to support all qualified nurses, regardless of whether the nurse possesses specialist wound care knowledge or not, in delivering safe and appropriate wound care. The wound assessment tool, using the acronym TIME, has been recently amended to now be known as TIMERS (Tissue, Infection/Inflammation, Moisture, Wound edge, Repair/Regeneration, Social). This article will examine what the newly amended wound assessment tool TIMERS represents, in addition to looking at the practical issues around its implementation in community settings.

Understanding and addressing dryness during wound healing.

Timely wound healing supports positive outcomes for both the patient and the clinician. The cause of a non-healing wound needs both identifying and addressing. A dry wound bed will result in a lengthy healing process, impacting both the patient and the clinician, physically and financially. It is imperative to correctly identify the cause of a non-healing wound and address the causative factors using evidence-based best practice. A non-healing wound may be attributed to various factors, such as inappropriate dressing, lack of hydration, medication or underlying medical disease. Identification of the cause will support the most appropriate management choice. In order to explain the issues of a dry wound, it is imperative that the clinician first has an understanding of the concept of moist wound healing.

Skin considerations for older adults with wounds.

Ageing leads to a number of skin changes that not only place an older adult at risk of tissue damage, but can present as peri-wound problems for those with existing wounds, for example, incontinence-associated and moisture-associated dermatitis in individuals with pressure ulcers. Older adults with venous disease experience skin changes concomitant with venous hypertension, making the skin more at risk of breakdown, specifically the common complications of lipodermatosclerosis and venous eczema. In individuals with diabetic foot disease, skin changes related to autonomic neuropathy mean patients can experience dry skin that cracks easily, placing them at higher risk of infection. Common to all individuals with wounds requiring some sort of dressing is the risk of medical adhesive-related skin injury, where dressing application and removal need to be of the utmost priority to reduce the risk of injury. This article discusses some of the common peri-wound skin considerations in patients with chronic wounds.

Management of wounds in the community: five principles.

The care of any wound in the community requires multidisciplinary working between healthcare professionals. In this article, the authors offer five generalisable principles that colleagues providing community care can apply in order to achieve timely wound healing: (1) assessment and exclusion of disease processes; (2) wound cleansing; (3) timely dressing change; (4) appropriate (dressing choice; and (5) considered antibiotic prescription. High-quality wound care is an essential aspect of healthcare practice but lacks an evidence base and standardised practice at present. The practice and teaching of wound care should be more greatly emphasised in healthcare training for all disciplines.

A clinically effective primary wound dressing that supports self-care for chronic and acute wounds.

Wound care forms a large component of the ever-increasing workload of district and community nurses. The need for a cost-effective product that can be used on a variety of wounds and that meets multiple requirements (e.g. protease modulation, anti-microbial, peri-wound skin protection, maceration control and barrier function) is well recognised. The plethora of wound dressings available today all fulfil some, although not all, of these requirements. Choosing the correct dressing decreases healing time, provides cost-effective care and improves patient quality of life. This article looks at the important properties of wound care products, investigates the need to release nurse time and describes how patients with wounds can engage in effective self-care, with a focus on 1 Primary Wound Dressing® (1PWD), a cost effective, easy-to-use product that has already demonstrated clinical efficacy. Case studies showing the successful use of 1PWD are also presented to highlight the clinical application of this novel product.

Home care nurses' experience of providing health-care to patients with hard-to-heal wounds.

OBJECTIVE: To investigate and describe the experience of nurses working in home care, with responsibility for providing health-care to patients with hard-to-heal wounds. METHOD: A qualitative method with exploratory and descriptive design was used. Nurses from in three municipalities in Norway were recruited. Data collection was by questionnaire with semi-structured and open-ended questions. Content analysis with an inductive approach was carried out to analyse responses. RESULTS: A total of 21 nurses took part in the study. Participants' statements resulted in three generic themes within one main overall heading: 'Complex challenges, professional pride and joy'. The three themes included: 'The importance of nursing competence', covering nurses' perception of their own competence and the importance of seeing and treating the patient as a whole. 'The importance of organisation and frameworks' examines opportunities for continuing education, access to necessary equipment, good routines for wound management plans and continuity in patient monitoring. The final theme, 'The importance of cooperation' covers nurses' views on working with patients, resource staff, hospital staff and general practitioners. CONCLUSION: Nurses in home care are working with complex challenges, but also describe professional pride and joy when treating patients with hard-to-heal wounds. The criteria for success depends on both patients and nurses' knowledge and also organisational aspects and cooperation.

Use of platelet-rich plasma and platelet-derived patches to treat chronic wounds.

OBJECTIVE: To compare the healing results between platelet-rich plasma (PRP) and platelet-derived patches versus traditional advanced wound dressings in patients with chronic wounds. METHOD: Patients with and without diabetes were divided into two groups, each of which received either PRP patch treatments or the advanced wound dressings. All wounds were cleaned, debrided and assessed by physicians. The data were analysed and represented as mean ± standard deviation (SD). Student's t-test was used to calculate the significance of differences between both groups. Values of p<0.05 were considered statistically significant. RESULTS: Patients with and without diabetes receiving PRP patch treatments saw improvement in wound healing in two weeks (p=0.0083). Patients with diabetes who received platelet-derived patch treatment and PRP injection experienced wound size reduction to <25% of the original area by the fourth week of treatment, and >90% of the subjects had wounds of <10% their original size in the last three weeks of the trial. Conversely, the wound area in the control subjects receiving traditional advanced wound dressings remained at 25-50% of their original size from the fourth week of treatment to the end of the trial. The healing process of the PRP patch experimental group was statistically significant compared with the control group (p<0.0001). CONCLUSION: Combining treatments of PRP injections and platelet-derived patches significantly improved the healing outcomes of patients with chronic wounds, most notably in patients with diabetes, when compared with a traditional treatment of advanced wound dressings.

Práticas avançadas no cuidado integral de enfermagem a pessoas com úlceras cutâneas / Prácticas avanzadas de atención integral de enfermería a personas con úlceras cutáneas / Advanced practices in comprehensive nursing care for people with skin ulcer

Resumo Objetivo Identificar os desfechos clínicos de pessoas com úlceras cutâneas crônicas atendidas em consultas de enfermagem. Métodos Estudo transversal da análise dos registros de consultas de enfermagem a pessoas com úlceras crônicas atendidas em um Centro de Assistência de Enfermagem entre 1994 a 2015, sob a perspectiva da Saúde Coletiva. As variáveis investigadas foram epidemiológicas, clínicas de cicatrização da úlcera, abandono e óbito de usuários. Resultados Dentre os 343 prontuários de pessoas atendidas no serviço, identificou-se maior proporção de idosos, do sexo feminino, com ensino fundamental, de cor autorreferida branca, aposentados, dependentes do Sistema Único de Saúde e com condições crônicas de saúde. A etiologia das úlceras cutâneas foi maior nas neuropáticas e venosas sem resolutividade clínica prévia na rede de serviços de saúde. A cicatrização ocorreu em 67,6% das úlceras pela adoção centrada nos cuidados de enfermagem, e observou-se pequena taxa de abandono e óbito. Conclusão Desfechos clínicos satisfatórios de pessoas com úlceras cutâneas crônicas foram evidenciados nos registros de cuidados de enfermagem. A consulta de enfermagem mostrou-se potencial estratégia para a cicatrização de úlceras cutâneas.

Resumen Objetivo Identificar los resultados clínicos de personas con úlceras cutáneas crónicas atendidas en consultas de enfermería. Métodos: Estudio transversal de análisis de registros de consultas de enfermería realizadas por personas con úlceras crónicas en un Centro de Atención de Enfermería entre 1994 y 2015, bajo la perspectiva de la Salud Colectiva. Las variables investigadas fueron epidemiológicas, clínicas, de cicatrización de la úlcera, cesación del tratamiento y deceso del paciente. Resultados De las 343 historias clínicas de personas atendidas en el servicio, se identificó mayor proporción de ancianos, de sexo femenino, con enseñanza primaria, de color autorreferido como blanco, jubilados, dependientes del Sistema Único de Salud, con condiciones crónicas de salud. La etiología de las úlceras cutáneas fue mayor en las neuropáticas y venosas sin resolutividad clínica previa en la red de servicios de salud. La cicatrización ocurrió en el 67,6% de las úlceras por adopción enfocada en la atención de enfermería. Se observaron bajas tasas de cesación del tratamiento y decesos. Conclusión Los resultados clínicos satisfactorios de personas con úlceras cutáneas crónicas fueron evidenciados en los registros de atención de enfermería. La consulta de enfermería se constituyó en estrategia potencial para la cicatrización de úlceras cutáneas.

Abstract Objective To identify clinical outcomes of people with chronic skin ulcer seen in nursing consultations. Methods Cross-sectional study of the analysis of nursing consultation records for people with chronic wound treated at a Nursing Care Center from 1994 to 2015, from the perspective of Collective Health. The variables investigated were epidemiological, wound advanced treatment centers, abandonment and death. Results There was a high proportion of elderly, female, with complete elementary and middle school, white self-reported color, retirees, dependents on the Brazilian Unified Health System ( Sistema Único de Saúde ) and with chronic health diseases identified among the 343 patients medical records. Etiology of skin ulcer was higher in the neuropathic and venous areas without previous clinical resolution in the health services network. Healing occurred in 67.6% of wound by adoption focused on nursing care. A low rate of abandonment and death was observed. Conclusion There were satisfactory clinical outcomes of people with chronic skin ulcer as evidenced in nursing care records. Nursing consultation showed a potential strategy for advanced wound care.