Rising health care costs and the advent of managed care have generated significant interest and growth in health education. Despite this, knowledge of wound prevention and treatment is lacking. Because wound care is not considered a specialty, patients may not know where to find information about their wounds. In addition, many health care providers are not educated on the specific protocols about prevention and treatment of wounds; therefore, they are unable to educate their patients about wounds. Physicians readily admit that wound care is not part of their residency education, and many of them rely on nurses to educate them and their patients.
Nevertheless, educating patients and their caregivers is an essential component of wound care. Clinicians are challenged to provide patients with the appropriate information to ensure positive outcomes with limited time and resources. This information is needed to help patients avoid complications, to promote self-care and independence, to empower the caregiver, and to reduce readmissions.
The time available for patient/caregiver education varies in different care settings, from a few days in acute care to a few minutes in outpatient settings to an hour in the home care environment. Clinicians in long-term-care settings may have difficulty educating residents who have certain mental and physical disabilities. In the acute care setting, staff may have time to teach only the "need to know" and not the "nice to know."
For patient and caregiver education to be effective, clinicians must have the appropriate knowledge and skills in wound care and the ability to educate adults in all health care settings. This premise is supported by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).1 In addition, education is endorsed by managed care organizations and is considered a critical factor in the prevention of illness.
Clinicians are usually educated about wounds in lectures or seminars. Presenters of such programs often concentrate on scientific content and do not focus on the education process or adult learning principles.2 Unfortunately, there is little emphasis on the clinical setting or on patient education needs.
This article seeks to fill the gap by focusing on the adult learning process and considerations for teaching patients and their caregivers about wounds. Case studies illustrate the key points for educating them about pressure, venous, and diabetic ulcers.
PRINCIPLES OF ADULT LEARNING
Understanding the principles of adult learning will assist the clinician in developing, implementing, and evaluating the patient/caregiver education process. Knowles' adult learning theory3 describes education for the adult learner as being built on previous experience (andragogy), which requires the individual to be self-directed. The Knowles model is based on 6 major assumptions that include:
- need to know. Adults need to know why they need to learn before proceeding to learn.
- learner's self-concept. According to Knowles, adults feel responsible for their own decisions and lives. They often resent or resist situations where they feel others impose on their wills.
- role of the learner's experience. A wide range of individual differences are found in adult groups, including background, learning style, motivation, needs, interests, and goals. With that in mind, the emphasis in adult education should be on individualized teaching and learning strategies.
- readiness to learn. Adults become ready to learn what they need to know and to do to cope effectively with their real-life situations.
- orientation to learning. Adults are task-centered or problem-centered in their orientation to learning. They learn new knowledge, understanding, skills, values, and attitudes most effectively when these are presented in the context of real-life situations.
- motivation. The most potent motivators are internal pressures, such as the desire for increased job satisfaction, self-esteem, and quality of life.
According to Knowles, the pedagogical strategies used in teaching children may also be applied selectively to the adult learner.3 Pedagogy is the method of learning information for the first time from an authoritative figure. The teacher assumes full responsibility for decisions about what is learned, how and when it will be learned, and if it has been learned. Patients taught by this model are dependent, have no experience with the content area, do not perceive the relevance of the content, need to accomplish a required performance, and have no internal need to learn the content. When using this teaching method, it is important to apply andragogical strategies once the initial learning has taken place so the knowledge will develop and endure.
Tough4 pointed out the importance of pleasure and self-esteem as motivators for learning. Patients can achieve this through activities such as reading, listening, watching, or practicing. In another approach, Redman5 described principles of motivation that affect how people learn:
- Internal motivation is longer lasting than external motivation reinforced by rewards.
- Well-organized education materials increase motivation and decrease learner frustration.
- The learning environment influences the focus of the learner.
- Achievable goals must be set.
- A mild level of anxiety is a motivator for learning.
- Affiliation and approval enhance motivation.
- Learning results from a combination of motives.
An extensive literature search on adult education conducted by Brudage and Mackeracher6 revealed that considerations for the adult learner are past experiences and present concerns and roles relevant to work, family, and learning. The learner's mind, physical body, emotional responses, and cherished values must also be considered.
Pine and Horn7 were pioneers in adult education. Their adult learning principles are described in Table 1. Brookfield8 identified 6 principles of adult education:
- Participation is voluntary.
- Respect for self-worth is fostered.
- Adult learning is collaborative.
- Ongoing evaluation is critical for success of the endeavor.
- Adult education fosters a spirit of critical reflection.
- The aim of adult education is the nurturing of self-directed, empowered adults.
Not only do clinicians need to be competent,9 but they also need to ensure the competency of the patient and caregiver for the success of the plan of care. Education activities should be designed to initiate a change in behavior, knowledge, and skill. The clinician's challenge is to know if effective learning has taken place and, if not, to modify the education plan. Clinicians must also be skilled in verbal and nonverbal communication, such as touch and listening.10
MORE FACTORS TO CONSIDER
Other factors relevant to the adult learner should be considered. These include:
- psychological, social, and cultural issues. The clinician must understand strategies to promote effective coping skills and address ethnic, cultural, and religious values. Local religious organizations, community centers, schools, or minority health resource centers can offer valuable information. If the patient does not speak English, an interpreter and education materials in another language may be required. Social workers are an invaluable resource to assist with economic barriers such as the inability to purchase food, medications, topical therapies, or assistive devices.
- How chronic wounds affect body image is not well researched. As previously described, self-esteem is an important component to learning. A negative body image may contribute to low self-esteem and, in turn, have a negative impact on learning.11 Willis12 observed that people who feel good about themselves are more likely to feel motivated in their own care.
- the chronologic ages and developmental stages of the patient and the caregiver. This assists the educator in identifying special needs to be considered in developing the teaching plan. For example, older patients may fatigue more easily and have decreased energy levels and speed. They may also have loss of visual acuity and peripheral vision and problems with glare. Make sure the lighting is sufficient, reduce glare, and use materials with large print. Hearing loss is also very common, and older patients may need more time to process the information. Speak slowly and distinctly and face the patient. For short-term memory problems, written instructions and calendars are helpful. Patients will remember what they consider to be important or of interest to them.
- pain. The patient's ability to perform self-care activities and to learn new behaviors can be affected by pain. Caregivers may have difficulty participating in activities that they perceive as being hurtful to the patient. Effective and timely pain management can enhance the learner's cognitive ability. Strategies include pharmacology, electrical stimulation, positioning, and biofeedback techniques.
- the literacy of the patient and the caregiver. Reading ability and comprehension can be assessed by asking the patient or caregiver to read a section of written instructions aloud. Patient education materials should not be written at higher than the sixth grade reading level.
- mental and physical disabilities. Teaching plans should be individually tailored for disabilities, such as mental disabilities, paralysis, blindness, and deafness. A patient who experiences stress or anxiety may be unable to focus on teaching and may have difficulty retaining the information presented.
Other barriers to learning are environmental. Lack of privacy and space, poor lighting, and frequent interruptions can inhibit the learning process.
CONSIDERATIONS FOR THE TEACHING PLAN
Planning an adult education program13 requires the clinician to consider several important components that make teaching more relevant and effective. These include:
- needs assessment. What does the learner perceive to be important?
- context analysis. What does the content mean to the overall or long-term plan?
- objectives. What are the expectations of the learner at the completion of the program?
- learning/content. What is the content and how will it be presented?
- evaluation. How will the knowledge of the learner be assessed? How will the learner evaluate the education?
- related arrangements. Where and when will the teaching occur and what audiovisual and teaching materials will be used?
Innovative teaching strategies that are easy to understand, cost-effective, and useful in all care settings should be used. The patient/caregiver's level of comprehension and ability to understand and demonstrate the tasks are critical; that will determine how quickly the information can be delivered. The clinician must also take into account that many caregivers in home care are older and have their own health problems or may be reluctant to assist with care.
The clinician should expect to use more than 1 teaching tool, such as written instructions along with diagrams and verbal reinforcement. Other teaching tools include the Internet, computer software programs, television programs, newspapers, videos, tape players, written materials, community-based programs or Web sites, and local experts. The challenge for the clinician is to find education materials that are credible14 (Table 2). Katz15 has described various teaching techniques (Table 3).
WOUND CARE EDUCATION FOR THE PATIENT/CAREGIVER
Teaching and informing are very different processes that should not be confused by the clinician. Informing a patient how to change a dressing and having him or her nod in agreement does not imply that the information has been accepted. The patient and the caregiver must be actively engaged in the process. Learning occurs when they understand, accept, and view the information and techniques taught as important; when they can perform the skills; and when they incorporate new knowledge and attitudes into their daily life. Planned teaching provides needed teaching to a patient or a caregiver with specific goals tailored to the individual and the situation. For the wound care professional, this may be teaching designed to ensure the patient is informed about diabetic foot care.16
Many factors affect wound healing, and these factors influence the level and type of care a patient requires. Consequently, these factors affect the family. Clinicians must consider these challenges when caring for patients with chronic wounds that may last for weeks to years. Over the past decade, the focus of health care has shifted to the home setting, thus increasing the responsibilities of the patient's caregivers. The current wound care literature has little emphasis on the contributions made by caregivers in the care of patients with chronic wounds.17-19
Consideration of the patient's physical, emotional, social, economic, spiritual, and cultural needs is necessary in dealing with chronic wounds. However, there is little information in the literature regarding the psychosocial aspects of chronic wound management. In the literature that does exist, some predominant themes have emerged: the human cost of pain, immobility, social isolation, embarrassment, low self-esteem, negativity, and frustration. From this understanding, clinicians can identify patient and caregiver needs, set mutual goals, and help patients face the challenge of their wounds.20
WHAT THE GUIDELINES SAY
The importance of patient and caregiver education is reflected in many evidence-based practice guidelines. The pressure ulcer prevention guideline from the Agency for Health Care Policy and Research (AHCPR; now the Agency for Healthcare Research and Quality)21 states that the patient and family are integral to the prevention and management of pressure ulcers. The guideline lists 7 essential components of an education program (Table 4), including:
- etiology and risk factors for pressure ulcers
- risk assessment tools and their application
- skin assessment
- selection and/or use of support surfaces
- development and implementation of an individualized program of skin care
- demonstration of positioning to decrease risk of tissue breakdown
- instruction on accurate documentation of pertinent data.
The AHCPR guideline for treatment of pressure ulcers22 also encourages active participation of the patient and caregiver. It recommends that patients understand the variety, availability, and relevance of treatment options and participate in decisions regarding pressure ulcer management. Information on pain, outcomes, and duration of treatment should also be included.
Both AHCPR guidelines stress the importance of monitoring the effectiveness of education programs by testing the knowledge gained and skills mastered. They also discuss the use of quality improvement surveys to evaluate patient and caregiver knowledge of pressure ulcer management, implement recommended interventions, and measure pressure ulcer healing and prevention.
The Wound, Ostomy and Continence Nurses Society (WOCN) has developed a clinical practice guideline series that addresses pressure, arterial, neuropathic, and venous ulcers.23-26 The WOCN guidelines discuss the involvement of the patient and the caregiver in self-management and education about the causes and risk factors for these ulcers and how to minimize the risks (Tables 5-8).
Several other guidelines address the treatment of diabetic ulcers.27-31 Groups involved in this process include the American Diabetes Association (ADA),29 the American College of Foot and Ankle Surgeons,30 and the American Pharmacists Association (formerly the American Pharmaceutical Association).31 The American Orthopedic Foot and Ankle Society has a diabetic patient education leaflet with multilingual translation.32 Education is a critical element in prevention of foot ulcers and eventual lower-extremity amputation in patients with diabetes. One study emphasized the need for constant repetition and reinforcement of diabetic foot-specific education.33
Understanding patient education needs for wound care is multifactorial. Clinicians must utilize a diversity of resources to solve complex teaching needs encountered in the real world. The following case studies discuss such challenges.34
Case study 1: Pressure ulcer
A 38-year-old male who is a paraplegic as a result of a motorcycle accident 4 years earlier is admitted from home to an acute care facility with bilateral Stage IV ischial pressure ulcers and bowel and bladder incontinence. Both ulcers have yellow slough in the wound base and are draining copious amounts of foul-smelling, purulent drainage.
The patient's family members have been very supportive since the accident. They have obtained a pressure-reducing bed for him, as well as a cushion to use in his wheelchair to reduce pressure on the ulcers. Despite this support, the patient feels isolated and depressed because he is on bed rest to prevent the ulcers from worsening. In addition, his family members feel responsible for the ulcers. The patient and family had been instructed on how to prevent pressure ulcers while the patient was hospitalized after the accident; however, they have had minimal follow-up instruction. Clearly, they need more in-depth teaching regarding prevention and treatment modalities. Mobilization of additional resources, such as a visiting nurse, is necessary to reinforce this teaching.
The patient also needs to understand the role he can play in the treatment plan. His participation will not only give him a sense of control, but will also enable him to heal the ulcers more quickly and get back in his wheelchair and socialize. This, in turn, will reduce his depression.
The patient's risk factors for development of pressure ulcers must also be considered. These include immobility, friction, shear, decreased sensation, and incontinence. Immobility is certainly an issue: The patient cannot sit on the ulcers and is temporarily bed bound. The family will need to be taught how to reduce friction and shear by using a draw sheet while he is in bed and a transfer board or lift when he is finally able to be transferred to a wheelchair. As the patient has no sensation from the waist down, he cannot regularly shift his weight to reduce pressure. Key points in educating the patient and family about reducing pressure include:
- knowledge of pressure points when sitting or lying on his back or side
- pressure reduction with support surfaces, such as specialty beds, mattresses, or overlay mattresses and seat cushions
- proper positioning in the chair or wheelchair: (1) use good posture to prevent friction and shear; (2) avoid sitting on the ulcer; (3) off-load pressure by changing position at least every hour, or as directed by the health care provider; (4) avoid donut-shaped rings
- proper positioning in bed: (1) avoid lying directly on an ulcer; (2) turn and reposition every 2 hours, or as directed by the health care provider; (3) avoid lying directly on a trochanter (use the 30-degree side-lying position); (4) elevate the heels off the bed with a pillow or foam; (5) avoid the use of donut-shaped rings; (6) use pillows to keep knees and ankles from coming in contact; (7) elevate the head of the bed no higher than 30 degrees, as long as the patient can tolerate it.
Incontinence is another risk factor that must be addressed. The patient is using a moisture barrier ointment for skin protection and adult briefs. However, some of the excrement is also absorbed by the dressings on his ulcers. This patient is an ideal candidate for a bowel and bladder program. His family can be taught how to perform intermittent self-catheterization and use suppositories for bowel control.
During a subsequent hospital stay, the bilateral ischial ulcers were surgically debrided and treated with an antibiotic for the wound infections. The family will need to learn the signs of infection, appropriate wound care dressings to use, and which signs to report to the health care provider.
A physical therapist assessed the patient's wheelchair cushion, found it inadequate to reduce pressure, and provided the patient with an appropriate cushion. His family members will require instruction in hand checks to be sure the cushion is providing adequate pressure reduction. In addition, they also need to collaborate with the company that provides the patient's specialty bed at home for periodic inspections and service.
Case study 2: Venous ulcer
A 78-year-old Hispanic female with an 8-month history of a heavily draining venous ulcer on her right lower extremity makes weekly visits to the local wound care center for treatment. She does not speak English. Although the partial-thickness ulcer has granulation tissue, its size has not decreased since her initial clinic visit 4 weeks ago. Despite the large amount of serous drainage, she admits that she is changing the dressing only about twice a week. On assessment, the skin surrounding the ulcer exhibits scaly dermatitis, hemosiderin staining, and 2+ pitting edema. The patient states that she cannot stand to wear the device that has been prescribed for compression therapy, the cornerstone of treatment for venous disease.
In this case, preventive measures are the key components to healing the present ulcer and preventing future ulcers. This patient is at especially high risk due to her age. In fact, teaching preventive strategies is even more critical in older patients with venous disease.
A special challenge for teaching this particular patient is the language barrier. The services of an interpreter will be required to help out. In addition, several written patient education materials can be purchased in Spanish.
Education for prevention of venous ulcers includes the following points:
- Do not smoke.
- Consume adequate nutrition.
- Keep skin clean and well lubricated.
- Elevate the legs above the heart.
- Avoid sitting with the legs crossed.
- Avoid standing for prolonged periods of time.
- Ambulate as tolerated several times a day.
- Take medications as prescribed.
- Use compression therapy as prescribed.
- Follow-up with the health care provider.
This is not the patient's first venous ulcer; she has had others in the past, all of which have healed uneventfully. The difference this time is that her venous disease has progressed, and now she has edema in her lower extremities, scaly dermatitis, and hemosiderin staining. She will need additional information on the use of emollients to prevent dry skin. Besides the strategies already given for prevention, she will also need the following instruction to reduce edema:
- Elevate the foot of the bed while sleeping.
- Exercise the feet and ankles when the legs are elevated.
- Avoid the use of constrictive clothing.
Contributing factors to the nonhealing ulcer are lack of appropriate dressing changes and inability to tolerate compression. An absorbent dressing is needed to wick away the drainage, which will prevent the wound from becoming too moist and the surrounding skin from becoming macerated. Alternative compression devices should be discussed with the patient to determine if she could tolerate another system. Once this is accomplished, she would need to be educated in the proper techniques for wound care dressing changes and use of compression therapy.
Case study 3: Neuropathic ulcer
An 82-year-old obese male has a 22-year history of type 2 diabetes with neuropathy and retinopathy. He has now developed a neuropathic ulcer on the plantar surface of his right foot, which he is attempting to care for himself at home.
The wound bed of this full-thickness ulcer has pale pink, dry tissue; a callus is surrounding the edge of the wound. Dorsalis pedis and posterior tibial pulses are palpable but weak. He does not comply with his prescribed diet, and although he takes insulin, his hemoglobin A1C is consistently elevated. Due to his obesity, poor eyesight, and loss of sensation, he cannot reach, see, or feel his feet. He lives alone, but his sister, who lives next door, has agreed to be his caregiver.
Although the patient wants to manage the wound himself, the reality is that he has physical issues (obesity and poor eyesight) that preclude self-care. His ability to identify skin breakdown is also impaired by his neuropathy.
Patients with diabetes and their caregivers require education to help them prevent neuropathic ulcers. This education includes the following advice:
- Avoid smoking.
- Keep diabetes under control.
- Avoid friction from ill-fitting shoes.
- Perform daily foot care (inspect the feet, wash and dry well between toes, wear clean socks).
- Prevent dry feet by applying a thin coat of a lubricating oil (such as baby oil) after drying the feet. Do not apply this oil between the toes.
- Avoid soaking the feet.
- Avoid wearing garters. Instead, wear properly fitted stockings that are not mended and that do not have seams. Change these stockings daily.
- Avoid wearing shoes without stockings or socks, and do not wear sandals with thongs between the toes.
- Visit a health care professional for foot care for toenails, corns, and calluses.
- Avoid over-the-counter medications for corns and calluses, antiseptic solutions, and adhesive tape.
- Wear well-fitting footwear; leather footwear is preferred.
- Inspect the inside of shoes for foreign objects, nail points, torn linings, and rough areas.
- Wear orthotic footwear to correct an altered gait or orthopedic deformities.
- Avoid crossing the legs.
- Reduce pressure on bony prominences.
- Avoid temperature extremes (cold and hot).
- Avoid external heat sources, including heating pads, hot water bottles, hydrotherapy, and other hot surfaces.
- Follow-up with a health care provider on a routine basis. Notify the provider immediately if a sore, blister, cut, or scratch develops.
The patient's age is a contributing factor to his neuropathic ulcer. This risk is enhanced by the fact that he does not follow his prescribed diet. A dietitian or visiting nurse can provide diet teaching to help the patient learn how to control his blood glucose level. His sister will need to be taught how to prepare meals that not only meet the requirements of the diet, but that also satisfy the patient's desires.
The patient's poor eyesight makes it difficult for him to read the numbers on his insulin syringe. His sister has agreed to learn how to give him insulin injections. However, she has short-term memory loss. This means she will need to keep written instructions on hand, as well as give return demonstrations of the injection procedure. Coupled with a healthier diet, better glucose control may help the patient begin to lose weight.
Obesity is a significant problem in the patient's self-care of the neuropathic ulcer; he has difficulty lifting his foot for wound care due to his weight. His sister will need to be educated in the use of appropriate wound care dressing to hydrate the wound and promote moist wound healing; she will also need instruction in preventive foot care as outlined above. Again, her short-term memory loss requires provision of written instructions to help her remember the steps for her brother's wound care. She should also provide return demonstrations with the visiting nurse or wound care nurse.
The 3 factors presently delaying wound healing in this patient include decreased blood supply, a dry wound, and the callus surrounding the wound. Unfortunately, the patient is not a candidate for bypass surgery to increase circulation to the area. He can have the callus surrounding the ulcer surgically removed. The patient will then need to be fitted for special orthotic footwear to off-load the pressure from the ulcer and prevent the occurrence of a new callous. His sister will be given instruction on how to inspect the foot for further callus formation and when to inform the health care provider if it appears that the callus has recurred.
As the US population ages, the number of indolent or chronic wounds will continue to rise. Patient and caregiver education is an essential component of successful chronic wound management. Knowledge of the principles of adult learning; evidence-based guidelines; and other resources available to clinicians, patients, and caregivers are keys to successful healing of chronic wounds.
1. Joint Commission on Accreditation of Hospitals. Comprehensive accreditation manual for hospitals. Chicago, IL: JCAHO; 1996.
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3. Knowles M. The Adult Learner, A Neglected Species. Houston, TX: Gulf Publishing Company; 1990.
4. Tough A. How adults learn and change. Diabetes Educ 1985;11(Suppl):21-5.
5. Redman BK. The Practice of Patient Education, 8th ed. St. Louis, MO: CV Mosby; 1997.
6. Brudage DH, Mackeracher D. Adult learning principles and their application to program planning. Research report for the Ministry of Education of Ontario. Queen's Park, Ontario, Canada; 1980.
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8. Brookfield S. Understanding and Facilitating Adult Learning. San Francisco, CA: Jossey-Bass; 1986.
9. Hess, CT. The art of skin and wound care documentation. Adv Skin Wound Care 2005;18:43-55.
10. Ojanlatva A. Vandenbussche C, Heldt H, et al. The use of problem-based learning in dealing with cultural minority groups. Patient Educ Couns 1997;31:171-6.
11. Toth PE, Stenger B. Teaching wound care to patients, families and healthcare providers. In: Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 3rd ed. Wayne, PA: HMP Communications; 2001.
12. Willis J. Beautiful Again: Restoring Your Image and Enhancing Body Changes. Santa Fe, NM: Health Press; 1994.
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14. Ayello AE. Critique of AHCPR's consumer guide-"Treating Pressure Sores." Adv Wound Care 1995;8(5):18, 20, 22, passim.
15. Katz JR. Back to basics: providing effective patient teaching. Am J Nurs 1997;97(5):33-6.
16. O'Shea HS. Teaching the adult ostomy patient. J Wound Ostomy Continence Nurs 2001;28:47-54.
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25. Wound, Ostomy and Continence Nurses Society. Guideline for the Management of Patients with Lower-Extremity Neuropathic Disease. Glenview, IL: Wound, Ostomy and Continence Nurses Society; 2004.
26. Wound, Ostomy and Continence Nurses Society. Guideline for the Management of Patients with Lower-Extremity Venous Disease. Glenview, IL: Wound, Ostomy and Continence Nurses Society; 2005.
27. Tomaselli, N. Guidelines for diabetic foot ulcers: a nurse's perspective to the panel discussion. Wounds 2001;13(5):17E-20E.
28. Inlow S, Orsted H, Sibbald RG. Best practices for the prevention, diagnosis and treatment of diabetic foot ulcers. Ostomy Wound Manage 2000;46(11):55-68; quiz 70-1.
29. American Diabetes Association. Consensus development conference on diabetic foot wound care. Diabetes Care 1999;22:1354-60.
30. Frykberg RG, Armstrong DG, Giurini J, et al. Diabetic foot disorders: a clinical practice guideline.
J Foot Ankle Surg 1999;39(Suppl):S1-S60.
31. APhA drug treatment protocols: management of foot ulcers in patients with diabetes. J Am Pharm Assoc (Wash) 2000;40:467-74.
32. Trepman E, Bracilovic A, Lamborn KK, et al. Diabetic foot care: multilingual translation of a patient education leaflet. Foot Ankle Int 2005;26:64-7.
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34. Tomaselli N. Health promotion and patient education. In: Morison MJ, Ovington LG, eds. Chronic Wound Care: A Problem-Based Learning Approach. Edinburgh, Scotland: Mosby; 2004.
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