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Management of Vascular Leg Ulcers

Wipke-Tevis, Deidre D. PhD, RN; Sae-Sia, Wipa MSN, PhD

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Advances in Skin & Wound Care: October 2005 - Volume 18 - Issue 8 - p 437-445

Vascular leg ulcers are a clinical challenge, with an estimated prevalence between 0.1% and 1%. They may be caused by peripheral arterial disease (PAD), chronic venous insufficiency (CVI), or a mixture of both. Although the pathogenesis differs among cases, the underlying problem leading to impaired healing is circulation. Poor circulation decreases delivery of oxygen and nutrients, prevents removal of metabolic waste products such as carbon dioxide, and ultimately delays healing.

Most patients with leg ulcers are treated in the outpatient setting, with 56% of patients requiring home care. Monthly home health care costs for ulcer care are estimated at up to $2500.

This article differentiates the pathogenesis of venous and arterial ulcers and identifies the critical aspects of caring for patients with vascular ulcers. Leg ulcers caused by lymphedema, pyoderma gangrenosum, vasculitis, infection, and malignancy are not discussed.


Annual prevalence of venous ulcers in community-dwelling adults aged 65 and older is 1.69 per 100 person-years, with an overall incidence of 0.76 for men and 1.42 for women. Venous ulcer prevalence and incidence are greater in the long-term-care population than in the community at large, with an admission prevalence of 2.5% and a 1-year incidence of 2.2%.

Chronic venous insufficiency is the most common cause of leg ulcers, accounting for up to 81% of all cases. Causes of CVI include:

  • venous valve incompetence (deep, perforator, and/or superficial veins)
  • deep vein obstruction/thrombosis
  • arteriovenous fistula
  • calf muscle pump failure (eg, paralysis, decreased ankle range of motion, or ankle joint deformity).

As a result of CVI, hydrostatic pressure in the veins increases so that serous fluid and red blood cells (RBCs) move from the veins to the tissue, resulting in leg edema. Eventually, enzymes break down the RBCs, causing release of hemosiderin; this results in brownish staining of the skin. Over time, the patient develops lipodermatosclerosis, in which normal skin and subcutaneous tissues are replaced by fibrous tissue. This condition results in thick, hardened, contracted skin at the ankle (ie, gaiter area).

Risk factors for venous ulcer development include:

  • a family history of maternal venous insufficiency
  • a history of deep vein thrombosis, diabetes mellitus, chronic heart failure, or recent edema
  • obesity
  • severe trauma to the leg
  • vigorous exercise
  • for women, the number of pregnancies.

Thrombophilia, an increased tendency for the blood to clot and form thromboses, is present in as many as 41% of patients with venous ulcers. Congential conditions that cause thrombophilia include antithrombin III, protein C, or protein S deficiency; factor V Leiden and prothrombin 20210A mutations; and acquired antiphospholipid and anticardiolipin antibodies. The presence of thrombophilia may cause the venous ulcer to be more resistant to treatment. If a patient with a venous ulcer has thrombophilia, the clinician should also monitor anticoagulant drug therapy and coagulation blood tests such as prothrombin time and/or international normalized ratio.


  • Palpating pulses: In patients with venous ulcers, popliteal, dorsalis pedis, and posterior tibial pulses typically are palpable. Doppler ultrasound may be necessary to assess pulses if edema is severe. Capillary refill in the toes takes less than 3 seconds. The leg is warm, with minimal change in skin temperature from the knee to the foot. The patient may have visible varicose veins. The ankle-brachial index (ABI) is 0.9 or more.
  • The ABI can be easily determined by measuring the systolic blood pressure at the ankle (using the Doppler and a sphygmomanometer) and dividing it by the systolic blood pressure at the arm (Figure 1). In general, an ABI of 0.9 or more is considered to be normal and indicates that the arterial circulation in the arm and foot are equivalent. However, it should be noted that patients with diabetes mellitus or renal disease may have a falsely elevated ABI due to arterial calcification, and thus, require further vascular testing to rule out PAD.
  • Figure 1
    Figure 1:
    MEASURING THE ABI. A Doppler ultrasound and sphygmomanometer are used to measure an ankle-brachial index.
  • Venous valvular incompetence can be measured using a Doppler ultrasound equipped with a photoplethysmography (PPG) sensor. The PPG sensor is placed 10 cm above the medial malleolus. Sitting with legs bent at a 120-degree angle and feet on the floor, the patient performs 6 cycles of rapid dorsiflexions. Each cycle consists of a toe raise followed by a heel raise. If the venous valves are competent, refill time is 20 seconds or more. If the valves are incompetent, rapid refilling occurs (less than 20 seconds) by retrograde flow and isdiagnostic of venous insufficiency.
  • Ulcer location: Venous ulcers (Figure 2) are classically located above the medial malleolus. However, they also may occur near the lateral malleolus, and in severe cases, may encircle the entire ankle. The wound margin tends to be irregularly shaped, and the ulcer base may be covered with yellow slough. When debrided, tissue in the ulcer base is dark red and ulcer drainage may be copious, particularly when the leg is edematous. The ulcer often is quite painful, particularly when infection or edema is present. The periulcer skin has brownish skin pigmentation due to hemosiderin deposition.
  • Figure 2
    Figure 2:
    VENOUS ULCER. Venous ulcers are typically moist with irregular edges and firm, fibrotic and indurated surrounding skin.
  • Eczema, or "stasis dermatitis," often is present on the affected leg, and pruritis is a common symptom. Additional tissue trauma or infection may occur if the patient scratches the area with the fingernails. The periwound skin is thickened, hardened, and indurated. The extremity often is edematous, but it is a hardened "woody" edema. Table 1 1 highlights the differences between venous and arterial ulcers.
  • Table 1
    Table 1:


  • Activity: Standing or sitting with the feet dependent for long periods lowers skin oxygen and should be avoided in patients with venous ulcers. They should be instructed to shift their weight frequently when standing and to walk around at least once per hour. A daily walking program is encouraged. Recent research suggests that vigorous exercise (eg, running, jogging, tennis, hockey, football, soccer, squash, basketball, alpine skiing, judo) increases the likelihood of ulceration; consequently, patients with a venous ulcer should be instructed to avoid these activities.
  • Positioning: The legs should be elevated above the heart level for 30 minutes, 3 or 4 times daily. At night, leg elevation is recommended to reduce edema. This can be accomplished by placing blocks under the foot of the bed or several thick blankets between the mattress and box springs. Recliners also are useful for leg elevation. If a recliner is unavailable, it is acceptable for the patient to elevate the legs with several pillows while lying on the couch.
  • Compression therapy: Compression is essential to venous ulcer healing and prevention of recurrence. The level of compression required depends on the severity of the CVI. Many options are available, including elasticized tubular support bandages, elastic wraps, adhesive elastic wraps, wraps with hook-and-loop closure (eg, Circ-Aid), marked elastic wraps, paste bandage (Unna boot) with elastic wrap, multilayer bandage regimens (2, 3, or 4 layers), sequential pneumatic compression devices, and custom-fitted compression stockings (Figures 3-4).
Figure 3
Figure 3:
ELASTIC WRAP. At rest, the markings on this marked elastic wrap are rectangular. When stretched to the appropriate level of tension, the rectangles become squares.
Figure 4
Figure 4:
MULTILAYER COMPRESSION BANDAGE SYSTEM. Multilayer compression bandage systems use 2, 3, or 4 layers to increase sub-bandage pressure and maintain the leg's volume.

Before compression therapy, arterial status assessment is essential because many patients with leg ulcers may have both CVI and PAD. If pedal pulses are palpable, it usually is safe to apply compression. However, it is advisable to obtain an ABI measurement with Doppler ultrasound. An ABI of less than 0.8 suggests that the patient may have PAD as well as CVI and should have a low level of compression. An ABI of less than 0.5 indicates that the patient has severe PAD, should not have compression therapy, and requires referral to a vascular surgeon.

The classic compression treatment for venous ulcers has been the paste bandage (ie, the Unna boot). This paste bandage is impregnated with zinc oxide, glycerin, gelatin, and perhaps, calamine. It is applied without tension in a circular fashion from the distal foot, above the toes, to the tibial tuberosity below the knee. Various techniques are used in applying the boot, including open-heeled, closed-heeled, reverse-fold, cutting and restarting, and pleated procedures. During Unna boot application, it is important that the patient dorsiflex the foot so that it is at a 90-degree angle to the leg.

The Unna boot, which usually is covered with an elastic wrap or tubular support bandage, dries to form a semirigid cast. This cast generally is changed once or twice weekly, depending on ulcer drainage and leg edema. A primary dressing (eg, hydrocolloid, foam, or calcium alginate) usually is applied to the ulcer before Unna boot application. The Unna boot is useful in the initial phases of treatment for severe edema. However, after the edema decreases, the Unna boot is limited in its ability to accommodate limb volume changes and inability to absorb drainage from highly exudative wounds.

Consequently, many clinicians advocate the use of a multilayer bandage regimen to increase sub-bandage pressure and more effectively maintain the leg's volume. The regimen developed by Charing Cross Hospital in London includes several layers:

  • spirally wrapped orthopedic wool to absorb exudate and protect bony prominences
  • a spirally wrapped cotton crepe bandage
  • a highly elastic conformable compression bandage applied in a figure 8 with a 50% overlap
  • a spirally wrapped elastic cohesive bandage to hold the layers in place.

Kits containing all of these layers are commercially available.

Alternatively, a pneumatic compression pump may be used to provide compression. This system consists of an inflatable boot and a pneumatic pump that rhythmically fills the boot with air. Single-chamber boots that inflate to a specific pressure or multichamber boots that inflate in sequential order are available. A recent systematic review concluded that long-term use of pneumatic compression pumps in the home environment may be an alternative to other compression therapies for patients who are unable, or refuse, to adhere to other compression methods or for patients who have previously failed treatment with other compression devices. Pneumatic compression is contraindicated in clients with significant PAD, edema from chronic heart failure, active phlebitis, deep vein thrombosis, or the presence of localized wound infection or cellulites.


  • Compression therapy: Compression is a lifelong, daily therapy for patients with CVI. Once the ulcer is healed, patients should be fitted for custom compression stockings. They should remove the stocking and bathe before bedtime. After bathing, the skin should be moisturized with a lotion or cream, absorbed by the skin during the night. To prevent edema formation, stockings should be replaced in the morning before the patient rises from the bed.
  • Devices such as a silk bootee or metal frame may assist with stocking application in older adults who have limited hand mobility. Stockings with a zipper in the back aid in application. A newly developed stocking features 2 pieces-a piece that covers the foot and ankle area and a footless piece that covers the ankle to the knee. This may be more convenient for older adults to use.
  • Patients should purchase 2 pairs of stockings. This enables them to wear clean stockings while the dirty stockings are being washed. Advise patients to follow the manufacturer's washing instructions, which usually suggest hand washing with a mild detergent (not soap) and air drying. Stockings should be replaced every 4 to 6 months.
  • Unfortunately, Medicare does not cover stockings because they do not fall into any Medicare statutorily defined benefit category. Depending on the style, brand, and pressure of the stockings purchased, the out-of-pocket cost for knee-high stockings is approximately $75/pair.
  • Weight management: Obesity, often a problem in the venous ulcer patient population, is thought to impede venous return in the abdomen. To promote healing and prevent recurrence, weight loss is recommended for obese individuals. However, this can be challenging for patients with activity and mobility limitations. Furthermore, dieting may not be advisable during a period when an ulcer is active. Involvement of a dietitian, a physical therapist, and a physician is useful in weight reduction.
  • Surgical treatment: For advanced CVI with ulceration (CEAP stage C4 to C6), venous vascular surgery is considered an option. The classic Linton procedure has fallen out of favor. In its place, the relatively new surgical technique called subfascial endoscopic perforator surgery has reportedly improved healing rates and reduced the risk of recurrence of venous leg ulcers. Depending on the patient's presentation, the procedure may or may not include superficial vein stripping.


Arterial ulcers, also known as ischemic ulcers, occur in patients with PAD (Figure 5). Peripheral arterial disease is caused by the progressive narrowing of the arteries due to the development of atherosclerotic plaque, which decreases blood flow in the arteries. As an atherosclerotic plaque increases in size, perfusion to tissues distal to the plaque is decreased. Decreased perfusion causes ischemia and, if left untreated, results in cell death, ulceration, and ultimately, gangrene.

Figure 5
Figure 5:
ARTERIAL ULCER. This image shows a necrotic great toe with blisters on the toes and foot, representing arterial insufficiency.

Risk factors for PAD include cigarette smoking, hypertension, hyperlipidemia, diabetes mellitus, obesity, hyperhomocysteinemia, hypertriglyceridemia, hyperuricemia, family history, sedentary lifestyle, and stress. Although PAD typically appears in the sixth to eighth decade of life, it occurs earlier in persons with diabetes mellitus.

Trauma is the most common precipitating event for an arterial ulcer. In a patient with PAD, a small bump or scrape on a wheelchair or table leg is sufficient to cause ulceration. Ulcer healing is delayed due to the lack of oxygen and nutrients.


In patients with arterial ulcers, the popliteal, dorsalis pedis, and posterior tibial pulses are diminished or absent. Doppler ultrasound usually is required to assess the pulses. The skin is cool, with a noticeable temperature gradient down the leg. The patient will experience either intermittent claudication (ie, reproducible pain in the leg or buttock induced during walking or exercise) or rest pain.

Rest pain is ischemic pain in the toes or forefoot experienced at rest that is relieved at least partially by placing the foot in a dependent position. Elevating the leg above the level of the heart causes the foot to become pale, whereas putting the foot in a dependent position results in a rubrous appearance of the foot and calf. The ABI is less than 0.80.

Arterial ulcers, classically located below the ankle on the lateral malleolus or tips of toes, usually are small, and the ulcer margin is rounded and smooth. The ulcer tissue may be covered with eschar (black necrotic tissue). In the absence of eschar, the tissue is pale pink with minimal exudate or drainage. The skin of the leg is thin, friable, pale, and shiny. The hair on the leg and toes is decreased or absent, and the toe-nails are thick and flaky. Edema is rare unless patients sit with their legs dependent at all times in order to minimize rest pain.


  • Activity and positioning: Leg elevation is contraindicated in patients with arterial ulcers. The legs at rest should be in a neutral position. A daily walking program is advisable. If rest pain is present, walking is not possible, and placing the legs in a dependent position is indicated. This can be accomplished by placing blocks under the head of the bed (ie, reverse Trendelenberg position). Patients with arterial ulcers should not wear compression bandages or stockings.
  • Medical treatment: Measures to increase arterial blood flow are necessary for the healing of arterial ulcers. Pentoxyphylline (Trental) and cilostazol (Pletal) are the 2 medications approved by the Food and Drug Administration (FDA) for promoting blood flow in individuals with intermittent claudication due to PAD. Recent clinical trials have demonstrated that cilostazol, a phosphodiesterase inhibitor that prevents platelet aggregation and increases vasodilatation, is superior to pentoxyphylline in increasing pain-free walking distance, maximal walking distance, and health-related quality of life. It should be noted that the FDA prohibits the use of cilostazol in patient with chronic heart failure.
  • In addition, Ginkgo biloba, a commonly available over-the-counter herbal supplement, also can increase walking distance for individuals with intermittent claudication. However, little data are available to suggest that pentoxyphylline, cilostazol, or Ginkgo biloba succeeds in treating arterial ulcers.
  • Interventional techniques may be used for small, isolated plaques located in the larger arteries proximal to the area of ulceration. Interventional techniques include percutaneous transluminal balloon angioplasty and percutaneous placement of intravascular stents. Radiologists use an intra-arterial catheter to perform these procedures.
  • Surgical treatment: Vascular surgery is the treatment of choice for patients with diffuse atherosclerosis or complete occlusion. Depending on the disease's location, procedures may include aortoiliac, aortofemoral, femoropopliteal, and femorodistal bypass grafts. The bypass may be created using either autogenous (native) vein, human umbilical vein, cyropreserved vein, or prosthetic graft material. Arterial ulcer healing usually occurs once adequate blood flow is restored. If risk factors are not reduced, the atherosclerosis may progress and occlude the bypass graft, necessitating repeat vascular surgery or, in the worst-case scenario, amputation.


  • Assessment of healing: This includes an evaluation of the wound tissue, drainage, wound margin, and periulcer skin. In a healthy ulcer, the wound contains clean granulation tissue that progresses from a pale pink to a beefy red. The tissue is granular, moist, and without any adherent exudate, slough, or necrosis. The drainage is clear, serous, or serosanguinous without odor. The ulcer margin has an intact, pearly pink epithelial edge, and the periwound skin is intact, without redness or maceration.
  • Ulcer size should be evaluated and documented weekly. Although controversy exists regarding the most accurate method to evaluate healing, a tracing on a clear plastic sheet and/or linear measurements of length, width, and depth are usually satisfactory in the clinical setting. Tracings are particularly useful in demonstrating progress toward healing to the patient and family.
  • One user-friendly means of tracing ulcers is to use a clear, double-layer plastic food storage bag. After the ulcer is traced, the layer that contacted the ulcer is discarded and the layer with the tracing is retained. The tracing can be photocopied and placed in the medical record. Color photographs also may be useful, particularly if multiple clinicians treat the patient.
  • Blood flow: For all ulcers, it is optimal to maximize blood flow and minimize systemic vasoconstriction. Cigarette smoking causes peripheral vasoconstriction, delays healing, and should be avoided. A warm environment also prevents vasoconstriction. Preventing cool drafts, keeping the feet and legs covered, and wearing socks are helpful.
  • Pain management is critical for the prevention of vasoconstriction. High levels of pain stimulate the sympathetic nervous system to release catecholamines (eg, epinephrine), causing vasoconstriction, and thus, impairing blood flow. Pain assessment should include the location, intensity, quality, duration, and pain precipitators and relievers. Interventions to minimize ulcer pain include occlusive dressings, analgesics, distraction, relaxation, music, or application of transcutaneous electric nerve stimulation.
  • Care of the wound and skin: All arterial and venous ulcers are colonized with microorganisms. Ulcer cleansing at each dressing change with normal saline or a nontoxic wound cleanser is recommended to decrease the bacterial load. When adherent slough is present, normal saline irrigation may be performed using a 30-115 mL syringe with an 18-19 gauge angiocatheter. Surgical, sharp, mechanical, enzymatic, or autolytic debridement can be used to remove necrotic tissue that harbors and supports bacterial growth. However, debridement is contraindicated in ulcers when healing is accompanied by severe PAD.
  • In patients with vascular leg ulcers, the skin is very dry and flaky. Daily moisturizing of the skin decreases itching and prevents cracking. Although lanolin-based creams traditionally have been recommended, many clients have allergic reactions to lanolin-based products. Creams or lotions with fragrance, alcohol, or preservatives also should be avoided.
  • Dressings: Dressings that provide a moist wound healing environment currently are considered the mainstay of wound care. Although placing a wet dressing, letting it dry, and then tearing out the adherent tissue successfully debrides the wound, this procedure also causes pain and delays repair. Various dressings are available that assist in maintaining a moist wound, including transparent film dressings, hydrocolloids, hydrogels, hydrofibers, foams, calcium alginates, impregnated gauze, gauze moistened with saline, and composite dressings. Dressings commonly used on vascular ulcers include hydrocolloids, hydrogels, foams, and calcium alginates. Recent research has found that venous leg ulcer care and cost per ulcer healed over a 12-week management period were lower for patients treated with hydrocolloid dressings than for those treated with impregnated saline gauze or human skin construct.
  • Essential nutrients: Nutritional status and intake should be evaluated in patients with vascular ulcers. Nutrients thought to be most critical for healing include protein, vitamin C, vitamin A, and zinc. Glucose control is essential for healing of patients with diabetes mellitus. Patients with or at risk for nutritional problems should be referred to a dietitian or a diabetes educator for additional assessment.
  • Fighting infection: Infection is present when the tissue has been invaded by microorganisms. Clinical signs of infection in chronic ulcers include change in quantity, color, or odor of the drainage; presence of pus; erythema of the wound edges; local pain, edema, or both; abnormal or absent granulation tissue; delayed healing; increased temperature; and cellulitis. A change in the sensation around the wound may be the only sign of infection in immunocompromised patients.
  • A culture of the ulcer is required when symptoms of infection are present. A punch biopsy is considered to be the most accurate wound culture method. In some care settings, however, it is often not practical to obtain, properly store, and transport the biopsy specimen within the necessary time frame required by the laboratory. Consequently, swab cultures are used most often.
  • Before a culture is obtained, remove any purulent drainage or debris by cleansing the ulcer with normal saline (without bacteriostatic agents). Once cleansed, a 1-cm area of the ulcer should be swabbed vigorously enough to produce fluid. Do not obtain the culture from purulent drainage or slough in the ulcer.
  • Topical bactericidal agents such as povidone-iodine, hypochlorite solutions, and hydrogen peroxide are toxic to new cells and are not recommended. Cadexomer iodine gel, which contains small iodine-containing microspheres suspended in propylene glycol, has been found useful in treating infected ulcers. When applied to the wound, the microspheres absorb the exudate and bacteria, after which the iodine kills the bacteria without impairing healing.
  • Nanocrystalline silver-coated dressings are a more recent antimicrobial option that feature a broad spectrum of antimicrobial activity and low toxicity; they cause minimal pain and sensitivity reactions. Furthermore, some data suggest that silver-coated dressings may enhance the rate of venous ulcer healing.
  • Sensitivity reactions frequently occur in leg ulcer patients. The most common causes of sensitivity reactions include topical antibiotics (eg, neomycin, gentamicin, amikacin, tobramycin, bacitracin), balsam of Peru, benzocaine, lanolin-based ointments, and preservatives such as parabens. If topical agents are used, the clinician should assess for signs of a sensitivity reaction (ie, increased erythema, worsening eczema, and/or itching) and discontinue their use if a reaction is suspected.
  • Infection, when confirmed by a positive culture, is usually treated by surgical debridement, wound excision, and systemic antibiotics. Debridement involves removal of necrotic tissue, a haven for bacterial growth. Venous ulcers of less than 1 month's duration usually are colonized with Gram-positive organisms (Staphylococcus aureus and group A beta hemolytic Streptococci) and respond well to cephalexin, 250 mg every 6 hours or 500 mg every 12 hours. Dicloxacillin commonly is used, but may not adequately cover streptococcal infections. Ciprofloxacin or ofloxacin are used successfully to treat multiresistant Gram-negative bacteria. However, it should be noted that 50% of S. aureus isolates from leg ulcers are resistant to oxacillin, with 36% of Pseudomonas isolates resistant to ciprofloxacin.
  • Grafting the ulcer with skin: The development of biologic skin equivalents represents a relatively new advancement in treating venous leg ulcers. Apligraf, for example, is a cultured human skin equivalent that consists of combined dermal and epidermal layers, while Dermagraft consists of living fibroblasts on a vicryl mesh. Randomized controlled trials have reported that treatment with Apligraf resulted in a greater proportion of healed ulcers within 6 months (63% vs. 49%) when compared with compression therapy alone. The therapy is expensive (approximately $1000 per application) and should be reserved for chronic, difficult-to-heal venous ulcers.

Chronic vascular ulcers can degenerate into a malignancy (ie, Marjolin's ulcer), and those with the following characteristics are suspect:

  • increase in size despite appropriate treatment
  • malodorous or painful wounds
  • wounds with hypertrophic (excess) granulation tissue
  • wounds with an irregular base or margin
  • wounds that experience excess bleeding.

In addition, primary epidermoid cancers may mimic venous ulcers in appearance, location, and symptoms, especially in persons with greater exposure to ultraviolet rays on their lower extremities. Consequently, a biopsy of the wound base and margin is recommended for any long-standing or suspicious leg ulcer to determine if a malignancy is present.


Caring for patients with vascular leg ulcers is a complex process that requires a thorough evaluation of the patient and his or her risk factors. Local wound care is not sufficient to promote healing. A holistic approach that includes interventions for activity, pain management, nutrition, and management of comorbid risk factors is critical. Once healing is achieved, patients need education about the lifelong lifestyle changes that are necessary to prevent ulcer recurrence.


Support provided by American Heart Association Beginning Grant-In-Aid 0160286Z and National Institute of Nursing Research R01 NR05280. The authors thank Dyann Helming, BSN, RN, for her assistance with the figures. Adapted from Wipke-Tevis DD, Sae-Sia W. Caring for vascular leg ulcers. Home Healthcare Nurse 2004;22:237-47.


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                                                                            Wipke-Tevis DD, Williams DA. Transcutaneous tissue carbon dioxide (TcPCO2) in normals and patients with venous insufficiency. FASEB J 1999;13(4):A16.
                                                                              Wright KD, Shirey J. A pain management protocol for wound care. Ostomy Wound Manage 2003;49:18-20.

                                                                                CONTINUING MEDICAL EDUCATION INFORMATION FOR PHYSICIANS

                                                                                Wolters Kluwer Health is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

                                                                                Wolters Kluwer Health designates this educational activity for a maximum of 1 category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she spent in the activity.

                                                                                PROVIDER ACCREDITATION INFORMATION FOR NURSES

                                                                                This Continuing Nursing Education (CNE) activity for 2.0 contact hours is provided by Lippincott Williams & Wilkins (LWW), which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation and by the American Association of Critical-Care Nurses (AACN 00012278, CERP Category A). This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 00012278 for 2.0 contact hours. LWW is also an approved provider of CNE in Alabama, Florida, and Iowa and holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA #75. All of its home study activities are classified for Texas nursing continuing education requirements as Type 1.

                                                                                Your certificate is valid in all states. This means that your certificate of earned contact hours is valid no matter where you live.

                                                                                CONTINUING EDUCATION INSTRUCTIONS

                                                                                • Read the article beginning on page 437.
                                                                                • Take the test, recording your answers in the test answers section (Section B) of the CE enrollment form. Each question has only one correct answer.
                                                                                • Complete registration information (Section A) and course evaluation (Section C).
                                                                                • Mail completed test with registration fee to: Lippincott Williams & Wilkins, CE Group, 333 7th Avenue, 19th Floor, New York, NY 10001.
                                                                                • Within 3 to 4 weeks after your CE enrollment form is received, you will be notified of your test results.
                                                                                • If you pass, you will receive a certificate of earned contact hours and an answer key. Nurses who fail have the option of taking the test again at no additional cost. Only the first entry sent by physicians will be accepted for credit.
                                                                                • A passing score for this test is 11 correct answers.
                                                                                • Nurses: Need CE STAT? Visit for immediate results, other CE activities, and your personalized CE planner tool. No Internet access? Call 1-800-933-6525 for other rush service options.
                                                                                • Questions? Contact Lippincott Williams & Wilkins: 646-674-6617 or 646-674-6621.

                                                                                Registration Deadline: October 31, 2007 (nurses); October 31, 2006 (physicians)

                                                                                PAYMENT AND DISCOUNTS:

                                                                                • The registration fee for this test is $16.95 for nurses; $20 for physicians.
                                                                                • Nurses: If you take two or more tests in any nursing journal published by LWW and send in your CE enrollment forms together, you may deduct $0.75 from the price of each test. We offer special discounts for as few as six tests and institutional bulk discounts for multiple tests. Call 1-800-933-6525, for more information.
                                                                                © 2005 Lippincott Williams & Wilkins, Inc.