Develop an educational booklet on wound care management for Unity NTUC FairPrice Submitted by

Develop an educational booklet on wound care management for Unity NTUC FairPrice
Submitted by: Hooi Po Yi
Matriculation Number: 16024825
Supervisor: Ho Sz Ting
School of Applied Science
July 2018
Table of Contents
Tables of Contents …………………………………………………………………………… 2
Abstract ……………………………………………………………………………………… 3
Acknowledgement ……………………………………………………………………………. 4
List of Figures ……………………………………………………………………………….. 5
List of Tables ………………………………………………………………………………… 6
Chapter 1: Introduction ……………………………………………………………………… 7
Chapter 2: Methodology ……………………………………………………………………. 16
2.1 Development of the booklet ………………………………………………………… 16
2.2 Survey ……………………………………………………………………………….. 16
2.3 Data Analysis ………………………………………………………………………… 17
Chapter 3: Observations and Results ………………………………………………………. 18
3.1 Demographics ……………………………………………………………………….. 18
3.1.1 Age Group ……………………………………………………………………. 18
3.1.2 Education Background ……………………………………………………….. 18
3.1.3 Role(s) in Chronic Wound Management ……………………………………… 19
3.2 Survey Response ……………………………………………………………………. 19
3.2.1 Usefulness of each section …………………………………………………… 19
3.2.2 Usefulness of Addition Resources ……………………………………………. 22
3.2.3 Pictures in the booklet ………………………………………………………… 22
3.2.4 Usefulness of Flowchart ……………………………………………………… 24
3.2.5 Product Directory …………………………………………………………….. 25
3.2.6 Knowledge BEFORE & AFTER reading the booklet ………………………… 26
3.2.7 Recommendation of the booklet ……………………………………………… 28
3.2.8 Comparison between role(s) in chronic wound management and recommendation of the booklet ………………………………………………………………………… 28
Chapter 4: Discussion ………………………………………………………………………. 30
Chapter 5: Conclusion ……………………………………………………………………… 36
Chapter 6: Directions for Future Studies …………………………………………………… 37
References ………………………………………………………………………………….. 38
Appendixes …………………………………………………………………………………… 41
Abstract
The aim of this project was to produce a booklet to help caregivers and patients to manage chronic wounds effectively. Some research on wound care management for chronic wounds were conducted and the information was to be included into the booklet. A survey for the feedback on the booklet was then collected from various participants. The survey showed that the booklet was able to provide useful information on wound care management for chronic wounds but would require further improvement to help patients understand our booklet better.
Acknowledgements
I would like to give special thanks to my teammates (Ho Lingyan Joyce, Loh Han Kiat, Fong Shi Ni and Natasha Chia Xin Ying) for their effort in producing the booklet together and sending the survey to people. Also, special thanks to our project supervisor Ms Ho Sz Ting, Lecturer in Diploma in Pharmaceutical Sciences for her guidance throughout the production of the booklet. I would also like to give thanks to [email protected], NTUC Health Co-operative Limited for supporting the development of our booklet.

List of Figures
Figure 1. Location for pressure ulcers ……………………………………………………….. 8
Figure 2. Locations for venous ulcers ……………………………………………………….. 9
Figure 3. Example of arterial ulcers located at the tip of the toes ………………………….. 11
Figure 4. Locations of Diabetic foot ulcer …………………………………………………. 12
Figure 5. The age group of the surveyees ………………………………………………….. 18
Figure 6. The education background of the surveyees ……………………………………… 18
Figure 7. Usefulness of additional resources for understanding the topics better ………….. 22
Figure 8. Relevancy of pictures …………………………………………………………….. 22
Figure 9. Sufficiency of pictures …………………………………………………………… 23
Figure 10. Usefulness of pictures …………………………………………………………… 23
Figure 11. Clarity of pictures ………………………………………………………………. 24
Figure 12. Usefulness of flowchart to identify right dressings to use ………………………. 24
Figure 13. Helpfulness of product directory in identifying suitable dressings …………….. 25
Figure 14. Usefulness of direction for use in product directory ……………………………. 25
Figure 15. Likelihood of participants recommending the booklet …………………………. 28
List of Tables
Table 1. The role(s) of surveyees in chronic wound management …………………………. 19
Table 2. Usefulness of skin structure ……………………………………………………….. 19
Table 3. Usefulness of Acute vs Chronic wounds ………………………………………….. 19
Table 4. Usefulness of how does acute wound become chronic wound …………………… 20
Table 5. Usefulness of information on Pressure ulcer ………………………………………. 20
Table 6. Usefulness of information on leg ulcer …………………………………………… 20
Table 7. Usefulness of information on Diabetic foot ulcer ………………………………… 20
Table 8. Usefulness of information on Ulcer management ………………………………… 21
Table 9. Usefulness of Product Directory ………………………………………………….. 21
Table 10. Usefulness of information on Nutrition ………………………………………….. 21
Table 11. Usefulness of information on Do(s) and Don’t(s) ……………………………….. 21
Table 12. Knowledge on types of chronic wounds before and after reading the booklet ……………………………………………………………………………………… 26
Table 13. Knowledge on how to care for chronic wound before and after reading the booklet ……………………………………………………………………………………… 26
Table 14. Knowledge on what type of wound dressing to use before and after reading the booklet ……………………………………………………………………………………… 26
Table 15. Knowledge on how to prevent chronic wounds before and after reading the booklet ……………………………………………………………………………………… 27
Table 16. Knowledge on nutrition for chronic wound before and after reading the booklet………………………………………………………………………………………. 27
Table 17. Knowledge on factors that cause different types of chronic wound before and after reading the booklet ………………………………………………………………………… 27
Table 18. Comparison between role(s) of participants and recommendation of booklet ….. 28
Chapter 1: Introduction
Wounds can generally be classified as acute and chronic wounds. An acute wound usually happens because of surgery or trauma known as surgical wounds and traumatic wounds respectively. 2 Surgical wounds are usually cuts made by healthcare professionals such as doctors during the surgery, which may be left open to heal on its own or either be closed with the use of stitches, adhesive or staples. 2 Whereas traumatic wounds are usually caused by abrasion, puncture, laceration and incision. 2 These 2 types of wounds usually progress through the normal wound healing phase and take approximately 4 to 6 weeks to heal.

However, an acute wound can develop into a chronic wound when it fails to progress through the normal wound healing phases and remains stalled in the inflammatory phase, resulting in the prolonged recovery of the wound. 3
For a wound to heal normally, it requires an adequate blood supply of oxygen and nutrients, and no infection to the wound. 8 However, if our body is lacking one or more requirements for wound to heal normally, the wound healing process is hindered, contributing to the development of chronic wounds. 8
Generally, patients are at risk of developing chronic wounds due to medical conditions such as obesity, diabetes, high blood pressure and high cholesterol. 8 Also, elderly and immobile patients such as bedridden patients are at risk of developing chronic wounds. 8 Besides that, unhealthy lifestyle habits such as smoking, poor personal hygiene and insufficient exercise will increase risk of developing chronic wounds. 8
The most common types of chronic wounds are pressure ulcers, leg ulcers (arterial and venous ulcers) and diabetic foot ulcers. 8
Pressure ulcers are also known as bedsores, which is the damage to the skin or underlying tissue that is caused by constant pressure. 5 It usually happens over a bony area such as heels and tail bones, which is likely to develop in immobile patients such as wheelchair-bound or bedridden for a long time. 5

Figure 1. Location for pressure ulcers
Some signs that indicates the development of pressure ulcers are abnormal changes seen in skin colour, inflammation, pus-like discharge, skin can feel cool or warm compared to other locations of the skin and tender areas. 5
There are several factors that contributes to the development of the pressure ulcers. The first factor is old age as elderly are found to have a decrease in inflammatory response, their skin gets thinner as they age, and they also do not exercise regularly. 17 The second factor is decreased in mobility such as paralysis and spinal cord injuries, leading to higher chance of developing pressure ulcers as they may not have the strength to be able to reposition themselves, resulting to poor circulation to the area where pressure is applied. 5
The third factor is poor intake of nutrition and fluids, as the lack of fluids, protein, vitamins and minerals can result in patients being unable to maintain a healthy skin and not able to prevent any breakdown of the tissues. 5 The fourth factor is decreased in pain sensation which have a high chances of developing pressure ulcers as patients may not be able to sense any sort of pain in the location where pressure ulcers are developing, so they will not notice that an ulcer is currently developing. 5 The fifth factor is moisture of the wound, as wounds that are found to be very dry will slow down the healing process, while wounds that are found to be very wet are at risk to infections to the wounds. 17
However, pressure ulcers can be prevented if patients or caregivers do their part in preventing pressure ulcers from developing. The patients have to be repositioned regularly to avoid any prolonged pressure on the skin. For wheelchair-bound patients, patients should attempt to shift their weight for every 15 minutes, and request for some help from their caregivers with repositioning every hour. 5 Also, if the patients have strength in their upper body to lift themselves, they are advised to try doing push up while sitting on the wheelchair. 5 Caregivers should also try to look for a wheelchair that is tailor-made to be used to relieve pressure to the skin. 5
For bedridden patients, caregivers should try to look for a specialized mattress such as air mattress to prevent pressure ulcers from developing for long-term bedridden patients. 5 Bedridden patients should be repositioned every two hours to promote blood circulation, and caregivers should elevate their bed at the head area but should not lift it for more than 30 degrees, to prevent shearing from happening. 5
For patients who is sitting on the chair, they should not be placed more than 10 degrees for reclining backward, as to allow the patients to move freely. 30 Their feet should also be able to touch the floor. The other ways that patients can prevent pressure ulcers from developing are managing their skin well, maintain good intake of nutrition and fluid, stop smoking, manage their stress well and lastly exercise regularly if possible. 5
Patients are advised to try changing their position to alleviate pressure on their skin, if they are found to be showing some signs of pressure ulcers is developing. 5 However, if there is still no improvement seen in the wound after 24 to 48 hours, they should go and see a doctor. 5
The sign and symptoms of infections of pressure ulcers are fever (more than 37.5oC), foul-smelling drainage from the wound or increased redness, warmness and swelling around the wound. 5 If patients with bedsores are found with the signs and symptoms of infection, they should go see a doctor immediately.

There are two types of leg ulcers, venous and arterial ulcers. Venous ulcers are found to be the most common types of leg ulcer. 4 These two types of leg ulcers are usually located in the lowest extremities of the body.

Venous ulcers happen when valves in the blood vessels that run through the legs do not function well, leading to blood pooling in the blood vessels. 23 Blood pooling in the blood vessels can result in swelling that eventually lead to formation of venous ulcer. 23 It usually located under the knees and inner part of the ankle. 29

Figure 2. Locations for Venous ulcers
Some signs that indicates the development of venous ulcers are itchiness, swollen legs, rash or dry skin, discoloration of the skin and foul-smelling discharge from the wounds. 4
There are several factors that contributes to the development of the venous ulcers. The first factor is family history of leg ulceration, as it can increase the risk of developing venous ulcers if the patient’s grandparents or parents have developed leg ulcers previously. 31 The second factor is patients who have a leg ulcer previously are more likely to develop venous ulcers again. 31 As the previous venous ulcers may already damage their venous system, so higher chances of a recurrence.
The third factor is patients previously have medical conditions such as varicose (swollen or enlarged veins), phlebitis (inflamed veins) and deep vein thrombosis (blood clot in the leg), have a high chance of developing venous ulcers. 31 As inflammation of the veins is likely to occur again. The fourth factor is standing for prolonged period, as patients found to be standing for more than 3 hours without sitting, can result in blood pooling to their legs. 31
The fifth factor is patients have a surgery or injury in their legs previously, are likely to develop venous ulcers as there will be reduced blood flow to the location of the wound. 29 The sixth factor is elderly, as they are usually at risk of developing venous ulcers due to insufficient exercise because of mobility issues so they may experience poor blood circulation in their legs. 29
The seventh factor is patients recovering from hip and knee surgery as they are bedridden for a prolonged period of time. 22 The eighth factor is patients with mobility issues such as paralysis, leg fracture and obesity. 29 These two factors are at higher risk of developing venous ulcers, as there is a decrease in the amount of movement made by patients, resulting in poor blood circulation to the legs.

However, venous ulcers can be prevented if patients can do their part in preventing the development of venous ulcers. Patients who are a smoker should quit smoking as smoking can cause blood vessels to narrow which hinders blood flow. 23 They should also reduce standing for a prolonged period of time, as it can result blood pooling in the veins on their legs. 23 Besides that, they should keep their legs elevated when resting or sitting down, to remove pressure from the veins on their legs and promoting blood flow out of the veins, letting blood to flow away from their legs. 23
Patients should exercise regularly by doing some light exercise such as brisk walking and jogging, to improve blood circulation. 2223 This can also help them to maintain a healthy weight, as obesity is one of the contributing factor that lead to venous ulcers. 2223 They are also advised to use compression stocking to improve blood circulation in the legs and minimize the risk of venous ulcers from developing. 2223
Patients can manage venous ulcers by compression bandages or compression stockings. Compression bandages are used to wrap around venous ulcers on the leg, to apply pressure on the legs to help with blood flow towards the heart. 22 Several types of bandages can be used for compression, such as elastic cohesive bandages and elastic crepe bandages.

Compression stockings are supposed to be worn by patients at all times, except that they can remove the stockings only when they are preparing to go to bed. 1522 As compression stockings can help to improve blood circulation in the patient’s leg, to reduce the risk of recurrence of venous ulcers. 15 It is advisable to purchase a minimum of 2 pairs of compression stockings, so that they can wash the compression stockings daily with soap and water, which allow it to dry before using it again. 15 It is also recommended to replace the compression stockings within 3 to 6 months. 15
However, if the patients find their compression stockings to be uncomfortable for them, they should consult their doctor to get a recommendation for another kind of compression stockings that may be suitable for them. 15 However, they should continue to wear the compression stockings until they have consulted their doctor. 15
The signs and symptoms of infection of venous ulcers are worsening pain, green/unpleasant discharge from the ulcer, redness and inflammation found around the ulcer and fever (more than 37.5oC). 22 If the patients are found to have one or more of the signs and symptoms of infection, they should go and see a doctor immediately.

Arterial ulcers are also known as ischemic ulcers, which happens due to poor blood circulation to the lowest extremities of the body. 14 This caused the death of overlying skin and tissues, since there is a lack of oxygen supplied. 14 This resulted in an open wound that is located at toes, heels, feet or outer part of the ankle. 29

Figure 3. Example of arterial ulcers located at the tip of the toes
Some signs that indicates the development of venous ulcers are ulcers that appears red, yellow or black, punched out appearance of the wounds, no bleeding observed, wounds are deep till tendons may be seen and lifting legs will cause wounds to become pale and cool when touch. 414
There are several factors that contributes to the development of the arterial ulcers. The first factor is smoking, as it narrows blood vessels that hinders the blood flow. 29 The second factor is medical conditions such as diabetes, high blood pressure, high cholesterol, renal failure, obesity, collagen-vascular disorders and previously had heart diseases and peripheral vascular diseases, as it can result in narrowing or hardening of blood vessels which hinders blood flow, hence increases risk of developing arterial ulcers. 29 The third factor is disorder in clotting and circulation as it can reduce blood flow and supply of oxygen to the tissue, increasing the chances of developing arterial ulcers. 29
However, arterial ulcers can be prevented if patients do their part to prevent the development of arterial ulcers. Patients should inspect their feet and legs daily, such as their ankles, heels and in-between their toes, to check for any changes in colour and area of the sore. 14 They are also advised to wear shoes that properly fits them, to avoid putting any pressure on their toes. 14 Also, the socks that they wear should fit them perfectly, as wearing an oversize sock can result in friction that caused a wound. 14
Patients should avoid prolonged standing or sitting in the same position, to prevent poor blood circulations in their legs. They should ensure that their feet are kept warm and to avoid walking barefooted to prevent any injury to their feet. 14 Also, they should never put on compression stockings without the permission of their doctor, as compression stockings can restrict the blood flow in their legs. 14
Patients can manage arterial ulcers by making lifestyle modifications and managing long-term medical conditions, to improve the blood circulation and help in wound healing. 14 For diabetic patients, patients should try to maintain their blood sugar level for arterial ulcers to heal faster. 14 They should also manage their blood pressure and cholesterol levels. 14 Also, patients who are obese are advised to lose weight and continue maintaining a healthy weight. 14 Lifestyle modification that can help to manage arterial ulcers are to stop smoking, nutritious diet, sufficient sleep daily and exercising regularly to improve blood circulation that can help in wound healing. 14
The sign and symptoms of infections of arterial ulcers are increased drainage than previously, yellowish/cloudy drainage, bleeding, odour, fever (more than 37.5oC), chills, redness, increased warmness or inflammation around the ulcer and pain increased. 14 If the patients found any of the signs and symptoms of the infection, they should go and see a doctor immediately.

Diabetic foot ulcers happen when blood sugar level is not controlled well, which results in poor blood circulation. 10 This can damage the nerves found in the patient’s feet, resulting the patient to have a decreased feeling to their feet, so they do not realize that there is an injury to their leg, which could lead to diabetic foot ulcers. 10

Figure 4. Locations of Diabetic Foot Ulcer
Some signs that indicates the development of diabetic foot ulcers are redness, swelling, bleeding and blister.

There are several factors that contributes to the development of the diabetic foot ulcers. The first factor is smoking as it can narrow the blood vessels which results in poor blood circulation. 32 This can slow down the wound healing process of the wound. The second factor is high blood sugar level as it can cause narrowing of the blood vessels, preventing sufficient blood and oxygen supply to be delivered to the legs. 20 The third factor is nerve damage as it can decrease feeling of pain, so wounds may go unnoticed and infections may occur as a result. 2010
The fourth factor is weak immune system as it can cause inability to fight against bacteria, leading to an infection. 20 The fifth factor is patients wearing shoes that is not fitted well, as it can put on more pressure in the ulcer. 10 The sixth factor is poor personal hygiene habits, contributes to bacteria to invade the wound, leading to infection. 32 The seventh factor is excess alcohol consumption, as it can result in poor healing in wounds and resulted issues with the nerves in the body. 32 The eighth and ninth factors are obesity and elderly, as they are found to have a poor blood circulation which is due to insufficient exercise. 32
However, diabetic foot ulcers can be prevented if patients do their part. Patients should always have a good personal hygiene and trim their toe nails regularly. 20 They should go for a body check-up regularly to ensure that their blood sugar level is maintained. It is advised for them to maintain a healthy weight as obesity is a contributing factor to diabetic foot ulcer. They should wear shoes which are comfortable for them to reduce the pressure placed on their feet. 9 Basically, controlling their blood sugar level at normal level can reduce the risk of developing diabetic foot ulcer. 9 Lastly, they should inspect their feet daily for diabetic foot ulcer so that they can visit a doctor if they found signs of diabetic foot ulcer. 20
Diabetic foot ulcers can be managed by wearing diabetic shoes to reduce the risk of ulcer from developing and to promote good blood circulation in the feet. 32 Also, shoe inserts should be placed in the shoes to prevent hardening of the skin and formation of corns on the feet. 32 Compression socks also should be worn to help in blood circulation in their legs and reduce any friction to their feet, which reduce the risk of ulcers developing. 12 Hydrogel dressings can be used to absorb the discharge from wound and to keep the wounds hydrated. 6
The signs and symptoms of infection are redness, increased warmness or inflammation around the ulcer, increased drainage, pus, odour, fever (more than 37.5oC) and increased firmness around the ulcer. 9 If the patients have the signs and symptoms, they should go and see a doctor immediately. They should also visit a doctor straight away if their foot ulcer is found to be white, black or blue. 9
For chronic wounds to heal faster, it is advisable to ensure that the chronic wounds are covered at all time, and not be exposed for a long time. 27 This is because wounds are found to heal faster when they are kept at a warm temperature. 27 Also, when we leave the wound uncovered, it can cause the temperature to decrease resulting in the wound to heal slower. 27 However, different types of wound dressings are used depending on the conditions of the wound.

The first condition of the wound to consider is moisture of the wound. 19 If the moisture of the wound is found to be too wet, it is advisable to select a wound dressing that can absorb the moisture, such as an alginate dressing. 19 However, if the moisture of the wound is found to be dry, it is advisable to select a dressing that provides moisture to the wound, such as a hydrogel dressing. 19
Next, the second condition of the wound to consider is the presence of necrotic tissue or slough in the wound. 19 If the wound bed is found to be granulating and there is no presence of slough or necrotic tissue, it is required to protect the weak wound bed and keep a moist environment to the wound, so it is advisable to use a wound dressing such as transparent film dressing. 19 Whereas, if the wound is necrotic or sloughy, it is advised to select wound dressings which promotes moisture in the affected area of wound to break down it. 19 This is to allow our body to debride the dead tissues in the wound naturally. 19 The types of wound dressings to use are alginate or hydrocolloid dressings, according to the amount of discharge from the wound. 19
The third condition of the wound to consider is whether the wound is showing any sign of infections. 19 If the wound is found to have an infection, it is advisable to select a wound dressing that is impregnated with silver to reduce the number of microorganism in the wound. 19 The last condition to consider is the presence of odor in the wound. 19 It is advisable to select dressings that will absorb the odor that was released by the microorganism from the wound, such as charcoal dressings. 19
Basically, there are several considerations for selecting the most ideal wound dressings for the patients. The wound dressings should be affordable, as some patients may have budget constraints. Also, it should protect the wound from infection, which means the wound dressings should be impenetrable to microorganisms. 7 Besides that, it should either help to maintain the moisture environment in the wound. 7 Then, it should be able to absorb excess discharge from the wound. 7
Next, it should provide thermal insulation, as wound can heal faster when there is a warmer temperature. 7 The dressings should also allow gaseous exchange between the environment and the wound. 7 Before the wound is fully healed, the wound dressings should protect the healthy tissues that is formed during the healing phase. 7 Lastly, the wound dressing should be remove easily when the wound is healed to prevent any further injury and must be intact once removed. 7
Besides the wound dressing to help with wound healing, nutrition also plays an important role in aiding wound healing and reduce the risk of infection. The nutrients that patients should take for faster recovery are carbohydrates, proteins, fats, vitamin A, Vitamin B complex, vitamin C, vitamin E, copper, iron and zinc. However, patients with chronic wounds should avoid nitrate-rich foods like processed meats such as bacon and deli meats. 1 This is because taking excess nitrates can damage blood vessels, which may prevent sufficient nutritious blood flow for wound healing. 1
Generally, patients should do their part in the recovery of their chronic wounds. Patients should be encouraged to quit smoking as the ingredient in the cigarette which is nicotine will narrow the blood vessels which stops the required nutrients to be transferred to the wounds. 27 They are also advised to exercise for at least about 150 minutes per week, such as aerobic exercises which can be brisk walking or riding a bicycle. 13 This can help to promote blood circulation for faster recovery of the wound. 27 Also, they should ensure that they have a balanced amount of nutrition required for their diet for faster recovery of the wound. Lastly, patients are advised to maintain good personal hygiene when dressing the wounds, by ensuring a good hand washing techniques before changing the wound dressings. They should also monitor for any signs and symptoms of infection, so that they can consult their doctor immediately.

Chapter 2: Methodology
2.1 Development of the booklet
Before to the booklet was developed, the content page for the booklet on wound care management for chronic wounds was first drafted.

After drafting the content page for the booklet on wound care management for chronic wounds, the team visited various hospital and retail pharmacies to look for the wound care products that are available in Singapore. The hospital visited were Khoo Teck Puat Hospital (KTPH), Ng Teng Fong General Hospital (NTFGH), Singapore General Hospital (SGH), Parkway East Hospital and Yishun Community Hospital. The retail pharmacies visited at various locations in Singapore were Unity, Watson and Guardian. Permission from the staff at the hospital and retail pharmacy was obtained to take photo of the products, which were included in the booklet.

Then, the team searched for information on wound care management for chronic wounds to include into the booklet. The information was taken from library resources, online resources and YouTube videos. Information obtained from library and online resources was combined into the booklet. Also, the team used the package inserts of the wound care products from RP-Unity Retail Teaching Dispensary to add on the instructions on the use of wound care products. Besides that, YouTube videos provided extra information on the use of wound care products.

2.2 Survey
The survey for the feedback on “wound care management for chronic wounds” booklet was collected from 169 participants. Participants were asked to read the booklet first before completing the survey, which consist of 9 multiple-choice questions, 2 checkboxes questions, 1 linear scale questions and 2 open-ended questions. The three questions of the survey were to obtain demographic information of the participants. While the remaining questions of the survey were to obtain feedback on the booklet.
The participants were requested to complete 12 compulsory questions for the survey, as the 2 open-ended questions is optional for this survey.

The survey was sent together with the soft copy of the booklet to participants through email and also through WhatsApp or Telegram to participants. Some of the participants were provided hard copies of the booklet. The survey was completed using team members’ mobile phones or computers for participants who are middle-age or elderly, as they do not use technology well.
2.3 Data Analysis
Firstly, the feedback given to the team by the participants from the 2 open-ended questions were summarised. This was to make the necessary changes to the booklet according to the feedback, so that the booklet can be more user-friendly.

Secondly, for the survey data collected from participants, an application called IBM SPSS Statistics 24 was used to do the data analysis. The software was used to generate the data that was collected from the survey into bar chart, pie chart and table form (frequency table, mean table, etc).

Chapter 3: Observations ; Results
3.1 Demographics
3.1.1 Age Group

Figure 5. The age group of the surveyeesOut of the 169 participants, 10 participants are less than 18 years old, while 89 participants are between 18 to 24 years old. There are 17 participants between 25 to 34 years old and 28 participants is between 35 to 44 years old. While 18 participants are between 45 to 54 years old, 4 participants are between 55 to 65 years old and 3 participants are above 65 years old.

3.1.2 Education Background

Figure 6. The education background of the surveyeesOut of 169 participants, 1 participant is a primary school graduate, while 37 participants are an O-level/N-level graduate. 76 participants are a diploma/A-level/Nitec/Higher Nitec/IB diploma graduates, while 37 participants are a degree graduate. 18 participants are postgraduates.

3.1.3 Role(s) in Chronic Wound Management

Table 1. The role(s) of surveyees in chronic wound management
Out of 169 participants, 2 participants are patients with chronic wound, while 5 participants are caregivers. There are 31 participants who are healthcare professionals, while 1 healthcare professional who is also a patient with chronic wound and 2 healthcare professionals who are also a caregiver. 128 participants do not have any roles in chronic wound management.

3.2 Survey Response
3.2.1 Usefulness of each section
Skin Structure

Options Frequency Percentage (%)
No 139 82.2
Yes 30 17.8
Total 169 100.0
Table 2. Usefulness of skin structure
Out of 169 participants, 139 participants did not find the information on skin structure to be useful, while 30 participants found the information to be useful.

Acute vs Chronic Wounds
Options Frequency Percentage (%)
No 90 53.3
Yes 79 46.7
Total 169 100.0
Table 3. Usefulness of Acute vs Chronic wounds
Out of 169 participants, 90 participants did not find this section to be useful, while 79 participants found this section to be useful.

How does acute wound become chronic wound?
Options Frequency Percentage (%)
No 95 56.2
Yes 74 43.8
Total 169 100.0
Table 4. Usefulness of How does acute wound become chronic wound
Out of 169 participants, 95 participants did not find this section to be useful, while 74 participants found this section to be useful.

Information on Pressure Ulcer
Options Frequency Percentage (%)
No 125 74.0
Yes 44 26.0
Total 169 100.0
Table 5. Usefulness of Information on Pressure ulcer
Out of 169 participants, 125 participants did not find this section to be useful, while 44 participants found this section to be useful.

Information on Leg Ulcer
Options Frequency Percentage (%)
No 135 79.9
Yes 34 20.1
Total 169 100.0
Table 6. Usefulness of Information on Leg Ulcer
Out of 169 participants, 135 participants did not find this section to be useful, while 34 participants found this section to be useful.

Information on Diabetic Foot Ulcer
Options Frequency Percentage (%)
No 121 71.6
Yes 48 28.4
Total 169 100.0
Table 7. Usefulness of Information on Diabetic Foot Ulcer
Out of 169 participants, 121 participants did not find this section to be useful, while 48 participants found this section to be useful.

Information on Ulcer Management
Options Frequency Percentage (%)
No 104 61.5
Yes 65 38.5
Total 169 100.0
Table 8. Usefulness of Information on Ulcer Management
Out of 169 participants, 104 participants did not find this section to be useful, while 65 participants found this section to be useful.

Product Directory
Options Frequency Percentage (%)
No 110 65.1
Yes 59 34.9
Total 169 100.0
Table 9. Usefulness of Product Directory
Out of 169 participants, 110 participants did not find this section to be useful, while 59 participants found this section to be useful
Information on Nutrition
Options Frequency Percentage (%)
No 95 56.2
Yes 74 43.8
Total 169 100.0
Table 10. Usefulness of Information on Nutrition
Out of 169 participants, 95 participants did not find this section to be useful, while 74 participants found this section to be useful.

Information on Do(s) and Don’t(s)
Options Frequency Percentage (%)
No 70 41.4
Yes 99 58.6
Total 169 100.0
Table 11. Usefulness of Information on Do(s) and Don’t(s)
Out of 169 participants, 70 participants did not find this section to be useful, while 99 participants found this section to be useful.

3.2.2 Usefulness of Additional Resources

Figure 7. Usefulness of additional resources for understanding the topics better
Out of the 169 participants, 80 participants thought the additional resources were helpful for them to understand the topics better. 79 participants did not use the additional resources provided. 9 participants thought the additional resources were too excessive, while 1 participant thought the additional resources were insufficient.

3.2.3 Pictures in the booklet
Relevancy of pictures

Figure 8. Relevancy of Pictures
Out of the 169 participants, 3 participants selected “totally disagree”, while 2 participants selected “disagree”. 16 participants selected “neutral”. While 87 participants selected “agree” and 40 participants selected “totally agree”.

Sufficiency of pictures

Figure 9. Sufficiency of Pictures
Out of the 169 participants, 2 participants selected “totally disagree”, while 6 participants selected “disagree”. 29 participants selected “neutral”. While 96 participants selected “agree” and 36 participants selected “totally agree”.

Usefulness of pictures

Figure 10. Usefulness of Pictures
Out of 169 participants, 4 participants selected “totally disagree”, while 3 participants selected “disagree”. 24 participates selected “neutral”. While 97 participants selected “agree” and 41 participants selected “totally agree”.

Clarity of pictures

Figure 11. Clarity of Pictures
Out of 169 participants, 3 participants selected “totally disagree”, while 2 participants selected “disagree”. 28 participants selected “neutral”. While 93 participants selected “agree” and 43 participants selected “totally agree”.

3.2.4 Usefulness of flowchart

Figure 12. Usefulness of flowchart to identify right dressings to use
Out of 169 participants, 16 participants selected “no, it is difficult to follow” and 153 participants selected “yes, it is easy to follow”.

3.2.5 Product Directory

Figure 13. Helpfulness of product directory in identifying suitable dressings
Out of 169 participants, 15 participants selected “no” and 154 participants selected “yes”.

Figure 14. Usefulness of directions for use in product directory
Out of 169 participants, 11 participants selected “no” and 158 participants selected “yes”.

3.2.6 Knowledge Before ; After reading the booklet
Types of chronic wounds
Frequency Mean
Before – Types of chronic wounds 169 2.5030
After – Types of chronic wounds 169 3.6568
Table 12. Knowledge on types of chronic wounds before and after reading the booklet
The mean score for knowledge on types of chronic wounds after reading the booklet is found to be higher than before reading the booklet.

How to care for chronic wound
Frequency Mean
Before – How to care for chronic wound 169 2.4497
After – How to care for chronic wound169 3.6331
Table 13. Knowledge on how to care for chronic wound before and after reading the booklet
The mean score for knowledge on how to care for chronic wound after reading the booklet is found to be higher than before reading the booklet.

What type of wound dressing to use?
Frequency Mean
Before – What type of wound dressing to use 169 2.5621
After – What type of wound dressing to use 169 3.6213
Table 14. Knowledge on what type of wound dressing to use before and after reading the booklet
The mean score for knowledge onwhat type of wound dressing to use after reading the booklet is found to be higher than before reading the booklet.

How to prevent chronic wounds?
Frequency Mean
Before – How to prevent chronic wounds169 2.4970
After – How to prevent chronic wounds 169 3.6331
Table 15. Knowledge on how to prevent chronic wounds before and after reading the booklet
The mean score for knowledge on how to prevent chronic wounds after reading the booklet is found to be higher than before reading the booklet.

Nutrition for wound care
Frequency Mean
Before – Nutrition for wound care 169 2.5325
After – Nutrition for wound care 169 3.6686
Table 16. Knowledge on nutrition for chronic wound before and after reading the booklet
The mean score for knowledge on nutrition for wound care after reading the booklet is found to be higher than before reading the booklet.

Factors that cause the different types of chronic wounds
Frequency Mean
Before – Factors that cause the different types of chronic wounds 169 2.4556
After – Factors that cause the different types of chronic wounds 169 3.6509
Table 17. Knowledge on factors that cause the different types of chronic wound before and after reading the booklet
The mean score for knowledge on factors that cause the different types of chronic wounds after reading the booklet is found to be higher than before reading the booklet.

3.2.7 Recommendation of the booklet

Figure 15. Likelihood of participants recommending the booklet
Out of 169 participants, 2 participants selected “1 – very unlikely”, while 3 participants selected “2 – unlikely”. 42 participants selected “3 – neutral”. 89 participants selected “4 – likely”, while 33 participants selected “5 – very likely”.

3.2.8 Comparison between role(s) in chronic wound management and recommendation of the booklet

Table 18. Comparison between role(s) of participants and recommendation of booklet
From the table, it shows 2 patients with chronic wound are very likely to recommend the booklet as the mean score is 5 out of 5. For 5 caregivers, it shows that they are likely to recommend the booklet as the mean score is 3.6. For 31 healthcare professionals, it shows that they are likely to recommend the booklet as the mean score is 3.87.

For 1 healthcare professionals who is also a patient with chronic wound, it shows that they are likely to recommend the booklet as the mean score is 4. For 2 healthcare professional who are also caregivers, it shows that they are likely to recommend the booklet as the mean score is 4.5. For 128 participants who do not have any role in chronic wound care management, it shows that they are likely to recommend the booklet as the mean score is 3.86.

Chapter 4: Discussion
For the survey, the age group of the participants was collected to check whether various ages can understand the booklet well, so that the booklet can be further improved to make it more user-friendly across all age groups. From the survey, it was observed that majority of the participants was between 18 to 24 years old. This is attributed to the survey being mostly sent to peers, who are around 18 to 20 years old.
From the survey, it was observed that majority of the participants were not involved in wound care management for chronic wounds, as majority of the participants are on the younger side and is unlikely to develop chronic wounds. Also, the chances of finding patients with chronic wound is very slim, as the team did not have a chance to interact with patients with chronic wounds. Besides that, finding a caregiver is a little hard, as most participants were found to be not living together with elderly at home, so they are unlikely to become a caregiver. For an instance, the team was supposed to follow the nurse from [email protected] for a home visit to see how the nurse changes the dressings for patients with chronic wounds. However, it was cancelled as patients were uncomfortable having students around during the wound dressings.
It was difficult to get healthcare professionals to participate in the survey as they had commitment to their work in the hospital or pharmacy. For an instance, there was once when the team obtained permission to collect feedback from pharmacy assistants who were at NTUC HQ for training. However, when the team reached the location, the pharmacy assistants were not interested in participating in the survey
The participants were asked on which sections of the booklet do they find to be useful for them, to have an understanding which particularly section does everyone find it to be useful for them. For skin structure, it can be observed that more participants selected this section to be not useful for them. As some participants mentioned that skin structure is found to be irrelevant in the booklet, since the information on the skin structure was never found to mentioned again in the booklet. Besides that, they also mentioned that there is insufficient information for the skin structure, such as which part of skin is being affected for each type of chronic wounds. However, most participants probably do not find this section useful as this section does not have anything to do with wound care management for chronic wounds, as understanding skin structure does not guide them on how to treat or prevent chronic wounds which is the main point for the booklet.

For acute vs chronic wounds, it can be observed that more participants selected this section to be not useful. As some participants mentioned that they did not see information that they wanted for the comparison of the acute and chronic wounds, such as consequences of the 2 types of wounds, what to expect for the 2 types of wounds and pain level for each types of wound. Also, there is no pictures to represent the differences between acute and chronic wounds, so the participants may not know the differences between the 2 types of wounds. Those participants probably felt that due to the lack of the mentioned information, they were unable to have proper understanding on the differences between acute and chronic wounds. Besides that, many words used in this section contains medical terms so those participants who are not healthcare professionals, found to have difficulties understanding those terms.

For how does acute wound become chronic wounds, it can be observed that more participants selected this section to be not useful. They mentioned that had difficulties understanding this section due to the way which the sentences were being phrased. Most participants felt that we should just list down the important points in the section, like the specific conditions that lead to chronic wounds.

For pressure ulcers, it can be observed that more participants selected this section to be not useful. As most of the participants is not involved in chronic wound management, so they may not necessarily want to know much about pressure ulcers, as it seems irrelevant to them. While some participants wanted more elaboration to understand on how each factor can lead to pressure ulcers. Besides than, they mentioned that there is missing information for the prevention of prevention of pressure ulcers such as air mattress. Most participants also felt that more information could be added into the pressure ulcers, so that others can understand pressure ulcers even though they may not be involved in wound care management for chronic wounds, since they could also use the information learnt from the booklet to help patients with chronic wounds.

For leg ulcer, it can be observed that more participants selected this section to be not useful. As many participants who is not a healthcare professional do not know the existence of leg ulcers, so they prefer more elaboration on the leg ulcers to help them to better understand the leg ulcer well, so that they can help others who may experience leg ulcers in future. Also, they mentioned that more information can be added under the venous leg ulcers to the different type of bandages, like what type of wound is it suitable for and what type of patients used which bandages. Most participants felt that this section used too many words that is in medical terms, so they had some difficulties understanding this section well.
For diabetic foot ulcers, it can be observed that more participants selected this section to be not useful. As most of the participants is not involved in chronic wound management, so they feel that the information on diabetic foot ulcer is not necessarily useful for them, as they may not want to know about it. Most participants mentioned that although they can understand the information well in this section, but they felt that there is insufficient information to help them to understand diabetic foot ulcer well.

For ulcer management, it can be observed that more participants selected this section to be not useful. As some participants find the flowchart to be hard to follow, making it difficult for participants to identify the right dressings. As the words or boxes of the flowchart is a bit too small to be seen. Also, they mentioned that the flowchart did not insert pictures for each healing process and dressings, so it will be hard for them to identify the right dressings, especially for elderly who have problems with their eyesight. Besides that, some words used in this section were found to be in medical terms, such as “exudate” and “necrosis”, hence it may be difficult to understand for general population.

For product directory, it can be observed that more participants selected this section to be not useful. As participants felt that we only support certain brand of the wound care products, instead of listing out brands of wound care products that was available in Singapore, mainly in the pharmacy. This also gives patients or caregivers to have a limited choice to choose wound care products that is affordable and suitable for them. Also, some participants mentioned about a lack of information such as how often to change each type of dressing. Some participants mentioned that instructions to use the wound care products is not necessary as it can be found in the package insert that can be found inside the box that contains the wound care products. Generally, most of the participants found the product directory to be not useful as they felt that they can obtain help in selection of wound care products from nurses or even pharmacist when they need the wound care products, without referring to the booklet.

For nutrition, it can be observed that more participants selected this section to be not useful. As it is mentioned that there is a lack of information, such as amount of calories intake. They felt that if the amount of calories to take is missing, patients may take insufficient calories which may slow down the wound healing process. Also, they mentioned that the food to avoid for wound is missing, which means that the information on food to avoid was not placed well in the booklet, resulting participants to miss out on this part of information. Most participants felt that we should list down the amount of each nutrients to take per day inside the booklet, to guide patients on taking the sufficient amount of nutrition. Besides that, they also mentioned that we did not list down the contact of where they can seek help for nutrition when needed.
For do(s) and don’t(s), it can be observed that more participants selected this section to be useful. As this section can be used for both acute and chronic wounds, to ensure that wounds can recover faster. However, there is still some participants mentioned to us to include the types of aerobic exercise that patients with wounds can do.

Next, the participants were asked if the additional resources provided in the booklet is useful for them to understand the topics well, to check if the additional resources such as QR code and links are useful for the participants. It can be observed that more participates find the additional resources to be useful, as it was able to guide them well on the management of the chronic wounds through videos that demonstrate on the use of wound care products. However, it was noticed that many participants did not use the additional resources, as it was found that it was troublesome to use the additional resources since most of them used their mobile phone to read the booklet. Besides that, some participants who were given hard copy booklet to read had difficulties using QR code, so they did not used the QR code. Also, they find it troublesome to type in the website link, hence they end up did not use the additional resources given to them.

While some participants find the additional resources to be too excessive, as they mentioned that the information seen in the additional resources can also be found in the booklet too. Hence, they felt that it was unnecessary to add in some of the additional resources into the booklet. Also, there is one participant find the resources to be insufficient, as he/she feel that the additional resource provided can help them to understand better together with the information inside the booklet.

After that, the participants were asked about the pictures in the booklet, to check if they find the pictures in the booklet are relevant, sufficient, clear and useful. It can be observed that majority of the majority of the participates agree that the pictures are relevant, sufficient, useful and clear. This is because participants felt that we can made further improvement for the pictures in the booklet, by replacing or inputting more pictures into the booklet. As participants mentioned that it will be better to include more relevant pictures into the booklet, instead of placing irrelevant pictures into the booklet such as a picture of a doctor. Generally, they mentioned to only include in pictures that is related to wound care management for chronic wounds, instead of displaying pictures that does not have anything to do with it.

While some participates mentioned that more pictures can be added to the booklet, to make the booklet look less wordy. They personally advised us to use pictures to represent the instruction to use each type of wound care products, to guide the patients and caregivers better, as using words to represent the instruction at times may be confusing for them. Whereas, some participants mentioned that some pictures with words inside were found to be unclear, as they were barely able to see until the words found inside the pictures. Hence, they advised us to replace those pictures with a clearer one. Also, they also mentioned that we should increase the size of some pictures in the flowchart used for the section on wounds, as they would want to see what product they can buy to prevent the wounds from happening, such as diabetic shoes.

Also, they mentioned that the pictures were useful to help them know how the wound care products and types of chronic wounds look like. However, they mentioned that it would be better to include more useful pictures into the booklet such as pictures on the differences between acute and chronic wounds for comparison purposes. As most pictures shown in the booklet were unable to be used to help them to guide them well in wound care management for chronic wounds.
Then, the participants were asked if they find the flowcharts in the booklet useful for them to identify the right dressing to use, to see if participants have any difficulties identifying the types of wound dressings to use for different healing phase. It can be observed that most participants find that the flowchart is useful to them in identifying the right dressings to use. As the flowchart include different healing phase and conditions of the wounds, to help them identify the right dressings to use depending on the healing phase and conditions.

However, some participants found the flowchart to be hard to follow, as the flowchart is too small to see, making the participants to have difficulties following the flowchart to identify the right dressings, especially for the middle-aged and elderly who had problems with their eyesight. Also, they advised the team to include pictures of different healing phase and products into the flowchart to help them identify the right dressings easily. Some participants also asked us to rephrase some words in the flowchart as the words are mainly in medical terms, so they do not understand the word which lead to them unable to identify the right dressings to use.

Next, the participants were asked if they think that the product directory help them identify the suitable dressings for the chronic wounds, to see if the brand name and type of dressings together with pictures provided in the product directory can allow them to find the products easily in the pharmacy. It can be observed that most participants selected that product directory help them identify the suitable dressings, as they felt that they were able to find those products on their own in the pharmacy without the help from the pharmacist or store assistant. Since all the details of the wound care products were able provided in the booklet, so they can just bring along the booklet when they are buying the wound care products.

However, some participants felt that the product directory does not help them to identify suitable dressings for chronic wounds, as they felt that some products listed in the product directory may not be suitable for all patients, as some patients may be sensitive to certain dressings used for chronic wounds. Also, they felt that we only supported a certain brand instead of listing all the brands available in Singapore, not providing an option to allow patients to choose what they want.

After that, the participants were asked if they find the direction for use in the product directory helpful for them, to see if it can guide them well in using the wound care products. It can be observed that most participants selected that the direction for use is helpful for them, as they found that the step by step instruction to use the wound care products help them to understand how to use the products correctly. However, some participants did not find the direction to use to be useful as they may be unsure if they can follow the steps correctly, so they prefer pictures to represent each step. Also, they felt that the direction to use for wound care products is not necessary in the booklet, as the instruction to use the wound care products can be found together in the wound care products that patients or caregiver purchased.

Then, the participants were asked on their knowledge on wound care management for chronic wounds before and after reading the booklet, to check if there is any improvement in their knowledge on wound care management for chronic wounds after reading the booklet. It is observed that the mean is higher for the knowledge after reading the booklet. This means that there is an improvement seen in the knowledge on wound care management for chronic wounds after reading the booklet, since higher the mean is the better the result obtained. Most participants mentioned that their understanding for chronic wounds is found to be very little until they read our booklet, which they found out that there is more information that they do not know about the chronic wounds. Basically, the booklet helped them to gain more understanding on chronic wounds, which they also mentioned that they can used those knowledge gained from the booklet to help their friends and family.

The participants were asked on how likely participants will recommend the booklet, to check whether the booklet has sufficient information that will benefit their family or friends with chronic wounds. It can be observed that more participants are just likely to recommend the booklet to their family and friends. As they mentioned that the booklet consists of many medical terms that is not suitable for patients or caregivers, as they may have difficulties understanding the whole booklet well. Also, they mentioned it would be better if we are able to reduce the amount of words used in the booklet to reduce the number of pages in the booklet. Besides that, it was also mentioned that some sections in the booklet has insufficient information to help them to understand well, so many participants would not fully recommend the booklet to others.
From the data, it is encouraging to see that the 2 patients with chronic wounds found the booklet useful enough for themselves that they wanted to recommend it to other. Whereas, other participants also give us a high rating on the likelihood that they will recommend the booklet to others.

Chapter 5: Conclusion
Chronic wounds can take up to several weeks to heal, which may require wound dressing daily depending of the amount of discharge on the patient’s wound. Although the chronic wound is usually managed by the nurses from the hospitals, but the nurses does not see the patients on a daily basis to change the wound dressings, so the patient’s caregiver is often required to help them to care for their wounds and change their dressings when necessary. However, it was found that many people especially caregivers do not have much knowledge on caring for chronic wounds and how to change the dressings when required. Hence, a booklet on wound care management for chronic wound was developed for the caregivers to help them understand on how to manage chronic wounds on their own when the nurses is not available to help them out.
Chapter 6: Direction for Future Studies
A simplified version of the booklet can be made to summarize the important points of the information inputted in the original booklet into layman terms. It is also advised to come up with a pamphlet for each type of chronic wounds so that the caregivers will only get the information that they need when they visit any pharmacy for advice on the care for chronic wounds. Besides that, an online version of the booklet and pamphlet should be made available as it is more convenient for caregivers, as they may accidentally misplace the booklet at home.
It would be good if the booklet and pamphlet can be produced in different languages, such as in Chinese, Tamil and Malay. As some caregivers are not able to understand English well, but they can understand easily in their own mother tongue language. Additionally, instructional videos can be produced on how to care for each type of wounds and demonstration on how to change the wound dressings can be provided. This is to show caregivers on how to clean the chronic wounds and to change the wound dressings correctly.

After the suggestion mentioned above is done, a second survey is recommended to be conducted to check if the booklet is user-friendly. However, it is advising to ask a new set of participants to do the survey instead of asking participants from the first survey to do the survey again, as it may result inaccurate data to be collected.References
3 Foods to Avoid During a Wound Healing Regimen. (2016, October 31). Retrieved from Advanced Tissue: https://www.advancedtissue.com/3-foods-avoid-wound-healing-regimen/
Acute Wounds. (n.d.). Retrieved from Wound Care Centers: https://www.woundcarecenters.org/article/wound-types/acute-wounds
Acute Wounds vs. Chronic Wounds. (2015, June 4). Retrieved from Strive Medical: https://strivemedical.com/blog/acute-wounds-vs-chronic-wounds/
Anthony, K. (2018, February 7). Arterial vs Venous Ulcers. Retrieved from Healthline: https://www.healthline.com/health/arterial-vs-venous-ulcers
Bedsores (Pressure Ulcers). (n.d.). Retrieved from Mayo Clinic: https://www.mayoclinic.org/diseases-conditions/bed-sores/symptoms-causes/syc-20355893
Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. (2013). Retrieved from International Best Practice: http://www.woundsinternational.com/media/best-practices/_/673/files/dfubestpracticeforweb.pdf
Chronic Wound Treatment vs Moist Environment. (n.d.). Retrieved from Matopat: http://en.matopat-global.com/our-solutions-view/chronic-wound-treatment-vs-moist-environment/
Chronic Wounds. (n.d.). Retrieved from Wound Care Centers: https://www.woundcarecenters.org/article/wound-types/chronic-wounds
Diabetes – foot ulcers. (2016, May 17). Retrieved from MedlinePlus: https://medlineplus.gov/ency/patientinstructions/000077.htm
Diabetes and Foot Ulcers. (n.d.). Retrieved from Diabetes UK: https://www.diabetes.co.uk/diabetes-complications/diabetic-foot-ulcers.html
Diabetes, Foot Care and Foot Ulcers. (n.d.). Retrieved from Qmedicine: http://www.qmedicine.co.in/top%20health%20topics/D/Diabetes,%20Foot%20Care%20and%20Foot%20Ulcers.html
How to Spot and Treat Common Diabetic Foot Ulcer Symptoms. (2016, December 15). Retrieved from Advanced Tissue: https://www.advancedtissue.com/how-to-treat-common-diabetic-foot-ulcer-symptoms/
Laskowski, E. R. (2016, August 20). Exercise: How much do i need every day? Retrieved from Mayo Clinic: https://www.mayoclinic.org/healthy-lifestyle/fitness/expert-answers/exercise/faq-20057916
Mancini, M. C. (2016, May 24). Ischemic Ulcers – Self-Care. Retrieved from MedlinePlus: https://medlineplus.gov/ency/patientinstructions/000742.htm
Martin, L. J. (2016, August 22). Compression Stockings. Retrieved from MedlinePlus: https://medlineplus.gov/ency/patientinstructions/000597.htm
Non-Healing Leg or Ankle Wounds . (n.d.). Retrieved from South Bay Vascular: http://www.southbayvascular.com/non-healing-leg-or-ankle-wounds
Nordqvist, C. (2017, December 22). Bed sores or pressure sores: What you need to know. Retrieved from Medical News Today: https://www.medicalnewstoday.com/articles/173972.php
Pressure Ulcer Prevention. (n.d.). Retrieved from Jewish General Hospital : http://jgh.ca/en/qiPressureUlcerPrevention?mid=ctl00_LeftMenu_ctl00_TheMenu-menuItem008
Swezey, L. (2013, September 24). Selecting the Right Wound Dressings and Bandages. Retrieved from Wound Educators: https://woundeducators.com/selecting-the-right-wound-dressings-and-bandages/
Top 5 Causes of Diabetic Foot Ulcers and How to Prevent Them. (2014, October 27). Retrieved from LiveWell with UnityPoint Health: https://www.unitypoint.org/livewell/article.aspx?id=7a88ede4-3631-4063-a4ba-cd0b98b738ca
Understanding Debridement: An Important Part of Wound Healing. (2014, December 30). Retrieved from Advanced Tissue : https://www.advancedtissue.com/understanding-debridement-important-part-wound-healing/
Venous Leg Ulcer. (2016, Febuary 2). Retrieved from NHS Choices: https://www.nhs.uk/conditions/leg-ulcer/
Venous Leg Ulcers: Risk Factors, Treatment and Prevention. (n.d.). Retrieved from Healthpedian: https://www.healthpedian.org/venous-leg-ulcers-risk-factors-treatment-and-prevention/
Venous Skin Ulcers on Legs. (n.d.). Retrieved from WebMD: https://www.webmd.com/skin-problems-and-treatments/venous-skin-ulcer#1
Watson, S. W. (2016, July 15). Do I Need Diabetic Shoes? Retrieved from HealthLine: https://www.healthline.com/health/diabetes/diabetic-shoes
What is a Chronic Wound? (n.d.). Retrieved from OakBend Medical Center: https://www.oakbendmedcenter.org/what-is-a-chronic-wound/
Wounds – how to care for them. (2014, August). Retrieved from Better Health Channel: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/wounds-how-to-care-for-them
Macnair, P. (2014, February 20). Foot and leg ulcers. Retrieved from Netdoctor: https://www.netdoctor.co.uk/conditions/skin-and-hair/a3617/foot-and-leg-ulcers/
Leg Ulcers Arterial & Venous. (n.d.). Retrieved from Vascular Center of Wichita Falls: http://vascularcenterwf.com/conditions/venous-leg-ulcer/
Dealey, C. (2012). The Care of Wounds A GUIDE FOR NURSE (fourth edition). United Kingdom: Wiley Blackwell.

Raj Mani, L. T. (2011). The Basic Needs to Achieve Wound Healing. India: Jitendar P Vij.

BIBLIOGRAPHY Team, T. H. (2016, February 18). Diabetic Foot Pain and Ulcers: Causes and Treatment. Retrieved from Healthline: https://www.healthline.com/health/diabetic-foot-pain-and-ulcers-causes-treatments#risk-factors

Appendix
PDF version of “Wound care management for chronic wounds” booklet