Table of Contents · harm when administering drugs subcutaneously, intravenously, or intramuscularly.2 As a result, skin-related problems are often the primary health concern. The

Audrey Fotouhi, Joseph Friedli, Mohamed Fakih, Emily Marlow,

Eric Blumenfeld, Robert Burns, Dr. Sarkis Kouyoumjian

1

Table of Contents

Wound Identification and Basic Care in a Homeless Population ......................................... 2

Injection Wounds ................................................................................................................. 3

Diabetic Ulcers ..................................................................................................................... 5

Burns .................................................................................................................................... 7

Frostbite ............................................................................................................................... 9

Venous Stasis Ulcers ........................................................................................................... 12

MRSA ................................................................................................................................ 14



2

Wound Identification and Basic Care in a Homeless Population

Persons experiencing homelessness are three to six times more likely to be suffering from

serious illness or injury.1 Factors that increase this population’s risk for acute and chronic

wounds include communal bathing and eating, lack of facilities for washing and toileting, unsafe

and unsanitary shelters, exposure to crime and trauma, inadequate nutrition, no place for bed rest,

no place to store medications, excessive smoking and drinking, little or no income, and absence

of family and other support to help in times of illness.

Traditionally, wound care is simple. Keep the wound clean and try to eliminate the cause.

Because people experiencing homelessness are less likely to have access to the materials

necessary to keep their wounds clean and to prevent the issue in the future, this protocol will list

some basic wound care options for commonly seen wounds, that could be used in a clinic dealing

with persons experiencing homelessness.

1 A Publication Of The HCH Clinicians’ Network. "Wound Care Difficult for Homeless Patients and Providers." Wound Care

Difficult for Homeless Patients and Providers 8.3 (2004): 1-4. National Health Care for the Homeless Council. The

HCH Clinicians’ Network, June 2004. Web. 22 Nov. 2016.



3

Injection Wounds

Injection wounds are typically found in intravenous drug users (IVDU’s) who suffer

harm when administering drugs subcutaneously, intravenously, or intramuscularly.2 As a result,

skin-related problems are often the primary health concern. The skin acts as a protective barrier

to the human body, but becomes compromised in the area where intravenous injections occur.3

Possible negative consequences include infections of skin such as abscesses and cellulitis, pain,

and venous ulcers. IVDU’s preferably inject drugs intravenously because it leads to a faster

response, yet all three types of administration lead to clinical issues due to the dangers and risks

of the nature of injection (i.e. contamination of equipment). The most common health

complication, an abscess, occurs at the site of injection, where damage to the skin and tissue of

the site allow the local spread of bacteria. Pain may be acute or chronic, depending on whether or

not the pain is caused by abscesses from injection wounds or by chronic venous insufficiency.4

Chronic venous insufficiency (CVI) is defined as the dysfunction of vein valves. CVI

develops in IVDU’s who inject drugs over a long period of time, putting patients at further risk

for developing a deep vein thrombosis or venous ulcers, and is a particular problem for injections

in the groin, legs, and feet. Additional discussion of venous stasis ulcers is given below.

Injection wounds must be assessed with regards to size, location, depth, color, drainage,

odor, pain, and infection, among other factors. It is important to note that injections may cause

deep tissue trauma in addition to any superficial appearance of a wound. Previous studies have

shown that there is a progression of injection sites used by IVDU’s; beyond the popular forearm

site, IVDU’s may use their hand, foot, neck, leg, and groin as alternative locations for injection.

Treatments must consider type, size, depth, and drainage. Under anesthetic, abscesses are

treated through incision and drainage, followed by prescribed antibiotics. CVI may lead to

edema and skin changes which can be treated by leg elevation and compression

dressings/support stockings. Gauze is the most common dressing and should be moistened with

saline or antibiotics.

Injection-related risk behavior is associated with homelessness.5, 6 Self-management of

injection wounds is not always sufficient for treatment as many patients employ behaviors that

increase the likelihood of harm, including the manipulation of wounds, negligent care, or

acquiring antibiotics without a prescription.7 Advice for preventing and treating injection wounds

2 Pieper, Barbara and John A. Hopper. “Injection Drug Use and Wound Care.” Nursing Clinics of North America 40.2 (2005):

349-363. Web. 28 Nov. 2016. 3 Coull, Alison F et al. “Prevalence of Skin Problems and Leg Ulceration in a Sample of Young Injecting Drug Users.” Harm

Reduction Journal 11 (2014): 22. PMC. Web. 28 Nov. 2016. 4 Pieper. “Injection Drug Use and Wound Care.” Nursing Clinics of North America 40.2 (2005): 349-363. 5 Song, John Y. et al. “The Prevalence of Homelessness among Injection Drug Users with and without HIV Infection.” Journal of

Urban Health : Bulletin of the New York Academy of Medicine 77.4 (2000): 678–687. PMC. Web. 28 Nov. 2016. 6 Linton, Sabriya L. et al. “The Longitudinal Association between Homelessness, Injection Drug Use, and Injection-Related Risk

Behavior among Persons with a History of Injection Drug Use in Baltimore, MD.” Drug and alcohol dependence 132.3

(2013): 457–465. PMC. Web. 28 Nov. 2016. 7 Roose, Robert J., A. Seiji Hayashi, and Chinazo O. Cunningham. “Self-Management of Injection-Related Wounds Among

Injecting Drug Users.” Journal of addictive diseases 28.1 (2009): 74–80. PMC. Web. 28 Nov. 2016.



4

is complicated because IVDU’s typically inject drugs as a conscious choice. When injecting

drugs, IVDU’s must ensure they have clean equipment (needles) in order to avoid infections and

should consider the potential negative repercussions of injections. Consultation with medical

professionals to treat consequent wounds from injections is highly recommended. Increased

education about the health risks of drug injections is warranted for homeless populations that are

more susceptible to relapse of drug use.



5

Diabetic Ulcers

Patients with insufficiently controlled diabetes often present with neuropathy and/or

vasculopathy of the extremities, particularly the feet. Prolonged lack of blood flow and nervous

input can lead to ulceration that, if left untreated, can develop severe infection and necrosis

necessitating hospitalization and amputation. This is particularly common among populations

experiencing homelessness, because they often lack the resources or ability to properly manage

their disease.8 Initial assessment and diagnosis of a diabetic foot ulcer should be performed by a

medical professional. If an undiagnosed diabetic ulcer is suspected, patients should be referred

immediately to their primary care physician for immediate evaluation. In order to identify a

potential ulcer in the clinic, several steps should be taken.9

First, confirm that the patient has a diagnosis of diabetes and check their glucose level if

possible. Next, question the patient about management of their disease and determine risk factors

for foot ulcers including poorly controlled glucose levels, smoking, alcohol use, time spent

walking and/or standing, quality of footwear, and access to healthcare. Portable Ha1c testing kits

can be used to test for long term management of the disease. To check pedal pulses, check the

dorsalis pedis on dorsum of foot between metatarsals 1 and 2 and the posterior tibial pulse

behind the medial malleolus. Check capillary filling time in the digits by pressing on the toes

until the skin becomes pale and count the seconds until color returns after releasing pressure on

the toes. A time longer than 5 seconds is considered prolonged. Lastly, look for areas of redness

and heat around the potential ulcer.

Depending on the severity of the ulcer, a physician may prescribe antibiotics, perform

debridement (removal of necrotic tissue to prevent spread of infection), lance and drain

abscessed tissue, and assign specific dressings. Patients previously diagnosed and being treated

for a diabetic foot ulcer may appear in the clinic with any of the following dressings or

treatments: hydrogels, foams, calcium alginates, absorbent polymers, growth factors, skin

replacements. Again, depending on the severity of the ulcer, these dressings may require a nurse

or physician in order to be changed, however the dressings of some less severe ulcers may be

changed by the patient themselves.10

If the patient has dressings and requires assistance, consider these important tips for

proper application. Avoid bandaging over toes, which can prevent proper blood flow to the

extremities already experiencing decreased supply. Instead, layer gauze over the toes and anchor

to the foot with tape. Avoid creases and making the bandage too bulky, being particularly careful

around weight-bearing areas. Be mindful of fragile skin that may tear from strong adhesive tapes.

If available, cleanse the area with a saline solution before re-bandaging, which can reduce

8 Kalinowski, A., Tinker, T., Wismer, B, and Meinbresse, M. Adapting Your Practice: Treatment and Recommendations for

Patients who are Homeless with Diabetes Mellitus. Health Care for the Homeless Clinicians’ Network. (2013). Web.

28 Nov. 2016. 9 Kruse, I. and Edelman, S. “Evaluation and Treatment of Diabetic Foot Ulcers.” Clinical Diabetes 24.2 (2006): 91-93. PMC

Web. 28 Nov. 2016. <dx.doi.org/10.2337/diaclin.24.2.91> 10 Sage, R. “When Diabetic Foot Ulcers Can Be Managed At Home.” Podiatry Today 17.10 (2004). Web. 28 Nov. 2016.

http://dx.doi.org/10.2337/diaclin.24.2.91










6

possibility of infection. Avoid tight bandaging, particularly around the toes and minimize space

between the wound and the bandage. Be mindful of the patient’s footwear and how it will

accommodate the bandage.11

All patients at risk for diabetic foot ulcers should be counseled on preventative actions

they can take to maintain foot health. With a population experiencing homelessness, regular

approaches to treatment and care may not be feasible.12 Regardless, all patients should be

encouraged to: reduce and/or cease tobacco and other drug use; seek out regular foot exams by a

medical professional; perform daily self-evaluations of foot health – patients can be taught to

check their own pedal pulses and watch out for signs of ulceration; report any injuries, however

minor, to their doctor; reduce time spent standing or walking; elevate feet to at or above heart

level when at rest; keep socks and shoes dry and remove them at night when possible; wash and

thoroughly dry socks as often as possible – patients should be provided with resources as to

where they can obtain fresh socks for free; closely monitor glucose levels and seek treatment for

their diabetes; better manage their diet if possible – save portions of meals for later if access to

food is limited.

11 International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. Wounds International (2013). Web. 28

Nov. 2016. 12 Kalinowski. Adapting Your Practice: Treatment and Recommendations for Patients who are Homeless with Diabetes Mellitus.

Health Care for the Homeless Clinicians’ Network. (2013).






7

Burns

Burn injuries occur frequently among homeless populations, usually as a result of

exposure to an open flame or heated metal while cooking or attempting to keep warm.13

Additionally, burns as a result of violence among the homeless occur at a rate of six times higher

than that of the general population, and patients brought into the ER due to these injuries have

been positively correlated with higher consumption of alcohol and illicit drugs.14 Lastly,

homeless populations are at a high risk of acquiring sun burns and overheating. Depending on

location, someone on the street might have trouble finding adequate shelter during the warm

summer months, and can be exposed to more sunlight than is healthy, as well as run the risk of

overheating while carrying their belongings with them.15

Treatment of burns is dependent mostly on the severity of the burn. If a patient comes to

the clinic with a first or less severe second degree burn, treatment usually follows the following

protocol. First, try to gently remove any restrictive clothing or accessories around the region of

the burn, as the injury might swell up and become constricted.16 Keep the burn covered with a

cool, damp towel or piece of cloth. The moisture keeps the material from sticking to the wound,

thus preventing damage when it is removed. Avoid immersing the wound in cold water, as this

can lead to a loss of heat and lowered blood pressure in the region. Also, if the wound area is

significantly large, avoid cool water or moisture because it could lead to hypothermia if the

patient is returning to a cold environment. If available, apply an antibiotic ointment, silvadene

cream or aloe vera gel to the area of the burn, to both help keep the wound cool and help to

prevent infection. If the patient is going to the hospital, avoid applying any ointment to the

wound as it may interfere with the physicians ability to assess the wound. In those instances, a

clean dry dressing is sufficient to offer comfort to the patient. If available, loosely wrap the

wound in a nonstick dressing to form a barrier against dirt and clothing which may irritate the

burn while it is healing. Make sure that any bandaging is done loose enough that it does not

constrict the site should it swell, and that any material used is designed to avoid sticking, as this

could cause tearing of the wound when removed. Advise the patient against rupturing any

blisters that might develop as the burn heals, as this can make for an easy site of infection, as

well as cause irritation and scarring. If the patient’s burn is due to an incident involving heated

metal, recommend that they seek out a tetanus booster shot if possible. If the patient presents

with a burn larger than three inches in diameter or a wound that covers a sensitive area or joint,

13 Frederick P. Rivara, Janessa M. Graves, and Mackelprang, Jessica L. “Homeless in America: Injuries Treated in US

Emergency Departments, 2007-2011.” International Journal of Injury Control and Safety Promotion 21.3 (2014): 289–

297. PMC. 14 Kramer, C. Bradley et al. “Assault and Substance Abuse Characterize Burn Injuries in Homeless Patients.” Journal of Burn

care & Research : Official Publication of the American Burn Association 29.3 (2008): 461–467. PMC. 15 Brickner P et al., eds. Clinical Concerns in the Care of Homeless Persons. Under the Safety Net: The Health and Social

Welfare of the Homeless in the United States. New York: Norton; 1990. 16 Subbarao I, et al., eds. American Medical Association Handbook of First Aid and Emergency Care. New York, N.Y.: Random

House; 2009.



8

such as the hands, feet, face or groin, recommend seeking further medical assistance at a local

hospital or burn center. Severe second degree and third degree burns can cause damage much

deeper than the skin, sometimes down the to bone, and the superficial care available in a free

clinic is likely unable to treat these injuries.

Giving advice for preventing future burns is difficult, as these wounds are very rarely

self-inflicted and occur as accidents. General advice one can give to a patient is to avoid sleeping

or resting too long next to an open fire or hot surface, such as a steam grate. While the heat

provided by these is welcomed on cold nights, it is possible to burn oneself while sleeping and

not wake up quick enough to prevent the damage. Additionally, if the patient admits to substance

use, caution against cooking while under the influence, as they could lose their balance and make

contact with whatever surface or fire they are using to cook. Lastly, as mentioned above,

homeless populations present with higher cases of burns caused by violence between parties.17

Advise the patient to avoid situations where another person poses a threat to them, especially

around open fires or hot surfaces. These provide the possible assailant with an easily accessed

weapon in the form of forcing the victim to make contact with the flame/surface.

17 Kramer. “Assault and Substance Abuse Characterize Burn Injuries in Homeless Patients.” Journal of Burn care & Research:

Official Publication of the American Burn Association 29.3 (2008): 461–467.



9

Frostbite

Frostbite is defined as the acute freezing of tissues and crystallization of fluids as

consequence of prolonged exposure to freezing temperatures.18, 19 Frostbite is caused by

cutaneous vasoconstriction through which blood flow is diverted away from anatomic structures

such as the hands, feet, ears, nose and lips. The severity of injury is related to both the skin-

surface temperature gradient and duration of exposure. Mortality may occur if injured tissue

becomes infected or from concurrent hypothermia. Frostbite is of higher incidence among

African Americans and those experiencing homelessness, with predisposition factors including

inadequate shelter, diabetes, thyroid disease, alcohol consumption, psychiatric illness, and drug

use. 20, 21, 22, 23 Detroit’s homeless population should be considered at increased risk for frostbite

and its identification in a clinical setting is essential for proper treatment and positive patient

outcomes.

Initial symptomatology includes localized numbness, coldness, stinging, burning, and

throbbing, complete loss of sensation of the affected area, loss of fine muscle dexterity, and

severe joint pain. More favorable prognostic indicators include more superficial site of injury,

sensation to pinprick, and healthy-appearing skin. Poor prognostic indicators include absence of

edema, hemorrhagic blisters, persistent cyanosis, and frozen appearance of tissue.

Rapid rewarming is considered the single most effective therapy for frostbite.24

Treatment may also involve medical and surgical measures, and therefore patients with

suspected frostbite must receive immediate and advanced medical attention to minimize the

extent of injury. Burn units such as those at Detroit Receiving Hospital and Henry Ford Medical

Center are likely the best option for aggressive treatment.25

When encountering frostbite in the field, first and foremost remove the patient from the

cold. Replace wet and constrictive clothing with dry loose clothing. Remove any jewelry from

the affected area and dress the extremity in a manner that minimizes mechanical trauma. Sterile

non-adherent dressings may be applied. The initial appearance of frostbite does not accurately

18 Murphy, James V., Paul E. Banwell, and Anthony H. Roberts. "Frostbite: Pathogenesis and Treatment : Journal of Trauma and

Acute Care Surgery." LWW. The Journal of Trauma and Acute Care Surgery, Jan. 2000. Web. 27 Nov. 2016. 19 Crawford Mechem, C., David Cheng, and Ramy Yakobi. "Frostbite." Frostbite: Background, Pathophysiology, Etiology.

Medscape, 26 Feb. 2016. Web. 27 Nov. 2016. 20 DeGroot, D. W., J. W. Castellani, and J. O. Williams. "Epidemiology of U.S. Army Cold Weather Injuries, 1980-1999."

National Center for Biotechnology Information. U.S. National Library of Medicine, May 2003. Web. 27 Nov. 2016. 21 Petrone, P., E. J. Kuncir, and J. A. Asensio. "Surgical Management and Strategies in the Treatment of Hypothermia and Cold

Injury." National Center for Biotechnology Information. U.S. National Library of Medicine, Nov. 2003. Web. 27 Nov.

2016. 22 Golant, A., R. M. Nord, and N. Paksima. "Cold Exposure Injuries to the Extremities." National Center for Biotechnology

Information. U.S. National Library of Medicine, Dec. 2008. Web. 27 Nov. 2016. 23 Valnicek, S. M., L. R. Chasmar, and J. B. Clapson. "Frostbite in the Prairies: A 12-year Review." National Center for

Biotechnology Information. U.S. National Library of Medicine, Sept. 1993. Web. 27 Nov. 2016. 24 McCauley, R. L., D. N. Hing, and M. C. Robson. "Frostbite Injuries: A Rational Approach Based on the Pathophysiology."

National Center for Biotechnology Information. U.S. National Library of Medicine, 23 Feb. 1983. Web. 27 Nov. 2016. 25 Kowal-Vern, A., and B. A. Latenser. "Demographics of the Homeless in an Urban Burn Unit." National Center for

Biotechnology Information. U.S. National Library of Medicine, Jan.-Feb. 2007. Web. 27 Nov. 2016.



10

predict the eventual extent and depth of tissue damage, and therefore every case must be treated

as an emergency.

Forced-air rewarming with portable units can be used effectively to warm victims of

frostbite in the field and during transport to a specialized medical center.26 However, rewarming

should be avoided if it cannot be maintained. Partial thawing and refreezing releases multiple

inflammatory agents that cause more harm than good.27 Mechanical trauma (massaging or

rubbing) and rewarming at higher temperatures and for longer periods of time are detrimental to

preserving viable tissue and should be avoided. Direct dry heating using fire or a heater can lead

to burns secondary to loss of temperature sensation and so should also be avoided. Walking on

frozen frostbitten areas and risking tissue chipping and fracture is considered better than thawing

and refreezing.

As tissue is rewarmed, reperfusion injury becomes prominent. Edema typically appears

within several hours and may last for several days. Severe throbbing, hyperemia, and

paresthesias often occur and may last for several weeks. Clear blister formation suggests more

superficial injuries whereas the hemorrhagic blister formation suggests involvement of deeper

tissues and a poorer prognosis. Deep frostbite injuries of the tendons, muscles, and/or bones are

often associated with necrosis and self-amputation.28

Healing can take 6-12 months with long-term sequelae including cold sensitivity,

paresthesias and sensory deficits, peeling or cracking skin, loss of fingernails or toenails,

hyperhidrosis or anhidrosis, muscle atrophy, premature closure of epiphyses, decreased

mineralization of bone, joint stiffness, tremor, phantom pain of amputated extremities, and

abnormal color changes indicative of vasospasm.

Patients should be informed that the frostbitten area may be more sensitive to cold, with

associated burning and tingling. Individuals who have sustained a cold-related injury are at a

greater risk of developing a subsequent cold-related injury and therefore should be counseled

about their increased susceptibility and appropriate strategies to avoid it. They should also be

given general advice on preparing for cold weather exposure.

Wound infection is observed in 30% of frostbite patients, often caused by Staphylococcus

aureus. Evidence of secondary infection includes increased pain, swelling, erythema, fever, red

streaking, and purulent discharge. Patients with evidence of secondary infection should be

referred for immediate medical care.

Long-term prevention of frostbite should be discussed with patients and includes keeping

hands and feet dry, using mittens instead of gloves, wearing multiple layers of clothing, wearing

at least 2 pairs of socks, avoiding tight or restrictive clothing, avoiding perspiration by using

26 Ducharme, MB, GG Giesbrecht, and J. Frim. "Forced-air Rewarming in -20 Degrees C Simulated Field Conditions." National

Center for Biotechnology Information. U.S. National Library of Medicine, 15 Mar. 1997. Web. 27 Nov. 2016. 27 Britt, L. D., W. H. Dascombe, and A. Rodriguez. "New Horizons in Management of Hypothermia and Frostbite Injury."

National Center for Biotechnology Information. U.S. National Library of Medicine, 7 Apr. 1991. Web. 27 Nov. 2016. 28 Su, H., Z. Li, and Y. Li. "[Treatment of 568 Patients with Frostbite in Northeastern China with an Analysis of Rate of

Amputation]." National Center for Biotechnology Information. U.S. National Library of Medicine, 31 Dec. 2015. Web.

27 Nov. 2016.



11

adequately ventilated clothing, increasing fluid and calorie intake in cold weather, avoiding

alcohol and tobacco as they promote peripheral vasoconstriction, maintaining a current tetanus

immunization, keeping toenails and fingernails trimmed, avoiding rubbing of affected areas,

seeking shelter from wind and cold, covering the face and head, avoiding wet clothing, and

avoiding prolonged periods in the same position.



12

Venous Stasis Ulcers

Venous stasis ulcers are wounds that occur due to improper functioning of the venous

valves, usually those of the lower leg.29 Vascular insufficiency results from walking, standing, or

sitting in an upright position for extended periods of time. Buildup of fluid in the lower legs

causes lack of circulation, which can lead to breakdown of the skin and tissues and eventually, an

ulcer. Because persons suffering with homelessness often sleep upright, blood flow to the legs is

impaired, causing swelling that can lead the skin to burst open and create sores.30 These wounds

are usually recurrent.

On physical examination, these ulcers are generally irregularly shaped, shallow, and

located over bony prominences, for example, the shin.31 Open ulcers are can persist for weeks to

years and severe complications include cellulitis, osteomyelitis, and malignant change.

Traditional treatment options for venous stasis ulcers includes bed rest with elevation of

the injured area, debridement, and compression stockings.32 Compression stockings serve to

force blood and lymphatic fluid back to the center of the body, rather than remaining in the lower

legs. In a homeless population, these options may not be possible. Bed rest with elevation can be

very difficult for a person experiencing homelessness because they may be on the move, without

access to a consistent place to wash the wound and rest. In addition, compression stocking can be

hard to put on, difficult to dry, and expensive to purchase.

Cheap debridement options for this population include applying wet-to-dry saline

dressing and doing in office irrigation.33 In addition, applying pressure bandages, teaching the

patient how to apply pressure bandages, and sending them off with a few days of supplies is

another possible treatment option. Because removing the cause of these ulcers usually requires

management of the patient’s chronic conditions (often hypertension), referring the patient to a

family practitioner who would be able to see them on a regular basis would also be beneficial.

When used with compression therapy, aspirin (300 mg per day) has shown to be effective.

Sending the patient out of office with a supply of aspirin could also be helpful. If the clinic can

afford it, having disposable compression stockings is another suggestion. Another option is a

Unna boot. An Unna Boot is a special gauze (usually 4 inches wide and 10 yards long) bandage,

which can be used for the treatment of venous stasis ulcers and other venous insufficiencies of

the leg. The gauze is impregnated with a thick, creamy mixture of zinc oxide and calamine to

29 A Publication Of The HCH Clinicians’ Network. "Wound Care Difficult for Homeless Patients and Providers." The HCH

Clinicians’ Network, June 2004. 30 Harrison, Erica. "Health And Homelessness: How CoCs Can Help." Clarity Human Services. Bitfocus, Inc., 8 July 2013. Web.

22 Nov. 2016. 31 Collins, Lauren, and Samina Seraj. "Diagnosis and Treatment of Venous Ulcers." American Family Physician 81.8 (2010):

989-96. Diagnosis and Treatment of Venous Ulcers. American Family Physician, 15 Apr. 2010. Web. 22 Nov. 2016. 32 A Publication Of The HCH Clinicians’ Network. "Wound Care Difficult for Homeless Patients and Providers." The HCH

Clinicians’ Network, June 2004. 33 Wechter, Debra G., David Zieve, and Isla Ogilvie. "Wet to Dry Dressing Changes: MedlinePlus Medical Encyclopedia."

MedlinePlus Medical Encyclopedia. National Institute of Health, 13 Mar. 2015. Web. 25 Nov. 2016.



13

promote healing. It may also contain acacia, glycerin, castor oil, and white petrolatum. If an

Unna boot is applied, it will need to be replaced once a week.

Below is a brief protocol for in office cleaning and dressing of venous stasis ulcers.

Wearing gloves, gently clean the wound with a clean, soft washcloth with only soap and sterile

saline. Rinse the wound with water and pat dry. Check the wound for swelling, increased or

spreading redness, or a foul odor. With a new pair of sterile gloves on, soak sterile gauze with

sterile saline. Squeeze the gauze until there is no saline dripping from it. Pack the wound with

the wet gauze. Cover the wound with sterile dry gauze. To hold the gauze in place, either wrap

with rolled gauze or an ACE bandage, or use paper tape to tape the edges of the gauze to the

skin.



14

MRSA

Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that is resistant

to a type of antibiotic called Methicillin and several other antibiotics. It is commonly carried on

the skin or inside the nose of healthy people and causes minor skin infections that may look like

a pimple or boil and can be red, swollen, and painful or have pus or some drainage. More serious

infections can cause skin and soft tissue infections, bloodstream infections and pneumonia.34

MRSA infections often spread from direct skin-to-skin contact or contact with objects

that have come in contact with an infected site. However, there’s a rule of 5Cs that increases the

likelihood of obtaining MRSA: Crowding, frequent skin-to-skin Contact, Compromised skin

(i.e., cuts or abrasions), Contaminated items and surfaces, and lack of Cleanliness. Detroit’s

homeless population would be at a greater risk to contracting any Staphylococcus infection,

especially MRSA, because the rugged living conditions in Michigan often lead to many cuts and

abrasions on their hands and feet. This, in conjunction with a lack of shelter, puts homeless

patients at high risk for MRSA infections.

MRSA can be treated by several means. In cases where the abscess is accompanied by

cellulitis, the infection will require antibiotics. In some cases, MRSA infections can be treated by

draining the abscess or boil without prescribing antibiotics. Only a healthcare provider should

drain the abscess. Other forms of staph and MRSA require the use of antibiotics to treat the skin

infection. The patient should take all the medication prescribed by the physician, even if they

feel better to ensure to eradicate the whole infection and prevent resistance build up to that

specific antibiotic.

While there are means to treat MRSA, there are also many means to prevent the spread of

MRSA. The first measure is to cover the wound with a clean, dry bandage. Secondly,

consistently wash your hands with soap daily and ensure that family and others in close contact

also wash their hands with soap or use an alcohol-based hand sanitizer. Thirdly, one should

avoid sharing personal items such as uniforms, washcloths, razors or other items that can be

shared with others. These items could be a possible source of infection to spread from one person

to another.35

While these are the traditional means to treat the skin infection and prevent the spread of

infection, not all homeless individuals have access to proper healthcare and may not be health

conscious as their main focus is obtaining their next meal and finding appropriate shelter for the

day and night. There are still several options we can use to help this population including

applying clean, dry bandages over their skin infection and wounds and teaching them how to

apply bandages on their own. In addition, we can give them several supplies of alcohol-based

hand sanitizer and remind them to apply the hand sanitizer every time they change their bandage

or whenever they deem their hands dirty. We could also refer them to their primary care

34 "MRSA and the Workplace." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 14 July

2016. Web. 28 Nov. 2016. 35 Weber, Dr. Stephen. "MRSA Research Center." MRSA Research Center : FAQs for Patients & Families | University of

Chicago. University of Chicago Medicine Research Center, 2016. Web. 28 Nov. 2016.



15

physician or the Emergency Department to drain their abscess because they shouldn’t be

draining their abscess on their own. Lastly, we should remind them to not share any personable

items that could come in possible contact with wounds such as razors, washcloths, and

uniforms.36

The following is a protocol for applying a bandage over a MRSA skin infection. First,

wash hands with soap and water and then put on disposable gloves. Second, remove the old

dressing and then put the old dressing in a plastic bag. Now, take off the gloves, and put them in

the plastic bag, too. Then, rewash and dry your hands and put on a new, clean pair of disposable

gloves. Finally, apply the new dressing. If the sore is leaking, extra dressings will be required to

keep the drainage from leaking out. Take off the second pair of gloves and put them in the plastic

bag. Seal or tie the bag, and throw it away in your regular trash.37

Closing

In closing, caring for infections and other conditions of the skin is a challenging and

difficult problem. Hopefully this article will make you more comfortable with diagnosing and

treating these conditions.

36 "MRSA and the Workplace." Centers for Disease Control and Prevention, 14 July 2016. 37 “Caring for MRSA at Home.” Health Hints (2007): 1+. Caring for MRSA at Home. The Texas A&M University System, Nov.

2007. Web. 28 Nov. 2016.

Documents

Table of Contents · harm when administering drugs subcutaneously, intravenously, or intramuscularly.2 As a result, skin-related problems are often the primary health concern. The