Holistic wound management begins with a focused health history and comprehensive wound assessment that is best performed by the Certified Wound Care Nurse (CWCN(R)) or the Advanced Practice Certified Wound Care Nurse (CWCN-AP(R)).1 Successful wound healing outcomes are dependent on the initial health history interview, taking into consideration the individual's overall physical, psycho-social, and emotional well-being.1-3 Moreover, conducting a focused assessment of potential risk factors and existing comorbidities builds the foundation for a wound care focused care plan with achievable goals.1-3 Incorporating the CWCN(R) and CWCN-AP(R) to serve as wound care experts across various populations and healthcare settings can positively impact care outcomes. Furthermore, under the guidance of a certified wound care clinician, the Certified Wound Treatment Associate (WTA-C(R)) can further improve wound care outcomes through the provision of specialized primary nursing.
The CWCN(R) or CWCN-AP(R) should formulate a comprehensive care plan that employs a wound care focused health history interview while incorporating a holistic approach to the individual's family, social, personal, and developmental history. In certain environments such as inpatient care settings, an evidence-based risk assessment tool, such as the Braden Scale, Braden Q Scale, or Norton Plus Scale, can be utilized to determine the potential risk for wound worsening or the capability for faster wound healing.1,4
The establishment of these baseline elements is vital to building an appropriate care plan that will also guide the clinician in performing a wound care focused health assessment.1 Incorporating basic diagnostic test results aids in the creation of an individualized wound care plan as they provide an objective framework that is customized to individual patient needs.1 In addition, the WTA-C(R) can provide primary care focused data collection and documentation to support a comprehensive wound care plan for the collaborative care team.
The wound care nurse must evaluate the individual's visual and nonvisual cues during communication as these exert a crucial influence on individualized care planning. For example, nonvisual communication cues may signal the need for implementing plans to address pain that may impact the individual's current health and risk status.1,2
These foundational competencies are a vital component of the WOCNCB(R)-certified wound care nurse's toolkit toward successful care planning, wound assessment, and provision of care. In preparation for the WOCNCB(R)-administered certification exam, careful attention must be placed on performing a comprehensive patient health history that serves as the initial blueprint for successful wound healing outcomes.
1. Bates-Jensen BM. Assessment of the patient with a wound. In: McNichol LL, Ratliff CR, Yates SS, eds. Wound, Ostomy, and Continence Nurses Society Core Curriculum: Wound Management. Second Edition. Wolters Kluwer; 2022:56-92. [Context Link]
2. Hess CT. Comprehensive patient and wound assessments. Adv Skin Wound Care. 2019;32(6):287-288. doi:10.1097/01.ASW.0000558514.64758.7f. [Context Link]
3. Brennan MR. Wound assessment: a step-by-step process. Nursing (Brux). 2019;49(8):62-64. doi:10.1097/01.NURSE.0000559936.42877.4a. [Context Link]
4. Lim E, Mordiffi Z, Chew HSJ, Lopez V. Using the Braden subscales to assess risk of pressure injuries in adult patients: a retrospective case-control study. Int Wound J. 2019;16(3) 665-673. doi:10.1111/iwj.13078. [Context Link]
WTA-C(R) QUESTION
1. When taking a health history, the WTA-C(R) recognizes which of the following factors places the patient at risk for skin tears?
A. Sialorrhea
B. Morbid obesity
C. Permanent ileostomy
D. Long-term corticosteroid use
Exam content outline: 1.1.b
Cognitive level: Recall
ANSWER: D
Rationale: Sialorrhea, also known as drool, obesity, and ileostomies all increase a patient's risk for moisture-associated skin damage (MASD). Corticosteroid use inhibits collagen synthesis, leading to thin and fragile epidermis with long-term use, increasing the risk of skin tears.
1. Krapfl LA, Peirce BF. General principles of wound management: Goal setting and systemic support. Chapter 5. In: McNichol LL, Ratliff CR, Yates SS, eds. Wound, Ostomy, and Continence Nurses Society Core Curriculum Wound Management. Second Edition. Wolters Kluwer; 2022:99.
2. Thayer D, LeBlanc K, Rozenboom BJ. Prevention and management of moisture-associated skin damage (MASD), medical adhesive-related skin injury (MARSI), and skin tears. In: McNichol LL, Ratliff CR, Yates SS, eds. Wound, Ostomy, and Continence Nurses Society Core Curriculum Wound Management. Second Edition. Wolters Kluwer; 2022:322-353.
CWCN(R) QUESTIONS
1. The CWCN(R) taking an initial patient history recognizes which of the following as an indicator potential for poor wound healing?
A. Wound presence for 14 months
B. Diabetes, with an HgbA1c of 5.6
C. Hypertension controlled with medication
D. Independence with activities of daily living
Exam content outline: 010103
Cognitive level: Recall
ANSWER: A
Rationale: Independence with activities of daily living is a normal finding and indicates potential for wound healing. Option C is incorrect because although hypertension is a risk factor for poor wound healing, medication-controlled hypertension improves the potential for wound healing. Diabetes is a risk factor for poor wound healing; however, hemoglobin A1c of 5.6 is a normal finding, indicating well-controlled diabetes and improved potential for wound healing. Option A is correct because data indicate that wound duration of greater than 12 months is significantly less likely to heal within a 12- to 20-week time frame.
1. Bates-Jensen B. Assessment of the patient with a wound. In: McNichol LL, Ratliff CR, Yates SS, eds. Wound, Ostomy, and Continence Nurses Society Core Curriculum Wound Management. Second Edition. Wolters Kluwer; 2022:56-92.
2. The CWCN(R) is conducting a health history for a paraplegic patient with a chronic stage 4 sacral pressure injury. Which statement by the patient warrants further assessment?
A. "I always use a wheelchair with an air-fluidized cushion."
B. "I always use diapers as I cannot control when I have to urinate."
C. "I always ensure that my bed and wheelchair are free from sharp materials."
D. "I always keep my appointments with my physical therapist."
Exam content outline: 010104
Cognitive level: Application
ANSWER: B
Rationale: Incontinence and moisture are causative agents for wound deterioration. Constant diaper use can contribute to worsening of a pressure injury as it causes maceration and further skin breakdown from excessive moisture and continuous exposure to urinary and fecal incontinence.1 Option A is incorrect as an air-fluidized cushion is an appropriate support surface to prevent the worsening of pressure injuries. Option C is incorrect as it is essential to ensure that medical devices are free from potential causes of skin trauma. Finally, option D is incorrect, as regular therapy sessions contribute to successful wound healing outcomes.
1. Bates-Jensen BM. Assessment of the patient with a wound. In: McNichol LL, Ratliff CR, Yates SS, eds. Wound, Ostomy, and Continence Nurses Society Core Curriculum: Wound Management. Second Edition. Wolters Kluwer; 2022:56-92. [Context Link]
CWCN-AP(R) QUESTION
1. The CWCN-AP(R) is obtaining a health history for a 70-year-old female patient with a lower extremity wound. The patient states that the wound has been present "for about 3 months and just doesn't want to go away." She also states that she is unsure how the wound started, "I just noticed it one day." She has tried several over-the-counter topical treatments, with no change in the wound, and reports that the wound has increased in size over the 3 months, with increase in pain. She also reports the wound "bleeds easily." Which diagnostic test would be the most beneficial for this wound?
A. Erythrocyte sedimentation rate (ESR)
B. Wound culture via the Levine method
C. MRI
D. Wound biopsy
Exam content outline: Domain 1, Task 1, 010107
Cognitive level: Analysis
ANSWER: D
Rationale:
ESR: An ESR can determine if there is inflammation in the body but is not a typical first-line lab test for initial wound assessment.1
Wound culture: One would want to assess the area for infection prior to performing a wound culture, especially in the initial assessment. If a culture is desired after the initial assessment, the best intervention would be to perform topical debridement and then to obtain a deeper culture into the actual wound bed to avoid normal flora on the surface.1
MRI: The best intervention would be to start with a plain x-ray film of the area, which is noninvasive, quicker, and costs less. The results of the x-ray film can determine if an MRI is needed in the future.
Biopsy: As the wound is atypical in that it has not responded to any topical treatments in several weeks, has increased in size, and bleeds easily, and she has increased pain, the best initial approach would be to perform a biopsy.2 Atypical wounds can be caused by cancer, vasculitis, calciphylaxis, etc. A biopsy will help narrow the diagnosis and ensure the proper treatment of these wounds.
1. Nagle SM, Stevens KA, Wilbraham SC. Wound assessment. In: StatPearls [Internet]. StatPearls Publishing; January 2022. https://www.ncbi.nlm.nih.gov/books/NBK482198. Updated October 19, 2022. Accessed January 19, 2023. [Context Link]
2. Bowers S, Franco E. Chronic wounds: evaluation and management. Am Fam Physician. 2020;101(3):159-166. [Context Link]