CWCA (ABWM) cheat sheet

Core wound assessment elements: location, etiology, stage or classification, measured size (length x width x depth in cm), undermining and tunneling, tissue types as percentages of the wound bed, exudate amount/type/odor, periwound skin condition, wound edges, and pain (using a validated scale).

Length is measured head-to-toe along the longest axis; width is measured perpendicular to length; depth is measured at the deepest point with a sterile cotton-tipped applicator, and undermining/tunneling is recorded as depth plus clock-face position.

Pressure injury staging: Stage 1 = intact skin with non-blanchable erythema; Stage 2 = partial-thickness loss with dermis exposed (no adipose); Stage 3 = full-thickness loss with adipose visible but no fascia, muscle, tendon, or bone; Stage 4 = full-thickness loss with exposed fascia, muscle, tendon, cartilage, or bone.

Unstageable pressure injury = full-thickness loss obscured by slough or eschar until enough is removed to reveal the wound base; Deep Tissue Pressure Injury = intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discoloration.

Reverse staging is not valid: a healing Stage 4 injury is documented as a healing full-thickness wound, never re-labeled as a lower stage; only 'closed' or 'healed' status is used once epithelialization is complete.

Ankle-brachial index: values below 0.90 suggest peripheral arterial disease; values above 1.30 suggest non-compressible, calcified vessels (common in diabetes and renal disease) and results are unreliable.

Braden Scale subscales are sensory perception, moisture, activity, mobility, nutrition, and friction/shear; possible range is 6-23, with scores of 18 or lower indicating risk.

Wound culture is obtained from a cleansed wound bed using the Levine technique (viable tissue, pressure to express fluid) rather than from pooled exudate; tissue biopsy is the reference standard.

Diabetic foot ulcer depth and ischemia are graded with systems such as Wagner (0-5) or the University of Texas classification; depth plus infection plus ischemia drives amputation risk.

TIME framework: Tissue management (remove non-viable tissue), Infection/inflammation control, Moisture balance, and Edge advancement (address non-advancing margins, callus, or senescence).

Debridement methods: sharp/surgical (fastest, selective), enzymatic (collagenase), autolytic (moisture-retentive dressings, slow and selective), mechanical (wet-to-dry, non-selective), and biological (larval).

Sharp debridement is withheld when perfusion is inadequate (ischemic wound without revascularization), over exposed bone, tendon, or joint without specialist support, and is used cautiously in coagulopathic or anticoagulated patients.

Moist wound healing supports faster keratinocyte migration, autolytic debridement, and reduced pain compared with dry healing; excessive moisture causes maceration and periwound breakdown.

Dressing selection by exudate: films for protection and autolysis in dry wounds; hydrocolloids and hydrogels for low-exudate or dry wounds; foams for moderate exudate; alginates and hydrofibers for heavy exudate with a secondary cover dressing.

Hydrogels donate water or glycerin to the wound bed and rehydrate slough; alginates absorb exudate, gel on contact, and require a secondary dressing to secure them.

Cavities are packed loosely so the dressing contacts all surfaces without pressure; overpacking causes pressure necrosis and impairs drainage.

Silver-containing dressings provide antimicrobial action but are avoided in pregnancy, near eyes and mucous membranes, during MRI, and beyond roughly two weeks of continuous use; they are not for clean, healing wounds.

Negative pressure wound therapy typically applies -125 mmHg continuous or intermittent suction, increases granulation and reduces edema, and is contraindicated with untreated osteomyelitis, malignancy in the wound bed, or exposed vessels and organs.

Local signs of wound infection: new or increasing pain, erythema, warmth, edema, purulent drainage, friable granulation tissue, delayed healing, and malodor.

NERDS identifies superficial infection: Non-healing, Exudate increase, Red and friable tissue, Debris, and Smell; these support topical antimicrobial use plus cleaning and debridement.

STONEES identifies deep or spreading infection: Size increase, Temperature elevation, Os (probe to bone), New breakdown, Erythema/edema, Exudate, and Smell; these warrant systemic antibiotics and imaging.

Biofilm is a structured microbial community in a self-produced matrix; it often produces no classic inflammatory signs and is managed by repeated debridement combined with antimicrobial dressing or solution.

A positive probe-to-bone test, elevated ESR/CRP, visible bone, or MRI findings support the diagnosis of osteomyelitis, which requires prolonged targeted antibiotic therapy and often surgical resection.

Cultures are indicated only when clinical infection is present; swabs are taken after wound cleansing to avoid culturing surface colonizers and contaminants.

Wounds with purulent drainage that cannot be contained require contact precautions (gloves, gown, dedicated equipment) in addition to standard precautions.

Methicillin-resistant Staphylococcus aureus risk rises with prior colonization, recent hospitalization, recent antibiotic exposure, and residence in a long-term care facility.

Diabetic foot infections are classified as mild, moderate, or severe; mild infections are typically treated with oral antibiotics for one to two weeks plus debridement and offloading.

Albumin reflects long-term protein status and is suppressed by inflammation and hepatic or renal disease; prealbumin has a half-life of about two days but also falls with inflammation, so neither is a stand-alone nutrition diagnosis.

Adults with pressure injuries and malnutrition generally require 1.25-1.5 g/kg/day of protein and 30-35 kcal/kg/day of energy, with intake monitored and documented.

Fluid needs are commonly estimated at 30-35 mL/kg/day (or about 1 mL per kcal); dehydration reduces perfusion while overhydration worsens edema and periwound maceration.

Vitamin C and zinc are cofactors in collagen synthesis; supplementation is indicated only for documented or suspected deficiency, not routinely for all wounds.

Hyperglycemia impairs leukocyte chemotaxis and phagocytosis, collagen synthesis, and microcirculation; hemoglobin A1c above roughly 7-8% is associated with delayed healing and higher infection risk.

Smoking causes vasoconstriction and elevated carboxyhemoglobin, reducing tissue oxygenation; cessation improves healing outcomes and reduces surgical complication rates.

Systemic corticosteroids suppress collagen synthesis and inflammatory signaling, blunting both healing and classic infection signs; immunosuppressants and chemotherapy act similarly.

In peripheral arterial disease, revascularization is the priority before definitive wound closure; rest pain, claudication, hairless skin, and diminished pulses point to arterial insufficiency.

Chronic venous insufficiency produces dependent edema, hemosiderin staining, and lipodermatosclerosis; compression is the cornerstone of therapy when the ABI is above 0.8.

Teach-back confirms comprehension: the learner restates instructions in their own words, and the clinician re-teaches until accuracy is demonstrated.

Plain-language teaching targets a fifth- to sixth-grade reading level, uses short sentences and pictures, and limits each session to three to five key points.

Adherence to offloading is the strongest modifiable determinant of diabetic foot ulcer healing; total contact casting is the reference standard, with removable cast walkers and offloading boots as alternatives.

Patients prescribed multilayer compression should be told that initial discomfort and difficulty donning the wrap are expected and that the garment should not be removed without clinician direction.

Pressure injury prevention teaching covers at least every-two-hour repositioning, daily skin inspection, keeping skin clean and moisturized, and adequate protein and fluid intake.

Barriers to adherence that must be assessed include cost, transportation, limited dexterity, poor vision, low health literacy, and lack of a capable caregiver.

Warning signs to report immediately include fever, spreading redness, increased pain, foul odor, purulent drainage, and new skin breakdown.

Written instructions, interpreter services, and caregiver demonstration improve retention and reduce readmissions; motivational interviewing supports shared goal setting.

Self-care basics include keeping the dressing dry and intact, avoiding scratching or self-debridement, and following the agreed dressing change schedule.

Reposition bedbound patients at least every two hours and chairbound patients every 15 minutes or teach them to shift weight; keep head-of-bed elevation at or below 30 degrees to limit shear.

Support surfaces are classified as reactive (changes pressure only in response to load, such as foam or static air) or active/powered (alternating pressure, low-air-loss); higher-risk patients need group 2 or 3 surfaces.

Elevate heels off the mattress entirely; avoid donut cushions, ring devices, and massage over bony prominences because they concentrate pressure and impair perfusion.

Braden scores of 18 or lower trigger prevention protocols; Norton and Waterlow scales are alternative risk tools.

Skin care uses pH-balanced cleansers, lukewarm water, and moisturizer; avoid hot water, harsh soaps, and vigorous rubbing of fragile skin.

Venous leg ulcers are typically shallow, irregular, and located near the medial malleolus with edema and hemosiderin staining; treatment is sustained compression of roughly 30-40 mmHg plus elevation after ABI screening.

Arterial ulcers are punched-out and painful, occur on toes, heels, or the lateral malleolus, and show absent pulses and cool, hairless skin; compression is contraindicated and revascularization is considered.

Diabetic foot ulcers require pressure redistribution through total contact casting, removable cast walkers, or offloading footwear, plus callus removal and daily inspection.

Leg elevation above heart level reduces venous hypertension, while prolonged standing and dependency worsen venous ulcer disease.

SBAR (Situation, Background, Assessment, Recommendation) is the standard structured handoff format for escalating wound changes between clinicians.

The interprofessional wound team includes physicians, nurses, physical and occupational therapists, dietitians, podiatrists, and vascular or plastic surgery specialists, each contributing to an individualized plan.

Sharp or surgical debridement is performed only by clinicians with documented training and competency, consistent with state nurse practice acts and organizational policy.

Documentation must be objective, measurable, timely, and authenticated; subjective labels such as 'wound looks better' are replaced by measured dimensions and described tissue types.

Present-on-admission status must be documented at the first assessment, since hospital-acquired pressure injuries affect reimbursement and public quality reporting.

Discharge planning includes home health referral, durable medical equipment orders, dressing supply arrangements, and clear follow-up appointments to prevent care gaps.

Quality indicators track pressure injury incidence and prevalence, healing rates, infection rates, and adherence to risk assessment documentation.

Evidence-based wound practice draws on current guidelines such as those from NPUAP/EPUAP/PPPIA and the Wound, Ostomy and Continence Nurses Society.

Standard precautions plus transmission-based precautions, patient privacy protections, and informed consent govern all wound care encounters.