CWCA (ABWM) flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Braden Scale

Six-item pressure injury risk tool covering sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Scores range from 6 to 23, and 18 or below indicates increased risk.

Unstageable pressure injury

Full-thickness tissue loss in which slough or eschar covers the wound bed and hides the true depth. It cannot be staged until enough necrotic tissue is removed.

Deep tissue pressure injury

Intact or open skin with persistent non-blanchable deep red, maroon, or purple discoloration, reflecting damage to underlying tissue from pressure and shear forces.

Ankle-brachial index

Ratio of ankle systolic pressure to brachial systolic pressure. Below 0.90 suggests peripheral arterial disease; above 1.30 suggests calcified, non-compressible vessels.

Levine culture technique

Method of sampling a cleansed wound bed by rotating a swab with enough pressure to express fluid from about one square centimeter of viable tissue.

TIME framework

Wound bed preparation model standing for Tissue management, Infection and inflammation control, Moisture balance, and Edge advancement of non-advancing wound margins.

Autolytic debridement

Use of moisture-retentive dressings so the body's own enzymes liquefy necrotic tissue. It is selective and essentially painless, but slower than sharp debridement.

Hydrogel dressing

Water- or glycerin-based dressing that donates moisture to dry or minimally exuding wounds and supports autolytic removal of slough and eschar.

Alginate dressing

Highly absorbent seaweed-derived dressing that gels on contact with exudate. Used for moderate to heavy drainage and always needs a secondary cover dressing.

Negative pressure wound therapy

Controlled subatmospheric suction, typically -125 mmHg, that removes exudate and stimulates granulation. Contraindicated with untreated osteomyelitis, malignancy, or exposed vessels.

NERDS criteria

Mnemonic for superficial wound infection: Non-healing, Exudate increase, Red friable tissue, Debris, and Smell. Findings support topical antimicrobial therapy plus debridement.

STONEES criteria

Mnemonic for deep or spreading infection: Size increase, Temperature, Os (probe to bone), New breakdown, Erythema/edema, Exudate, Smell. These warrant systemic antibiotics.

Biofilm

A structured community of microorganisms embedded in a self-produced matrix on the wound surface. It resists antibiotics and requires repeated debridement plus antimicrobial agents.

Probe-to-bone test

A blunt sterile probe passed through an ulcer reaches bone, raising strong suspicion of osteomyelitis in a diabetic foot wound and prompting imaging and cultures.

Contact precautions

Added precautions for wounds with purulent drainage that cannot be contained, requiring gloves, gown, and dedicated equipment alongside standard precautions for every contact.

Prealbumin

Transport protein with a roughly two-day half-life used as a short-term nutrition marker. Levels fall with inflammation or infection regardless of actual dietary intake.

Protein needs for wound healing

Adults with pressure injuries and malnutrition generally require about 1.25 to 1.5 grams of protein per kilogram of body weight each day to support repair.

Compression therapy contraindication

Compression is withheld in significant peripheral arterial disease, typically when the ankle-brachial index is below 0.8, until revascularization has been evaluated.

Hyperglycemia and wound healing

Elevated blood glucose impairs leukocyte function, collagen synthesis, and microcirculation. Hemoglobin A1c above roughly 7 to 8 percent predicts delayed healing and infection.

Teach-back method

The learner explains the information back in their own words; the clinician re-teaches until understanding is accurate rather than assuming comprehension from a nod.

Plain language teaching

Using everyday words, short sentences, and pictures at a fifth- to sixth-grade reading level, and limiting each session to three to five key points.

Total contact cast

Reference-standard offloading device for neuropathic plantar foot ulcers. Molded and irremovable, it redistributes pressure across the entire plantar surface during ambulation.

Barriers to adherence

Practical obstacles such as cost, transportation, limited dexterity, poor vision, low health literacy, or absent caregiver support that undermine a self-care plan.

Repositioning schedule

Turn bedbound patients at least every two hours and seated patients every 15 minutes or teach weight shifting. Keep head-of-bed elevation at or below 30 degrees.

Reactive support surface

A surface that changes pressure distribution only in response to the patient's load, such as foam or static air. Used for low- to moderate-risk patients.

Donut cushion

Ring-shaped device that concentrates pressure at its edges and compresses surrounding circulation. It is contraindicated for pressure injury prevention and treatment.

Venous leg ulcer signs

Shallow, irregular ulcers near the medial malleolus with edema, hemosiderin staining, and lipodermatosclerosis. Treated with sustained compression after arterial assessment.

Arterial ulcer characteristics

Punched-out, painful ulcers on toes, heels, or lateral malleolus with absent pulses, cool hairless skin, and pallor. Compression is contraindicated; revascularization is considered.

SBAR

Structured handoff format standing for Situation, Background, Assessment, and Recommendation. It standardizes communication between clinicians during escalations and care transitions.

Present on admission

Documentation that a pressure injury existed before hospital admission. This determines hospital-acquired status and affects reimbursement and public quality reporting.

Interprofessional wound team

Group including physicians, nurses, physical and occupational therapists, dietitians, podiatrists, and vascular specialists who coordinate an individualized, evidence-based wound plan.

Debridement competency

Sharp debridement may be performed only by clinicians with documented training and demonstrated competency, in accordance with state law and organizational policy.