CWOCN cheat sheet

Pressure injury staging: 1 = intact skin with non-blanchable erythema; 2 = partial-thickness loss or serum-filled blister; 3 = full-thickness loss with visible fat, no exposed bone/tendon/muscle; 4 = exposed bone, tendon, muscle, or fascia.

Unstageable pressure injury is full-thickness loss obscured by slough or eschar; deep tissue injury shows persistent non-blanchable maroon or purple skin.

Braden Scale has six subscales and scores 6–23; lower scores indicate higher pressure injury risk, and many facilities use ≤18 as the risk threshold.

Wagner diabetic foot grades: 0 intact skin, 1 superficial ulcer, 2 deep to tendon or bone, 3 deep with abscess or osteomyelitis, 4 localized gangrene, 5 whole-foot gangrene.

Venous leg ulcers: apply graduated compression of 30–40 mmHg at the ankle after ABI testing; ABI <0.8 or >1.3 requires caution and vascular evaluation.

Moist wound healing supports epithelialization and autolytic debridement; choose dressings by exudate level, wound bed, and presence of infection or dead space.

Wound infection signs include increasing pain, erythema, warmth, purulent drainage, odor, fever, and elevated WBC; biofilm may cause persistent inflammation without classic signs.

Debridement methods include sharp, mechanical, enzymatic, autolytic, and biologic; autolytic debridement uses moisture-retentive dressings and is selective but slow.

Pressure injury nutrition: provide 1.25–1.5 g protein/kg/day when malnourished with adequate calories, vitamin C, and zinc; consult a dietitian.

Ostomy types: colostomy usually has formed or semi-formed stool; ileostomy has liquid to loose output of 500–1200 mL/day; urostomy drains urine continuously with mucus.

Healthy stoma is moist and beefy red or pink; dusky, blue, or black color suggests ischemia and needs immediate evaluation.

Measure stoma and cut barrier opening 2–3 mm larger; remeasure because stoma size shrinks over the first 6–8 weeks after surgery.

Empty drainable pouch at one-third to one-half full; change pouch every 3–7 days, and urostomy pouches every 2–4 days.

High-output ileostomy is >1500 mL/day and risks dehydration, sodium, potassium, and magnesium loss; monitor intake, urine output, and electrolytes.

Irrigation is appropriate only for descending or sigmoid colostomy; contraindicated for ileostomy, urostomy, transverse colostomy, and during chemotherapy or radiation.

Peristomal skin damage causes include effluent leakage, moisture-associated maceration, candidiasis, allergic contact dermatitis, and mechanical trauma from adhesive removal.

Peristomal candidiasis presents with itchy red satellite lesions; treat with topical antifungal powder and correct the barrier seal.

Diet after ileostomy: chew well, eat small frequent meals, increase fluids, and introduce high-fiber foods gradually; avoid gas-forming foods as tolerated.

Bladder capacity is about 400–600 mL; first urge to void typically occurs at 150–250 mL.

Stress incontinence = leakage with increased abdominal pressure; urge incontinence = leakage with sudden urgency from detrusor overactivity; overflow = leakage from retention.

Post-void residual >200 mL suggests incomplete emptying; >300–400 mL often requires intervention such as catheterization.

Pelvic floor muscle training: 8–12 contractions, 3 sets/day, hold 3–10 seconds, for at least 8–12 weeks.

Bladder training uses timed voiding with gradually longer intervals and urge suppression; scheduled toileting after meals uses the gastrocolic reflex for bowel training.

Bristol Stool Scale: types 1–2 constipation, 3–4 ideal, 6–7 diarrhea; stool consistency strongly affects fecal continence.

Clean intermittent catheterization is usually every 4–6 hours with drained volume <400–500 mL per catheterization.

CAUTI prevention: avoid unnecessary indwelling catheters, use closed drainage, maintain unobstructed flow, perform hand hygiene, and remove catheters promptly.

Antimuscarinic and beta-3 agonist medications reduce detrusor overactivity; monitor anticholinergic effects such as dry mouth, constipation, and confusion in older adults.