CWOCN flashcards

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

Braden Scale

A six-item risk assessment tool scoring sensory perception, moisture, activity, mobility, nutrition, and friction/shear; total scores range 6–23, with lower scores indicating higher pressure injury risk.

Stage 3 pressure injury

Full-thickness skin loss extending into subcutaneous fat; bone, tendon, muscle, and fascia are not exposed. Slough or eschar may be present but does not obscure the depth of tissue loss.

Unstageable pressure injury

Full-thickness skin and tissue loss obscured by slough or eschar, so true depth cannot be determined. Removal of the covering is needed before staging.

Deep tissue pressure injury

Intact or non-intact skin with persistent non-blanchable dark red, maroon, or purple discoloration, indicating damage to underlying soft tissue from pressure and shear.

Wagner grade 3

Diabetic foot ulcer with deep ulceration extending to tendon or bone, accompanied by abscess, osteomyelitis, or joint sepsis.

Venous ulcer compression

Graduated compression of 30–40 mmHg at the ankle is standard for venous leg ulcers; check ankle-brachial index first because arterial disease may contraindicate compression.

Autolytic debridement

Selective debridement using the body's own enzymes under a moisture-retentive dressing, such as a hydrocolloid or transparent film, to soften and separate necrotic tissue.

Wound tunneling

A channel extending from the wound base into surrounding tissue; measure depth and document direction using clock positions, with 12 o'clock toward the patient's head.

Moist wound healing

Maintaining a moist wound bed with appropriate dressings promotes cell migration, epithelialization, and autolytic debridement while reducing pain and scarring compared with dry wounds.

Pressure injury prevention

Repositioning at regular intervals, using pressure-redistribution surfaces, managing moisture and nutrition, and performing skin assessments reduce pressure and shear injury.

Ankle-brachial index

Ratio of ankle systolic pressure to brachial systolic pressure; values below 0.9 suggest peripheral arterial disease and warrant caution before applying compression.

Biofilm

A structured community of microorganisms attached to a wound surface and encased in a protective matrix, making infection persistent and resistant to antimicrobial treatment and host defenses.

Ileostomy output

A healthy ileostomy typically produces 500–1200 mL of liquid or loose effluent daily; output above 1500 mL/day is high-output and risks dehydration and electrolyte loss.

Healthy stoma color

A healthy stoma is moist and beefy red or pink. Dark, dusky, blue, or black coloration suggests ischemia and requires immediate evaluation.

Stoma sizing

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

Urostomy characteristics

An ileal conduit urostomy drains urine continuously and produces mucus from the bowel segment; the pouch must be emptied frequently and changed every few days.

Colostomy irrigation

Irrigation is suitable only for descending or sigmoid colostomies; it is contraindicated for ileostomies, urostomies, transverse colostomies, and during chemotherapy or radiation.

Peristomal moisture-associated damage

Caused by effluent leaking under the barrier, producing maceration and erythema; correct the pouch fit and use skin barrier products to protect the skin.

High-output ileostomy management

Monitor fluid intake, urine output, and electrolytes; replace losses with oral rehydration solution and consult providers because sodium, potassium, and magnesium depletion can occur.

Pouch emptying frequency

Empty a drainable ostomy pouch when it is one-third to one-half full to prevent weight-related leakage and skin breakdown.

Peristomal candidiasis

Fungal infection presenting as itchy, red, pustular, or satellite lesions under the barrier; treat with topical antifungal powder and improve barrier seal.

Ostomy pouch change

Change the pouching system every 3–7 days or when leaking; urostomy pouches often need changing every 2–4 days because of continuous urine output.

Post-void residual

Urine remaining in the bladder after voiding; a residual above 200 mL suggests incomplete emptying, and values above 300–400 mL often require catheterization.

Stress incontinence

Involuntary urine loss with increased abdominal pressure from coughing, sneezing, laughing, or exercise, caused by urethral hypermobility or intrinsic sphincter deficiency.

Urge incontinence

Involuntary urine loss accompanied by a sudden strong desire to void, caused by detrusor overactivity; bladder training and antimuscarinic medications are common treatments.

Overflow incontinence

Continuous or intermittent urine leakage from an overdistended bladder, often due to outlet obstruction or acontractile detrusor, with elevated post-void residual.

Pelvic floor muscle training

Voluntary contractions of the pelvic floor, typically 8–12 repetitions three times daily, held for 3–10 seconds, continued for at least 8–12 weeks for benefit.

Bladder training

A behavioral program using scheduled voiding with gradually increasing intervals and urge-suppression techniques to improve bladder control and reduce urgency episodes.

Intermittent catheterization frequency

Clean intermittent catheterization is usually performed every 4–6 hours, keeping drained volume below 400–500 mL per catheterization to protect bladder and kidneys.

Bristol Stool Scale

A seven-type stool classification; types 1–2 indicate constipation, types 3–4 are ideal, and types 6–7 indicate diarrhea relevant to fecal incontinence management.

Gastrocolic reflex

Colonic motor activity increased after meals, especially breakfast, producing the urge to defecate; scheduled toileting after meals supports bowel training programs.

CAUTI prevention

Avoid unnecessary indwelling catheters, use closed drainage, maintain unobstructed flow, perform hand hygiene, and remove the catheter as soon as it is no longer indicated.