CWCN cheat sheet

Braden Scale has six subscales (sensory perception, moisture, activity, mobility, nutrition, friction/shear); total score ranges 6–23, and ≤18 indicates risk, with lower scores meaning higher risk.

NPIAP staging: Stage 1 = intact skin with nonblanchable erythema; Stage 2 = partial-thickness loss with exposed dermis; Stage 3 = full-thickness loss with subcutaneous fat visible; Stage 4 = exposed fascia, muscle, tendon, or bone; unstageable = base obscured by slough or eschar; deep tissue injury = persistent maroon or purple discoloration.

Pressure injuries are never downstaged: a healed Stage 3 is documented as a healed Stage 3, not as Stage 1.

Measure greatest length head-to-toe and greatest width perpendicular to it in centimeters, then calculate area; assess depth with a cotton-tipped applicator and trace the perimeter for irregular wounds.

Ankle-brachial index: 0.90–1.30 is generally normal; ≤0.90 suggests peripheral arterial disease; ≥1.30 suggests noncompressible, calcified arteries; abnormal values warrant vascular referral.

Obtain wound culture by tissue biopsy or the Levine technique (rotate a swab with pressure over 1 cm² of cleansed viable wound bed); surface swabs grow colonizers, not pathogens.

Localized infection cues are NERDS (nonhealing, exudate, red/friable tissue, debris, smell); spreading deep infection cues are STONEES (size increase, temperature, probe-to-bone, new breakdown, erythema/edema, exudate, smell).

PUSH Tool scores three items - surface area, exudate amount, and tissue type - for a total of 0–17; decreasing totals indicate healing progress.

Albumin below 3.5 g/dL and prealbumin below 15 mg/dL suggest nutritional depletion, but must be interpreted with weight trend, intake history, and inflammatory status rather than used alone.

Moist wound healing is the default; select dressings by exudate volume, wound bed tissue, depth, infection status, and periwound skin integrity.

Debridement methods: sharp or surgical (fastest), enzymatic, autolytic (selective, slow), mechanical, and biological (larval); choice depends on tissue type, perfusion, pain, and setting.

Do not debride stable, dry, intact heel eschar or ischemic wounds until perfusion has been evaluated.

Cleanse with normal saline or potable water at 4–15 psi (for example, a 35-mL syringe with a 19-gauge catheter); avoid cytotoxic agents such as hydrogen peroxide or acetic acid on healing tissue.

Negative pressure wound therapy is commonly set at −125 mmHg continuous; it is contraindicated over malignancy in the wound, untreated osteomyelitis, exposed vessels or organs, and non-enteric fistulas.

Venous leg ulcers: apply graduated compression of 30–40 mmHg at the ankle only after ABI confirms adequate arterial flow; add leg elevation and calf pump exercise.

Arterial ulcers need revascularization and offloading, not compression; neuropathic diabetic foot ulcers need total contact casting or another irremovable offloading device.

Reposition at-risk patients on an individualized schedule, keep head of bed at or below 30° when clinically allowed, use a 30° lateral tilt, and float heels off the mattress.

Topical antimicrobials (silver, cadexomer iodine, PHMB) are used for a defined, time-limited course when bacterial burden or biofilm is suspected, then reassessed and de-escalated.

Teach-back ("show me" or "tell me in your own words") confirms comprehension and is more reliable than asking whether the patient understands.

Write instructions at roughly a 5th–6th grade reading level, use large print and pictures, and provide a qualified interpreter rather than relying on family members.

For malnourished adults with pressure injuries, teach daily protein intake of 1.25–1.5 g/kg and 30–35 kcal/kg, with dietitian follow-up.

Warning signs to report: fever, new or increasing pain, spreading redness, increased or foul-smelling drainage, and tissue that opens or blackens.

Compression stockings are applied in the morning before edema develops, seated smooth without wrinkles or rolls, with daily skin inspection.

Diabetic foot teaching: inspect feet daily including between toes, never walk barefoot, wear protective footwear, and keep glucose within the individually agreed target.

Offloading adherence teaching should state that continued weight-bearing on a diabetic foot ulcer delays healing and raises infection and amputation risk.

Smoking cessation is part of wound teaching because nicotine causes vasoconstriction and carbon monoxide reduces oxygen delivery to healing tissue.

Document each teaching topic, the method used, the learner's response, and barriers such as low literacy, vision loss, cognitive impairment, or language at every session.

Legal scope of practice comes from the state Nurse Practice Act and board rules; CWCN certification documents expertise but does not expand that legal scope.

OSHA Bloodborne Pathogens Standard requires an exposure control plan, offered hepatitis B vaccination, personal protective equipment, sharps disposal, and annual training.

Use standard precautions for every wound: hand hygiene before and after, gloves at minimum, plus gown, mask, and eye protection when splash or spray is likely.

Documentation must capture location, etiology or stage, measurements, wound bed tissue percentages, exudate, periwound skin, odor, pain, intervention performed, and patient response.

Under CMS programs, Stage 3, Stage 4, and unstageable pressure injuries acquired during hospitalization are non-reimbursable hospital-acquired conditions, and pressure injury rate is a nursing-sensitive indicator.

Incidence equals new pressure injuries during a period divided by patients at risk during that period; prevalence equals existing cases at a point in time divided by patients surveyed.

Sharp or surgical debridement requires informed consent and documented competency or privileging according to facility policy.

Refer or collaborate: dietitian for malnutrition, physical therapy for mobility and offloading, vascular surgery for abnormal ABI or ischemic rest pain, and podiatry for foot deformity.

Delegate wound care tasks only to personnel with documented competency under state delegation rules; the RN retains accountability for assessment and evaluation of outcomes.