CWCN flashcards
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- Braden Scale risk cutoff
- A total score of 18 or less indicates risk for pressure injury, and lower scores indicate higher risk; the scale has six subscales and ranges from 6 to 23.
- PUSH tool components
- The PUSH Tool scores three wound characteristics: surface area, exudate amount, and tissue type. Total scores range from 0 to 17, with lower scores indicating healing.
- Stage 2 pressure injury
- Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist; adipose and deeper tissues are not visible, and slough may be present.
- Unstageable pressure injury
- Full-thickness skin and tissue loss in which slough or eschar obscures the wound base, so true depth cannot be determined until enough cover is removed.
- Deep tissue pressure injury
- Intact or non-intact skin with persistent nonblanchable deep red, maroon, or purple discoloration, or epidermal separation revealing a dark wound bed, caused by pressure and shear.
- Levine wound culture technique
- After cleansing, rotate a sterile swab with enough pressure over a 1 cm² area of viable wound bed for about five seconds to express fluid from deeper tissue.
- Ankle-brachial index interpretation
- An ABI of 0.90 or less suggests peripheral arterial disease and 1.30 or greater indicates noncompressible arteries; values between 0.90 and 1.30 are generally normal.
- NERDS criteria for localized infection
- Five signs of superficial wound infection: nonhealing, exudate, red and friable tissue, debris, and smell. Three or more findings support topical antimicrobial treatment.
- TIME framework
- A wound bed preparation framework: Tissue management, Infection or inflammation control, Moisture balance, and Edge advancement of epithelial margins, used to guide dressing selection.
- Typical NPWT pressure setting
- Most negative pressure wound therapy orders use continuous −125 mmHg with dressing changes two to three times weekly; lower pressures are chosen for fragile or painful wounds.
- NPWT contraindications
- Do not apply negative pressure over malignancy within the wound, untreated osteomyelitis, exposed vessels or organs, or non-enteric fistulas, and avoid it in wounds needing added moisture.
- Compression for venous leg ulcers
- Graduated compression of 30 to 40 mmHg at the ankle is standard for venous ulcers; confirm adequate arterial flow with ABI before applying strong compression.
- Autolytic debridement
- Use of moisture-retentive dressings so endogenous enzymes liquefy necrotic tissue. It is selective and relatively painless but requires adequate perfusion and moisture.
- Sharp debridement cautions
- Avoid sharp debridement of stable dry heel eschar or ischemic wounds until perfusion is assessed; use sterile technique, control bleeding, and obtain consent per policy.
- Wound irrigation pressure range
- Use 4 to 15 psi for wound cleansing, commonly achieved with a 35 mL syringe and 19-gauge catheter, which removes debris without damaging new tissue.
- Silver dressing indication
- Used for wounds with or at risk of bacterial burden, including burns and infected wounds; silver needs moisture to activate and should stop once infection resolves.
- Total contact cast purpose
- Gold standard offloading for neuropathic diabetic foot ulcers; it redistributes plantar pressure and enforces adherence, but requires adequate perfusion and no deep infection.
- Cytotoxic cleansers to avoid
- Hydrogen peroxide, povidone-iodine, acetic acid, and sodium hypochlorite damage fibroblasts and new tissue, so they are not used for routine cleansing of healing wounds.
- Teach-back method
- Ask the patient to explain or demonstrate the teaching in their own words. This confirms comprehension and reveals gaps more reliably than asking if they understand.
- Protein needs for pressure injury
- Adults with a pressure injury and malnutrition need about 1.25 to 1.5 g of protein per kg daily plus 30 to 35 kcal/kg, with dietitian involvement.
- Wound infection signs to report
- Teach patients to report fever, increasing pain, spreading redness, increased drainage, foul odor, or wound reopening promptly to the care team.
- Compression stocking application timing
- Apply compression stockings in the morning before edema develops, when legs are smallest; inspect skin and smooth out wrinkles or rolls that could cause banding.
- Plain-language teaching materials
- Written wound care instructions should be near a fifth to sixth grade reading level, use large print and pictures, and be provided in the patient's preferred language.
- Offloading adherence teaching
- Explain that walking on a diabetic foot ulcer slows healing and raises infection risk, and reinforce use of the prescribed cast, boot, or wheelchair at every visit.
- Smoking cessation and wound healing
- Nicotine causes vasoconstriction and carbon monoxide reduces oxygen delivery, both impairing healing; cessation support should be offered to every patient with a wound.
- Nurse Practice Act authority
- State law that defines nursing scope of practice, including which wound assessments and interventions a registered nurse may perform, teach, and delegate.
- OSHA Bloodborne Pathogens Standard
- Requires employers to provide an exposure control plan, offered hepatitis B vaccination, personal protective equipment, sharps engineering controls, and training to exposed workers.
- Hospital-acquired condition pressure injuries
- Full-thickness and unstageable pressure injuries acquired during hospitalization are treated as non-reimbursable hospital-acquired conditions under CMS payment programs.
- Pressure injury incidence formula
- The number of new pressure injuries developing in a unit or facility during a defined period, divided by the number of patients at risk during that same period.
- Wound care documentation elements
- Record location, etiology or stage, measurements, wound bed tissue, exudate, periwound skin, odor, pain, the intervention performed, and the patient's response in each note.
- Consent for sharp debridement
- Sharp or surgical debridement requires documented consent covering risks such as bleeding, infection, and pain, along with alternatives, before the procedure is performed.