A thorough understanding of wound characteristics and wound care terminology is essential when preparing for the wound content of WOCNCB certification examinations. At this time, no organized standards for wound terminology exist. (See the glossary at the end of this feature.) The test-taker should be aware that many terms are interchangeable or are different in various areas of the country. Read the stem of the question carefully to determine what is being asked and how a specific term is used. Some examples of different terms with the same meaning may include rolled wound edges, also known as epibole; resurfaced wound, also known as a reepithelialized wound; cutaneous malignant wound, also known as a fungating wound; and hyperplasia, also known as hypertrophic granulation tissue. Many abbreviations are used in advanced wound care and wound healing modality documentation. For example, HBO (hyperbaric oxygen), TcPO2 (transcutaneous oxygen pressure), PVR (pulse volume recordings), ABI (ankle-brachial index), MMPs (matrix metalloproteinases), ECM (extracellular matrix), and NPWT (negative pressure wound therapy). The Self-Assessment Exam is helpful when preparing for testing. Visit the WOCNCB Web site http://www.wocncb.org for the examination content outline, sample questions, and information on how to purchase the Self-Assessment Exam.
1. A left lateral anterior calf wound presents with a shallow, yellow wound bed with irregular elevated edges; it is extremely painful. A purplish-colored halo is noted in the periwound skin. These characteristics are most consistent with:
- Arterial ulcer
- Pyoderma gangrenosum
Content Outline: 010105
Cognitive Level: Recall
The correct answer is D. This recall question requires the test-taker to have an understanding of healthy wound and periwound characteristics and then recognize abnormalities upon assessment. The candidate must also possess a strong grasp of wound care terminology to rule out distractors. Pyoderma gangrenosum lesions are commonly associated with systemic disease, usually initiated by a minor traumatic event, and are very painful, and biopsy may be helpful in ruling out other etiologies. The diagnosis of pyoderma gangrenosum, though, is a diagnosis of exclusion.
- Option A. Calciphylaxis lesions begin as purple-indurated nodules that become necrotic and progress to open ulcerations. The test-taker should notice that the “purplish-colored halo” cited in the stem is not characteristic of wounds due to calciphylaxis.
- Option B. Vasculitic lesions can be erythematous and nonblanchable macules, hemorrhagic vesicles, with palpable purpura or necrosis. The terminology here can be confusing as the presentation of lesions due to vasculitis can be similar to pyoderma gangrenosum in many ways. The test-taker should be very familiar with the specific terms that describe various lesions. The ability to describe characteristics unique to each type of atypical lower extremity ulcer is essential to choosing the correct answer.
- Option C. Arterial wounds are characteristically pale with a “punched-out” appearance on a cool lower extremity with absent hair and dry periwound skin. Familiarity with the characteristics of common lower extremity diagnoses will aid the test-taker in identifying common conditions such as arterial disease and arterial wounds. However, even though some of these characteristics are similar to pyoderma, the stem does not describe a classic arterial wound.
Bryant RA. Intrinsic diseases and uncommon cutaneous wounds. In: Acute and Chronic Wounds Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012:419–424.
Doughty DB. Arterial ulcers. In: Acute and Chronic Wounds Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012:180, 184.
Ermer-Seltun J. Lower extremity assessment. In: Acute and Chronic Wounds Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012:170.
Nix DP. Skin and wound inspection and assessment. In: Acute and Chronic Wounds Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012:110–117.
Wound, Ostomy and Continence Nurses Society. Guideline for Management of Wounds in Patients With Lower-Extremity Arterial Disease. WOCN Clinical Practice Guideline; no 1. Mt Laurel, NJ: Wound, Ostomy and Continence Nurse's Society; 2008.
2. An 85-year-old bed-bound male patient is a new admission to your home care practice. He presents with a dry eschar covering the left calcaneus. There is no drainage, erythema, or induration. He has nonpalpable pedal pulses and his heels are offloaded with foam boots.
Which of the following would be the most appropriate intervention?
- Conservative sharp debridement
- Paint eschar with povidone-iodine solution
- Surgical consult for debridement
- Enzymatic debridement with crosshatching
Content Outline: 010206
Cognitive Level: Application
The correct answer is B, Paint eschar with povidone-iodine solution. The test-taker needs to review the stem and identify the key points. The patient is elderly, bed-bound, and nonpalpable pedal pulses, and has a stable, noninfected heel eschar. Debridement would increase infection potential, and without adequate circulation wound healing may not occur. All of the other options include different methods of debridement, making them incorrect.
Ramundo J. Wound debridement. In: Acute and Chronic Wounds Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012:279–281, 287.
Wound, Ostomy and Continence Nurse's Society. Guideline for Prevention and Management of Pressure Ulcers. WOCN Clinical Practice Guideline; no 2. Mt Laurel, NJ: Wound, Ostomy and Continence Nurse's Society; 2010.
3. A 75-year-old woman with a venous ulcer of 1-year duration has been treated with a 4-layer compression wrap weekly. The wound dimensions decreased each week for 6 weeks. For the last 2 weeks, the wound dimensions have not changed. The wound base is pale and smooth, and drainage is minimal and odorless; periwound skin is intact. Based on this assessment, which advanced wound care regimen would the wound nurse implement?
- Collagen-based MMP inhibitor
- Polyurethane foam
Content Outline: 010105
Cognitive Level: Analysis
The correct answer is B; begin an MMP inhibitor. This analysis question requires the test-taker to analyze this scenario and to determine the most likely reason that this wound has begun to deteriorate. The most likely cause of wound “stalling” is increased levels of inflammatory substances such as proinflammatory MMPs. This question requires the test-taker to analyze the reasons that a wound may stall and also to be familiar with the generic names for commonly used wound dressings as well as the function of each dressing.
Option A is incorrect as hydrofiber dressings are intended for use with moderate to heavily draining wounds and is simply a product change.
Option C is incorrect as hydrogel dressings are indicated for dry wounds. Addition of a hydrogel to the wound will only add moisture to the wound bed with minimal drainage and is intended for daily dressing changes.
The last option, D, is also incorrect. Foams are intended for moderate to heavily draining wounds and once again are simply a product or dressing change, which will do little to jump-start this stalled wound.
Doughty D, Sparks-DeFriese B. Wound healing physiology. In: Acute and Chronic Wounds Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012:74, 75, 217.
Rolstad BS, Bryant RA, Nix DP. Topical management. In: Acute and Chronic Wounds Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012:291–297.
Ulrich D, Smeets R, Unglaub F, Woltje M, Pallua N. Effect of oxidized regenerated cellulose/collagen matrix on proteases in wound exudate of patients with diabetic foot ulcers. J Wound Ostomy Continence Nurs. 2001;38:522–526.
Wound, Ostomy and Continence Nurse's Society. Guideline for Management of Wounds in Patients With Lower Extremity Venous Disease. WOCN Clinical Practice Guideline; no 2. Mt Laurel, NJ: Wound, Ostomy and Continence Nurse's Society; 2011.
Glossary of Terms
Debridement—the process of removing nonviable tissue.
Enzymatic—use of a topical agent containing enzymes able to interact with tissue to break down and loosen its structure aiding in removal.
Eschar—nonviable wound tissue presenting as hard, dry, black/brown/tan colored, having the appearance of leather.
Hemorrhagic vesicles—small sac filled with blood; they are superficial and small in diameter.
Hydrofiber—made of carboxymethylcellulose, absorbs wound drainage converting to a gel and maintains a moist wound environment.
Hydrogel—water- or glycerin-based product used primarily to maintain or add moisture to the wound.
Macule—discoloration of skin such as a freckle and may be flat like a mole.
MMP inhibitor—made of oxidized regenerated cellulose (ORC) and collagen.
Nodules—raised, firm on palpation, located deeper in dermis
Nonblanchable—remains reddened and no capillary refill after removing finger pressing lightly on lesion or skin around lesion or wound
Purpura—reddish/purple discolorations larger than 0.5 cm.
Polyurethane foam—varying in size, these dressings contain small open cells absorbing and holding drainage away from the wound bed.