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Getting Ready for Wound Certification

Comprehensive Assessment

Botham, Phillip; Simmons, Jessica

Journal of Wound Ostomy & Continence Nursing: January/February 2019 - Volume 46 - Issue 1 - p 70–72
doi: 10.1097/WON.0000000000000501
Getting Ready for Certification
Free

Phillip Botham, MSN, RN, CWON, Botham Consulting Services, LLC, Charleston, South Carolina.

Jessica Simmons, MSN, APN, FNP-C, CWON, DNC, Swedish American Health System, Rockford, Illinois.

Correspondence: WOCNCB, 555 East Wells Street, Ste 1100, Milwaukee, Wisconsin 53202-3823 (info@wocncb.org).

The authors declare no conflicts of interest.

The WOCNCB wound care certification examination is a 120-item multiple-choice test administered electronically at specified testing sites around the country. There are a number of useful strategies to keep in mind when answering multiple-choice tests. Read the question stem critically and carefully. Identify key intervention words such as “assess” or “teach” and key words that describe the characteristics of a wound. These words will direct the test taker to what action is needed by the nurse in a given situation or what type of wound is the focus of the question. Pay special attention to key words such as “least,” “most,” or “best.” These key words indicate that the question is focused on your ability to prioritize assessments or interventions. If details are given in the question stem such as age of a patient, gender, or past medical history, take special note of their relationship to the situation described in the question. Details are included for a reason and help identify the correct answer. Read each answer option carefully and completely. Eliminate answer options that you know to be incorrect. Ensure that key words, such as “best treatment,” applies in the answer option. If any part of an answer option does not apply, the entire option is incorrect and can be eliminated as a possible correct answer. The sample questions included in this column will give you practice in answering questions with important key words. Further practice in test taking is available on the WOCNCB Web site. Computerized practice testing called the Self-Assessment Examination (SAE) and flash cards in each of the specialties are available for purchase. Both the SAE and the flash cards include practice examination questions (or items) built from the detailed content outline and include an explanation or rationale for correct and incorrect answer choices. Refer to the WOCNCB Web site (www.wocncb.org) for ordering information.

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PRACTICE QUESTIONS

1. How would the WOC nurse document skin injury present on each buttock at the site where the buttocks touch each other?

  1. Intertriginous dermatitis (ITD)
  2. Incontinence-associated dermatitis (IAD)
  3. Moisture-related pressure injury
  4. Stage 2 pressure injury

Outline location: 010101

Cognitive level: Application

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ANSWER A:

Crucial to the comprehensive assessment of patients with wounds to the trunk and lower extremities is determining baseline wound characteristics that provide direction for treatment. One challenge in wound assessment is differentiating among pressure, moisture, and traumatic injuries to the skin. The question stem gives the test taker key information that points to the correct answer choice, intertriginous dermatitis. The stem describes a skin injury that is sometimes referred to as a kissing injury that presents as mirror image skin damage, often in a linear pattern, on touching tissues such as in the gluteal cleft or skin folds. In most cases, injuries occur in areas prone to moisture. These injuries generally do not occur over bony prominences and are not related to pressure such as with a stage 2 pressure injury or with moisture-related pressure injury. Moisture-associated skin damage (MASD) is a grouping of clinical presentations that are impacted by a variety of moisture-related causative factors. Incontinence-associated dermatitis occurs over the perineal area, buttocks, groin, and at times the natal cleft and is directly related to exposure to urine or feces. The question stem does not specify that incontinence was present.

1. Bates-Jensen BM. Assessment of the patient with a wound. In: Doughty D, McNichol L, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:38–68.

2. Bryant R. Types of skin damage and differential diagnosis. In: Bryant R, Nix D, eds. Acute and Chronic Wounds Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:82–102.

2. The WOC nurse is completing an initial assessment on a patient with controlled type 2 diabetes mellitus (DM) and a chronic diabetic neuropathic foot ulcer. Which of the following factors has the lowest risk of impacting the development of a sustainable wound care plan?

  1. Cultural factors
  2. Financial resources
  3. Cognitive ability
  4. Disease process

Outline location: 010109

Cognitive level: Application

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ANSWER D:

In this situation (controlled type 2 DM), successful wound management is not dependent on the disease process as it is controlled. Successful wound management is dependent on the clinician, the patient, and family developing a sustainable plan of care based upon mutually agreed-upon goals. Shared goal-setting can be impacted by many factors: perceived susceptibility, severity, benefit, barriers, and self-efficacy. The Health Belief Model (HBM) is a useful framework to assist clinicians in developing mutually agreed-upon goals. A challenge for the wound care nurse is in the development of cultural competent tools and processes that identify factors that are present with each encounter. Partnership with the patient and family, in a culturally competent manner, can produce successful plans of care regardless of disease process. Cultural factors such as preferred language, cultural, religious, or spiritual beliefs, gender-specific roles and behaviors, diet, and perceived provider/patient roles, impact outcomes of the management plan. Financial resources are a key component to consider when developing the plan of care. The WOC nurse needs to take into account available resources from third party payers as well as significant others involved in the care of the patient, which, in turn, can impact travel to appointments, availability of medications, adequate nutrition, and wound care supplies. Cognitive deficits can significantly impact successful wound management plans. Many barriers are subtle and not overtly obvious to the clinician, such as spiritual practices, gender roles, and literacy. Review of past medical history and use of specific assessment and interview techniques often provides cues to culturally specific factors that should be addressed to optimize the plan of care.

1. Bryant R. Eliminating noncompliance. In: Bryant R, Nix D, eds. Acute and Chronic Wounds Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:428–440.

2. Rijswijk LV. Patient and caregiver education: significance and guidelines. In: Doughty D, McNichol L, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:80–89.

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ADVANCED PRACTICE QUESTIONS

1. When reviewing a patient's medication list, which medication is LEAST LIKELY to impact wound healing?

  1. Warfarin
  2. Levothyroxine
  3. Infliximab
  4. Meloxicam

Outline location: 1A

Cognitive level: Application

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ANSWER B:

A full medication profile including all prescription, over-the-counter, and homeopathic medications is required as part of obtaining a comprehensive health history of a patient. Levothyroxine is indicated for thyroid conditions, most commonly hypothyroidism, and has no known effect on wound healing, thus making this the correct answer.

Infliximab can impede wound healing by inhibiting the normal inflammatory response. This, in turn, can cause delay in the wound healing, and additional risks include wound dehiscence and infection. Warfarin and other anticoagulants inhibit clotting factor production, thus preventing the wound from achieving hemostasis. Nonsteroidal anti-inflammatory drugs such as meloxicam function to reduce prostaglandin and thromboxane synthesis. Since prostaglandins function as an inflammatory mediator and thromboxane causes platelet aggregation, suppressing these functions will affect hemostasis and the inflammatory response.

1. Krapfl LA, Peirce B. General principles of wound management goal setting and systemic support. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:75.

2. Levine J. The effect of oral medication on wound healing. Adv Skin Wound Care. 2017;30(3):137–142.

3. Meloxicam [monograph]. Epocrates Version 18.6 [iPad]. San Francisco, CA: Epocrates, Inc. http://www.epocrates.com. Accessed July 22, 2018.

2. The advanced practice registered nurse would consider which of the following tests as the BEST option to further evaluate a diabetic foot ulcer that has increased in depth and bone is now probed?

  1. Wound culture
  2. Magnetic resonance imaging (MRI)
  3. X-ray
  4. Complete blood cell count

Outline location: 1C

Cognitive level: Analysis

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ANSWER B:

The wound described in the question stem is suggestive of possible osteomyelitis. Osteomyelitis is defined as a bone infection that is typically caused by bacteria; however, fungi, parasites, and viruses may be causes as well. Osteomyelitis can be endogenous or exogenous. Endogenous osteomyelitis is caused by pathogens carried by blood from a site of infection in another area of the body. On the other hand, exogenous osteomyelitis is caused by an infection that enters the body via open fractures, surgical procedures, or wounds and spreads from soft tissue into adjacent bone. Osteomyelitis can be challenging to confirm; yet, it should be considered when bone is exposed. Magnetic resonance imaging will evaluate soft tissue and bone pathology, making it the best answer choice. Magnetic resonance imaging is considered the gold standard in diagnosing osteomyelitis, having a 90% sensitivity with 79% specificity in the diagnosis of osteomyelitis even early on in the disease course. A wound culture may be helpful in identifying infection in the wound; however, it will not be an accurate indicator of bacterial penetration to the bone. X-rays can detect abnormalities in both bone and soft tissue such as osteomyelitis or soft tissue gas; yet, the sensitivity of an x-ray is variable based on the timing in which the x-ray was obtained. Severity of osteomyelitis may not be shown on an x-ray until 10 to 14 days after the onset of symptoms. A complete blood cell count may show an elevated white count, which would be sensitive for inflammation/infection but would not be specific to confirm osteomyelitis.

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REFERENCES

1. Crowther-Radulewicz C, McCance K. Alterations of musculoskeletal function. In: McCance KL, Huether SE, Brashers VL, Rote NS, eds. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Maryland Heights, MO: Mosby; 2010:1587–1588.
    2. Groll M, Woods T, Salcido R. Osteomyelitis: a context for wound management. Adv Skin Wound Care. 2018;31(6):253–262.
    3. Varnado M. Lower extremity neuropathic disease. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:495.
      4. Weir D, Schultz G. Assessment and management of wound-related infections. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:168–169.
        © 2019 by the Wound, Ostomy and Continence Nurses Society.