Since its inception in 1978, the Wound, Ostomy, and Continence Nursing Certification Board (WOCNCB) has shown a deep commitment to maintain patient and public safety by upholding the gold standard in wound, ostomy, continence, and foot care nursing. The WOCNCB certification in wound, ostomy, and continence nursing validates specialty skills and expertise for nurses prepared at the baccalaureate level. Wound, ostomy, and continence (WOC) specialty nursing has been a part of an evolving health care system that encompasses increasing complexity and an expanding variety of health care environments. These environments require a more team based approach; the WOC nurse is a vital component of the team. The WOCNCB has kept pace with our changing health care environment by offering multi-level (eg, advanced) WOC certification. In 2012, the WOCNCB introduced the Advanced Practice certification for the Advanced Practice Registered Nurse (APRN). The WOC Advanced Practice certification validates basic WOC specialty practice and advanced specialty knowledge, as well as the core competencies of the APRN role. Recognizing the complexity of WOC practice in multiple health care environments, the WOCNCB recently launched certification for the wound treatment associate. The WTA-C (certified wound treatment nurse) is a nurse (RN or LPN) who provides daily wound monitoring and basic wound care, and plays an important role of pressure injury prevention. The WTA-C nurse has been trained by and practices under the direct supervision of the WOCNCB® certified wound care nurse or a licensed independent practitioner such as a physician or APRN who specializes in wound care.
For all 3 levels of WOCNCB wound care certification, it is essential to have a strong understanding of the principles of wound management. Included in this column are sample questions from each level of wound care certification. Each question focuses on those principles of wound care that underlie clinical decision-making on all 3 levels. The rationale and supporting information for each question is provided and additional information for examination preparation can be found published on the WOCNCB® Web site.
SAMPLE CWOCN-AP QUESTIONS
1. The APRN is consulted to evaluate a malodorous wound. What would be the most appropriate treatment?
Outline Location: 4C2c
Cognitive Level: Application
Correct Answer B: Metronidazole
The underlying wound care principle in this question is that optimum wound care involves creating and maintaining a physiologic wound environment. Wound odor is often caused by anaerobic pathogens in the wound. Odor is common with chronic wounds and can be distressing to patients leading to social isolation and other psychosocial conditions such as depression. While there are multiple methods to managing wound odor, the question focuses on medication management. The answer options include different antimicrobial agents. Metronidazole is an antibiotic that belongs to the nitroimidazole class and is activated through reduction of its nitro group (NO2). While its use is considered to be “off-label,” it is effective in controlling odor by reducing odor-producing anaerobic pathogens in wounds. Metronidazole is available as a gel, powder, paste, cream, or tablet and applied directly to the wound bed. Minocycline is a tetracycline antibiotic used to treat acne vulgaris and has no known efficacy in controlling wound odor. Fluconazole and Miconazole belong to the azole class of antifungals. While Fluconazole and Miconazole are both prescribed to treat candidiasis, there is no evidence of either medication being effective in managing odor.
Akhmetova A, Saliev T, Allan I, Illsley M, Nurgozhin T, Mikhalovskey S. A comprehensive review of topical odor-controlling treatment options for chronic wounds. J Wound Ostomy Continence Nurs. 2016;43(6):598–609.
Eammons K, Dale B. Palliative wound care. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:697.
Minocycline [monograph]. Epocrates Version. 18.8 [iPad0]. San Francisco, CA: Epocrates, Inc. http://www.epocrates.com. Accessed October 4, 2018.
Rolstad B, Bryant R, Nix D. Topical management. In: Bryant R, Nix D, eds. Acute and Chronic Wounds Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:290.
2. A newly diagnosed patient with diabetes with an A1C of 10.2 has a wound on the lateral aspect of the foot with evidence of exposed tendon (Wagner grade 2). What would be the most appropriate intervention for this patient?
- Evaluate for hyperbaric oxygen therapy (HBOT)
- Order a pulse volume recording study
- Refer to a diabetic educator
- Start enzymatic debridement
Outline Location: 4C5c; 4D2
Cognitive Level: Analysis
Correct Answer C: Referral to a diabetic educator
The principle of wound care applicable in this question is that hyperglycemia can have a negative impact on bacterial control, affecting wound healing in all phases. According to the American Diabetes Association, a goal for glycemic control for non-pregnant adults is an A1C less than 7. This goal may become more or less stringent based on factors such as history of hypoglycemia or patient age and therefore must be individualized to the patient. A key component in managing glycemic control is lifestyle and diabetes self-management. A referral to a diabetic educator facilitates the knowledge and skills needed for diabetic patients to make changes to manage and control their condition. The question stem provides critical information to answer this question correctly. The patient has newly diagnosed diabetes and has a foot ulcer with complications. The A1C of 10.2 is indicative of poor glycemic control, which will likely impair wound healing. One of the initial components of the plan for this patient would be to promote a favorable environment for wound healing, which in this case means adequate glycemic control. Hyperbaric oxygen therapy (HBOT) has been utilized as an adjunct therapy for diabetic foot ulcers and limb salvage by delivering oxygen to the tissue. Centers for Medicare & Medicaid Services (CMS) indications for diabetic foot ulcers require a Wagner grade 3 or higher for HBOT. While vascular disease is often associated with diabetes, the stem does not provide information indicating microvascular disease such as an abnormal ankle brachial index (ABI) or increased urinary albumin levels. Ordering a pulse volume study would not be an appropriate answer choice. Diabetic foot wounds will often require debridement with a surgical debridement approach to reduce infection and promote healing.
Broussard C. Hyperbaric oxygenation. In: Bryant R, Nix D, eds. Acute and Chronic Wounds Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:345–347.
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; 2016:74.
American Diabetes Association. Standards of Medical Care in Diabetes 2018 Abridged for Primary Care Providers. Clini Diabetes. 2018;36(1):14–37.
Varnado M. Lower extremity neuropathic disease. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:484.
WOCN Society. Guideline for Management of Wounds in Patients With Lower-Extremity Neuropathic Disease. WOCN Clinical Practice Guideline Series #3. Glenview, IL: WOCN Society; 2012:17.
SAMPLE CWOCN QUESTION
3. A patient with darker skin tone has a lower extremity wound. After a saturated dressing is removed, the periwound skin was assessed as gray in color and wrinkled in appearance. What is the best treatment for this wound?
- Zinc-based barrier to peri-wound, nonadhesive foam dressing
- Liquid acrylate barrier film to peri-wound, adhesive foam dressing
- Petrolatum ointment to peri-wound, adhesive foam dressing
- Hydrogel to wound base, transparent adhesive dressing
Outline Location: 010210
Cognitive Level: Application
Correct Answer B: Liquid acrylate barrier film to periwound, adhesive foam dressing
A careful reading of the question stem reveals that this patient has a lower extremity wound of unknown origin. The stem does tell the wound nurse that there is a saturated dressing that indicates the current dressing is contributing to poor exudate management. The appearance of the gray peri-wound skin color and wrinkled texture in an individual with a darker skin tone describes peri-wound moisture-associated skin damage (MASD). The principles underlying treatment for this type of wound are to manage exudate and prevent further peri-wound skin damage. The strategies to prevent peri-wound MASD would include applying absorptive dressings, increasing the frequency of dressing changes, and preventing wound effluent from sitting on the peri-wound skin. Foam dressings are absorptive by design, and are considered an appropriate treatment option for exudate management. Current evidence supports use of acrylate liquids, zinc oxide, and petrolatum-based barriers to manage and prevent peri-wound maceration. It is important to consider how the choice of a peri-wound moisture barrier may impact the adhesive and absorptive properties when selecting dressings. The best treatment choice is to apply a liquid acrylate barrier film to the peri-wound skin, and cover with adhesive foam dressing. The liquid acrylate dries to a transparent film that allows for skin inspection, will manage and protect the periwound skin, and will not interrupt the adhesive properties of the dressing. The petrolatum ointment applied to peri-wound skin would offer protection from effluent, however, it would disrupt the adherence property of the adhesive foam dressing. The zinc-based barrier would protect the peri-wound skin and not adversely affect the non-adhesive foam dressing, however this choice would require a secondary dressing to keep it in place. Additionally, the zinc-based barriers are thick, can be quite messy, and may be difficult to remove or clean, which would require more nursing time to complete the dressing change and may negatively impact the patient experience. Hydrogels are designed to add moisture to a dry wound bed, and affixing a transparent adhesive dressing would not contribute to exudate management, leading to additional periwound maceration.
Thayer D, Rozenboom B, Baronoski S. “Top-down” injuries, prevention and management of moisture-associated skin damage (MASD), medical adhesive-related skin injury (MARSI), and skin tears. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:282.
Jazarowski K, Murphree R. Wound cleansing and dressing selection. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:282.
SAMPLE WTA-C QUESTIONS
4. The wound treatment nurse will consider the following when educating a patient and family about the relationship between nutrition and wound healing.
- High blood glucose levels are helpful because it will prevent protein being used as an energy source.
- Patients who are trying to lose weight should adhere to a calorie-restricted diet.
- Vitamins A and C are water-soluble vitamins that help with collagen formation.
- Protein needs for a patient with a wound may increase to 1.25 to 1.5 g/kg per day.
Outline Location: Domain 3, Task 2(b)
Cognitive Level: Application
Correct Answer D: Protein needs for a patient with a wound may increase to 1.25 to 1.5 g/kg per day.
In order to correctly answer this question, it is important to understand the key relationship between wound healing and adequate wound nutrition. Protein is necessary for wound healing. Protein deficits can lead to delayed wound healing. The daily allowance for protein intake is 0.8 g/kg per day to maintain health. However, when a patient has a wound, protein needs increase to 1.25 to 1.5 g/kg per day to promote formation of collagen and proteoglycans. Adequate intake of dietary glucose is needed to maintain normal metabolism and to prevent protein from being used as an energy source. Blood glucose levels need to remain within normal limits, however high blood glucose levels will impair wound healing. During wound healing, metabolic rates will rise causing a need for increased caloric intake. Patients who reduce calories in an effort to lose weight run the risk of curtailing intake of nutrients essential for wound healing. While both vitamins A and C are linked to collagen formation, vitamin A is a fat-soluble vitamin that is involved in different steps of collagen deposition, primarily scar formation. Vitamin C is water soluble and a cofactor in collagen formation.
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; 2016:74.
Stotts NA. Nutritional assessment and support. In: Bryant R, Nix D, eds. Acute and Chronic Wounds Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:395–396.
5. Which patient behavior would indicate that teaching about self-care and venous insufficiency is effective? The patient reports:
- donning compression stockings first thing in the morning.
- elevating the legs when sitting first thing in the morning.
- not wearing the compression wrap consistently because shoes often do not fit.
- not taking the prescribed diuretic because of increased nocturia.
Outline Location: Domain 2, Task 2(i)
Cognitive Level: Analysis
Correct Answer A: The patient reports donning compression stockings first thing in the morning.
The principle of wound care applicable in this question is reduction of edema in relation to venous insufficiency. Key factors that contribute to venous insufficiency are incompetent valves leading to distended superficial veins, changes in gait, which affect the calf muscle pump, and extravasation of blood components increasing interstitial fluid. Compression therapy is a mainstay in treating venous insufficiency and for maintenance therapy. Compression works to mechanically reduce the diameter of the distended vessels, support the calf muscle pump, and decrease edema by increasing pressure in the interstitial space. Patients should be instructed to apply their stockings in the morning when their edema is minimal. Elevating the feet is an important component in the plan of care, but the best time to elevate the feet is at times when edema is worse such as later in the afternoon or after standing for a prolonged period of time. The patient with the poor-fitting shoes and lack of compression may indicate nonadherence to the treatment plan, and consequently, show no improvement with their edema. More teaching about the relationship between compression and reduction of edema along with appropriate shoes may be needed. The patient's nonadherence with taking his diuretic due to nocturia indicates a lack of understanding between his medication and its therapeutic effect. Medication education about the need for taking the diuretic possibly in the morning may improve adherence.