Performing Focused Skin and Wound Assessment as a Cornerstone of Successful Wound Healing Outcomes

A successful roadmap to effectively guide wound care clinicians in achieving excellent care outcomes begins with a focused assessment to determine current skin and wound status.1,2 The Certified Wound Care Nurse (CWCN®) or the Advanced Practice Certified Wound Care Nurse (CWCN-AP®) are clinical experts trained to perform focused skin and wound assessments, which are key to optimal wound healing. Under the guidance of the CWCN® or CWCN-AP®, the Certified Wound Treatment Associate (WTA-C®) further enhances a successful healing roadmap by serving as an expert frontline resource in skin and wound care. A focused skin and wound assessment begins with visual observations and palpations, especially over bony prominences, skin areas under medical devices, skin folds, extremities, and feet.1 If wounds and other skin conditions are noted, the CWCN® and CWCN-AP® must utilize expert knowledge to effectively develop a care plan pathway toward wound healing.1,2 In addition to accurately identifying wounds, the CWCN® and CWCN-AP® must employ current skin and wound classification systems to determine its etiology.1 Wounds can result from various factors such as pressure, friction, trauma, surgery, autoimmune disease, malignancy, thermal injury, or infection.1 Wounds may be classified as pressure injuries, medical adhesive-related skin injury (MARSI), moisture-associated skin damage (MASD), and skin tears.1 The certified wound care nurse must successfully ascertain the need for crucial diagnostic studies to support the accuracy of focused assessments.1,2 To achieve wound healing, the certified wound care nurse must competently perform focused wound assessments beginning with the initial client encounter, as this serves as the cornerstone of successful care planning for healing.1–3 WOCNCB®-certified wound care nurses must have foundational knowledge on performing focused skin and wound assessment; furthermore, a key element towards successful preparation for the certification exam is to have foundational knowledge on these core competencies of the CWCN®, CWCN-AP®, and WTA-C®. WTA-C® Question The WTA-C® is performing a focused skin inspection and recognizes which of the following would be classified as a type 2 skin tear based on the International Skin Tear Advisory Panel (ISTAP) classification system? Partial flap skin loss No flap skin loss Total flap skin loss Linear skin loss Exam Content Outline: 1.2.e Cognitive Level: Recall ANSWER: A Rationale: With a type 2 skin tear, there is a partial flap loss.1 The skin cannot be repositioned to cover the wound bed; this leaves a small area of exposed wound bed. With a type 1 skin tear, there is a linear tear or flap where the skin can be repositioned to cover the exposed wound bed.1 A type 3 skin tear is a total flap loss.1 The skin is absent or unable to be repositioned, leaving a wholly exposed wound bed.1 REFERENCE 1. Bryant, R. Skin damage: types and treatment. In Bryant, R., Nix, D. eds. Acute and Chronic Wounds Intraprofessionals from Novice to Expert. 6th ed. St. Louis, MO: Elsevier, 2024: 167. CWCN ®Question2. While performing a focused assessment of a healing Stage 3 Pressure Injury, the CWCN® notes that granulation tissue can best be described as which of the following? Yellow and waxy Pink and smooth Red and bumpy Brown and hard Exam Content Outline: 010201 Cognitive Level: Recall ANSWER: C Rationale: Granulation tissue is red, bumpy, shiny, and moist.1 Granulation tissue contains new capillaries, fibroblasts, connective tissue proteins, inflammatory cells, and collagen. Subcutaneous fat is described as yellow and waxy.1 It can be globular when moist but can crystallize and be tan or brown when dry. The dermis is described as pink and smooth.3 It contains collagen, hair follicles, elastin, and glands such as sweat, apocrine, and sebaceous. A scab is described as brown and hard.1 It contains hard, dry blood and serum.1 REFERENCES 1. Nix, D. Skin and wound inspection and assessment. In: Bryant, R., Nix, D. eds. Acute and Chronic Wounds Intraprofessionals from Novice to Expert. 6th ed. St. Louis, MO: Elsevier, 2024: 199. 2. Hurlow, J., Katan, L. Wound infection and bioburden: detection and management. In: Bryant, R., Nix, D. eds. Acute and Chronic wounds Intraprofessionals from Novice to Expert. 6th ed. St. Louis, MO: Elsevier, 2024: 420-422. CWCN-AP® Question3. The CWCN-AP® is performing a focused assessment of an infected pressure injury at the outpatient wound clinic and notes this as a barrier to wound healing. A plan to utilize antiseptic wound dressings for wound management is considered. Which antiseptic wound dressings inhibit new biofilm formation and reduce mature biofilm colonies? Silver Gentian violet Cadexomer iodine Xylitol Exam Content Outline: 010203 Cognitive Level: Application ANSWER: C Rationale: Cadexomer iodine has been shown to reduce mature biofilm colonies, eradicate young biofilm colonies, and inhibit the creation of new biofilm.1 Silver can weaken bacterial biofilms when used in concentrations greater than 5 micrograms/milligram.1 Gentian violet has been shown to diminish fungal biofilms.1 Xylitol can weaken the biofilm matrix when combined with Lactoferrin but is not commercially available in wound care products.1 REFERENCES 1. Hurlow, J., Katan, L. Wound infection and bioburden: detection and management. In: Bryant, R., Nix, D. eds. Acute and Chronic wounds Intraprofessionals from Novice to Expert. 6th ed. St. Louis, MO: Elsevier, 2024: 420-422.