CWOCN Exam

This chapter covers the comprehensive assessment that surrounds the wound: the health and medication history, psychosocial and functional factors, interpretation of nutrition data, pain assessment, and the laboratory, imaging and vascular studies the WOC nurse should know how to read and when to recommend.

A wound is a sign of an underlying problem. The history should identify the cause and the barriers to healing.

Psychological stress raises cortisol and catecholamines, which suppress inflammation and slow healing. Depression is common with chronic wounds and reduces adherence, nutrition and mobility. Assess social support, caregiver availability and skill, living situation, finances and insurance coverage for supplies and offloading devices, health literacy, cultural beliefs about wounds and treatments, body image concerns (odor, exudate, visible dressings), and the patient's own priorities. Odor and leakage frequently cause social isolation.

Clinical Scenario: A 58-year-old man with a plantar diabetic foot ulcer has not improved in six weeks despite a prescribed offloading walker. On interview he says he removes the walker at work because he is a delivery driver and fears losing his job. The WOC nurse recognizes that the barrier is psychosocial and occupational, not a product failure. The best next step is to explore options with him (a different offloading device acceptable at work, a work note, social work referral for job or financial concerns) rather than changing the dressing.

Wounds raise the body's need for calories, protein, fluid and micronutrients. The WOC nurse screens and refers; the registered dietitian completes the full nutrition assessment.

Screen for unintended weight loss (commonly flagged at 5% in 30 days or 10% in 180 days), poor intake, chewing or swallowing problems, appetite loss and body mass index extremes. A nutrition-focused physical exam looks for muscle wasting (temples, clavicles, thighs), loss of subcutaneous fat, edema and signs of deficiencies.

Nutrition Targets for Adults With Pressure Injuries (NPIAP-Aligned)

Worked example: a 70 kg woman with a Stage 3 sacral pressure injury needs about 70 times 30 to 35, which is 2,100 to 2,450 kcal per day; protein of 70 times 1.25 to 1.5, which is 87.5 to 105 g per day; and fluid of about 1 mL per kcal, roughly 2,100 to 2,450 mL per day unless restricted.

Albumin and prealbumin are not reliable indicators of nutritional status. Both are negative acute-phase proteins that fall with inflammation, infection and stress and shift with hydration status (dilution in fluid overload, concentration in dehydration). A low albumin in a septic patient may reflect inflammation rather than intake. Use weight trends, intake records and the physical exam instead, and refer to the registered dietitian.

Common Trap: An answer option that says "order a prealbumin to determine whether the patient is malnourished" looks clinical but is not the best choice. The best answer usually involves weight history, intake assessment, nutrition screening and dietitian referral.

Other metabolic data matter too. Hemoglobin A1C reflects glucose control over about the past 2-3 months; elevated glucose impairs leukocyte function and collagen formation. Hemoglobin and hematocrit identify anemia that limits oxygen delivery. Blood urea nitrogen, creatinine and sodium help evaluate hydration and renal function, which changes protein targets.

Pain is both a symptom and a clue. Arterial ulcers are typically very painful; neuropathic ulcers are often painless; venous ulcers ache and improve with elevation; pyoderma gangrenosum, calciphylaxis and Martorell ulcers are disproportionately painful. A sudden increase in wound pain is a common sign of infection.

Types of wound pain:

Nociceptive pain (tissue damage) is described as aching, throbbing or sharp; neuropathic pain (nerve damage) as burning, shooting, tingling or electric. The distinction matters because neuropathic pain responds to agents such as anticonvulsants and certain antidepressants recommended to the provider.

Pain Assessment Tools

Assess pain before, during and after dressing changes, and document location, intensity, quality, timing, aggravating and relieving factors and the effect on sleep and function.

The WOC nurse interprets results and recommends studies to the provider when the clinical picture calls for them.

Diagnostic Studies in Wound Assessment

Exam Tip: When an item describes a wound that looks unusual, is in an atypical location or has not responded to appropriate care for weeks, the best answer is often to recommend a biopsy to rule out malignancy or an atypical etiology.

Treat the whole patient: the history should identify the cause of the wound and every barrier to healing.

Psychosocial barriers such as depression, cost, job demands and caregiver limits often explain nonadherence.

Nutrition targets: about 30-35 kcal/kg/day, 1.25-1.5 g protein/kg/day, about 1 mL fluid per kcal; supplements only for deficiency.

Albumin and prealbumin reflect inflammation and hydration, not nutritional status; use weight, intake and physical findings and refer to the dietitian.

Assess pain before, during and after procedures with a tool matched to the patient; a sudden increase can signal infection.