Candidates preparing for wound certification examination must be educated on the common extrinsic, systemic, host, and local wound factors that contribute to delayed wound healing. These include modifiable and nonmodifiable factors such as smoking, medications, disease states, obesity, nutrition, stress, ischemia, alcohol, and edema.1 In many instances, these factors are interconnected, such as with edema.
Edema is the collection of fluid in the subcutaneous and interstitial spaces due to a systemic or local condition. It has many causes including infection, gravity, sedentary behaviors, fluid overload, injury, hypoproteinemia, organ failure, and chronic venous insufficiency. Venous leg ulcers (VLUs) are the most common wounds associated with edema.2 These account for up to 70% of all leg ulcers3 and result in over 2 million lost working days per year.4 Lymphedema is also a common medical condition complicating wound healing, with 250 million cases globally.5 The prevalence of lymphedema is expected to increase due to obesity and an aging population. Lymphedema is also strongly associated with infection and hospitalizations. These risks can be controlled through skin care, compression, and regular use of sequential intermittent pneumatic pumps.6
After a clinician has performed a comprehensive patient assessment, compression therapy is a standard of care for not only VLUs but also all chronic ulcers in the setting of edema.3 Its use is associated with expedited wound healing and a decreased incidence of wounds.7 Edema is more than just fluid; it contains proteins and other proinflammatory cellular waste products. It impairs wound healing through multiple mechanisms including decreased perfusion from the capillary bed to the wound surface, fibroblast inhibition, endothelial cell suppression, and proinflammatory accumulation of cellular waste products in the interstitial space.8
Deciding to utilize compression in the treatment of edema is part of a holistic patient-centered treatment plan that includes other common causes and barriers to the treatment of edema. Nonadherence to plans of care that would otherwise address edema can also impact wound healing. The Advanced Practice Certified Wound Care Nurse (CWCN-AP) and Certified Wound Care Nurse (CWCN) must be aware of the role infection and edema play in delayed wound healing as well as interventions that can treat or prevent these conditions. To reduce ulcer recidivism, patients often require education including the continued use of compression therapy in the long term even after ulcers have healed.3,7,9 Candidates preparing for WOCNCB wound certification should also be aware of patient considerations that would preclude the use of compression and what tests might be performed to ascertain whether compression is safe for patients.
1. Khalil H, Cullen M, Chambers H, Carroll M, Walker J. Elements affecting wound healing time: an evidence-based analysis. Wound Repair Regen. 2015;23(4):550-556. doi:10.1111/wrr.12307. [Context Link]
2. Son A, O'Donnell TF Jr, Izhakoff J, Gaebler JA, Niecko T, Iafrati MA. Lymphedema-associated comorbidities and treatment gap. J Vasc Surg Venous Lymphat Disord. 2019;7(5):724-730. doi:10.1016/j.jvsv.2019.02.015. [Context Link]
3. Alavi A, Sibbald RG, Phillips TJ, et al, What's new: management of venous leg ulcers: treating venous leg ulcers. J Am Acad Dermatol. 2016;74(4):643-666. doi:10.1016/j.jaad.2015.03.059. [Context Link]
4. Murphy C, Atkin L, Swanson T, et al International consensus document. Defying hard-to-heal wounds with an early antibiofilm intervention strategy: wound hygiene. J Wound Care. 2020;29(suppl 3b):S1-S28. [Context Link]
5. Ratliff CR. Lymphedema. In: Bryant R, Nix D, eds. Acute & Chronic Wounds Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:214-224. [Context Link]
6. Karaca-Mandic P, Hirsch AT, Rockson SG, Ridner SH. The cutaneous, net clinical, and health economic benefits of advanced pneumatic compression devices in patients with lymphedema. JAMA Dermatol. 2015;151(11):1187-1193. doi:10.1001/jamadermatol.2015.1895. [Context Link]
7. Burian EA, Karlsmark T, Norregaard S, et al Wounds in chronic leg oedema. Int Wound J. 2022;19(2):411-425. doi:10.1111/iwj.13642. [Context Link]
8. Aviles F. Managing the "weepy leg" of chronic wound edema. Today's Wound Clinic. 2019. https://www.hmpgloballearningnetwork.com/site/twc/articles/managing-weepy-leg-ch. Accessed May 4, 2022. [Context Link]
9. Bernatchez SF, Eysaman-Walker J, Weir D. Venous leg ulcers: a review of published assessment and treatment algorithms. Adv Wound Care (New Rochelle). 2022;11(1):28-41. doi:10.1089/wound.2020.1381. [Context Link]
PRACTICE QUESTIONS
Certified Wound Care Nurse CWCN Question
1. A patient presents to the outpatient wound center with a VLU on their right medial malleolus that has failed to respond to advanced wound dressings. Their ankle brachial index (ABI) is 0.95. The patient has not been wearing compression stockings stating that they are too difficult to apply. Which of the following alternative compression choices could be offered to increase adherence to the compression goal while also delivering the recommended 30 to 40 mm Hg of pressure when properly applied?
A. Two layers of short-stretch compression bandages
B. Velcro compression garments/wraps
C. Tubular elastic compression via longitudinal fuzzy wales
D. Thromboembolism deterrent stockings
Content outline: 020207
Cognitive level: Application
Answer: B
Rationale: Velcro compression garments/wraps are the only choice listed that would deliver 30 to 40 mm Hg of compression when properly applied. Two layers of short-stretch compression bandages would deliver approximately 20 mm Hg. Tubular elastic compression via longitudinal fuzzy wales would deliver 15 to 20 mm Hg. Thromboembolism deterrent stocking stockings are not intended to control edema and would deliver 8 to 18 mm Hg.1
1. Alavi A, Sibbald RG, Phillips TJ, et al What's new: management of venous leg ulcers: treating venous leg ulcers. J Am Acad Dermatol. 2016;74(4):643-666. doi:10.1016/j.jaad.2015.03.059. [Context Link]
Certified Wound Care Associate-WTA-C Question
2. A 76-year-old patient is receiving skilled nursing care in the home for the management of edema due to chronic venous disease. The home care nurse is aware that an ABI test must be performed and provides procedural education. Which patient response indicates the patient requires more education?
A. I will avoid stimulants or heavy exercise for an hour prior to the test.
B. I will be placed in a flat, supine position.
C. I will be referred for further testing and evaluation if the ABI is less than 1.0.
D. The cuff will inflate the 20 to 30 mm Hg above the point where the pulse is no longer audible.
Content outline: 1.2.h
Cognitive level: Application
Answer: C
Rationale: Referral for further testing and evaluation occurs if the ABI is less than 0.90 or greater than 1.30. Patients should be placed in a comfortable position and should avoid stimulants as can create false results. Inflation of the cuff should be 20 to 30 mm Hg above the point where the pulse and can no longer be heard.1
1. WOCN Wound Committee. Ankle brachial index. J Wound Ostomy Continence Nurs. 2012;39(2S):S21-S29. doi:10.1097/WON.0b013e3182478dde. [Context Link]
Advanced Practice Certified Wound Care Nurse-CWCN-AP Question
3. A patient with a history of a noncomplicated diabetic foot ulcer comes to the clinic with complaints of increased pain, periwound erythema and edema, and elevated fasting blood sugar levels. Erythema is less than 2 cm around the ulcer and is limited to the skin or subcutaneous level. Vital signs are stable. The patient has no recent antibiotic therapy or hospitalization, ischemia, or gangrene. The provider decides to treat for the most common pathogen in diabetic foot infections and recognizes the first step would include which of the following:
A. Narrow-spectrum antibiotics for staphylococcal and streptococcal pathogens
B. Anti-fungal
C. Broad-spectrum antibiotics
D. Referral to vascular
Content outline: 040314
Cognitive level: Synthesis
Answer: A
Rationale: Narrow-spectrum antibiotics are the first choice for the treatment of Staphylococcus aureus, the most common pathogen in diabetic foot infections.1 Treatment of staphylococcal and streptococcal pathogens is appropriate as this is a limited infection.1 Broad-spectrum antibiotics may cover gram-negative microbes, methicillin-resistant Staphylococcus aureus (MRSA) if the patient has a history of MRSA or severe infection, or anaerobes. Vascular referral is not indicated at this time.2
1. Lipsky BA, Berendt AR, Cornia PB, et al Infectious Disease Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-e173. [Context Link]
2. Woody J. Overview of diabetic foot care for the nurse practitioner. J Nurse Pract. 2020;16(1):28-33. doi:0/1016/j.nurpura.2019.08.11. [Context Link]