Wound Care Mnemonics: 12 Memory Tricks for the WCC Exam

Pressure injury stages (NPIAP 2016)

“Blanch-not, Blister, Fat, Fascia-to-bone”

1. 1Blanch-not: intact skin with nonblanchable erythema of a localized area (may look different in darkly pigmented skin)
2. 2Blister: partial-thickness loss with exposed dermis - pink or red moist bed, or an intact or ruptured serum-filled blister; no fat, slough, eschar or granulation
3. 3Fat: full-thickness skin loss with fat visible; granulation and rolled edges (epibole) common; slough or eschar may be present; may undermine or tunnel
4. 4Fascia-to-bone: full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone
5. UUnstageable: depth hidden by slough or eschar; stable, dry eschar on the heel or an ischemic limb should not be removed
6. DTPIDeep tissue pressure injury: intact or nonintact skin with persistent nonblanchable deep red, maroon or purple discoloration or a blood-filled blister

Use it when: When a stem describes tissue in the wound bed and asks for the stage, or asks what can and cannot be staged.

Careful: Never reverse-stage: a healing Stage 4 stays a 'healing Stage 4', it never becomes a Stage 2. Stage 2 excludes moisture-associated skin damage, skin tears, burns and abrasions. Purple or maroon discoloration is DTPI, not Stage 1. Mucosal membrane pressure injuries are not staged at all, and 'pressure ulcer' plus Roman numerals is the pre-2016 wording.

Braden Scale subscales

“Sore Muscles Are Making Nurses Frown”

1. SSensory perception (1-4)
2. MMoisture (1-4)
3. AActivity (1-4)
4. MMobility (1-4)
5. NNutrition (1-4)
6. FFriction and shear (1-3)

Use it when: When a stem gives subscale findings and asks for the total, the risk level, or which prevention step the low subscale calls for.

Careful: Lower is worse: totals run 6-23 and 18 or below is the commonly used at-risk cutoff (the original study used 16). Friction and shear is scored only 1-3. Children use the Braden Q, which adds tissue perfusion and oxygenation. A low subscale should drive a matching intervention - for example a low moisture score calls for incontinence and moisture management.

Venous vs arterial ulcers

“Veins weep at the ankle; arteries die at the toes”

Venous: gaiter area (often above the medial malleolus), shallow, irregular edges, heavy exudate, red granular bed, edema, hemosiderin staining, lipodermatosclerosis; pain eases with elevation. Arterial: toes, heels, lateral malleolus or pressure points; punched-out, deep, pale or necrotic bed, little exudate; cool, shiny, hairless skin, weak or absent pulses, delayed capillary refill; pain worse with elevation and relieved by dangling the leg.

Use it when: When a stem describes location, exudate, skin changes and pulses and asks for the etiology or the first treatment (compression vs vascular referral).

Careful: Check the ABI before any compression. Mixed venous-arterial disease is common. In diabetes, calcified arteries can give a falsely high ABI (above 1.3), so a toe-brachial index or toe pressure is used instead.

Nutrition for wound healing

“30-35 calories, 1.25-1.5 protein, 1 mL per calorie”

For adults with a pressure injury who are malnourished or at risk (NPIAP/EPUAP/PPPIA 2019): energy 30-35 kcal/kg/day, protein 1.25-1.5 g/kg/day, and roughly 1 mL of fluid per kcal per day unless restricted. Screen intake, weight change and hydration, and refer to a dietitian.

Use it when: When a stem gives a weight and asks for daily protein or calorie needs, or asks which finding warrants a dietitian referral.

Careful: Albumin and prealbumin fall with inflammation and illness, so current ASPEN and Academy guidance does not treat them as markers of nutritional status - expect the exam to still mention them, but read them in context. Protein targets are adjusted down in kidney disease.

Wound bed preparation

“TIME (or DIME) to heal”

1. T / DTissue non-viable / Debridement: remove slough, eschar and debris - only if the wound can heal
2. IInfection and inflammation: control bioburden and persistent inflammation
3. MMoisture balance: add moisture to dry wounds, absorb excess from wet ones
4. EEdge (epithelial edge advancement): non-advancing or undermined edges mean reassess, then consider advanced or adjunct therapy

Use it when: When a stem lists a stalled wound's features and asks what to address first or why the edge is not advancing.

Careful: DIME (Sibbald 2011) starts by asking whether the wound is healable. For a non-healable or maintenance wound - poor perfusion, palliative care - you do not aggressively debride or keep it moist; you keep it dry, stable and comfortable. Treat the cause and patient-centered concerns before local care.

Debridement methods

“Some Eschar Always Must Break”

1. SSharp / surgical: fastest and selective in skilled hands; needs adequate perfusion, scope of practice and bleeding control
2. EEnzymatic: collagenase ointment; selective; inactivated by some heavy-metal antimicrobials such as silver
3. AAutolytic: the body's own enzymes under a moisture-retentive dressing; slowest, painless, avoid in infected wounds
4. MMechanical: wet-to-dry gauze, irrigation, pulsed lavage, hydrotherapy; wet-to-dry is nonselective and painful
5. BBiologic: sterile medical maggots (larval therapy); selective, works in infected wounds

Use it when: When a stem gives the patient's pain, anticoagulation, infection status or setting and asks which method fits.

Careful: Painful wound or anticoagulated patient: autolytic or enzymatic, not sharp. Infected wound: not autolytic alone. Stable dry heel eschar or an ischemic limb: no debridement at all until perfusion is assessed. Wet-to-dry is outdated because it removes viable tissue.

Dressing selection

“Dry - wet it. Wet - dry it. Deep - fill it. Dead - remove it.”

Dry wound: hydrogel or a moisture-retentive cover. Light to moderate exudate: hydrocolloid or thin foam. Moderate to heavy exudate: foam, calcium alginate or gelling fiber. Deep wound or cavity: loosely fill dead space with an alginate, gelling fiber or gauze rope, then cover. Necrotic tissue: debride by the method that fits. Superficial clean wound: transparent film.

Use it when: When a stem describes depth, exudate and tissue type and asks for a dressing category.

Careful: Alginates and gelling fibers need exudate - on a dry wound they stick and dehydrate it. Hydrocolloids and films are occlusive, so they are a poor fit for infected or heavily draining wounds. Pack loosely; tight packing adds pressure. The exam tests categories, not brand names.

Local vs deep infection

“NERDS stay on top; STONEES go deep”

1. NNon-healing despite good care
2. EExudate increased
3. RRed, friable granulation that bleeds easily
4. DDebris: slough or eschar
5. SSmell after cleansing
6. SSTONEES - Size bigger
7. TTemperature raised (more than 3 deg F warmer than mirror skin)
8. OOs: probes to or exposes bone
9. NNew areas of breakdown or satellite lesions
10. EExudate increased
11. EErythema and edema of the periwound
12. SSmell

Use it when: When a stem lists wound signs and asks whether to start a topical antimicrobial or refer for systemic antibiotics.

Careful: Three or more NERDS signs point to superficial (local) bioburden: topical antimicrobial dressings. Three or more STONEES signs point to deep or surrounding infection: systemic antibiotics. A wound that probes to bone needs an osteomyelitis work-up. In diabetes, signs can be blunted - new pain in an insensate foot or erratic glucose is a red flag.

Pressure injury prevention bundle

“SSKIN”

1. SSurface: pressure-redistributing mattress and cushion matched to risk
2. SSkin inspection: check bony prominences and under devices every shift
3. KKeep moving: individualized repositioning schedule, 30-degree tilt, floating heels
4. IIncontinence and moisture: cleanse promptly, use a skin protectant
5. NNutrition and hydration: screen and refer

Use it when: When a stem gives a Braden score or a high-risk patient and asks for the best preventive step.

Careful: Repositioning frequency is set by the patient's risk, skin and support surface - every 2 hours is a common default, not a fixed rule. Do not massage reddened bony prominences, and never use donut or ring cushions, which concentrate pressure around the edge.

Positioning angles

“Thirty-thirty”

Head of bed at or below 30 degrees to reduce sliding and sacral shear, and a 30-degree lateral tilt (pillow or wedge behind the back) instead of lying directly on the trochanter. Float the heels off the bed with the knee slightly flexed.

Use it when: When a stem asks for head-of-bed height, side-lying position or heel protection.

Careful: Medical needs override the rule for limited periods: higher elevation for meals, tube feeding, ventilated patients or respiratory distress. A 90-degree side-lying position loads the greater trochanter and is the classic wrong answer.

Phases of wound healing

“Healing Is Pretty Methodical”

1. HHemostasis: minutes to hours - vasoconstriction, platelet plug, fibrin clot
2. IInflammation: about days 1-6 - neutrophils then macrophages clear debris; redness, heat, swelling
3. PProliferation: about day 4 to week 3 - fibroblasts lay down collagen, granulation, angiogenesis, contraction, epithelialization; healing ridge by days 5-9
4. MMaturation (remodeling): about day 21 to 1-2 years - collagen reorganizes; scar flattens and pales

Use it when: When a stem gives a postoperative day or wound appearance and asks the phase, or asks why a chronic wound has stalled.

Careful: Chronic wounds typically stall in the inflammatory phase. Remodeled scar regains only about 80% of the original tensile strength, so a healed wound is never as strong as intact skin. The phases overlap; the days are approximations.

Measuring and documenting a wound

“Head is 12: length 12-to-6, width 3-to-9”

Use the clock method with the patient's head at 12 o'clock: length runs head-to-toe (12 to 6), width runs side-to-side (3 to 9), depth is measured at the deepest point with a sterile applicator. Undermining and tunneling are documented by clock position and depth, for example 'tunnel at 3 o'clock, 2.5 cm'. Measure the same way, at the same interval (commonly weekly), to track progress.

Use it when: When a stem asks how to measure or record a wound, or how to describe undermining or tunneling.

Careful: Some facilities use greatest length by greatest perpendicular width instead - the exam rewards consistency with the stated method. Length x width overestimates true area; tools such as the PUSH score combine area, exudate and tissue type to show trend.