Skin Integrity
Name two factors that increase risk for skin breakdown.
: Pressure, moisture, friction, shear, poor nutrition.
Stage 1 pressure injury is characterized by what?
Non-blanchable redness of intact skin.
What is the purpose of a moist wound environment?
Promotes healing and cell regeneration.
What is a stoma?
A surgically created opening for waste elimination.
True or False: You should document “appears infected.”
False—describe findings (redness, drainage, odor) instead.
Which scale is used to assess risk for pressure injury?
Braden Scale.
What layer of tissue is visible in a stage 3 pressure injury?
Subcutaneous tissue.
When changing a wound dressing, why is it important to assess the type and amount of drainage before cleaning the wound?
It provides baseline data about healing or infection and guides selection of appropriate dressing type.
What color should a healthy stoma be?
Pink to red, moist.
What elements are needed to document three characteristics of a wound assessment?
Size, color, drainage, odor, pain, periwound condition.
What score on the Braden Scale indicates high risk?
12 or below.
Unstageable pressure injury—why can’t it be staged?
Covered by slough or eschar.
What type of wound is best treated with hydrocolloid dressing?
Minimal exudate wounds.
What finding requires immediate notification of the provider?
Pale, dusky, or black stoma.
What should you do before and after dressing changes?
Perform hand hygiene and provide patient education.
Which lab value can indicate poor nutrition affecting skin healing?
Low albumin or prealbumin.
Identify one prevention strategy for immobile patients.
Repositioning, heel protectors, pressure-relief mattress.
Define “dehiscence.”
Partial or total separation of wound layers.
During pouch change, you notice skin irritation around the stoma. What should the nurse do first?
Remove residue, gently cleanse the area, assess for leakage, and ensure the wafer opening fits snugly around the stoma to protect the skin.
Which interdisciplinary team member helps with complex wounds?
Wound care nurse or wound specialist.
Explain why repositioning every 2 hours prevents skin breakdown.
It relieves pressure, improves perfusion, and reduces ischemia.
What is the first nursing action when a new pressure injury is noted?
Assess and document, notify provider, initiate care plan.
What is the correct order of wound dressing removal and application?
Remove old dressing → assess → cleanse → apply new dressing → document.
What are two key nursing education points to prevent complications with a new colostomy?
Measure the stoma regularly as swelling decreases; empty the pouch when it’s one-third full; avoid heavy lifting to prevent herniation; teach signs of complications (e.g., skin breakdown, stoma color change).
You notice new drainage on a patient’s dressing—what do you do first?
Assess the wound before applying new dressing or reinforcing existing dressings and notify physician as needed.