pressure injuries
What is the earliest sign of a pressure injury?
Redness that does not blanch
What is the best time to perform a skin check?
During bathing, dressing, or brief changes
What type of redness should always be reported?
Non-blanchable redness
What is the most important detail to include when documenting a skin issue
location
Name three things to assess during a skin check.
Color, temperature, moisture
What type of force occurs when a patient slides down in bed and skin stretches internally?
Shearing
Why should skin be patted dry instead of rubbed?
To prevent friction and skin damage
A dark purple area on intact skin is a sign of what?
Deep tissue injury
Name two additional details that should be documented.
Size, color, drainage, or changes
What does warm skin in one area suggest?
Possible infection or inflammation
A wound has yellow, soft dead tissue inside it. What is this called?
Slough
Why is it important to dry thoroughly under skin folds?
To prevent fungal infections and moisture damage
What does a rash with small red dots around it (satellite lesions) indicate?
Fungal infection
Why is “skin red” considered poor documentation?
It is too vague and lacks detail
Why must you check under medical devices?
They can cause hidden pressure injuries
A wound is covered with black, hard tissue and depth cannot be determined. What type of injury is this?
Unstageable pressure injury with eschar
A patient has a red, moist rash in the groin area. What type of skin issue is most likely?
Moisture-associated skin damage or possible fungal infection
A patient reports burning and you see shiny, wet skin. What should you suspect?
Moisture-associated skin damage
A patient refuses hygiene care and has skin redness. What must you document?
Refusal, condition of skin, and actions taken
A patient pulls away during care but says nothing. What should you suspect?
Pain or underlying skin issue
Explain how pressure, friction, moisture, and shear together contribute to a Stage 3 or 4 pressure injury.
Pressure reduces blood flow, moisture weakens skin, friction damages surface, and shear damages deeper tissue → leads to deep breakdown
Describe the full daily care routine to prevent skin breakdown in an incontinent, bedbound patient.
Frequent brief changes, gentle cleansing, pat dry, barrier cream, repositioning, and regular skin checks
A wound looks small on the surface but has odor, drainage, and increased pain. What complication should you suspect?
Tunneling or undermining (deeper wound damage)
Why is documenting subtle changes in skin condition critical for patient outcomes?
Early changes can indicate worsening conditions and allow early intervention
Explain why DSPs are essential in preventing severe skin breakdown.
They perform frequent care and can identify early changes before they worsen