Percutaneous Tubes
Cleanse daily with soap and water.
Stabilize tube to prevent leakage and skin breakdown.
Deflate and inflate balloon once a week.
For peritubular skin breakdown:
- Apply stoma powder + barrier film (cavilon) OR
- Hydrocolloid dressing OR
- Moisture barrier ointment (zinc oxide).
For hypergranulation tissue, treat with silver nitrate (typically applied by wound care nurse) or topical steroid cream (e.g., triamcinolone).
Card 2
Ostomies
Basic Steps for Changing an Ostomy Appliance (2 of 2)
Answer
Ostomies
If using a two-piece pouch, snap the pouch onto the plastic ring on the skin barrier before placing barrier on skin.
Remove backing from skin barrier and apply carefully over stoma. Hold in place for a few minutes.
Additional Considerations:
- For skin breakdown, use a "crusting" technique. Lightly apply ostomy (pectin) powder on skin and seal in with barrier spray (e.g., cavilon) before applying new appliance.
- For a flat stoma, skin folds or dimples, or problems with leakage, utilize stomahesive paste or an adhesive ring to obtain a better seal.
- A belt can provide extra support. It wraps around the patient and attaches on either side of the pouch.
Card 3
Ostomies
Basic Steps for Changing an Ostomy Appliance (1 of 2)
Answer
Ostomies
Assemble supplies: New ostomy appliance, warm/wet washcloths, stoma measuring guide and pen, curved scissors, trash bag, tissues (to catch output when changing appliance).
Gently remove current ostomy appliance. Use adhesive remover wipes if needed. Place in trash bag.
Gently cleanse skin with warm washcloth and allow skin to dry completely. Avoid use of soap and wipes, as they leave residue on the skin!
Measure stoma using the measuring guide. Find the circle size on the card that fits closest to the stoma without touching it (≤ ⅛" bigger than the stoma).
Trace the chosen circle size onto the back of the skin barrier (wafer). Cut opening with the curved scissors.
Card 4
Ostomies
Nursing Care
Answer
Ostomies
Surgical procedure that reroutes part of the intestine through the abdominal wall, forming a stoma.
NC:
- For new ostomies, make sure a wound/ostomy consult has been initiated to provide patient teaching re: ostomy care.
- Empty bag when it is 1/3 - 1/2 full.
- Change ostomy appliance immediately for leaking!
- Change ostomy appliance about twice a week (more frequently for ileostomies).
Assess stoma regularly - should be pink/moist. Pale or blue stoma indicates ischemia and is a medical emergency.
Card 5
Negative Pressure Wound Therapy (NPWT)
Basic Dressing Change Steps:
- Application of New Dressing
Answer
Negative Pressure Wound Therapy (NPWT)
Apply barrier film (e.g., cavilon) to peri-wound skin.
Cut foam (in dressing kit) to the appropriate size (slightly smaller than the wound dimensions) and place in the wound bed. Foam should not be touching the adjacent skin!
Apply NPWT drape over the entire area, covering the foam and ~ 1-2" of skin around the wound.
Cut quarter-sized hole in the drape over the wound.
Apply track pad over the hole. Connect the track pad tubing to the canister tubing.
Turn the wound VAC on. Ensure foam "sucks down" into the wound and a good seal is obtained (observe seal check on machine).
Label with date, time, initials, foam color and count in wound.
Card 6
Negative Pressure Wound Therapy (NPWT)
Basic Dressing Change Steps:
- Removal of Old Dressing & Wound Preparation
Answer
Negative Pressure Wound Therapy (NPWT)
Provide pain medication to the patient prior to the procedure (if needed).
Assemble supplies: Wound VAC dressing change kit, normal saline (NS), adhesive remover wipes, cotton-tipped applicators, gauze, barrier film (e.g., Cavilon), measuring strip.
Use adhesive remover wipes to gently remove the drape (tape) surrounding the foam.
Moisten the foam with NS and carefully remove from the wound bed.
Clean the wound bed and surrounding skin with NS. Make sure there are no pieces of foam left in the wound.
Take wound measurements and photo.
Card 7
Negative Pressure Wound Therapy (NPWT)
Troubleshooting for Wound Vac Alarm
Answer
Negative Pressure Wound Therapy (NPWT)
Make sure wound VAC is plugged in, canister is fully inserted, tubing is unclamped, and tubing is not compressed (e.g., under patient or furniture).
Listen and feel for an air leak around the wound dressing. If an air leak is detected, apply clear tegaderm or NPWT drape to seal the affected area.
If the leak (or source of the alarm) cannot be determined, and the wound VAC is not functioning for ≥ 2 hours, turn off device and remove dressing (including ALL pieces of foam). Apply saline-moistened non-woven gauze or a new wound VAC dressing.
Card 8
Negative Pressure Wound Therapy (NPWT)
Purpose
Nursing Care
Answer
Negative Pressure Wound Therapy (NPWT)
NPWT = Wound VAC (Vacuum-Assisted Closure). Applies suction to the wound to remove excess drainage, promote faster granulation ("filling in" of wound) and wound contraction.
NC:
- Ensure wound VAC is plugged in, running, and not alarming for blockages or leaks.
- Check canister for drainage. Replace canister if needed.
- Make sure wound dressing has a good seal (i.e., air not getting in), and the foam dressing has a "sucked down" appearance.
- Confirm NPWT orders are in place and the Wound Care team has scheduled the patient for dressing changes (typically done on M-W-F). Dressing changes need to be done every 2-3 days.
Card 9
Skin Cancer
Main Types
ABCDE Skin Assessment
Treatment
Answer
Skin Cancer
Main Types:
- Basal cell carcinoma: Waxy nodule with pearly borders.
- Squamous cell carcinoma: Oozing, crusting lesion.
- Melanoma: Irregular lesion, various color hues.
Assessment: Assess lesions and moles on patient's skin for the following:
- A = Asymmetry (one half of mole doesn't match the other).
- B = Border (irregular border).
- C = Color (pigment varies across mole).
- D = Diameter (width > 6 mm, the size of a pencil eraser).
- E = Evolving (change in appearance, new bleeding).
Tx: Excision, cryosurgery, topical chemotherapy, Mohs surgery.
Burns
Clean: Gently clean wound with mild soap and water.
Debride: Surgical, enzymatic, or mechanical debridement for necrotic tissue.
Topical Antimicrobial Agents: Bacitracin, mupirocin, silvadene, or sulfamylon (penetrates eschar) as ordered. Note: Silvadene and sulfamylon may cause pain upon application.
Wound Dressings:
- Non-adherent contact layer (provides atraumatic removal) PLUS gauze and/or gauze wrap.
- Skin grafts: Elevate and immobilize graft site. Monitor for signs/symptoms of infection.
Viral Skin Infections
Herpes Simplex: HSV-1 (typically spread through contact with contaminated saliva) and HSV-2 (spread primarily by sexual contact).
- S/S: Painful vesicular or ulcerative lesions on the mouth/lips or genital area.
- Tx: Topical or systemic antiviral agents, analgesics.
Herpes Zoster (Shingles): Caused by reactivation (from stress, infection, illness, etc.) of varicella-zoster virus (virus that causes chickenpox).
- S/S: Painful, unilateral vesicular rash that runs along a dermatome.
- Tx: Systemic antiviral agents, analgesics.
Bacterial Skin Infections
Folliculitis: Inflammation of a hair follicle.
- S/S: Small erythematous nodule.
- Tx: Usually self-resolving. Hair removal, topical antibiotics.
Furuncle (boil): Bacterial infection of multiple hair follicles and the adjacent tissue.
- S/S: Larger erythematous, pus-filled nodule.
- Tx: Warm compresses, incision and drainage.
Cellulitis: Infection of the deeper connective tissue.
- S/S: Erythema, warmth, pain, edema, fever, malaise.
- Tx: Systemic antibiotics.
Card 14
Neuropathic Wounds
Patient Teaching
Answer
Neuropathic Wounds
See a podiatrist regularly. Get professionally fitted shoes.
Inspect feet daily using a mirror. Check shoes for objects before putting on.
Apply moisturizer to feet, but not between toes.
Wear cotton socks (no synthetic fabrics) and shoes. Do not go barefoot or wear open-toe shoes.
Cut nails straight across, file away sharp corners. Do not use OTC products (e.g., corn/callus removal agents).
Do not use heating pads on feet. Check water temperature w/elbow before stepping into a tub or shower.
Card 15
Neuropathic Wounds
Treatment:
- Offload from Affected Area
- Control Glucose Levels
- Topical Wound Care & Surgery
Answer
Neuropathic Wounds
Offload from Affected Area: Utilize modified footwear, assistive devices, or Total Contact Cast (TCC) to eliminate pressure from the area.
Control Glucose Levels: Maintain BS levels between 110 - 140 mg/dL.
Topical Wound Care:
- Ischemic wounds w/dry eschar: Paint daily with betadine.
- Open wounds: Apply cadexomer iodine (Iodosorb) or collagen dressing for clean, non-healing ulcers.
Surgery: Surgical debridement (or amputation) may be required for grossly infected or non-healing wounds.
Neuropathic Wounds (Diabetic Foot Ulcer)
Nerve damage results in lack of sensation. Skin breakdown occurs due to painless and repetitive trauma from friction and/or pressure.
RF: Diabetes, smoking, spinal cord injury.
S/S: Reduced sensation, neuropathic pain (tingling, burning), muscle atrophy, foot/toe deformities (ex: Charcot deformity), dry/cracked skin.
Wound Characteristics: Typically located on the plantar surface of the foot (most common on 1st metatarsal head), or where shoes rub the toes or heel. Wound often surrounded by callous.
Card 17
Arterial Insufficiency vs Venous Stasis Wounds
Comparison
Answer
Arterial Insufficiency vs Venous Stasis Wounds
Arterial Insufficiency
Venous Stasis
Cool/shiny skin, lack of hair, no edema.
Edematous legs, brown discoloration.
↓ Pedal pulses, prolonged capillary refill.
Typically normal pedal pulses and capillary refill.
Deep, punched-out appearance.
Shallow, irregular wound edges.
Dry, necrotic wounds on the toes.
Heavily draining wounds on medial malleoli.
Pain relieved by dependent positioning (dangling).
Aching pain relieved by elevation.
Compression Therapy
Compression Wraps:
- Provide wound care and apply lotions/creams prior to applying compression wraps.
- Wrap from the base of the toe to just below the knee.
- For a 2 layer wrap: Apply padding layer, then apply Coban.
- Maintain adequate tightness, but avoid overly constrictive wraps!
Compression Stockings:
- Switch from wraps when edema has been eliminated and exudate is controlled.
- Educate patient to apply stockings first thing in the morning. Utilizing a "stocking donner" can make it easier to apply stockings.
- Stockings need to be worn consistently and replaced every 3 - 6 months.
Venous Stasis Ulcers
Improve Venous Return: Elevate legs, compression therapy.
- Note: Compression therapy is contraindicated for uncompensated heart failure.
Topical Therapy:
- Apply ammonium lactate lotion or urea cream for dry/scaly skin.
- Protect periwound skin from wound exudate with barrier film or barrier cream.
- Utilize alginate or absorptive foam dressing to absorb exudate. Use silver alginate or cadexomer iodine for infected wounds.
Venous Stasis Ulcers
Lower extremity ulceration resulting from long-term venous insufficiency.
Patho: Distended veins/incompetent valves allow blood to backflow and pool in the lower extremities, leading to edema and skin breakdown/ulceration.
RF: Obesity, immobility, pregnancy, history of DVT.
S/S of Venous Insufficiency: Edema, aching pain in legs (relieved by elevation), brown discoloration (stasis dermatitis).
Wound Characteristics: Wounds are typically located around the medial malleolus. Wounds are often shallow, with irregular edges and heavy drainage.
Lower-Extremity Arterial Disease (LEAD) Wounds
Revascularization (angioplasty, peripheral bypass graft): Wounds will NOT heal without adequate blood flow. Recommend vascular surgeon consult.
Topical/Systemic Therapy:
- Dry/stable eschar, no infection: Paint wound with betadine daily. Leave OTA (open to air) or cover with dry gauze.
- Infected wound: Systemic antibiotics, topical antimicrobial agent (e.g., cadexomer iodine) or chemical/enzymatic debridement until surgical debridement can be performed.
Avoid bedside sharp debridement due to risk for infection!
Lower-Extremity Arterial Disease (LEAD) Wounds
Ischemic wounds caused by inadequate blood flow to the lower extremities.
Patho: Atherosclerosis causes partial or total arterial occlusion. This deprives the lower extremities of oxygen and nutrients and leads to tissue necrosis.
RF: Hypertension, diabetes, smoking, hyperlipidemia.
S/S: Intermittent claudication (leg pain that ↑ w/exertion, and ↓ w/dangling), pallor with elevation, dependent rubor, prolonged capillary refill time, ↓ pedal pulses, cool/shiny skin, lack of hair on calves.
Wound Characteristics: Wounds are located distally (often on the toes). Wound base is pale or necrotic (eschar). Wounds are often small, deep, and dry with a "punched out" appearance.
Moisture-Associated Damage (MASD)
Periwound MASD: Wound exudate causes maceration and inflammation of surrounding skin.
- Prevention/Treatment: Apply barrier film (e.g., cavilon) or barrier cream (e.g., zinc oxide ointment) to periwound skin. Use absorptive wound dressing (e.g., alginate) in the wound.
Peristomal MASD: Leaking of an ostomy appliance causes inflammation, erosion of the surrounding skin.
- Prevention/Treatment: Ensure properly sized pouch opening (≤ ⅛" larger than the stoma), empty and change pouch frequently (when bag is ¼ - ⅓ full). Treat denuded areas with "crusting" (ostomy powder + barrier film) or hydrocolloid dressing under the pouch.
Moisture-Associated Damage (MASD)
Incontinence-Associated Dermatitis (IAD)
- Presentation: Diffuse area of redness on buttocks and perineal area with or without skin breakdown.
- Prevention/Treatment: Condom catheter, PureWick, PrimaFit, moisture barrier products (e.g., zinc oxide ointment).
Intertriginous Dermatitis (ITD)
- Presentation: Erythema, linear breaks at the base of skin folds (under breasts, pannus) due to trapped moisture. Rash/lesions may also be present, indicating a possible fungal infection.
- Prevention/Treatment: Mattress with air flow, absorptive/wicking products (e.g., Interdry).
Card 25
Skin Tears
Prevention
Treatment
Answer
Skin Tears
Prevention: Avoid tape, remove tape atraumatically with adhesive remover wipes, moisturize dry skin, handle the patient gently (use care when boosting patient up in bed).
Treatment:
- Gently clean wound with normal saline or wound cleanser.
- Re-approximate skin if possible.
- If skin is able to be completely reapproximated, apply steri-strips and topical dressing.
- If some or all of the skin flap is lost, apply silicone contact layer (e.g., adaptic, mepitel one) over tear, cover with gauze, and secure. Change gauze PRN for drainage, change contact layer once a week (or per facility policy).
Dressing Selection for Wet Wounds
Shallow, Wet Wounds:
- Protect periwound skin with barrier film (e.g., cavilon).
- Apply dressing (choose one):
- Foam dressing (e.g., mepilex).
- Alginate + cover dressing.
- Silicone contact layer (e.g., adaptic, mepitel one) + gauze. Secure with gauze wrap or tape.
Deep, Wet Wounds:
- Protect periwound skin with barrier film (e.g., cavilon).
- Fill with alginate dressing.
- Apply cover dressing (gauze/tape or foam dressing).
Card 29
Wound Care Products
Common Dressings/Products (2 of 2)
Answer
Common Dressings/Products
Dressing/Product:
Use for:
Hydrogel
Hard eschar/slough, dry wounds. Provides moisture and promotes autolytic debridement.
Contact Layer (Mepitel, Adaptic, Xeroform, Oil Emulsion)
Dry wounds. Protects the wound bed and decreases trauma with dressing changes. Cover with secondary dressing.
Cadexomer Iodine (Iodosorb)
Infected wounds. Absorbs drainage, provides sustained release of iodine (antimicrobial).
Manuka honey-based dressings (Medihoney)
Infected wounds. Antibacterial, promotes autolytic debridement, prevents malodor.
Moisture barrier paste with zinc oxide (Calmoseptine, Calazime)
Superficial perineal wounds. For denuded skin: Apply ostomy powder, seal with barrier film (cavilon), then apply barrier paste.
Card 30
Wound Care Products
Common Dressings/Products (1 of 2)
Answer
Common Dressings/Products
Dressing/Product:
Use for:
Transparent Film (Tegaderm)
Superficial wounds with minimal drainage. Can also be used as a cover dressing. Avoid use on fragile skin.
Hydrocolloids (DuoDerm)
Superficial wounds with minimal drainage. Do not use on infected wounds. Promotes autolytic debridement. Requires less frequent dressing changes.
Silicone Border Foam (Mepilex)
Wounds with moderate drainage. Insulates, cushions wound (good for pressure injuries over bony prominences). May stick to wounds with minimal drainage.
Alginate and Hydrofiber Dressings
Moderate to heavily draining wounds. Not for use on dry wounds. Alginate dressings promote hemostasis. Both available in silver (antimicrobial) for infected wounds.
Card 31
Topical Wound Care
Removing Sutures
Removing Staples
Answer
Topical Wound Care
Suture/staple removal requires a provider order. Clean incision before and after removal. Count and chart the number of sutures/staples removed. Remove alternate sutures/staples to assess for wound dehiscence.
If wound dehiscence occurs during the removal process: STOP, place saline-moistened gauze over the open area, and notify the provider.
Removing Sutures: Utilize sterile suture removal kit. Grasp the knot of the suture with forceps and gently lift. Cut one side of the suture below the knot (close to the skin). Pull the cut suture through the skin.
Removing Staples: Utilize sterile staple removal kit. Place lower jaw of staple remover under the staple (in the CENTER of the staple) and squeeze the handles together.
Topical Wound Care
Wound Cleaning:
- Closed (Approximated) Wounds: Moisten gauze with NS or wound cleanser. Gently wipe from top to bottom (in one motion), starting directly over the incision and moving outward. Use a new piece of gauze for each downward stroke.
- Open Wounds: Moisten gauze with NS, wound cleanser, or prescribed solution. Clean the wound in full/half circles, starting in the center of the wound and moving outward. Use a new piece of gauze for each circle.
Wound Irrigation: Wear gown, mask, and eye protection. Use a 35 cc piston syringe with a 19 gauge catheter/needle. Use an irrigation force of ~ 8-15 psi. Irrigate wound with NS or prescribed solution.
Card 33
Topical Wound Care
Best Practices
Answer
Topical Wound Care
Gently clean wounds with normal saline or wound cleanser.
Provide a moist wound healing environment (i.e., NOT a desert, but NOT a swamp).
- Wet wounds: Apply dressing to absorb excess exudate, protect periwound skin from drainage.
- Dry wounds: Add wound gel (hydrogel) to maintain a moist wound surface.
Dry cell = Dead cell.
Cover wounds to insulate and protect from infection/trauma.
Monitor for infection. S/S: Purulent drainage, malodor, erythema, induration.
Monitor patient's response to wound care therapy.
Card 34
Obtaining a Wound Culture
Best Practices
Answer
Obtaining a Wound Culture
Obtain wound culture before beginning antibiotic therapy.
Irrigate wound with normal saline (DO NOT use wound cleanser).
Swab a 1 cm area of viable tissue in the wound bed for ~ 5 seconds with enough force to produce exudate.
Do NOT swab necrotic tissue or touch the skin surface with the swab.
Card 35
Wound Debridement
Autolytic
Enzymatic
Chemical
Sharp
Answer
Wound Debridement
Autolytic: Patient's own WBCs and natural enzymes slowly break down necrotic tissue. Requires a VERY moist wound bed, adequate WBCs, and good perfusion.
Enzymatic (e.g., collagenase): Topical enzyme product that loosens necrotic tissue from the underlying wound bed. Do NOT use with silver or iodine products (inactivates the enzyme).
Chemical (e.g., sodium hypochlorite, i.e., bleach): Antiseptic solution that dissolves necrotic tissue, ↓ bacterial counts, and controls odor. Use only for infected, malodorous wounds. Protect periwound skin!
Sharp: Surgical incision and drainage of necrotic wound, or conservative sharp bedside debridement of wound by certified wound care nurse (requires order by provider).
Mechanical debridement (i.e. wet-to-dry dressing) is generally contraindicated. It is painful and often removes viable tissue.
Card 36
Wound Assessment
Drainage
Wound Appearance
Answer
Wound Assessment
Drainage:
- Types of Drainage: Serous (clear, watery), sanguineous (bright red), serosanguineous (light pink, blood-tinged), or purulent (white/yellow/beige, malodorous).
- Amount of Drainage: Scant, small, moderate, large, copious.
Wound Appearance:
- Red = Healthy Tissue. Wound has a beefy red color. Protect and provide a moist wound healing environment.
- Yellow = Needs Cleaning. Wound contains slough (necrotic tissue, looks like "chicken fat") and/or has purulent drainage. Irrigate and clean wound!
- Black = Needs Debridement. Wound contains eschar (hard or rubbery black/brown necrotic tissue). Needs autolytic, enzymatic, chemical, or sharp debridement.
Wound Assessment
Tunneling: Determine direction of tunneling (e.g., 9 o'clock). Measure the depth of the tunnel (e.g., 5 cm).
- Chart as: 5 cm tunnel at 9 o'clock.
Undermining: Determine scope and direction of undermining (e.g., 7 to 11 o'clock). Measure deepest part of undermining (e.g., 3 cm).
- Chart as: Undermining from 7-11 o'clock up to 3 cm.
Wound Assessment
For all measurements, assume the patient's head is at 12 o'clock.
Length: Measure from 12 o'clock to 6 o'clock.
Width: Measure from 9 o'clock to 3 o'clock.
Depth: Insert cotton-tipped swab straight down (90° angle) into the wound at the deepest part. Mark the point on the swab that is even with the skin surface (using your thumb and forefinger). Remove the swab and hold against a measuring strip.
Card 39
Pressure Injury Treatment
Best Practices
Answer
Pressure Injury Treatment
Ensure the patient is on a pressure redistribution surface. Alternatively, a mattress overlay can be placed or specialty bed/mattress can be rented.
Offload the patient from the affected area (turn/position, elevate heels, etc.).
For pressure injuries with intact skin (e.g., stage I pressure injury, DTI), apply barrier film (e.g., cavilon).
For open wounds, select a dressing that maintains a moist wound healing environment.
Request wound consult (per facility policy) for: multiple stage II, stage III, stage IV, unstageable, DTIs, pressure injuries unresponsive to treatment.
Card 40
Other Pressure Injuries
Mucosal Membrane Pressure Injury
Medical Device-Related Pressure Injury
Answer
Other Pressure Injuries
Mucosal Membrane Pressure Injury: Damage to mucosal membrane with a history of a medical device being used at the site of the injury. Not staged.
- Examples: Nasogastric tube, endotracheal tube.
- Prevention: Reposition device frequently and secure it properly.
Medical Device-Related Pressure Injury: Prolonged use of medical device results in pressure injury that typically presents in a pattern or shape of the device.
- Examples: Oxygen tubing, urinary catheter, bed pans, braces, restraints.
- Prevention: Assess under device, reposition patient/device, pad skin, secure device properly.
Card 41
Deep Tissue Injury
Illustration
Depth of Injury
Description
Answer
Deep Tissue Injury
Depth of Injury: Damage occurs at the bone/muscle interface. Much deeper than a stage 1 pressure injury!
Description: Intact or non-intact skin with non-blanchable purple/maroon discoloration OR a blood-filled blister.
Card 42
Unstageable Pressure Injury
Illustration
Depth of Injury
Description
Answer
Unstageable Pressure Injury
Depth of Injury: Unknown, as wound base is obscured with necrotic tissue. Upon debridement, will reveal a stage III or IV pressure injury.
Description: Wound base is covered in slough (typically cream/yellow in color, resembles chicken fat) and/or eschar (black/brown color, hard or rubbery).
Card 43
Stage IV Pressure Injury
Illustration
Depth of Injury
Description
Answer
Stage IV Pressure Injury
Depth of Injury: Damage extends down to bone, muscle, tendon.
Description: Open wound. Full thickness skin loss with exposed muscle, tendon, and/or bone. Tunneling and/or undermining may occur.
Card 44
Stage III Pressure Injury
Illustration
Depth of Injury
Description
Answer
Stage III Pressure Injury
Depth of Injury: Damage extends to the subcutaneous tissue.
Description: Open wound. Full thickness skin loss with visible adipose tissue. Muscle, tendon, bone NOT visible. Tunneling and/or undermining may occur.
Card 45
Stage II Pressure Injury
Illustration
Depth of Injury
Description
Answer
Stage II Pressure Injury
Depth of Injury: Damage to epidermis and dermis.
Description: Open wound. Partial thickness skin loss with exposed dermis, red/moist wound base OR serous-filled blister.
Card 46
Stage I Pressure Injury
Illustration
Depth of Injury
Description
Answer
Stage I Pressure Injury
Depth of Injury: No open wound. Damage limited to epidermis.
Description: Non-blanchable, intact, red skin (erythema) over a bony prominence.
Card 47
Pressure Injuries
What is a Pressure Injury?
Outdated Terminology
Staging
Answer
Pressure Injuries
Damage to the skin and underlying soft tissue due to intense and prolonged pressure (or combination of pressure and friction/shear) to the area. Tissue compression impairs blood flow, which leads to inadequate perfusion and oxygenation (tissue hypoxia) and cell death.
Outdated Terminology: Decubitus ulcer, pressure ulcer, bed sore.
Staging:
- Assign stage (I, II, III, IV, unstageable, deep tissue injury) except for mucosal membrane pressure injuries (not staged).
- Do not "reverse" or "back" stage the injury as it heals.
- As a DTI or unstageable pressure injury evolves, it should be restaged.
Card 48
Skin Breakdown Prevention
Nursing Interventions for Patients at Risk
Answer
Skin Breakdown Prevention
Utilize pressure redistribution surface (foam or low air loss bed) or mattress topper. Keep HOB ≤ 30° if possible.
Reposition patient every 2 hrs (using pillow/wedge under hip).
Utilize waffle seat cushion while the patient is chair-sitting.
Apply heel protector boots.
Utilize padded dressings (e.g., mepilex) over bony prominences.
Place pillows under the patient's arms.
Apply moisture barrier (e.g., zinc-oxide ointment) for incontinence.
Moisturize dry skin.
Avoid tape on skin (use gauze wrap whenever possible).
Overall score of ≤ 18 = ↑ Risk of Skin Breakdown.
Patient Risk Assessment
RF: Immobility, older age, incontinence, poor nutrition, perfusion issues, vasopressors, diabetes, smoking, corticosteroids, prolonged surgery.
Norton Scale:
- 5 subscales: Physical condition, Mental condition, Activity, Mobility, Incontinence. Each subscale is scored from 1 - 4.
- Overall score of ≤ 14 = ↑ Risk of Skin Breakdown.
Braden Scale:
- 6 subscales: Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction/Shear. Each subscale is scored from 1 - 4 (except Friction/Shear, which is scored from 1 - 3).
- Overall score of ≤ 18 = ↑ Risk of Skin Breakdown.
Card 50
Skin Assessment on Admission
Best Practices
Answer
Skin Assessment on Admission
Have a second RN assist with admission skin assessment.
Take measurements and pictures of ALL wounds.
Complete charting on all wounds within 24 hrs of admission (even if you are unsure of the wound etiology, pressure injury stage, etc.). Charting can be clarified later!
If available, use the facility's pre-formatted orders to begin treatment for the wounds.
Request a wound consultation for severe wounds (or wound clarification).