Wound Care and Skin Integrity Flashcards

What is the PRIMARY cause of pressure injuries (pressure ulcers)?

Answer: Prolonged pressure that restricts blood flow to skin

Pressure injuries are caused by sustained pressure that reduces or cuts off blood supply to the skin and underlying tissue, leading to ischemia and tissue death.

Which bony prominence is at the HIGHEST risk for pressure injury development?

Answer: Sacrum and coccyx

The sacrum and coccyx (tailbone area) are the most common sites for pressure injuries because they bear substantial weight when a person lies in bed or sits.

A Stage 1 pressure injury appears as:

Answer: Non-blanchable redness of intact skin

A Stage 1 pressure injury is characterized by non-blanchable erythema (redness that does not turn white when pressed) on intact skin, indicating early tissue damage.

What does 'blanchable' redness mean?

Answer: The skin turns white when pressure is applied, then returns to red

Blanchable redness temporarily turns white when pressure is applied and returns to red when released, indicating intact capillary blood flow. Non-blanchable redness suggests pressure injury.

Which of the following is a risk factor for pressure injury development?

Answer: Urinary incontinence

Urinary incontinence exposes the skin to moisture and ammonia, which break down skin integrity and increase the risk of pressure injuries.

How often should a bedbound resident be repositioned to prevent pressure injuries?

Answer: At least every 2 hours

Current guidelines recommend repositioning bedbound residents at least every 2 hours (or more frequently as determined by care plan) to relieve pressure and restore blood flow.

The 30-degree lateral tilt position for pressure injury prevention is preferred over 90-degree because:

Answer: It reduces pressure on the trochanter (hip bone)

A 30-degree lateral tilt distributes body weight over a larger surface area and avoids direct pressure on the trochanter, reducing pressure injury risk compared to a full 90-degree side-lying position.

When should the CNA perform skin inspection?

Answer: During each repositioning and bathing

Skin should be inspected with each repositioning and during bathing/personal care to detect early signs of breakdown before a full pressure injury develops.

A CNA notices redness on a resident's heel that does not turn white when pressed. What should the CNA do?

Answer: Report the finding to the nurse immediately and document it

Non-blanchable redness is a Stage 1 pressure injury and must be reported to the nurse immediately so that a care plan can be initiated to prevent further deterioration.

Why should the CNA AVOID massaging reddened bony prominences?

Answer: Massage can further damage fragile capillaries and worsen tissue injury

Massaging reddened bony prominences was once thought to increase circulation, but current evidence shows it damages fragile capillaries in already-compromised tissue and should be avoided.

Which type of wound dressing helps maintain a moist wound environment?

Answer: Hydrocolloid or foam dressing

Moist wound healing is the standard of care. Hydrocolloid, foam, and hydrogel dressings maintain a moist environment that promotes cell migration and faster healing.

Signs of wound infection include:

Answer: Increased redness, warmth, swelling, purulent drainage, and odor

Classic signs of wound infection are redness, warmth, swelling, pain, purulent (pus-like) drainage, and malodor. These must be reported to the nurse immediately.

When the CNA observes a wound during peri-care, they should:

Answer: Document observations and report to the nurse

CNAs do not independently change wound dressings or apply medications. They should observe, document findings accurately, and report changes to the nurse.

What is the purpose of a heel protector boot for a bedbound resident?

Answer: To elevate the heel off the mattress surface and prevent pressure injury

Heel protector boots (or floated heels using pillows) completely offload pressure from the heel, which is one of the most common sites for pressure injuries in bedbound patients.

Moisture-associated skin damage (MASD) is BEST prevented by:

Answer: Keeping skin clean and dry, using moisture barriers

MASD is prevented by promptly cleansing skin after incontinence, thoroughly drying it, and applying barrier creams or ointments to protect against continued moisture exposure.

When repositioning a resident to prevent skin shear, the CNA should:

Answer: Use a draw sheet or slide board to lift rather than drag

Shear injury occurs when the skin moves in one direction while underlying tissue moves in another. Using lift sheets, transfer belts, or slide boards prevents dragging and reduces shear.

Which nutritional deficiency most directly impairs wound healing?

Answer: Vitamin C and protein deficiency

Protein is essential for tissue synthesis and repair, and Vitamin C is required for collagen formation. Deficiencies in either significantly impair wound healing.

A resident has a Stage 2 pressure injury. What does this look like?

Answer: Partial-thickness skin loss, possibly a shallow open ulcer or blister

Stage 2 involves partial-thickness loss of dermis, presenting as a shallow open ulcer with a pink-red wound bed, or an intact or ruptured blister.

Unstageable pressure injuries are characterized by:

Answer: Full-thickness loss covered by slough or eschar that obscures depth

An unstageable pressure injury has full-thickness skin and tissue loss but the wound bed is covered by slough or eschar, making it impossible to determine the true depth and stage.

A resident's skin tears easily during routine care. The BEST approach is to:

Answer: Handle skin gently, use non-adhesive dressings, and pad protruding areas

Fragile skin requires gentle handling, non-adhesive or silicone-based dressings, and padding of bony areas to prevent skin tears during transfers and repositioning.