Wound Care and Skin Integrity Flashcards

A resident has a pressure injury with black, hard, leathery tissue covering it. This tissue is called:

Answer: Eschar

Eschar is black, brown, or tan hardened dead tissue (necrotic tissue) that can obscure the true wound depth.

Which nutritional element is MOST important for wound healing?

Answer: Protein

Protein is essential for tissue repair, immune function, and collagen synthesis needed for wound healing.

A CNA observes that a resident's wound has increased redness, warmth, and swelling around it. These signs indicate:

Answer: Signs of wound infection requiring nurse notification

Increased redness, warmth, and swelling are classic signs of infection (calor, rubor, tumor) and must be reported to the nurse immediately.

Which type of drainage from a wound is considered abnormal and must be reported immediately?

Answer: Sanguineous drainage (bright red)

Sanguineous drainage indicates active bleeding, which requires prompt nursing assessment and intervention.

To prevent friction injuries when moving a resident up in bed, the CNA should:

Answer: Use a lift sheet or draw sheet to slide the resident

A lift or draw sheet reduces friction by allowing the resident to be lifted rather than dragged across the bed surface.

A resident with diabetes has a wound on their foot. Why does the CNA need to monitor this wound more carefully?

Answer: Diabetes impairs circulation and nerve sensation, slowing healing and masking pain

Diabetes compromises circulation and causes neuropathy, so wounds heal more slowly and residents may not feel pain indicating worsening.

Which action best protects the heels of a bedridden resident from pressure injuries?

Answer: Use heel protector boots or elevate heels off the mattress

Heel protector boots or elevating the heels completely off the mattress eliminate pressure on this vulnerable bony prominence.