Wound Care & Skin Integrity Flashcards

The Braden Scale is a clinical tool used to assess a patient's:

Answer: Risk of developing pressure injuries

The Braden Scale evaluates six factors (sensory perception, moisture, activity, mobility, nutrition, and friction/shear) to calculate a patient's risk of developing pressure injuries.

Which patient is at the HIGHEST risk for developing pressure injuries?

Answer: A patient who is paralyzed, incontinent, and malnourished

Combined immobility, incontinence (moisture), and malnutrition (poor tissue repair) dramatically increase pressure injury risk by impairing circulation, skin barrier function, and healing capacity.

A Stage 1 pressure injury presents as:

Answer: Non-blanchable erythema (redness) of intact skin

Stage 1 is defined as localized intact skin with non-blanchable redness, which does not turn white when pressed, indicating early tissue damage.

What is the purpose of using a pressure-redistribution mattress or cushion for at-risk patients?

Answer: To redistribute body weight and reduce pressure on bony prominences

Pressure-redistribution surfaces (such as foam, gel, or air mattresses) spread body weight over a larger area, reducing peak pressure at bony prominences to prevent tissue ischemia.

How should a healthcare aide accurately document wound observations?

Answer: Describe wound location, size, wound bed color, drainage type and amount, and surrounding skin condition objectively

Accurate wound documentation requires objective descriptions of location, approximate size, wound bed appearance, drainage characteristics, and periwound skin condition to track healing progress over time.

What action should a healthcare aide take if a patient's wound dressing becomes heavily saturated with drainage before the next scheduled change?

Answer: Report to the supervising nurse so the dressing can be changed and the drainage amount assessed

A saturated dressing can cause skin maceration and increase infection risk; the healthcare aide must notify the nurse, who will order an earlier dressing change and evaluate the cause of increased drainage.

Which intervention is most effective for preventing skin breakdown in a patient who is incontinent of urine and/or stool?

Answer: Promptly cleaning the skin after each incontinence episode and applying a moisture barrier cream

Prompt cleansing removes irritating urine and stool, while a moisture barrier (skin protectant) prevents prolonged contact of moisture and digestive enzymes with the skin, reducing maceration and breakdown risk.