Skin Integrity and Wound Care - Cheat Sheet
Your last-minute revision companion for Skin Integrity and Wound Care. This condensed reference covers pressure injury staging, wound assessment, healing phases, dressing selection, and ostomy care—all organized for rapid recall in the final 30 minutes before your NLE exam.
Skin Anatomy & Pressure Injury Physiology
Common values
Value
~32 mmHg
Symbol
CCP
Quantity
Capillary Closing Pressure
Value
Every 2 hours
Symbol
Q2H
Quantity
Repositioning interval (bedbound)
Value
Every 1 hour
Symbol
Q1H
Quantity
Repositioning interval (chairbound)
Important facts
- Skin is the body's largest organ and first line of defense.
- Three skin layers: epidermis (outer, avascular), dermis (blood vessels, nerves, hair, glands), subcutaneous tissue (fat, connective tissue).
- Pressure injuries are preventable — prevention is the nursing priority.
- High-risk pressure injury sites: sacrum, coccyx, heels, ischial tuberosities, greater trochanters, elbows, occiput.
- Contributing factors: pressure intensity/duration, shear, friction, moisture, immobility, sensory deficits, poor nutrition (low albumin/protein), advanced age, reduced tissue perfusion.
- Do NOT massage over bony prominences — can cause deep tissue damage (DTI).
Key definitions
Pressure Injury
Example
Sacral ulcer in a bedbound patient due to unrelieved pressure over the coccyx for >2 hours.
Localized damage to skin and underlying soft tissue, usually over a bony prominence, resulting from sustained pressure or pressure combined with shear that exceeds capillary closing pressure (~32 mmHg).
Capillary Closing Pressure
Example
Pressure >32 mmHg for prolonged periods causes irreversible cell death.
The pressure threshold (~32 mmHg) above which sustained occlusion cuts off oxygen and nutrients, leading to tissue ischemia.
Shear
Example
Patient slides down when HOB is at 45°; skin stays fixed but internal layers tear.
Sliding of the skeleton under fixed skin, typically when the head of the bed is raised too high, causing internal tissue damage without external abrasion.
Friction
Example
Heel dragging across bed sheets creates blistering and superficial damage.
Surface abrasion of the epidermis caused by rubbing or dragging the skin across a rough surface.
Maceration
Example
Incontinence-associated dermatitis; periwound skin breakdown from excessive exudate.
Softening and whitening of skin due to prolonged exposure to moisture (urine, sweat, wound drainage).
Diagrams to know
- Three layers of skin with anatomical structures
- Bony prominence sites at risk for pressure injury
- Mechanism of pressure-induced ischemia (capillary occlusion → oxygen deprivation → necrosis)
Pressure Injury Staging (NPUAP/NPIAP)
Important facts
- Pressure injuries are staged by the deepest visible tissue layer involved.
- Never reverse-stage a healing pressure injury; document as 'healing Stage X' (e.g., 'healing Stage 4').
- Stage 1 has intact skin with non-blanchable erythema — most reversible if pressure is relieved immediately.
- Stage 2 is partial-thickness; the blister in Stage 2 may be intact (blister) or ruptured (shallow ulcer).
- Stage 3 shows fat; if you see bone, tendon, or muscle, it is Stage 4, not Stage 3.
- Unstageable wounds are documented when slough/eschar obscures the base; debridement reveals true stage.
- Exception: Do NOT remove stable, dry, adherent, intact eschar on the heel or ischemic limb — it is a protective cover.
- DTI is a high-risk injury that can rapidly evolve; a dark purple/maroon area that blanches below the surface is a red flag.
- In darkly pigmented skin, non-blanchable erythema may appear as a color change (darker, purple, or blue), not redness.
- All stages of pressure injury can occur in any location, but heels and sacrum are highest risk in bedbound patients.
Key definitions
Stage 1 Pressure Injury
Example
Red area on sacrum that does not blanch with fingertip pressure; in Black patient skin, appears darker or purple.
Intact skin with non-blanchable erythema over a bony prominence; in dark skin, may show color change, temperature difference, firmness, or altered sensation without blanching.
Stage 2 Pressure Injury
Example
Shallow abrasion on heel with clear fluid seeping from an intact blister.
Partial-thickness skin loss with exposed dermis; presents as shallow open ulcer with red-pink wound bed, or intact/ruptured serum-filled blister; no slough or deeper tissue visible.
Stage 3 Pressure Injury
Example
Deep ulcer on buttock with yellow slough and visible fatty tissue at base.
Full-thickness skin loss; subcutaneous fat may be visible, but bone, tendon, muscle not exposed; may have slough/eschar, undermining, or tunneling.
Stage 4 Pressure Injury
Example
Sacral ulcer with visible bone and muscle; risk for sepsis and amputation if untreated.
Full-thickness skin and tissue loss with exposed or directly palpable bone, tendon, muscle, ligament, or cartilage; slough/eschar, undermining, tunneling often present; highest osteomyelitis risk.
Unstageable Pressure Injury
Example
Black eschar covering sacral ulcer; must debride to assess depth.
Full-thickness loss with base obscured by slough or eschar; true depth (and stage) cannot be determined until necrotic tissue is removed (will be Stage 3 or 4).
Deep Tissue Pressure Injury (DTI)
Example
Purple-maroon area on heel in a bedbound patient; may evolve to Stage 3–4 ulcer within hours.
Intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discoloration, or blood-filled blister, from damage to underlying soft tissue; may progress rapidly.
Diagrams to know
- Visual comparison of Stage 1 → Stage 2 → Stage 3 → Stage 4 cross-sections
- Distinction between Unstageable and DTI based on clinical presentation
- How to differentiate color changes in dark vs. light skin (Stage 1)
Wound Assessment & Documentation
Common values
Value
Length × Width × Depth (cm)
Symbol
L × W × D
Quantity
Pressure wound depth measurement
Value
15–23 = no risk; 13–14 = mild; 10–12 = moderate; ≤9 = severe risk
Symbol
Braden
Quantity
Braden Scale Risk Score
Important facts
- Measure wound size in length × width × depth (centimeters); use measuring tape or ruler.
- Assess for undermining and tunneling using a sterile cotton applicator; document extent and clock position (12 o'clock = head of bed).
- Serous exudate: clear, pale yellow — normal during inflammatory phase.
- Sanguineous exudate: bright red, bloody — normal immediately after injury; persistent bleeding suggests fragile granulation or infection.
- Serosanguineous exudate: pink or light red — common in healing wounds; transitional between serous and sanguineous.
- Purulent exudate: thick, yellow-green, foul-smelling — indicates bacterial infection; bacterial load (not just contamination) delays healing.
- Signs of infection: increasing erythema, warmth, edema, purulent drainage, foul odor, increased pain, fever, delayed healing.
- Assess periwound skin for maceration, erythema, induration, epithelialization, and signs of candidiasis.
- A foul-smelling wound does not always indicate infection in chronic wounds; may be due to anaerobic bacteria colonization (normal flora). Infection is confirmed by increased signs (warmth, erythema, edema, pain, fever) and positive culture.
- Document wound bed tissue composition as percentage (e.g., 60% granulation, 30% slough, 10% eschar).
Key definitions
Granulation Tissue
Example
Red, bumpy tissue in the base of a chronic wound; a sign of healing progress.
Healthy, newly formed connective tissue in the wound bed; appears beefy red, moist, and granular; indicates the proliferative phase of healing.
Slough
Example
Yellow stringy material in the wound base; indicates tissue necrosis or infection.
Non-viable (dead) tissue that is yellow, tan, or stringy in appearance; must be debrided to promote healing.
Eschar
Example
Black, leathery scab on a pressure injury; may indicate deep tissue necrosis.
Dry, black or brown necrotic (dead) tissue; must be debrided unless it is stable and protective (e.g., on heel or ischemic limb).
Undermining
Example
Probing the wound margin reveals a 2 cm pocket at the 3 o'clock position; the surface appears intact but tissue is destroyed underneath.
Destruction of tissue under intact skin edges; creates a pocket or cavity; assessed using a sterile applicator and documented by clock position.
Tunneling/Sinus Tract
Example
A narrow tract extending 3 cm at the 12 o'clock position suggests infection or poor drainage.
A narrow, linear channel extending from the wound into surrounding tissue; assessed with a sterile applicator and documented by length and clock position.
Exudate
Example
Thick, yellow-green purulent drainage suggests bacterial infection; clear serous fluid is normal in early healing.
Fluid that seeps from the wound; characterized by amount (none, scant, moderate, copious) and type (serous, sanguineous, serosanguineous, purulent).
Diagrams to know
- Wound bed tissue types: granulation vs. slough vs. eschar (visual/color chart)
- Clock positions for documenting undermining/tunneling (12 o'clock at head of bed)
- Types of exudate and what they indicate (serous, sanguineous, serosanguineous, purulent)
Phases of Wound Healing & Types of Intention
Common values
Value
Days 1–4
Symbol
Inflam
Quantity
Inflammatory phase duration
Value
Days 4–21
Symbol
Prolif
Quantity
Proliferative phase duration
Value
Day 21 to 1–2 years
Symbol
Matur
Quantity
Maturation phase duration
Value
~70–80% of original
Symbol
Strength
Quantity
Final tensile strength
Important facts
- Hemostasis is the FIRST phase (immediate) — vasoconstriction and clot formation.
- Inflammatory phase (days 1–4): Edema, warmth, pain, and redness are normal, not signs of infection. Expect increased exudate and white blood cells.
- Proliferative phase (days 4–21): Peak collagen deposition; risk of hypertrophic scar or keloid formation if wound is under tension.
- Maturation phase (day 21 to ~2 years): Collagen remodeling; wound strength increases but never reaches 100% — max ~80% of original strength.
- Factors that impair healing: advanced age, poor nutrition (low protein, vitamin C, zinc deficiency), diabetes/poor glycemic control, impaired perfusion (smoking, anemia), corticosteroids/immunosuppression, infection, moisture imbalance.
- Protein and vitamin C are critical for collagen synthesis; zinc is needed for enzyme function in wound healing.
- Primary intention wounds are low-risk; secondary intention wounds carry higher infection and complication risk.
- Tertiary intention is used strategically when infection risk is high initially.
- A healing wound is expected to progress through phases in order; stalled healing (no change for >2 weeks) warrants assessment and intervention.
Key definitions
Primary Intention Healing
Example
Elective abdominal surgery with clean incision closed with sutures; heals in ~7–10 days if uncomplicated.
Clean surgical wounds with well-approximated edges (sutured/stapled); minimal tissue loss, fastest healing, least scarring, minimal infection risk.
Secondary Intention Healing
Example
Pressure injury or traumatic wound allowed to granulate and epithelialize over weeks to months.
Wounds with significant tissue loss left open to heal by granulation from base upward; slower healing, more scarring, higher infection risk.
Tertiary (Delayed Primary) Intention Healing
Example
Contaminated surgical wound packed open for 3 days, then closed when infection risk is low.
Wound left open initially (to drain infection, clear debris) and closed surgically later; combines aspects of primary and secondary healing.
Hemostasis
Example
Blood clot forms within seconds of a cut; the wound stops bleeding.
Immediate phase of healing; vasoconstriction and platelet aggregation form a blood clot to stop bleeding.
Inflammatory Phase
Example
Wound is red, swollen, warm, and painful on days 1–3; this is normal, not infection.
Days 1–4 of healing; vasodilation, white blood cell migration, and phagocytosis of debris; edema, warmth, pain, and redness are expected.
Proliferative Phase
Example
By day 5, wound bed appears red and bumpy (granulation); edges begin to pink and flatten (epithelialization).
Days 4–21 of healing; fibroblasts lay down collagen, granulation tissue forms, and epithelialization begins; wound contracts and edges pull together.
Maturation/Remodeling Phase
Example
Incision scar remains red at 6 weeks but gradually fades; tensile strength continues to improve over months.
Day 21 to 1–2 years; collagen remodels, scar tissue matures, tensile strength increases (reaches ~70–80% of original by ~1 year).
Diagrams to know
- Timeline of healing phases: Hemostasis → Inflammatory (days 1–4) → Proliferative (days 4–21) → Maturation (day 21+)
- Cellular events in each phase (vasoconstriction/clotting → inflammation → collagen deposition → remodeling)
- Comparison of wound appearance by phase (bleeding → red/swollen → red/granular → pale/flattened)
Pressure Injury Prevention & Nursing Management
Common values
Value
30 degrees
Symbol
HOB
Quantity
Head of bed height (max)
Value
Every 2 hours
Symbol
Q2H
Quantity
Repositioning interval (bedbound)
Value
Every 1 hour
Symbol
Q1H
Quantity
Repositioning interval (chairbound)
Value
30 degrees
Symbol
Tilt
Quantity
Lateral tilt angle
Value
≤18 = at risk
Symbol
Braden
Quantity
Braden Scale risk threshold
Important facts
- Prevention is the priority — most pressure injuries are preventable with proper nursing care.
- Reposition every 2 hours in bed; every 1 hour in a chair (or teach independent shifting every 15 minutes).
- Use a repositioning schedule and document each turn to ensure consistency.
- Keep the head of the bed ≤30° when possible to reduce shear; higher angles increase shear forces.
- Use the 30-degree lateral tilt instead of direct side-lying on the greater trochanter.
- Float the heels by placing pillows under the calves so heels are off the bed surface completely.
- Do NOT massage over bony prominences — can cause or worsen deep tissue damage (DTI); gentle stroking is acceptable on surrounding skin.
- Keep skin clean and dry: - Cleanse promptly after incontinence or soiling. - Use pH-balanced, fragrance-free cleansers. - Pat dry gently; avoid vigorous rubbing. - Apply moisture-barrier creams to at-risk areas.
- Manage incontinence immediately; use absorbent pads, toileting schedules, and protective undergarments.
- Optimize nutrition and hydration: - Adequate protein (1.2–1.5 g/kg/day for wound healing). - Adequate calories (25–35 kcal/kg/day). - Vitamin C (75–90 mg/day; up to 500–1000 mg/day for wound healing). - Zinc (8–11 mg/day; deficiency impairs healing). - Involve dietitian for high-risk patients.
- Use the Braden Scale on admission and regularly (per facility protocol); lower score = higher risk.
- Reduce friction and shear: - Use draw sheets to lift patients; do not drag. - Elevate HOB cautiously; use half-chair position (avoid dangling legs). - Use incontinence pads to minimize friction on skin.
- Use pressure-redistribution surfaces for at-risk patients (Braden score ≤18 or clinical indicators).
- Educate patients and families on repositioning importance, skin inspection, and early warning signs.
Key definitions
Braden Scale
Example
A score of 12 indicates moderate risk; patient requires pressure-redistribution surface and 2-hour repositioning.
Validated risk assessment tool for pressure injury; assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear; scores 15–23 (no risk) to ≤9 (severe risk).
30-Degree Lateral Tilt
Example
Use pillows to support the back at 30° instead of direct side-lying on hip; reduces trochanter pressure.
Alternative to side-lying; patient's trunk is elevated at 30° to reduce direct pressure on the greater trochanter and reduce shear.
Pressure-Redistribution Surface
Example
Alternating-pressure mattress for a bedbound patient; low-air-loss bed for a patient in ICU.
Mattress or overlay that distributes body weight over a larger area to reduce pressure intensity (foam, gel, air, alternating-pressure, or low-air-loss mattresses).
Diagrams to know
- Braden Scale assessment components and scoring (sensory, moisture, activity, mobility, nutrition, friction)
- Repositioning schedule grid (2-hour intervals for bed; 1-hour for chair)
- Proper head-of-bed and body positioning to reduce shear and pressure
Wound Cleaning & Debridement
Important facts
- Clean wounds with normal saline — the gold standard for wound cleansing.
- Avoid cytotoxic agents on granulating wounds: Do NOT use hydrogen peroxide, povidone-iodine, chlorhexidine, or acetic acid on healthy granulation tissue (they kill new cells).
- Exceptions: Cytotoxic agents may be used on heavily contaminated or infected wounds initially, but discontinue once cleaned.
- Do NOT routinely irrigate pressure injuries — gentle cleansing is sufficient; excess irrigation removes protective microorganisms.
- Four debridement methods: 1. Autolytic — moist environment, slower, selective, painless (ideal for home care). 2. Enzymatic — enzyme topical, slower than sharp, selective, requires moist environment. 3. Mechanical — wet-to-dry dressing, fastest, non-selective (may damage healthy tissue), painful. 4. Sharp/Surgical — scalpel/laser, fastest, most selective, requires provider, minimal pain if done properly.
- Autolytic and enzymatic debridement require a moist wound environment to be effective.
- Do NOT apply enzymatic debridement if eschar is dry and stable on heel or ischemic limb (let it be protective cover).
- Sharp debridement is preferred for large areas of non-viable tissue to speed healing.
- Exception: Stable, dry, adherent eschar on the heel or ischemic limb should NOT be removed — it is a natural protective dressing.
- Frequency of debridement: May be needed daily (mechanical) to weekly (autolytic/enzymatic); reassess at each dressing change.
Key definitions
Debridement
Example
Enzymatic debridement using collagenase to soften and remove yellow slough from a pressure injury.
Removal of non-viable (dead) tissue (slough, eschar, desiccated tissue) from a wound to promote healing and prevent infection.
Autolytic Debridement
Example
Covering a wound with hydrogel allows the body's own enzymes to soften and liquefy eschar over 3–5 days.
The body's natural process of breaking down dead tissue using enzymes; enhanced by moist wound environment (hydrogel, hydrocolloid).
Enzymatic Debridement
Example
Applying collagenase (Santyl) to a pressure injury with adherent eschar; requires moist environment to work.
Topical enzyme (collagenase, papain-urea) applied to soften and break down necrotic tissue; faster than autolytic.
Mechanical Debridement
Example
Wet-to-dry gauge dressing that dries and adheres to necrotic tissue; pulling the dressing removes the tissue (painful and non-selective).
Physical removal of dead tissue using wet-to-dry dressings, irrigation, or ultrasonic devices; non-selective (can damage healthy tissue).
Sharp/Surgical Debridement
Example
Physician uses a scalpel to sharply excise black eschar and adherent slough from a Stage 4 pressure injury.
Removal of non-viable tissue using scalpel, scissors, or laser by a physician or advanced practice nurse; most selective and fastest method.
Diagrams to know
- Comparison of debridement methods: speed, selectivity, pain, and ideal use cases
- When to use each debridement type based on wound characteristics (dry vs. moist, large vs. small, contaminated vs. clean)
Dressing Selection & Wound Care Principles
Common values
Value
3–7 days
Symbol
HC
Quantity
Hydrocolloid wear time
Value
5–7 days
Symbol
TF
Quantity
Transparent film wear time
Value
Up to 20× its weight
Symbol
Alg
Quantity
Alginate absorption capacity
Value
125–200 mL/day
Symbol
VAC
Quantity
NPWT exudate removal
Important facts
- Core principle: Keep the wound bed MOIST and the periwound skin DRY.
- Moist wounds epithelialize faster (~50% faster) than dry wounds; do NOT let a wound dry out.
- Never use normal saline-soaked gauze as a primary dressing on a granulating wound — it dries out and damages tissue.
- Transparent film: Use for Stage 1, superficial wounds, as a secondary dressing; NOT for heavy exudate.
- Hydrocolloid: Use for Stage 2 and shallow Stage 3 with light-moderate exudate; yellow gel under dressing is normal (not pus); can stay 3–7 days.
- Hydrogel: Use for DRY wounds to add moisture; supports autolytic debridement; not ideal for heavily draining wounds.
- Foam: Use for moderate-to-heavy exudate; provides cushioning; good for pressure areas.
- Alginate: Use for heavy exudate and packing deep/tunneling wounds; can absorb up to 20× its weight; highly absorbent.
- Antimicrobial: Use for critically colonized or infected wounds; reduces bacterial load; examples: silver, iodine, honey-based dressings.
- NPWT (Wound VAC): Use for large Stage 3/4 wounds; removes exudate and promotes granulation; improves oxygenation; expensive but highly effective.
- Change dressings per manufacturer instructions and wound assessment: - Transparent film: 5–7 days or PRN if soiled. - Hydrocolloid: 3–7 days or PRN if leaking. - Hydrogel: Daily to every 3 days, depending on exudate. - Foam: 2–7 days based on exudate. - Alginate: Daily to every 3 days; remove all old dressing before reapplying.
- Secondary dressing: Often needed over foam, alginate, or hydrogel to secure and contain exudate.
- Avoid drying agents (alcohol, heat lamps, fan drying) on granulating wounds.
- Packing a deep wound: Use spiral technique to fill depth without dead space; avoid overstuffing (causes pressure and impairs healing).
Key definitions
Transparent Film Dressing
Example
Used on Stage 1 pressure injury or superficial abrasion; can stay 5–7 days if intact; allows continuous monitoring.
Thin, adhesive, semi-permeable plastic film (e.g., Tegaderm, Opsite); retains moisture, allows visualization, maintains moist environment.
Hydrocolloid Dressing
Example
Applied to Stage 2 pressure injury with light exudate; gels when wet (yellow gel is normal, not infection).
Occlusive wafer (e.g., DuoDERM) that absorbs moisture and supports autolytic debridement; creates moist environment; can stay 3–7 days.
Hydrogel Dressing
Example
Applied to a dry Stage 3 pressure injury or a painful wound; promotes moist environment and comfort.
Water-based, non-adhesive gel (e.g., Aquagel, Intrasite); adds moisture to dry wounds; supports autolytic debridement; soothing for painful wounds.
Foam Dressing
Example
Used on a Stage 3 pressure injury with moderate exudate on sacrum; provides padding and pressure relief.
Soft, non-adherent foam (e.g., Mepilex) that absorbs moderate-to-heavy exudate; provides cushioning and moist environment.
Alginate Dressing
Example
Packed into a deep Stage 3 wound with moderate-to-heavy drainage; can absorb up to 20× its weight in fluid.
Highly absorbent dressing made from seaweed calcium alginate; converts to gel when wet; ideal for heavy exudate and packing deep/tunneling wounds.
Antimicrobial Dressing
Example
Silver dressing (e.g., Acticoat) applied to a pressure injury with signs of infection; reduces bacterial load.
Contains silver, iodine, honey, or other antimicrobial agents; used for critically colonized or infected wounds.
Negative-Pressure Wound Therapy (NPWT/Wound VAC)
Example
Applied to a large Stage 4 pressure injury; removes 125–200 mL exudate daily, accelerating healing.
Sealed system with intermittent or continuous sub-atmospheric pressure; removes exudate, reduces edema, promotes granulation and contraction.
Diagrams to know
- Decision tree: Dressing selection based on wound moisture level (dry → hydrogel; moderate exudate → hydrocolloid/foam; heavy exudate → alginate/NPWT)
- Comparison chart of dressings: absorption capacity, moisture retention, transparency, wear time
- Cross-section of wound bed showing moist environment maintained by occlusive dressing vs. dry environment
Ostomy Care & Peristomal Skin Protection
Common values
Value
1–2 mm larger than stoma
Symbol
Fit
Quantity
Wafer opening size
Value
Every 3–7 days
Symbol
Q3–7D
Quantity
Appliance change interval
Value
When 1/3 to 1/2 full
Symbol
Empty
Quantity
Pouch emptying trigger
Value
At least 1.5–2 L/day
Symbol
Hydration
Quantity
Ileostomy daily fluid intake
Important facts
- Healthy stoma appearance: Red-pink, moist, slightly raised or flat, with a visible opening; vascular (mild bleeding with cleaning is normal).
- EMERGENCY SIGNS — Report immediately: - Stoma color: dusky, pale, dark, purple, or black = ischemia (emergency; contact provider). - Stoma retraction, prolapse (protrusion), or stenosis (narrowing). - Heavy bleeding, signs of infection.
- Wafer/barrier fit: Cut the opening 1–2 mm larger than the stoma (use measuring tool provided). - Too large: Effluent contacts skin and causes breakdown. - Too tight: Risk of stoma injury and stricture.
- Peristomal skin care: - Cleanse with warm water only (avoid soaps, oils, lotions; they interfere with adhesion). - Pat dry completely before applying new wafer. - Use skin barriers (powder, paste, wipes) as needed for protection. - Apply moisture-barrier creams only if NOT applying a new wafer immediately.
- Pouch emptying and changing: - Empty when one-third to one-half full to prevent leakage and pressure on seal. - Change appliance every 3–7 days or when leaking; do NOT wait for leakage to damage skin. - One-piece systems (pouch + wafer integrated) change together. - Two-piece systems (pouch snaps onto wafer) allow pouch removal without disturbing wafer.
- Ileostomy specifics: - Output is liquid to pasty, continuous throughout the day. - Enzyme-rich — high risk for peristomal dermatitis if not protected. - High dehydration and electrolyte loss risk — teach fluid intake (at least 1.5–2 L/day) and sodium/potassium supplementation. - Pouch may need emptying 4–6 times daily. - Monitor for food blockage (impaction); symptoms: no output, cramping, nausea.
- Colostomy specifics: - Output depends on location: ascending (liquid/pasty), transverse (paste), descending (formed). - Lower enzyme content → lower skin breakdown risk. - May be continent or require irrigation (per patient preference and type). - Diet plays a significant role in output consistency and odor.
- Odor management: - Use odor-barrier products (deodorant drops, sealed pouches). - Dietary factors: avoid foods that increase odor (eggs, fish, garlic, cabbage). - Good pouch seal prevents odor.
- Peristomal complications to recognize: - Dermatitis: Erythema, itching, breakdown around stoma (from effluent contact or allergy). - Candidiasis: Red rash with satellite lesions (from moisture and warm environment). - Stomal retraction: Stoma pulls inward (may require convex wafer). - Prolapse: Stoma protrudes excessively (usually resolves spontaneously; contact provider). - Stenosis: Stoma opening narrows (risk of obstruction; may require dilation or revision).
- Patient teaching before discharge: - Demonstrate appliance changes (return demonstration). - Teach skin care and signs of complications. - Provide written instructions, product samples, and contact numbers. - Discuss dietary considerations and fluid/electrolyte needs. - Connect with enterostomal nurse specialist and ostomy support groups.
- Urostomy care: Similar skin protection; monitor urine output (should be clear to pale yellow), catheter patency, and signs of infection (cloudy, foul-smelling urine, fever).
Key definitions
Ostomy
Example
Colostomy redirects fecal output to a pouch; ileostomy has liquid/pasty output rich in enzymes.
Surgically created opening (stoma) that diverts stool or urine; types include colostomy (colon), ileostomy (small intestine), and urostomy (ureter).
Stoma
Example
A healthy colostomy stoma is red and appears like a small mouth; gentle bleeding during cleaning is normal.
The surgically created opening; healthy stoma is red-pink, moist, and slightly raised or flat; it is vascular and may bleed slightly when cleaned.
Peristomal Skin
Example
The 1–2 cm of skin around the stoma where the wafer seal adheres; protected by proper barrier and appliance fit.
The skin immediately surrounding the stoma; at high risk for breakdown due to contact with effluent (stool/urine) and irritants.
Wafer/Skin Barrier
Example
DuoDERM or similar wafer barrier adhered around stoma; the pouch attaches to the wafer, not directly to skin.
Adhesive barrier that protects peristomal skin by creating a seal between skin and stoma; cut to fit the stoma snugly.
Ileostomy
Example
Output is continuous, watery, enzyme-rich; pouch may need emptying 4–6 times daily; high dehydration risk.
Ostomy created from the small intestine (ileum); output is liquid to pasty and rich in digestive enzymes; high risk for skin breakdown and dehydration.
Colostomy
Example
Descending colostomy has formed, brown output; proximal colostomy may have paste-like output.
Ostomy created from the colon; output is more formed (depends on diet and location in colon); lower skin breakdown risk than ileostomy.
Diagrams to know
- Anatomy of ostomy types: colostomy, ileostomy, urostomy (location in GI/urinary tract)
- Cross-section of proper wafer fit and stoma appearance (red, moist, centered)
- Emergency vs. normal stoma color changes (black/dusky = emergency; pink = healthy)
- Proper appliance change technique: removal, cleansing, barrier application, pouch attachment
Must remember
- Pressure Injury Staging Rule: Stage by DEEPEST visible tissue layer. Stage 1 = intact skin with non-blanchable erythema. Stage 2 = partial-thickness (dermis exposed). Stage 3 = full-thickness with fat visible (NO bone/tendon). Stage 4 = full-thickness with bone/tendon/muscle exposed. Unstageable = base obscured by eschar/slough (depth unknown).
- NEVER Reverse-Stage Pressure Injuries: A healing Stage 4 is documented as 'healing Stage 4,' never downgraded to a lower stage. Once a wound reaches a stage, it retains that stage classification even as it heals.
- DO NOT Remove Stable Eschar on Heels or Ischemic Limbs: Dry, adherent, intact eschar on the heel or ischemic limb is a protective barrier and should NOT be removed. This is the major exception to debridement protocols.
- Repositioning Schedule: Bedbound patients every 2 hours; chairbound patients every 1 hour (or teach independent 15-minute shifts). Use a repositioning schedule and document each turn. Head of bed ≤30° to reduce shear. Float heels with pillows under calves.
- Do NOT Massage Bony Prominences: Massage over bony prominences can cause deep tissue damage. Gentle stroking on surrounding skin is acceptable, but avoid direct massage on at-risk areas (sacrum, heels, trochanters).
- Clean Wounds with Normal Saline Only: Avoid cytotoxic agents (hydrogen peroxide, povidone-iodine, chlorhexidine) on granulating wounds—they harm new tissue. Use only on heavily contaminated/infected wounds initially, then discontinue.
- Moist Wound Healing Principle: Keep the wound bed moist and the periwound skin dry. Moist wounds epithelialize ~50% faster than dry wounds. Do NOT use dry gauze dressings on granulating wounds; choose occlusive/moisture-retentive dressings.
- Healthy Stoma: Red-pink, moist, slightly raised; mild bleeding when cleaning is normal. EMERGENCY signs: dusky, dark, purple, or black stoma = ischemia. Report immediately to provider. Wafer opening should be cut 1–2 mm larger than stoma.
- Ileostomy Risks: Liquid-to-pasty output rich in digestive enzymes = highest peristomal skin breakdown risk. HIGH dehydration and electrolyte loss. Teach fluid intake (≥1.5–2 L/day) and sodium/potassium monitoring.
- Braden Scale Priority: Use on admission and regularly. Lower score = higher risk. Scores: ≤9 = severe risk; 10–12 = moderate; 13–14 = mild; 15–23 = no risk. Patients scoring ≤18 require pressure-redistribution surfaces and frequent repositioning.
Last minute tips
- STAGE 2 vs. STAGE 3 Quick Distinction: Stage 2 = you see ONLY the dermis (shallow ulcer) or an intact/ruptured blister. Stage 3 = you see FAT. If you see bone, tendon, muscle, or cartilage, it's Stage 4, not Stage 3. Remember: Stage 3 = full-thickness skin loss, but subcutaneous tissue only (fat, no deeper structures exposed).
- Dressing Decision Tree: DRY wound? Use hydrogel. MODERATE exudate? Use hydrocolloid or foam. HEAVY exudate? Use alginate or NPWT. Light exudate or Stage 1? Use transparent film. Always ask: 'Is this wound too dry or too wet?' and match the dressing moisture level accordingly.
- Debridement Must-Know: Stable, dry eschar on heel = DO NOT REMOVE (protective cover). Moist, yellow slough = debride (autolytic, enzymatic, or sharp). Black eschar on sacrum/pressure areas = debride (unless stable on heel/ischemic limb). Wet-to-dry is painful and non-selective; use only in heavily contaminated wounds as a bridge, not long-term.
- Ostomy Color Emergency: Red-pink stoma = healthy (slight bleeding OK). Dark red, dusky, purple, or BLACK stoma = ischemia (EMERGENCY—call provider). This is one of the most commonly tested facts and a critical safety issue. If you see ANY color change from normal pink, investigate immediately.
- Prevention is Key in NLE Questions: If the question asks about pressure injury management and prevention options are presented, prevention (repositioning, nutrition, reducing pressure/shear) is ALWAYS the highest priority. Healing a pressure injury takes weeks; preventing it takes simple nursing actions every 2 hours.
Comparison tables
Pressure Injury Staging at a Glance
| Stage | Skin Integrity | Tissue Depth | Visible Structures | Clinical Presentation | Key Features |
|---|---|---|---|---|---|
| Stage 1 | Intact | Epidermis only | None | Non-blanchable erythema; color change in dark skin | Most reversible; relief of pressure may resolve immediately |
| Stage 2 | Partial-thickness loss | Dermis exposed | None (dermis only) | Shallow ulcer or intact/ruptured serum blister | Red-pink wound bed; no slough or deeper tissue visible |
| Stage 3 | Full-thickness loss | Subcutaneous fat visible | Fat visible, but NO bone/tendon/muscle | Crater-like ulcer; may have slough, eschar, undermining, tunneling | Depth variable; no exposed bone |
| Stage 4 | Full-thickness loss | Beyond subcutaneous tissue | Bone, tendon, muscle, ligament, or cartilage exposed | Large, deep ulcer; high infection risk | Highest osteomyelitis risk; often has undermining/tunneling |
| Unstageable | Full-thickness loss | Base obscured by eschar/slough | Cannot be determined (hidden) | Eschar or slough covering base | True depth unknown until necrotic tissue removed; will be Stage 3 or 4 |
| Deep Tissue Injury (DTI) | Intact or non-intact | Deep tissue damage only | Underlying soft tissue | Non-blanchable deep red/maroon/purple or blood-filled blister | May evolve rapidly; high-risk injury |
Wound Exudate Types & Clinical Significance
| Exudate Type | Appearance | Color | Normal or Abnormal? | What It Indicates |
|---|---|---|---|---|
| Serous | Clear, thin, watery | Pale yellow or clear | Normal | Early inflammatory phase; healthy healing progress |
| Sanguineous | Bloody, bright red | Bright red | Normal if minor; abnormal if heavy/persistent | Immediate post-injury; minor bleeding is normal; persistent bleeding suggests fragile granulation or infection |
| Serosanguineous | Pink or light red | Pink to light red | Normal | Transitional phase between serous and sanguineous; common in healing wounds |
| Purulent | Thick, creamy | Yellow-green, tan, white | Abnormal (indicates infection) | Bacterial infection; thick drainage with foul odor; requires antibiotic assessment |
Healing Phases: Timeline, Cellular Events & Clinical Signs
| Phase | Timeline | Primary Cells/Events | Wound Appearance | What to Expect (Normal) |
|---|---|---|---|---|
| Hemostasis | Immediate (seconds–minutes) | Vasoconstriction, platelet aggregation, clot formation | Bleeding slows/stops; blood clot visible | Clotting is immediate; bleeding stops within minutes |
| Inflammatory | Days 1–4 | Vasodilation, WBC migration, phagocytosis, complement activation | Red, warm, swollen, painful; increased exudate | Edema, warmth, pain, redness, increased exudate are NORMAL; NOT signs of infection |
| Proliferative | Days 4–21 | Fibroblast collagen deposition, angiogenesis, epithelialization, contraction | Red granulation tissue, pink epithelial edges, wound contracts | Beefy red granulation, granular texture, edges pink/flattening; contracting appearance |
| Maturation/Remodeling | Day 21 to ~2 years | Collagen remodeling, scar maturation, tensile strength increase | Scar pale/whitish, flattening; scar gradually fades | Scar matures over months; strength reaches ~80% of original; color improves |
Dressing Selection by Wound Characteristics
| Dressing Type | Best For | Exudate Level | Wear Time | Advantages | Disadvantages |
|---|---|---|---|---|---|
| Transparent Film | Stage 1; superficial wounds; secondary dressing | None to scant | 5–7 days | Allows visualization; retains moisture; waterproof | Cannot absorb heavy exudate; may cause maceration |
| Hydrocolloid | Stage 2; shallow Stage 3; light-moderate exudate | Light to moderate | 3–7 days | Occlusive; supports autolytic debridement; comfortable | Yellow gel under dressing normal; not for heavy exudate; may cause hyperplasia at edges |
| Hydrogel | DRY wounds; autolytic debridement; painful wounds | Adds moisture | Daily–every 3 days | Adds moisture; soothing; supports debridement | Poor absorption; not ideal for draining wounds |
| Foam | Moderate-heavy exudate; pressure areas; cushioning | Moderate to heavy | 2–7 days | Absorbs exudate; provides padding; comfortable | Opaque (cannot visualize); may macerate if left on wet wounds |
| Alginate | Heavy exudate; deep/tunneling wounds; packing | Heavy | Daily–every 3 days | Highly absorbent (20× weight); can pack deep cavities; hemostatic | Requires moist environment; must remove all old material; requires secondary dressing |
| Antimicrobial (Ag/I/Honey) | Critically colonized/infected wounds | Moderate to heavy | 3–7 days (varies by product) | Reduces bacterial load; silver most common | Higher cost; not for clean wounds; may cause discoloration |
| NPWT/VAC | Large Stage 3–4; chronic wounds; negative pressure indicated | Moderate to heavy | 3–5 days (therapy-dependent) | Removes exudate; promotes granulation; improves oxygenation; reduces edema | Expensive; requires power source; contraindicated in some cases (bleeding, malignancy); not portable |
Debridement Methods: Comparison
| Method | Speed | Selectivity | Pain Level | Mechanism | Ideal Use | Contraindications |
|---|---|---|---|---|---|---|
| Autolytic | Slow (3–5 days) | Selective (body's own enzymes) | None/painless | Moist environment enhances body's natural enzymatic breakdown | Dry wounds; home care; painless | Heavy exudate (will macerate) |
| Enzymatic | Moderate (3–10 days) | Selective | None/minimal | Topical collagenase/papain breaks down collagen in dead tissue | Eschar; slough; when sharp debridement unavailable | Bleeding eschar; on heels (stable eschar) |
| Mechanical | Fast (1–2 days) | Non-selective (damages healthy tissue) | Painful | Wet-to-dry dressing; irrigation; ultrasonic; tissue is removed with dressing | Heavily contaminated wounds (ER); as bridge until definitive care | Granulating wounds (harms new tissue) |
| Sharp/Surgical | Fastest (immediate) | Most selective | Minimal if done properly | Scalpel, scissors, laser; trained provider removes dead tissue | Large areas of eschar; Stage 4; rapid healing needed | Requires provider; coagulopathy; anticoagulation |
Ostomy Output & Management by Type
| Ostomy Type | Location | Output Consistency | Enzyme Content | Frequency | Skin Breakdown Risk | Key Nursing Concerns |
|---|---|---|---|---|---|---|
| Ileostomy | Small intestine (ileum) | Liquid to pasty | HIGH (digestive enzymes) | Continuous; 4–6 times/day | HIGHEST risk | Dehydration/electrolyte loss; enzyme-rich output; frequent pouch changes |
| Ascending/Proximal Colostomy | Right colon | Liquid/pasty | Moderate | Several times daily | High risk | Similar to ileostomy; fluid/electrolyte management |
| Transverse Colostomy | Transverse colon | Paste-like | Moderate | 1–2 times daily | Moderate risk | Variable output; dietary impact; odor management |
| Descending/Sigmoid Colostomy | Left colon/sigmoid | Formed/brown | Low | 1–2 times daily; may be continent | LOW risk | Formed output; may irrigate; similar to normal bowel habit |
| Urostomy | Ureter (ileal/colonic conduit) | Liquid (urine) | Minimal enzymes | Continuous (24/7) | Moderate risk | Monitor for UTI; catheter patency; cloudy/foul-smelling urine = infection |
Diagrams
Pressure Injury Staging Decision Tree
Visual decision tree for quickly identifying pressure injury stage based on depth of tissue destruction. Start with skin integrity assessment, then determine depth of involvement. Key decision points highlight critical distinctions between stages.
Skin Integrity & Wound Care: Complete Concept Map
Comprehensive concept map showing all major topics in skin integrity and wound care, organized hierarchically. Includes prevention strategies, staging, assessment parameters, healing phases, wound care interventions, and ostomy care. This visual organizes the entire chapter for rapid recall.
Wound Healing Phases & Progression
State diagram showing progression through the four phases of wound healing. Each phase has key cellular events, timeline, and clinical manifestations. This visual helps students understand healing as a sequential process and recognize what is normal at each stage.
Dressing Selection Decision Algorithm
Decision tree for selecting the appropriate wound dressing based on wound characteristics. Guides nurses through assessment of moisture level and wound depth to match the most appropriate dressing type. Includes rationale for each choice.
Ostomy Stoma Assessment: Normal vs. Emergency
Critical assessment flowchart for ostomy stoma color and viability. Distinguishes healthy stoma (red-pink) from warning signs (dark red) and emergency signs (dusky, purple, black). Color change is a critical safety assessment that must trigger immediate action. This is high-yield NLE content.