NLE Integumentary & Skin Integrity — Skin Integrity and Wound CareRevision Notes

Exam Tips

• When an NLE question asks 'which position increases shear?', choose semi-Fowler (HOB > 30°) or Fowler's position.
• Questions about 'highest risk site in a supine patient' = SACRUM; in a sitting patient = ISCHIAL TUBEROSITIES.
• If the question mentions 'albumin level of 2.0 g/dL' or 'BMI of 16', recognize this as a nutritional risk for impaired healing and pressure injury development.

Key Points

• The skin has THREE layers: epidermis (outermost, avascular), dermis (contains blood vessels, nerves, hair follicles, sebaceous and sweat glands), and subcutaneous/hypodermis (fat and connective tissue).
• The epidermis is avascular — it receives nutrients by diffusion from the dermis. This is why Stage 2 wounds that expose the dermis already have access to blood supply.
• A pressure injury forms when sustained pressure occludes capillaries and blocks oxygen/nutrients to tissue. The critical threshold is capillary closing pressure of approximately 32 mmHg.
• Pressure + time = tissue ischemia → necrosis. High pressure for a short time OR low pressure for a long time can both cause injury.
• Shear force is different from pressure: shear occurs when the skeleton slides downward (e.g., semi-Fowler position) but the skin stays fixed against the bed, stretching and tearing blood vessels internally.
• Friction abrades the surface (like a rug burn), making skin more vulnerable to breakdown.
• Moisture (incontinence, perspiration, wound drainage) causes maceration — softening and weakening of the skin — and increases friction. Note: Moisture-Associated Skin Damage (MASD) is a DISTINCT entity from pressure injury and should not be mislabeled.
• High-risk anatomical sites: SACRUM and HEELS (supine), ISCHIAL TUBEROSITIES (sitting/wheelchair), greater trochanters, elbows, occiput, malleoli.
• High-risk patient populations: elderly, immobile, malnourished (low albumin, protein-calorie deficit), incontinent, diabetic, patients with sensory deficits, those on vasopressors or corticosteroids.

Definitions

Section Title

Anatomy of the Skin and Pathophysiology of Pressure Injuries

Common Mistakes

• Confusing shear and friction: shear = internal tearing of blood vessels (no surface abrasion), friction = surface abrasion.
• Thinking only high pressure causes injury — low pressure over a long duration is equally harmful.
• Mislabeling MASD (diaper rash, incontinence dermatitis) as a pressure injury — MASD lacks the bony prominence location and is caused by moisture chemistry, not ischemia.
• Forgetting that occiput and ears are pressure sites, especially in patients receiving oxygen masks or NG tubes (medical device-related pressure injury).

Exam Tips

• Master the 'what is exposed?' question: nothing broken (Stage 1) → dermis (Stage 2) → fat (Stage 3) → bone/tendon/muscle (Stage 4) → can't see (Unstageable) → purple/maroon intact skin (DTI).
• When the NLE asks 'What is your initial assessment finding indicating Stage 2?', the answer includes serum-filled blister OR shallow red-pink ulcer — no slough, no fat visible.
• DTI key word in NLE options: 'blood-filled blister' or 'persistent purple/maroon discoloration' on intact skin.
• If an NLE item says 'the wound bed is covered with black leathery tissue and depth cannot be determined', the answer is UNSTAGEABLE.
• Do not confuse the 'blood-filled blister' of DTI with the 'serum-filled blister' of Stage 2 — blood-filled = DTI, serum-filled = Stage 2.

Key Points

• Staging = depth of tissue destruction. Always stage by the DEEPEST VISIBLE layer of tissue.
• STAGE 1 = INTACT skin with NON-BLANCHABLE ERYTHEMA over a bony prominence. Skin is not broken. In dark skin tones, the area may appear darker, warmer, firmer, or have altered sensation rather than visible redness.
• STAGE 2 = PARTIAL-THICKNESS loss of skin exposing the DERMIS. Presents as a shallow open ulcer (red-pink bed, no slough or eschar) OR an intact or ruptured SERUM-FILLED BLISTER. There is NO exposed fat, no slough, no eschar.
• STAGE 3 = FULL-THICKNESS loss where SUBCUTANEOUS FAT MAY BE VISIBLE, but BONE, TENDON, or MUSCLE are NOT exposed. Slough and/or eschar may be present. Undermining and tunneling may occur.
• STAGE 4 = FULL-THICKNESS loss with EXPOSED or DIRECTLY PALPABLE BONE, TENDON, MUSCLE, LIGAMENT, or CARTILAGE. Highest risk for OSTEOMYELITIS. Slough, eschar, undermining, and tunneling are often present.
• UNSTAGEABLE = Full-thickness loss where the WOUND BASE IS OBSCURED BY SLOUGH OR ESCHAR — depth (and therefore stage) CANNOT be determined. Once debrided, it will be a Stage 3 or 4.
• CRITICAL EXCEPTION: Stable, dry, adherent, intact eschar WITHOUT erythema or fluctuance on the HEEL or an ISCHEMIC LIMB must NOT be removed — it is the body's natural protective cover.
• DEEP TISSUE PRESSURE INJURY (DTI) = Intact or non-intact skin with PERSISTENT NON-BLANCHABLE deep RED, MAROON, or PURPLE discoloration OR a BLOOD-FILLED BLISTER from damage to underlying soft tissue. May evolve rapidly despite treatment.
• NEVER REVERSE-STAGE a healing pressure injury. A Stage 4 that is healing is always documented as 'healing Stage 4' — never downgraded to Stage 3 or Stage 2.
• Memory trick: Stages 1-2 = partial tissue layers; Stages 3-4 = full thickness. The dividing feature between Stage 3 and 4 is BONE/TENDON/MUSCLE visibility.

Definitions

Section Title

Pressure Injury Staging (NPUAP/NPIAP System)

Common Mistakes

• Reverse-staging a healing wound — this is WRONG per NPUAP/NPIAP. A Stage 4 never becomes Stage 3 during healing.
• Choosing 'Stage 2' when a serum-filled blister is present — the blister can be either intact or ruptured and still classify as Stage 2.
• Forgetting that DTI (deep tissue pressure injury) can look like a bruise on intact skin — it is NOT the same as a Stage 1 (which is erythema) or a superficial bruise from trauma.
• Choosing 'Stage 3' when bone is visible — visible bone = Stage 4, always.
• Trying to stage a wound covered in eschar or slough — it is UNSTAGEABLE until debrided.
• Removing heel eschar — this is a clinical error if the eschar is stable and the patient has ischemia or peripheral vascular disease.

Exam Tips

• NLE questions often ask to PRIORITIZE assessment findings. Purulent drainage with fever = systemic infection risk = highest priority (physiologic safety need — Maslow Level 1).
• When asked about a 'positive healing sign', choose epithelialization at wound edges or beefy red granulation tissue.
• Clock-face documentation of tunneling and undermining is a practical skill item likely tested in the clinical competency exam.

Key Points

• Wound assessment is a nursing responsibility under RA 9173 Section 28 — accurate documentation is a legal and clinical obligation.
• Measure wound dimensions: LENGTH (head to toe orientation) × WIDTH (side to side) × DEPTH (floor of wound) in centimeters.
• Assess WOUND BED TISSUE: Granulation tissue = beefy red, healthy, indicates healing. Slough = yellow/tan, nonviable. Eschar = black/brown, necrotic.
• Assess EXUDATE: Quantity (none, scant, moderate, copious) AND Type: Serous = clear watery; Sanguineous = bloody; Serosanguineous = pink/light red (mix); Purulent = thick, yellow-green, cloudy, foul odor — indicates infection.
• Assess WOUND EDGES and PERIWOUND SKIN: Is there maceration (soggy skin from excess moisture)? Erythema? Induration (hardness)? Epithelialization (new pink skin at wound edges — a positive sign)?
• Signs of WOUND INFECTION (local): Increasing erythema, warmth, edema, purulent exudate, foul odor, increased pain, delayed healing.
• Signs of SYSTEMIC infection: Fever, elevated WBC, increased heart rate — may indicate cellulitis, osteomyelitis, or sepsis.
• Bacterial CONTAMINATION ≠ COLONIZATION ≠ INFECTION. All wounds have some bacteria (contamination). Colonization is bacteria present without host reaction. INFECTION = bacterial load overwhelms host defenses, causing tissue damage and delayed healing.
• Document undermining by clock face: 'Undermining 2 cm from 9 o'clock to 11 o'clock' — always with the head of the bed as 12 o'clock.
• Document tunneling as: 'Tunneling 3 cm at 6 o'clock' — the direction (clock position) and depth in cm.

Definitions

Section Title

Wound Assessment

Common Mistakes

• Omitting depth measurement — all three dimensions (L × W × D) must be documented.
• Calling serosanguineous drainage 'infected' — it is normal after surgery or in early healing; only purulent exudate strongly suggests infection.
• Confusing 'contamination' with 'infection' — contamination (bacteria present) does not require antimicrobial treatment; infection (tissue invasion with host response) does.
• Measuring only the visible wound area and missing undermining or tunneling, which can significantly increase the actual tissue loss.

Exam Tips

• NLE frequently tests which phase a clinical scenario describes. Beefy red granulation, wound contraction = PROLIFERATIVE phase. Redness, warmth, edema in a fresh postoperative wound = INFLAMMATORY phase (normal).
• Asking 'what type of healing intention does a pressure injury use?' = SECONDARY intention (heals from base up by granulation).
• Asking 'what nutrient is critical for collagen synthesis?' = VITAMIN C (ascorbic acid). Also know: Vitamin A for epithelialization, Zinc for cell proliferation, Protein for all tissue repair.

Key Points

• THREE TYPES OF HEALING INTENTION: Primary, Secondary, Tertiary (Delayed Primary).
• PRIMARY INTENTION: Clean surgical wound with well-approximated (sutured/stapled) edges. Minimal tissue loss. Heals fastest with least scarring. Example: cesarean section incision, elective appendectomy.
• SECONDARY INTENTION: Wound with significant tissue loss, left OPEN to heal from the base upward by granulation tissue formation. Slower, more scarring, higher infection risk. Example: pressure injury, infected abscess opened for drainage.
• TERTIARY (DELAYED PRIMARY) INTENTION: Wound initially left open (to allow drainage or clear infection), then surgically closed later. Example: traumatic wound debrided and sutured 3–5 days later after infection control.
• FOUR PHASES OF HEALING (in order): Hemostasis → Inflammatory → Proliferative → Maturation/Remodeling.
• HEMOSTASIS: Immediate (seconds to minutes). Vasoconstriction + platelet aggregation + clot (fibrin) formation. Goal: stop bleeding.
• INFLAMMATORY PHASE: Days 1–4. Vasodilation, increased capillary permeability, leukocyte (neutrophils, macrophages) migration, phagocytosis of debris and bacteria. Clinical signs: redness, warmth, swelling, pain — these are EXPECTED and NOT signs of infection in this phase.
• PROLIFERATIVE PHASE: Days 4–21. Fibroblasts deposit COLLAGEN, granulation tissue forms, wound contracts, EPITHELIALIZATION occurs. This is when visible wound closure happens.
• MATURATION/REMODELING PHASE: Day 21 to 1–2 years. Collagen fibers reorganize, scar tissue strengthens. A healed wound only reaches 70–80% of original tensile strength — NEVER full strength.
• Factors IMPAIRING healing: Advanced age, protein malnutrition (low albumin), Vitamin C deficiency (needed for collagen synthesis), zinc deficiency, diabetes (impaired leukocyte function, poor perfusion), corticosteroids/immunosuppressants, smoking (vasoconstriction), infection, poor glycemic control, inadequate moisture balance.

Definitions

Section Title

Types and Phases of Wound Healing

Common Mistakes

• Thinking the inflammatory phase signs (redness, warmth, swelling, pain in days 1–4) represent infection — they are NORMAL during this phase.
• Confusing tertiary intention with secondary — tertiary is intentionally delayed closure; secondary is healed open without ever closing surgically.
• Forgetting that Vitamin C is essential for COLLAGEN synthesis (proliferative phase) — a patient with scurvy or poor dietary intake will have impaired wound healing.
• Assuming that once a wound looks closed, it has full tensile strength — it only reaches 70–80% at best.

Exam Tips

• Remember the Braden Scale mnemonic: SMAMNF (Sensory, Moisture, Activity, Mobility, Nutrition, Friction/Shear). Lower = riskier.
• NLE scenario: 'Patient score on Braden Scale is 12.' This means HIGH risk → implement full prevention protocol.
• When asked about the PRIORITY nursing intervention for a bedridden patient with a Stage 2 sacral wound, the answer is REPOSITION EVERY 2 HOURS (prevention and offloading) alongside wound dressing.
• Under Maslow's hierarchy, physiologic safety (preventing further breakdown, managing infection) takes priority over comfort or teaching when prioritizing NLE care plans.

Key Points

• PREVENTION IS THE PRIORITY — most pressure injuries in institutional settings (DOH-licensed hospitals, RHUs, LGU health facilities) are PREVENTABLE nursing-sensitive outcomes.
• REPOSITIONING schedule: Bedbound patients → every 2 HOURS. Chair/wheelchair-bound → every 1 HOUR. Independent patients are taught to shift weight every 15 MINUTES.
• Use 30-DEGREE LATERAL TILT (not full side-lying which puts pressure directly on the greater trochanter) when turning.
• Keep HOB at 30 DEGREES OR BELOW to minimize shear force at the sacrum. Temporary elevation (for meals, procedures) is acceptable.
• FLOAT THE HEELS: Place pillows under the calves, not under the heel itself. This distributes pressure along the calf and keeps heels free of surface contact.
• Use PRESSURE-REDISTRIBUTION SURFACES: foam, alternating-pressure (dynamic), or low-air-loss mattresses for high-risk patients.
• DO NOT MASSAGE OVER BONY PROMINENCES — massage can cause deep tissue damage by compressing blood vessels and causing friction against underlying bone.
• SKIN CARE: Use pH-balanced skin cleansers. Avoid soap and water routinely (alters skin pH). Manage incontinence promptly. Apply moisture-barrier creams to protect skin from effluent.
• Use the BRADEN SCALE for risk assessment: Subscales = Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction/Shear. LOWER SCORE = HIGHER RISK. Score ≤18 = at risk; Score ≤9 = very high risk.
• WOUND CLEANSING: Use NORMAL SALINE (0.9% NaCl) or approved wound irrigants. AVOID hydrogen peroxide and povidone-iodine on granulating wounds — they are cytotoxic and destroy healthy granulation tissue and epithelial cells.
• DEBRIDEMENT types: Autolytic (body's own enzymes + moist dressings), Enzymatic (collagenase ointment), Mechanical (wet-to-dry gauze, irrigation — least selective, avoid in granulating wounds), Sharp/Surgical (fastest; requires physician or advanced practice nurse).
• MOIST WOUND HEALING principle: Moist wound beds epithelialize FASTER than dry wounds. Dressings should maintain moisture at the wound bed while preventing periwound maceration.
• INFECTION CONTROL: Clean technique for chronic wounds; STERILE technique for acute/surgical wounds per institution policy (aligned with DOH-prescribed infection control standards).
• NUTRITION optimization: Protein 1.2–1.5 g/kg/day for wound healing; adequate caloric intake; Vitamin C and zinc supplementation as indicated. Refer to dietitian for high-risk patients.

Definitions

Section Title

Nursing Management: Prevention and Wound Care Principles

Common Mistakes

• Massaging bony prominences — this is CONTRAINDICATED in current wound care guidelines; it does NOT promote circulation and can cause deep tissue damage.
• Using hydrogen peroxide or betadine routinely on ALL wounds — only appropriate in specific situations (e.g., infected wounds briefly); harmful to granulating tissue.
• Thinking specialty mattresses eliminate the need for repositioning — WRONG. Repositioning must continue every 2 hours regardless of mattress type.
• Placing pillows UNDER the heel instead of under the calf — the heel must float freely without any surface contact.
• Using wet-to-dry gauze on granulating wounds — wet-to-dry is mechanical debridement that nonselectively removes both necrotic AND healthy tissue.

Exam Tips

• Match the dressing to the wound state: 'dry wound' → hydrogel; 'heavily draining, deep wound' → alginate; 'superficial wound, light drainage' → hydrocolloid.
• NLE scenario: 'A Stage 3 sacral wound with heavy exudate and a 4-cm tunnel.' Best dressing = ALGINATE rope for packing the tunnel + secondary foam dressing.
• NPWT/wound VAC key words in NLE scenarios: 'continuous or intermittent negative pressure', 'foam dressing sealed with occlusive drape', 'attached to suction collection canister'.

Key Points

• The guiding principle: KEEP THE WOUND BED MOIST AND THE PERIWOUND SKIN DRY. Select the dressing that achieves this based on wound characteristics.
• TRANSPARENT FILM (e.g., Tegaderm, OpSite): Thin, clear, adhesive film. USE FOR: Stage 1, superficial partial-thickness wounds, over IV sites, secondary dressing. Allows wound visualization without removal. NOT for moderate or heavy exudate.
• HYDROCOLLOID (e.g., DuoDERM, Comfeel): Occlusive wafer with gel-forming agents. USE FOR: Stage 2 and shallow Stage 3, light-to-MODERATE exudate. Supports AUTOLYTIC DEBRIDEMENT. Can stay 3–7 days. NOT for infected wounds (occlusive).
• HYDROGEL (sheet or amorphous): Adds MOISTURE to the wound. USE FOR: DRY wounds, painful wounds (cooling effect), partial and full-thickness wounds requiring moisture. Supports autolytic debridement. Requires a secondary cover dressing.
• FOAM (e.g., Mepilex, Allevyn): Highly absorbent. USE FOR: MODERATE-TO-HEAVY exudate wounds, pressure injury prevention over bony prominences, around tubes and drains.
• ALGINATE (calcium alginate, from seaweed): Highly absorbent fiber dressing. USE FOR: HEAVY EXUDATE, deep or tunneling wounds (rope alginate for packing). Gels on contact with wound fluid. Can aid hemostasis. Requires secondary dressing.
• ANTIMICROBIAL DRESSINGS (Silver, Cadexomer Iodine, Medical-grade Honey): USE FOR: Critically colonized or infected wounds. Silver has broad-spectrum antimicrobial properties.
• NEGATIVE-PRESSURE WOUND THERAPY (NPWT/Wound VAC): Applies subatmospheric pressure via a foam/gauze dressing and sealed tubing. USE FOR: Large Stage 3/4 wounds, complex wounds, flap/graft site preparation. REMOVES exudate, REDUCES edema, PROMOTES granulation tissue. Requires physician order.
• SUMMARY MEMORY AID — Exudate levels matched to dressing: NONE/MINIMAL → hydrogel (adds moisture) or transparent film. LIGHT-MODERATE → hydrocolloid. MODERATE-HEAVY → foam. HEAVY/DEEP → alginate. INFECTED → antimicrobial. LARGE COMPLEX → NPWT.

Definitions

Section Title

Dressing Selection Guide

Common Mistakes

• Using a hydrocolloid on a wound with heavy exudate — it will quickly saturate and leak, macerating periwound skin.
• Using a hydrogel on an already-wet, heavily exudating wound — this adds MORE moisture when moisture removal is needed.
• Forgetting that alginate must be moistened with saline before removal if it has dried out, to avoid traumatizing granulation tissue.
• Leaving a wound dressing on beyond its appropriate change interval — not all dressings are changed daily; hydrocolloids can stay 3–7 days unless saturated or leaking.

Exam Tips

• NLE emergency question: 'The nurse assesses the stoma and finds it is dark purple and dusky.' Action = NOTIFY PHYSICIAN IMMEDIATELY (ischemia).
• When asked about the PRIORITY nursing diagnosis for a new ileostomy patient, consider: Risk for Impaired Skin Integrity (peristomal) AND Risk for Deficient Fluid Volume (high liquid output) — use Maslow to prioritize physiologic needs.
• A question about 'the most appropriate skin cleanser for peristomal care' = plain water or gentle, non-moisturizing cleanser without oils.
• NLE discharge teaching scenario: ileostomy patient asks 'How often should I change my pouch?' = Every 3–7 days routinely, and earlier if it leaks.

Key Points

• An OSTOMY is a surgically created opening (stoma) through the abdominal wall to divert intestinal or urinary output.
• Types: COLOSTOMY (large intestine) = formed or semi-formed stool; ILEOSTOMY (small intestine) = liquid to pasty stool, rich in DIGESTIVE ENZYMES (proteases, lipases) — highest risk for peristomal skin breakdown; UROSTOMY/ILEAL CONDUIT = urine diversion.
• HEALTHY STOMA CHARACTERISTICS: RED-PINK color, MOIST surface, slightly RAISED or flush with skin. Mild bleeding during cleaning is NORMAL (stoma is highly vascular).
• EMERGENCY: A stoma that is DUSKY, PALE, DARK, PURPLE, or BLACK = ISCHEMIA → Report IMMEDIATELY. This is a vascular emergency requiring surgical evaluation.
• WAFER/BARRIER FIT: Cut the skin barrier opening approximately 1–2 mm LARGER than the stoma. Too large = effluent contacts skin (chemical burns). Too small = constriction, stoma injury.
• ILEOSTOMY output is particularly harmful to skin due to HIGH ENZYME CONTENT. The pouch should be emptied when ONE-THIRD to ONE-HALF FULL to prevent weight stress on the barrier seal and leakage.
• PERISTOMAL SKIN CARE: Cleanse with PLAIN WATER (avoid soaps with oils, lotions, or fragrances — they impair adhesion of the barrier). Pat dry thoroughly. Apply skin barrier paste or powder as needed.
• APPLIANCE CHANGE SCHEDULE: Every 3–7 days or EARLIER if leaking. Do NOT wait for leakage to cause skin breakdown.
• PERISTOMAL COMPLICATIONS to monitor: Erythema, itching (contact dermatitis), ulceration (enzymatic breakdown), candidiasis (fungal rash — antifungal powder needed), stomal retraction, prolapse, stenosis, parastomal hernia.
• FLUID AND ELECTROLYTE MONITORING for ileostomy patients: High-volume liquid output increases risk of DEHYDRATION, HYPONATREMIA, HYPOKALEMIA. Teach adequate fluid intake (2–3 L/day), sodium- and potassium-rich foods.
• PATIENT TEACHING before discharge (under RA 9173 mandate for health education): Appliance change procedure, skin inspection, output monitoring (volume and consistency), dietary guidance, activity restrictions, and when to call the health provider.

Definitions

Section Title

Ostomy Care and Peristomal Skin Integrity

Common Mistakes

• Panicking about mild stoma bleeding during cleaning — this is NORMAL because the stoma is highly vascular mucosa. The emergency is a purple or black stoma.
• Cutting the wafer opening too large — even a few millimeters of exposed skin will be damaged by effluent, especially with ileostomy's enzyme-rich output.
• Using soaps with oils or moisturizing ingredients on peristomal skin — these leave a residue that prevents the barrier from adhering properly.
• Waiting for leakage to change the appliance — this delays skin breakdown prevention. Change every 3–7 days on schedule.
• Forgetting to monitor electrolytes in ileostomy patients — high-output ileostomy can cause life-threatening dehydration and electrolyte imbalances.

Exam Tips

• NLE emergency scenario: 'A post-operative patient's abdominal incision opens and intestines are visible.' Priority action = cover with STERILE SALINE-MOISTENED gauze, position supine knees bent, call surgeon.
• Prioritization question: If a patient has both a Stage 4 sacral wound and a new fever with tachycardia, the PRIORITY is assessing for SEPSIS (systemic complication) — physiologic safety over wound management per Maslow.

Key Points

• OSTEOMYELITIS: Bone infection secondary to Stage 4 pressure injury. Suspect when bone is exposed, wound does not heal, or patient develops systemic signs of infection with a Stage 4 wound. Requires long-term IV antibiotics and possibly surgical debridement.
• SEPSIS: Systemic inflammatory response to wound infection. Signs: fever >38°C or hypothermia <36°C, tachycardia, tachypnea, altered mental status, elevated WBC. A complex wound with purulent drainage + fever warrants urgent medical evaluation.
• CELLULITIS: Spreading bacterial infection of skin and subcutaneous tissue around the wound. Presents as spreading erythema, warmth, and induration beyond the wound margins with systemic signs.
• WOUND DEHISCENCE: Disruption of surgical wound edges (skin layer). Risk factors: obesity, malnutrition, infection, improper suture technique, early removal of sutures. Management: cover with sterile saline-moistened gauze, notify surgeon.
• WOUND EVISCERATION: Protrusion of abdominal viscera through a dehisced surgical wound. EMERGENCY: Cover with sterile saline-moistened gauze (NEVER push organs back), keep patient supine with knees slightly flexed, call surgeon STAT.
• MARJOLIN ULCER: Rare malignant transformation (squamous cell carcinoma) in a chronic wound that fails to heal for years. Suspect when a chronic wound suddenly grows rapidly or changes character.
• PERISTOMAL COMPLICATIONS: Candidiasis (yeast rash, satellite lesions, treated with antifungal powder), stomal retraction (below skin level, difficult pouching), prolapse (extended stoma), parastomal hernia (bulging around stoma).
• FISTULA FORMATION: Abnormal connection between wound/tract and an internal organ or body surface, especially in deep Stage 4 wounds or radiation-damaged tissue.

Definitions

Section Title

Complications and High-Risk Clinical Scenarios

Common Mistakes

• Pushing eviscerated bowel back into the abdomen — this is strictly contraindicated. Cover with sterile, moist gauze.
• Mistaking the spreading erythema of cellulitis for normal post-wound inflammation — the key differentiator is that cellulitis SPREADS beyond the wound margin and is associated with systemic signs.
• Delaying sepsis recognition in a wound patient — any wound with purulent drainage + fever + tachycardia warrants urgent escalation of care under the hospital's rapid response protocol.