Pressure Injuries & Wound Healing — NCLEX Lesson A&P · Assessment · Integumentary · Pressure Injuries & Wound Healing Condition Lesson · NCLEX-PN / NCLEX-RN

Pressure plus time plus shear equals injury. A Stage 1 can become Stage 4 in hours. Healing needs perfusion, protein, moisture balance, and offloading. Your assessment prevents a never event.

In this lesson

Lesson Objectives
Why This Matters
Disease Overview
Pathophysiology
Risk Factors
Signs & Symptoms
Nursing Assessment
Diagnostic Tests
Laboratory Tests
Medications
Nursing Interventions
Potential Complications
Patient Education
Clinical Judgment
Clinical Connections
NCLEX High-Yield
Memory Aids
Case Study
Practice Questions
Key Takeaways
References

Lesson Objectives

Differentiate pressure injury stages 1, 2, 3, 4, unstageable, DTPI and other wound types and explain WHY staging matters.
Explain normal wound healing phases inflammatory, proliferative, maturation and factors that impair healing.
Identify early, late, emergency findings of pressure injury and wound infection, osteomyelitis, sepsis.
Prioritize prevention: Braden ≤18 bundle, offloading q2h, pressure redistribution surface, moisture barrier, nutrition protein 1.2-1.5g/kg, and skin checks.
Provide teaching for pressure injury prevention, wound care, nutrition, and when to seek emergency care.

Why This Disease Matters

Prevalence: Pressure injuries affect 2.5 million Americans yearly, 60,000 deaths related, cost $26.8 billion. 8% of hospitalized patients develop HAPI hospital-acquired pressure injury, 10-30% of LTC residents. Most common sites sacrum 36%, heels 30%, ischial tuberosities, trochanters. Stage 3-4 prevalence 1.5% hospitals but severe consequences.

Patient safety: Stage 3-4 and unstageable HAPI are never events CMS non-reimbursable, reportable, painful, increase length of stay 4-10 days, risk sepsis osteomyelitis death. Pressure injury can develop in <2 hours of unrelieved pressure. Device-related pressure injury from O2 tubing Foley CPAP masks NG tubes common and preventable. Malnutrition protein <0.8g/kg impairs healing.

NCLEX importance: Top tested integumentary topic. Braden Scale ≤18 risk → prevention bundle reposition q2h 30-degree lateral pressure redistribution surface moisture barrier nutrition skin check daily. Staging: Stage 1 non-blanchable erythema intact skin, Stage 2 shallow open pink partial thickness blister, Stage 3 full thickness fat visible, Stage 4 muscle bone tendon visible, unstageable slough/eschar covered can't stage, DTPI deep tissue purple maroon intact or non-intact. No massage Stage 1-2, no heat, no donut cushions, no wet-to-dry for pressure injuries — moist healing. Wound healing phases and factors: perfusion, oxygenation, infection, moisture balance, nutrition protein vitamin C zinc, diabetes, smoking, age, steroids.

Why nurses encounter them: Every med-surg, ICU, ED, LTC, home health sees pressure injuries. Post-op immobility, ICU intubated, spinal cord injury, elderly, diabetes PVD all high risk. Nurses prevent, assess, document, and manage.

Connecting to prior lessons From A&P: Skin epidermis avascular + dermis vascular with collagen elastin + subcutaneous fat insulation. Healing needs O2 and nutrients via blood, fibroblasts make collagen, angiogenesis new vessels, epithelialization. From assessment: Braden Scale 6 subscales Sensory Moisture Activity Mobility Nutrition Friction/Shear ≤18 risk, ABCDE melanoma, cap refill <3 sec perfusion, turgor sternum <3 sec hydration, blanching test with glass slide.

Disease Overview

Concept	What it is	How it affects physiology
Pressure Injury	Localized damage to skin and underlying tissue over bony prominence or device from pressure + shear, staged 1-4 unstageable DTPI	Pressure > capillary closing pressure 32 mmHg → ischemia → tissue necrosis from inside out muscle more sensitive than skin — deep damage may exist before skin opens
Wound Healing	Complex process to restore integrity: hemostasis → inflammatory → proliferative → maturation remodeling	Requires perfusion O2 nutrients protein vitamin C zinc, moisture balance, no infection, no pressure, no hyperglycemia, no smoking vasoconstriction

Pathophysiology

Normal physiology: Skin intact barrier, epidermis avascular, dermis vascular with collagen elastin, subcutaneous fat cushion. Pressure <32 mmHg capillaries open perfusion O2 nutrients delivered. Wound healing: Hemostasis seconds platelets clot, Inflammatory 0-5 days neutrophils macrophages clean bacteria, Proliferative 3-24 days fibroblasts collagen, angiogenesis new vessels, granulation red moist bumpy, epithelialization, contraction, Maturation 21 days to 2 years collagen remodeling strength 80% max. ↓ What goes wrong — Pressure Injury: Unrelieved pressure >32 mmHg over bony prominence sacrum heels ischial tuberosities trochanters scapulae occiput or device O2 tubing Foley → capillaries collapse → ischemia → tissue anoxia → cell death necrosis starts deep muscle more sensitive than skin, so deep damage may be present while skin still intact DTPI purple maroon. Shear when head of bed >30 degrees + sliding down → vessels stretch tear → deeper injury. Friction surface rubbing removes epidermis. Moisture urine/stool sweat → maceration softens skin → breaks down faster. Reperfusion injury when pressure relieved → inflammatory damage. WHY staging matters: deeper stage = deeper structures exposed higher infection osteomyelitis sepsis risk. ↓ How pressure causes symptoms: Stage 1 non-blanchable erythema intact skin does not blanch with pressure — WHY extravasated blood not in vessels. Warm tender maybe. Stage 2 partial thickness shallow open pink wound bed like blister or shallow crater no fat visible no slough. Stage 3 full thickness fat visible slough may be present undermining tunneling may be present. Stage 4 full thickness muscle bone tendon visible slough eschar undermining tunneling. Unstageable full thickness slough/eschar covered can't see depth can't stage until debrided. DTPI intact or non-intact purple maroon localized blood-filled blister — deep damage from pressure shear even if skin intact — may evolve to Stage 3-4 quickly. ↓ Wound healing — What goes wrong: Impaired if poor perfusion arterial insufficiency cool cap refill >3 sec, hypoxia, anemia Hgb low, hyperglycemia diabetes HbA1c >7 impairs WBC function collagen, infection bacteria >10^5, excess moisture or dryness, pressure unrelieved, malnutrition protein <0.8g/kg vitamin C zinc deficiency, smoking vasoconstriction, steroids immunosuppressants, age elderly thin fragile, edema, incontinence moisture MASD, friction shear. Chronic wound stuck in inflammatory phase no progression. ↓ Progression: Stage 1 if not offloaded → Stage 2 → Stage 3-4 → unstageable → osteomyelitis sepsis death. Chronic wound → biofilm → infection → sepsis.

Risk Factors

Non-modifiable	Modifiable / Preventable	High-risk populations
Age elderly >65 thin fragile subQ loss decreased elasticity, very young neonate thin skin, history prior pressure injury scar tissue weaker	Immobility Activity Mobility Braden, sensory impairment, moisture incontinence urine stool diaphoresis, poor nutrition protein <0.8g/kg weight loss cachexia, friction shear HOB >30 sliding, medical devices O2 tubing Foley CPAP NG tube casts braces, vascular disease arterial venous insufficiency, diabetes hyperglycemia neuropathy, anemia, edema, smoking, obesity, dry skin, cognitive impairment can't reposition self, prolonged OR time, hypotension poor perfusion	ICU intubated sedated, spinal cord injury paraplegia quadriplegia, elderly LTC bedbound, post-op immobility, diabetes PVD neuropathy, malnutrition, incontinent urine/stool, vascular disease, cachexia, prolonged hospitalization

Signs and Symptoms

Category	Finding & WHY
Early — Stage 1 and DTPI	Non-blanchable erythema intact skin does not blanch with pressure (WHY extravasated blood), warm tender firmer or boggy than surrounding (WHY inflammation edema), purple maroon intact or blood-filled blister DTPI (WHY deep pressure shear damage muscle more sensitive deep bleeding), pain may be present. WHY early: ischemia before skin breaks.
Expected — Stage 2	Partial thickness shallow open pink wound bed like blister or shallow crater no fat visible no slough/eschar, may be intact blister, surrounding skin may be erythematous, pain. WHY: epidermis + part of dermis lost.
Expected — Stage 3	Full thickness fat visible yellow lobular, slough yellow tan stringy may be present, undermining tunneling may be present where wound edges pull away, depth varies by location thick fat vs thin ear nose. WHY: full thickness loss through dermis into subQ.
Expected — Stage 4	Full thickness muscle bone tendon visible slough eschar may be visible undermining tunneling often present, depth varies, osteomyelitis risk. WHY: full thickness loss through subQ to muscle bone.
Expected — Unstageable and DTPI	Unstageable full thickness slough yellow tan or eschar brown black covered can't see depth can't stage until debrided except stable eschar heels dry adherent no erythema fluctuance do NOT debride. DTPI purple maroon intact or non-intact blood-filled blister intact or non-intact deep tissue damage may evolve quickly to Stage 3-4 even with treatment. WHY: slough/eschar hides depth, DTPI deep damage from pressure shear muscle more sensitive.
Expected wound healing	Inflammatory 0-5 days redness warmth swelling pain, proliferative 3-24 days granulation red moist bumpy new tissue, epithelialization pink edges, contraction wound smaller, maturation 21 days-2 years pale flat scar strength 80% max. WHY: normal healing phases.
Unexpected / Abnormal healing	No progression 2 weeks, increasing pain, foul odor, purulent drainage yellow green brown, periwound erythema induration warmth swelling, undermining tunneling increase, black eschar unstable, fever tachycardia hypotension confusion, crepitus, wound enlarges, bleeding, hyperglycemia. WHY: infection biofilm poor perfusion poor nutrition pressure unrelieved.
Emergency	Sepsis: fever >101 or hypothermia <95, tachy >100, tachypnea >22, hypotension <90 systolic, confusion, oliguria, wound purulent foul odor + erythema + crepitus + pain out of proportion = necrotizing fasciitis emergency surgery, osteomyelitis bone visible + fever + pain + elevated CRP. WHY: bacteria invade bloodstream bone.

Red flags Purple maroon DTPI intact or blood-filled blister may evolve to Stage 3-4 quickly. Unstageable slough/eschar covered can't stage. Stage 3-4 + foul odor + purulent drainage + fever + hypotension + confusion = infection osteomyelitis sepsis. Pain out of proportion + crepitus + bullae = necrotizing fasciitis.

Nursing Assessment

Subjective: onset duration wound, cause pressure immobility device, pain 0-10 at rest and dressing change, itch, drainage amount color odor, fever chills, nutrition protein intake weight loss, fluid intake, mobility ADLs can you reposition self, incontinence urine stool frequency, history diabetes PVD vascular disease anemia malnutrition prior pressure injury, smoking, meds steroids immunosuppressants anticoagulants, allergies latex adhesives, support at home caregivers.

Objective: vitals temp fever infection, HR tachy sepsis pain, BP hypo sepsis, RR SpO2, pain 0-10, weight BMI weight loss, I&O, labs. Skin: general color pallor cyanosis jaundice, temperature warm cool, moisture dry vs moist incontinence, turgor sternum, cap refill. Wound: location bony prominence/device, size LxWxD cm measure length head to toe width side to side depth deepest, shape, stage 1-4 unstageable DTPI per NPIAP, wound bed tissue type: granulation red moist bumpy healthy, slough yellow tan stringy non-viable, eschar brown black dry leathery non-viable except stable eschar heels, necrotic, bone muscle tendon visible, undermining clock method tunneling, drainage amount none/scant/moderate/copious color serous clear serosanguineous pink sanguineous red purulent yellow green brown odor, surrounding periwound skin erythema induration maceration moisture, pain 0-10 before during after dressing change, odor. Braden scale total and subscales, pulses, edema, devices. Photo per facility.

Priority / Focused	Why / Action
Braden ≤18 + bony prominences + device areas	Predicts pressure injury risk — ≤18 triggers prevention bundle. Check sacrum heels ischial tuberosities trochanters scapulae occiput elbows, under O2 tubing Foley CPAP NG casts braces. Braden q24-48h or change.
Stage + size + tissue type + drainage + periwound	Determines treatment and healing. Stage 1 non-blanchable intact, Stage 2 shallow pink no fat, Stage 3 fat visible, Stage 4 muscle bone, unstageable slough/eschar covered can't stage, DTPI purple maroon. Granulation red moist healthy, slough yellow non-viable needs debridement, eschar brown black except stable eschar heels do NOT debride dry adherent no erythema fluctuance. Undermining tunneling clock.
Infection signs	Fever tachy hypotension confusion oliguria, wound: increasing pain, foul odor, purulent drainage, periwound erythema induration warmth swelling, wound enlarges, delayed healing >2 weeks, crepitus pain out of proportion = necrotizing fasciitis emergency.
Nutrition perfusion	Protein <0.8g/kg vitamin C zinc deficiency impairs healing, albumin low, weight loss, anemia Hgb low O2 delivery low, diabetes hyperglycemia impairs WBC collagen, PVD cool cap refill >3 sec poor perfusion, smoking vasoconstriction, incontinence moisture MASD.

When to notify / act now DTPI purple maroon or unstageable slough/eschar covered + foul odor + purulent drainage + fever + hypotension + confusion + oliguria = infection osteomyelitis sepsis notify STAT wound care provider rapid response. Stage 3-4 with bone visible + fever. Pain out of proportion + crepitus + bullae + erythema = necrotizing fasciitis emergency surgery. Stable eschar heels dry adherent no erythema fluctuance do NOT debride — protect.

Diagnostic Tests

Test	Purpose / Why / Findings / Nursing
Wound culture and Gram stain + Tissue biopsy if chronic not healing	Purpose identify organism infection vs colonization. Why ordered: foul odor purulent drainage fever increasing pain wound enlarges. Expected no growth colonization may be present but not infection. Abnormal >10^5 bacteria infection. Prep clean wound before culture per facility, no antiseptic before culture, swab viable tissue not slough/eschar. Nursing label time, send ASAP, teach not all wounds need antibiotics colonization ≠ infection — only if systemic signs.
X-ray, CT, MRI if osteomyelitis suspected bone visible Stage 4	Purpose detect bone infection osteomyelitis. X-ray late changes, MRI gold standard bone edema. Prep NPO if contrast, check allergy BUN/Cr, hydration after. Nursing monitor vitals, wound care.
Photos + Measurement + Braden + PUSH Tool Pressure Ulcer Scale for Healing	PUSH scores size exudate tissue type 0-17 tracks healing decreasing score good. Braden risk. Photos per facility consent, measure LxWxD cm, clock method undermining. No prep. Nursing same position lighting distance for comparison.

Laboratory Tests

Lab	Purpose / Normal / Abnormal / Trend / Priority
CBC WBC 5-10k, CRP <1mg/dL, ESR <20mm/hr, Procalcitonin <0.5	Purpose infection inflammation. WBC high infection, CRP ESR high inflammation, procalcitonin high bacterial infection sepsis. Trend decreasing with treatment good. Priority WBC high + fever + hypotension + wound purulent = sepsis notify STAT.
Albumin 3.5-5.0 g/dL, Prealbumin 15-35 mg/dL, Total protein 6-8 g/dL, Hgb 12-16F 14-18M, Hct	Purpose nutrition healing capacity. Albumin low <3.5 malnutrition delayed healing, prealbumin short half-life more sensitive acute nutrition, protein low impairs collagen, Hgb low anemia low O2 delivery impairs healing. Trend rising good. Priority low albumin protein weight loss malnutrition needs nutrition consult protein 1.2-1.5g/kg for pressure injury healing.
Glucose 70-140, HbA1c <7%, BUN 7-20 Cr 0.6-1.2, Vitamin C, Zinc	Glucose high hyperglycemia impairs WBC collagen healing infection risk, HbA1c high poor control, BUN/Cr rising dehydration AKI, vitamin C zinc deficiency impairs collagen. Priority glucose >180 impairs healing need control.

Medications

Class / Meds	Mechanism & Nursing/Teaching
Topical wound care: Hydrocolloid, Hydrogel, Foam, Alginate, Transparent film — per wound type per provider/wound care	Mechanism: Maintains moist healing environment WHY moist heals faster than dry, protects, absorbs drainage. Hydrocolloid for Stage 1-2 shallow minimal drainage, hydrogel for dry wound adds moisture, foam for moderate-heavy drainage, alginate for heavy drainage, film for shallow minimal no drainage. Nursing: assess stage size tissue type drainage periwound before choosing per order/wound care, measure, document, change per order, no wet-to-dry for pressure injuries (damages granulation), no massage Stage 1-2, no heat, no donut cushions increase pressure.
Debridement: Enzymatic Collagenase (Santyl), Autolytic hydrocolloid/hydrogel, Mechanical (rare), Surgical per surgeon	Mechanism: Removes non-viable slough/eschar to allow granulation. Collagenase enzymatic debrides slough/eschar. Autolytic uses body's enzymes with moist dressing. Contra: stable eschar heels dry adherent no erythema fluctuance do NOT debride — protect, not for infected wounds alone need surgical. Nursing: assess tissue type slough yellow tan eschar brown black, apply per order only to wound bed not periwound, protect periwound, monitor for bleeding pain, document.
Antibiotics systemic if infection: Per culture, e.g., Cefazolin, Vancomycin if MRSA — NOT for colonization	Mechanism: Kills bacteria if systemic infection sepsis osteomyelitis. Indication: fever tachy hypotension purulent drainage periwound erythema induration wound enlarges + positive culture. NOT for colonization alone. Nursing: cultures before antibiotics per protocol, monitor WBC fever vitals, allergy, finish full course, monitor renal function BUN/Cr vancomycin nephrotoxic, teach.
Nutrition support: Protein supplements, Vitamin C, Zinc, Arginine per dietitian/provider if deficient	Mechanism: Protein building block collagen 1.2-1.5g/kg for pressure injury healing vs 0.8g/kg normal, Vitamin C collagen synthesis, Zinc cell proliferation, Arginine collagen immune. Nursing: monitor labs albumin prealbumin weight, consult dietitian, encourage protein intake meat eggs dairy beans, vitamin C citrus fruits, zinc meat, monitor glucose, teach.
Pain management: Acetaminophen, NSAIDs, Opioids for dressing change per order, Topical lidocaine per order	Mechanism: Controls pain during dressing change WHY pain increases stress impairs healing and causes movement. Nursing: pain 0-10 before during after, give 30min before dressing change per order, monitor sedation RR with opioids, non-pharm deep breathing distraction.

Nursing Interventions — Prioritized

Priority	Intervention & WHY
Airway / Breathing	Usually not primary unless sepsis with tachypnea SpO2 <90% crackles, O2 per order, semi-Fowler if dyspneic, monitor RR SpO2.
Circulation / Perfusion & Infection	Vitals q4h or q15min if fever/sepsis/hypotension, temp fever infection, HR tachy pain/sepsis, BP hypo sepsis, RR, SpO2, I&O hourly if sepsis/AKI, daily weight same scale/time, labs WBC CRP BUN/Cr albumin glucose. Wound cultures before antibiotics if infection signs per protocol, blood cultures if sepsis before antibiotics but antibiotics within 1hr if sepsis. Monitor wound infection signs: increasing pain foul odor purulent drainage periwound erythema induration warmth swelling wound enlarges delayed healing >2 weeks crepitus pain out of proportion = necrotizing fasciitis emergency surgery. Check pulses cap refill <3 sec perfusion, edema, devices.
Safety — Prevention & Pressure Relief	Braden on admission q24-48h or change, if ≤18 trigger bundle: offload reposition q2h 30-degree lateral not sacrum 90-degree, avoid dragging friction shear HOB ≤30 unless contraindicated aspiration risk, pressure redistribution surface low-air-loss alternating air mattress per order, offload heels with pillow under calves not under heels, device check q2h reposition O2 tubing Foley CPAP NG casts braces, no donut cushions increase pressure to surrounding tissue, no massage Stage 1-2 damages tissue, no heat, no wet-to-dry for pressure injuries damages granulation, keep skin clean dry, moisture barrier zinc oxide for incontinence MASD, perineal hygiene front to back change briefs frequently, manage moisture diaphoresis. For unstageable slough/eschar: debridement per order except stable eschar heels dry adherent no erythema fluctuance do NOT debride protect. For DTPI purple maroon intact or blood blister offload do NOT debride monitor may evolve to Stage 3-4.
Comfort — Wound Care	Pain 0-10 before during after dressing change, give analgesic 30min before per order, non-pharm deep breathing distraction, moist healing per order hydrocolloid hydrogel foam alginate film based on stage size tissue type drainage periwound, measure LxWxD cm clock undermining tunneling, photo per facility, document PUSH score size exudate tissue type, change per order, no wet-to-dry, protect periwound with skin prep, odor control.
Education / Interdisciplinary	Wound care nurse, dietitian protein 1.2-1.5g/kg for healing vitamin C citrus fruits zinc meat calories, PT/OT mobility repositioning exercises, pharmacy renal dosing, provider, social work, enterostomal therapist. Teach nutrition hydration smoking cessation, repositioning techniques, skin checks, when to seek emergency.

Potential Complications

Complication	Early signs	Nursing response / Emergency
Infection cellulitis → sepsis → septic shock	Increasing pain, foul odor, purulent yellow green brown drainage, periwound erythema induration warmth swelling, fever >101 tachy >100 tachypnea >22 hypotension <90 confusion oliguria <30 wound enlarges delayed healing >2 weeks	Vitals q15min O2 large-bore IV cultures wound and blood before antibiotics but antibiotics within 1hr if sepsis per protocol, lactate, I&O hourly daily weight, offload, wound care, labs WBC CRP lactate BUN/Cr, notify provider/rapid response, prepare fluids vasopressors.
Osteomyelitis	Stage 4 bone muscle tendon visible, persistent pain, foul odor, fever, elevated CRP ESR, wound not healing, exposed bone	Vitals, wound cultures, X-ray MRI gold standard bone edema, labs WBC CRP ESR, offload, wound care, antibiotics per culture long-term per order, surgical consult, notify provider.
Necrotizing fasciitis	Pain out of proportion + hot erythematous swollen + fever + crepitus + bullae + rapid spread	Rapid response surgery consult STAT emergency surgery, vitals O2 IV fluids, mark border, labs WBC lactate, blood cultures before antibiotics but antibiotics within 1hr if sepsis, NPO.
Chronic non-healing wound biofilm	No improvement 2 weeks, slough eschar persists, minimal granulation, moderate drainage, odor	Wound care consult, debridement per order except stable eschar heels, moist healing, nutrition protein 1.2-1.5g/kg vitamin C zinc, control glucose diabetes, perfusion cap refill pulses, offload pressure, treat incontinence moisture, smoking cessation.

Patient Education

Disease process: Pressure injury localized damage over bony prominence/device from pressure >32 mmHg + shear + friction + moisture, staged 1 non-blanchable erythema intact, 2 shallow open pink partial thickness, 3 fat visible full thickness, 4 muscle bone visible, unstageable slough/eschar covered can't stage, DTPI purple maroon intact or blood blister deep damage may evolve to 3-4. Healing phases inflammatory 0-5 days redness warmth swelling pain, proliferative 3-24 days granulation red moist bumpy, maturation 21 days-2 years scar 80% strength.
Lifestyle: Reposition q2h if bedbound 30-degree lateral not sacrum, q1h if chairbound shift weight q15min if able, pressure redistribution mattress per order, offload heels pillow under calves, avoid dragging friction shear HOB ≤30 unless aspiration risk, check skin daily especially sacrum heels, device areas O2 tubing Foley CPAP. Nutrition protein 1.2-1.5g/kg for healing meat eggs dairy beans, vitamin C citrus fruits, zinc meat, calories, hydration 2-3L if not contraindicated HF/CKD, manage diabetes glucose <180 HbA1c <7, quit smoking vasoconstriction, exercise mobility PT/OT.
Med adherence: Take antibiotics only if infection per culture finish full course even if feeling better, topical wound care per order hydrocolloid hydrogel foam alginate film moist healing, no wet-to-dry for pressure injuries, no massage Stage 1-2, no donut cushions, pain med 30min before dressing change, protein supplements vitamin C zinc if ordered.
Home care: Hand hygiene before/after dressing change, measure LxWxD cm photo per facility, note tissue type granulation red moist healthy slough yellow tan eschar brown black, drainage amount color odor, periwound skin, pain 0-10, change per order, protect periwound skin prep, moisture barrier zinc oxide for incontinence, perineal hygiene front to back change briefs frequently, keep skin clean dry, no heat.
Follow-up: Wound care nurse, dietitian, provider, labs WBC albumin, PUSH score decreasing good, Braden q24-48h, return if no improvement 2 weeks or worsening.
Warning / Emergency: Fever >101 chills, increasing pain foul odor purulent yellow green brown drainage periwound erythema induration warmth swelling wound enlarges, crepitus pain out of proportion bullae = necrotizing fasciitis emergency, hypotension tachy confusion oliguria = sepsis, bone visible + fever = osteomyelitis, bleeding. Call 911 for sepsis signs or rapid spread.

Clinical Judgment (NCSBN CJMM)

Recognize Cues: 75yo female bedbound after stroke, incontinent urine/stool, diabetes PVD, Braden 11 high risk, sacrum non-blanchable erythema Stage 1 4x5cm intact warm tender, surrounding skin moist macerated under brief, heels cool cap refill 4 sec, tenting 4 sec sternum dry mucosa, weight loss 4kg, albumin 2.8 low, HbA1c 8.5 high, temp 100.8F, HR 96, BP 108/68, crackles bases, left leg edema 2+ pitting, right forearm mole stable.
Analyze Cues: High risk Braden 11 sensory impaired immobility moisture incontinence poor nutrition friction shear, Stage 1 non-blanchable erythema intact early pressure injury from unrelieved pressure <2hr, moisture MASD incontinence, dehydration tenting dry mucosa poor intake, poor perfusion cool heels cap refill 4 sec PVD, malnutrition albumin low weight loss poor healing, hyperglycemia HbA1c high impairs WBC collagen infection risk, fever 100.8 UTI from incontinence, crackles fluid overload vs dehydration mixed, edema venous insufficiency.
Prioritize Hypotheses: #1 Stage 1 pressure injury with high risk progression + moisture + poor nutrition + poor perfusion + infection risk. #2 Risk for sepsis from UTI skin breakdown. #3 Dehydration malnutrition hyperglycemia.
Generate Solutions: Vitals q4h temp HR BP orthostatics, I&O hourly, daily weight same scale/time, Braden q24h, labs CBC BUN/Cr albumin prealbumin glucose HbA1c UA culture, offload reposition q2h 30-degree lateral not sacrum pressure redistribution mattress low-air-loss per order offload heels pillow under calves, moisture barrier zinc oxide change briefs q2h perineal hygiene front to back, skin check daily photo measure LxWxD PUSH, nutrition consult protein 1.2-1.5g/kg fluids if not contraindicated vitamin C zinc, control glucose insulin per order, wound care consult, no massage Stage 1 no donut no heat no wet-to-dry, device check, teach caregivers.
Take Action: Call provider, wound care, dietitian, implement bundle: reposition q2h 30-degree lateral, pressure redistribution surface, offload heels, moisture barrier zinc oxide, change briefs frequently, skin check daily photo, nutrition protein supplements per order, fluids per order, glucose control insulin per order, UA culture before antibiotics per protocol, vitals I&O daily weight, labs, document.
Evaluate Outcomes: After 3 days Stage 1 non-blanchable erythema improved blanchable pink, surrounding skin dry intact no maceration, heels warm cap refill 3 sec improved, tenting 4→2 sec mucosa moist, weight stable, albumin 2.8→3.0, glucose 180→140, temp 100.8→98.8, no odor no drainage, Braden 11→14 moderate risk. Continue bundle, follow-up wound care, education repositioning skin checks nutrition glucose control when to seek emergency.

Clinical Connections — commonly confused on NCLEX

Feature	Stage 1 Pressure Injury	Stage 2 Pressure Injury	Stage 3 Pressure Injury	Stage 4 Pressure Injury	Unstageable / DTPI
Cause	Pressure >32 mmHg + shear, intact skin, capillary damage extravasated blood non-blanchable	Pressure, partial thickness epidermis + part dermis	Pressure full thickness through dermis into subQ fat visible	Pressure full thickness into muscle bone tendon	Unstageable slough/eschar covered can't see depth, DTPI deep pressure shear purple maroon deep tissue damage
Assessment	Intact skin non-blanchable erythema does not blanch, warm tender firmer/boggy, no open, no slough/eschar	Shallow open pink wound bed partial thickness no fat visible no slough/eschar may be intact blister	Full thickness fat yellow lobular visible slough may be present undermining tunneling may be present	Full thickness muscle bone tendon visible slough eschar may be present undermining tunneling often present	Unstageable full thickness slough yellow tan or eschar brown black covered can't stage until debrided, except stable eschar heels dry adherent no erythema fluctuance do NOT debride. DTPI intact or non-intact purple maroon blood-filled blister deep damage may evolve to 3-4
Treatment	Offload reposition q2h 30-degree lateral pressure redistribution surface moisture barrier no massage no heat no donut, skin check daily	Offload, moist healing hydrocolloid foam per order, protect periwound, no wet-to-dry, monitor	Offload, moist healing foam alginate per order, debridement per order if slough/eschar except stable eschar heels, nutrition protein 1.2-1.5g/kg, wound care	Offload, moist healing, debridement per order except stable eschar heels, nutrition, X-ray MRI if osteomyelitis, surgical consult	Unstageable debridement per order except stable eschar heels protect, DTPI offload do NOT debride monitor may evolve, both need wound care
Priority nursing	Braden ≤18 bundle prevention reposition q2h, daily skin check, moisture barrier, nutrition, I&O daily weight, hold if infected	Same bundle + wound measurement LxWxD photo PUSH, pain 0-10 before during after dressing change, no wet-to-dry	Same bundle + debridement per order if needed + nutrition consult + labs WBC albumin + infection signs + notify if foul odor purulent fever hypotension	Same bundle + osteomyelitis workup X-ray MRI if bone visible fever + surgical consult + sepsis monitoring	Same bundle + do NOT debride stable eschar heels dry adherent, DTPI offload do NOT debride, monitor evolution, wound care, notify STAT if foul odor purulent fever hypotension

NCLEX High-Yield Review — What the NCLEX Wants You to Know

Braden ≤18 = risk → bundle: reposition q2h 30-degree lateral, pressure redistribution surface, offload heels pillow under calves, moisture barrier zinc oxide, skin check daily, nutrition protein 1.2-1.5g/kg, fluids if not contraindicated, manage friction shear HOB ≤30
Staging: Stage 1 non-blanchable erythema intact no open, Stage 2 shallow open pink partial thickness blister no fat, Stage 3 full thickness fat visible, Stage 4 muscle bone tendon visible, unstageable slough/eschar covered can't stage, DTPI purple maroon intact or blood blister deep damage may evolve
No massage Stage 1-2, no heat, no donut cushions, no wet-to-dry for pressure injuries — moist healing hydrocolloid hydrogel foam alginate film per order
Granulation red moist bumpy healthy, slough yellow tan stringy non-viable, eschar brown black dry leathery non-viable except stable eschar heels dry adherent no erythema fluctuance do NOT debride protect
Infection: increasing pain foul odor purulent yellow green brown drainage periwound erythema induration warmth swelling wound enlarges fever tachy hypotension confusion oliguria = sepsis — cultures wound and blood before antibiotics but antibiotics within 1hr if sepsis, offload, wound care, labs WBC CRP lactate
Nutrition: protein 1.2-1.5g/kg for healing vs 0.8 normal, vitamin C citrus fruits collagen, zinc meat, calories, glucose <180 HbA1c <7, hydration 2-3L if not contraindicated
Healing phases: inflammatory 0-5 days redness warmth swelling pain, proliferative 3-24 days granulation epithelialization contraction, maturation 21 days-2 years pale flat scar 80% strength — chronic wound stuck inflammatory no progression >2 weeks
PUSH tool size exudate tissue type decreasing score good, measure LxWxD cm clock undermining tunneling, photo per facility

Common distractors: Confusing Stage 2 shallow pink no fat vs Stage 3 fat visible, Stage 3 fat vs Stage 4 muscle bone. Thinking Stage 1 blanchable — Stage 1 non-blanchable does not blanch. Massaging Stage 1 to improve circulation — damages tissue worsens injury. Using donut cushions — increases pressure surrounding tissue. Wet-to-dry for pressure injuries — damages granulation painful. Debriding stable eschar heels dry adherent — do NOT debride protect. Not checking Braden q24-48h. Documenting "looks fine" vs objective LxWxD tissue type drainage.

Memory Aids

Braden S M A M N F — Sensory Moisture Activity Mobility Nutrition Friction/Shear — Low score = high risk ≤18 bundle
Stages: 1 non-blanchable red intact no open, 2 shallow pink open blister no fat, 3 fat visible, 4 muscle bone visible, Unstageable slough/eschar covered can't stage, DTPI purple maroon deep damage may evolve
Granulation red moist bumpy healthy, Slough yellow tan stringy non-viable, Eschar brown black dry leathery — except stable eschar heels dry adherent do NOT debride
No M H D W — No Massage Stage 1-2, No Heat, No Donut cushions, No Wet-to-dry for pressure injuries
Healing: I P M — Inflammatory 0-5 days redness warmth swelling pain, Proliferative 3-24 days granulation, Maturation 21 days-2 years scar 80% strength
Infection: pain + foul odor + purulent + erythema + fever + hypo + confusion = sepsis cultures before antibiotics but antibiotics within 1hr

Case Study

Patient: Mr. Carter 68M bedbound after spinal cord injury paraplegia, incontinent urine/stool, diabetes HbA1c 8.2, Braden 10 high risk, sacrum Stage 3 pressure injury 4x5x1cm full thickness fat visible yellow slough moderate serosanguineous foul odor, periwound erythema induration warmth, undermining 2cm at 3 o'clock, temp 101.2F HR 108 BP 96/60 RR 22 SpO2 95% RA, albumin 2.6 low, WBC 12k high, weight loss 5kg, pain 6/10 during dressing change, heels DTPI purple maroon intact 2x2cm bilateral.

Step 1 Recognize Cues: Stage 3 sacrum fat visible slough foul odor periwound erythema induration warmth undermining infection, DTPI heels purple maroon intact deep tissue damage, Braden 10 high risk sensory impaired immobility moisture incontinence poor nutrition friction shear, diabetes hyperglycemia impairs healing, albumin low malnutrition, weight loss, fever tachy hypotension early sepsis, pain 6/10, incontinence MASD.

Step 2 Analyze Cues: Pressure >32 mmHg sacrum + shear HOB >30 sliding + moisture incontinence → ischemia necrosis full thickness fat visible Stage 3, slough non-viable needs debridement except stable eschar heels, DTPI deep pressure shear muscle more sensitive purple maroon may evolve to Stage 3-4, infection periwound erythema foul odor purulent? moderate serosanguineous foul odor + fever tachy hypotension WBC high → cellulitis sepsis risk osteomyelitis if bone not visible yet but Stage 3 near bone, hyperglycemia impairs WBC collagen, malnutrition protein <0.8g/kg albumin low impairs healing.

Step 3 Prioritize: #1 Stage 3 infected pressure injury with risk sepsis + DTPI heels + high risk progression. #2 Risk osteomyelitis sepsis. #3 Malnutrition dehydration hyperglycemia poor perfusion.

Step 4 Plan: Vitals q15min-1h temp HR BP RR SpO2, O2 if needed, I&O hourly daily weight same scale/time, labs CBC WBC CRP lactate BUN/Cr albumin prealbumin glucose HbA1c wound culture before antibiotics per protocol blood cultures if sepsis, offload reposition q2h 30-degree lateral not sacrum pressure redistribution low-air-loss mattress offload heels pillow under calves not under heels, moisture barrier zinc oxide change briefs q2h perineal hygiene front to back, no massage Stage 3 no donut no heat no wet-to-dry, wound care consult debridement per order collagenase vs surgical except DTPI offload do NOT debride, moist healing foam alginate per order, measure LxWxD photo PUSH, pain analgesic 30min before dressing change per order, nutrition consult protein 1.2-1.5g/kg vitamin C zinc fluids if not contraindicated, glucose control insulin per order, device check, teach caregivers, notify provider STAT wound care surgery if needed.

Step 5 Take Action: Provider notified rapid response if hypotension worsens, wound culture sacrum before antibiotics per protocol + blood cultures if sepsis, antibiotics per order after cultures per protocol, O2 2L NC SpO2 95%, large-bore IV fluids per order 500mL NS reassess, reposition q2h 30-degree lateral, low-air-loss mattress, offload heels, moisture barrier, change briefs, wound care foam alginate per order, measure 4x5x1cm undermining 2cm at 3 o'clock photo, PUSH score, analgesic acetaminophen 650mg 30min before per order, nutrition protein supplements per order, glucose check insulin per order, labs, document.

Step 6 Evaluate & Discharge: After 5 days temp 101.2→99F HR 108→88 BP 96/60→110/70, WBC 12k→8k, pain 6→2, wound sacrum slough decreased granulation red moist increased size 4x5x1→3x4x0.8cm foul odor decreased drainage scant serosanguineous periwound erythema decreased, DTPI heels purple maroon unchanged not worsened offloaded, weight stable, albumin 2.6→3.0, glucose 180→140, Braden 10→12. Continue bundle, follow-up wound care, dietitian, PT/OT, teach repositioning q2h skin checks daily moisture barrier nutrition protein 1.2-1.5g/kg fluids if not contraindicated glucose control smoking cessation no massage no donut no heat no wet-to-dry moist healing when to seek emergency fever foul odor purulent erythema hypotension confusion oliguria rapid spread. Home health referral.

NCLEX Practice Questions

1. A nurse assesses a sacral wound: full thickness fat visible yellow slough, 4x5x1cm, undermining 2cm at 3 o'clock, moderate foul odor. What stage?

Stage 1 non-blanchable erythema intact
Stage 4 muscle bone tendon visible
Stage 3 full thickness fat visible may have slough undermining tunneling
Stage 2 shallow open pink partial thickness no fat

Rationale

Answer: 3. Why 3 correct: Stage 3 full thickness fat yellow lobular visible slough may be present undermining tunneling may be present depth varies. Stage 1 intact non-blanchable erythema no open, Stage 2 shallow open pink partial thickness no fat no slough/eschar, Stage 4 muscle bone tendon visible. Why others wrong: 1. Stage 1 intact no open no fat no slough. 2. Stage 4 muscle bone visible not fat. 4. Stage 2 shallow pink no fat no slough.

2. A bedbound client has Braden 11, incontinent urine/stool, albumin 2.5 low, sacrum Stage 1 non-blanchable erythema intact. What is priority bundle?

Keep supine on sacrum continuously and apply heat
Massage sacral area and use donut cushion and keep briefs wet
Wet-to-dry dressing for Stage 1 and leave open to air
Offload reposition q2h 30-degree lateral, pressure redistribution surface, offload heels, moisture barrier zinc oxide change briefs frequently perineal hygiene, nutrition consult protein 1.2-1.5g/kg, skin check daily, no massage no heat no donut no wet-to-dry

Rationale

Answer: 4. Why 4 correct: Braden ≤18 risk triggers bundle: offload reposition q2h 30-degree lateral not sacrum 90-degree, pressure redistribution low-air-loss alternating air, offload heels pillow under calves, moisture barrier zinc oxide change briefs q2h perineal hygiene front to back, nutrition protein 1.2-1.5g/kg for healing vitamin C zinc fluids if not contraindicated, skin check daily photo, no massage damages tissue no heat burns no donut increases pressure surrounding tissue no wet-to-dry damages granulation moist healing. Why others wrong: 1. Supine on sacrum heat worsens injury burns. 2. Massage damages Stage 1 donut increases pressure wet briefs MASD. 3. Wet-to-dry damages granulation painful not for pressure injuries moist healing.

3. A client has a heel wound: dry adherent brown black eschar intact no erythema no fluctuance no odor stable. What should the nurse do?

Do NOT debride stable eschar heels dry adherent intact no erythema fluctuance — protect offload monitor — per NPIAP stable eschar heels is natural cover do not remove
Apply wet-to-dry dressing and massage
Debride eschar immediately with collagenase
Leave open and apply heat

Rationale

Answer: 1. Why 1 correct: Stable eschar heels dry adherent intact no erythema no fluctuance no odor stable is natural cover protects — do NOT debride per NPIAP, offload heels pillow under calves monitor for erythema fluctuance infection, if becomes unstable boggy erythema fluctuance odor then debride per order. WHY: debriding stable eschar heels can cause osteomyelitis. Why others wrong: 2. Wet-to-dry damages granulation massage damages. 3. Debriding stable eschar heels risks bone infection. 4. Open heat burns dries.

4. A nurse assesses a wound with increasing pain, foul odor, purulent yellow green drainage, periwound erythema induration warmth, fever 101.4F, tachy 110, hypotension 90/60, confusion. What is priority?

Apply donut cushion and massage wound
Rapid response, vitals q15min, O2, large-bore IV, wound and blood cultures before antibiotics but antibiotics within 1hr if sepsis, lactate, I&O hourly, offload, wound care, labs WBC CRP BUN/Cr, notify provider STAT, prepare fluids vasopressors
Document and continue routine dressing changes
Give oral fluids and encourage ambulation only

Rationale

Answer: 2. Why 2 correct: Increasing pain foul odor purulent drainage periwound erythema induration warmth fever tachy hypotension confusion oliguria = wound infection cellulitis → sepsis septic shock emergency, need rapid response vitals q15min O2 large-bore IV cultures wound and blood before antibiotics but antibiotics within 1hr if sepsis per protocol lactate I&O hourly offload wound care labs WBC CRP BUN/Cr notify STAT fluids vasopressors. Why others wrong: 1. Donut massage worsens pressure injury. 3. Document only delays sepsis treatment. 4. Oral fluids only insufficient hypotension sepsis needs IV fluids.

5. A client has a pressure injury with granulation tissue red moist bumpy. What does this indicate?

Healthy healing tissue — moist healing appropriate, protect periwound, continue offloading nutrition
Necrotic tissue needs debridement
Stable eschar heels do not debride
Infection needs antibiotics

Rationale

Answer: 1. Why 1 correct: Granulation red moist bumpy healthy healing tissue new capillaries fibroblasts collagen — moist healing hydrocolloid foam per order, protect periwound, continue offload nutrition protein 1.2-1.5g/kg, measure PUSH decreasing good. Why others wrong: 2. Necrotic slough yellow tan eschar brown black non-viable needs debridement except stable eschar heels. 3. Stable eschar heels dry adherent brown black not granulation. 4. Infection purulent foul odor erythema fever.

6. SATA. Which are risk factors for pressure injury? Select all that apply.

Daily reposition q2h and pressure redistribution surface
Immobility Activity Mobility impairment, sensory impairment, moisture incontinence urine stool diaphoresis, poor nutrition protein <0.8g/kg weight loss, friction shear HOB >30 sliding, medical devices O2 tubing Foley
Moisture barrier and skin check daily
Prolonged OR time, hypotension poor perfusion, history prior pressure injury
Age elderly >65 thin fragile subQ loss, vascular disease arterial venous insufficiency, diabetes hyperglycemia neuropathy, anemia, edema, smoking, obesity, cognitive impairment

Rationale

Answers: 2, 4, 5. Why these: Risk factors: immobility sensory moisture incontinence poor nutrition protein <0.8g/kg friction shear HOB >30 devices O2 tubing Foley, elderly thin fragile vascular disease diabetes neuropathy anemia edema smoking obesity cognitive impairment can't reposition, prolonged OR time hypotension poor perfusion history prior pressure injury scar weaker. Why others not risk but prevention: 1. Reposition q2h pressure redistribution is prevention bundle not risk. 3. Moisture barrier skin check daily is prevention.

7. SATA. Which are appropriate for pressure injury prevention and wound care? Select all that apply.

Massage bony prominences, use donut cushions, apply heat, wet-to-dry for pressure injuries
Reposition q2h 30-degree lateral, pressure redistribution low-air-loss mattress, offload heels pillow under calves, avoid dragging, HOB ≤30 unless contraindicated
Keep supine on sacrum continuously and leave wounds open to air dry
Nutrition consult protein 1.2-1.5g/kg for healing vitamin C citrus fruits zinc meat calories fluids if not contraindicated glucose <180 HbA1c <7 smoking cessation
Moisture barrier zinc oxide, perineal hygiene front to back, change briefs frequently, skin check daily, device check q2h reposition tubing

Rationale

Answers: 2, 4, 5. Why these: Prevention reposition q2h 30-degree lateral pressure redistribution offload heels avoid dragging HOB ≤30, moisture barrier zinc oxide perineal hygiene change briefs skin check device check, nutrition protein 1.2-1.5g/kg vitamin C zinc fluids glucose control smoking cessation. Why others wrong: 1. Massage damages tissue donut increases pressure heat burns wet-to-dry damages granulation painful not for pressure injuries. 3. Supine continuously on sacrum increases pressure open to air dry delays moist healing.

8. Priority. The nurse has four clients. Who should be seen first?

Client with Stage 1 pressure injury non-blanchable erythema intact afebrile stable vitals
Client with dry cracked skin on legs no pain stable vitals
Client with Stage 3 sacral pressure injury foul odor purulent yellow green drainage periwound erythema induration warmth fever 101.6F hypotension 88/58 tachy 112 confusion oliguria 20mL/hr
Client with healing surgical incision no drainage afebrile stable

Rationale

Answer: 3. Why 3 first: Stage 3 foul odor purulent drainage periwound erythema induration warmth fever hypotension tachy confusion oliguria = infected pressure injury → sepsis septic shock emergency needs rapid response O2 IV fluids cultures wound and blood before antibiotics but antibiotics within 1hr lactate I&O. Why others later: 1. Stage 1 non-blanchable intact stable needs prevention offload. 2. Dry cracked stable needs emollients fluids. 4. Healing surgical incision stable routine.

9. Delegation. Which task can the RN delegate to LPN/VN for a client with pressure injury?

Assess and stage pressure injury and decide on debridement
Check vitals I&O daily weight Braden scale per protocol report wound size drainage odor periwound erythema fever pain and change dressing per order and reinforce repositioning nutrition per plan
Interpret wound culture and prescribe antibiotics
Teach initial diagnosis of pressure injury and order pressure redistribution mattress

Rationale

Answer: 2. Why 2 delegatable: LPN/VN can check vitals I&O daily weight Braden per protocol report wound size drainage odor periwound erythema fever pain change dressing per order reinforce repositioning nutrition per plan. Why others RN only: 1. Assess stage decide debridement RN/wound care/provider. 3. Interpret culture prescribe antibiotics provider/RN. 4. Teach initial diagnosis order mattress provider/RN.

10. NGN Case Study. A 70-year-old bedbound after stroke, incontinent urine/stool, diabetes HbA1c 8.3, Braden 10 high risk, sacrum Stage 3 5x6x1.2cm fat visible yellow slough moderate foul odor serosanguineous, periwound erythema induration warmth, undermining 3cm at 9 o'clock, temp 101.0F HR 110 BP 92/58 RR 22 SpO2 94% RA, albumin 2.7 low, WBC 13k high, weight loss 6kg, pain 7/10 during dressing change, heels cool cap refill 4 sec.

a) What condition and cues support it? b) What are 3 priority actions and why? c) What indicates improvement and what teaching to prevent recurrence?

Model answer

a) Stage 3 pressure injury infected with risk sepsis + high risk progression: Bedbound after stroke immobility sensory moisture activity mobility impairment, incontinent urine/stool moisture MASD, diabetes HbA1c high impairs WBC collagen, Braden 10 high risk, sacrum Stage 3 full thickness fat visible yellow slough non-viable moderate foul odor serosanguineous periwound erythema induration warmth undermining 3cm infection, fever 101 tachy 110 hypotension 92/58 confusion risk oliguria sepsis, albumin 2.7 low malnutrition weight loss 6kg poor healing, pain 7/10, heels cool cap refill 4 sec poor perfusion PVD.

b) Priorities: 1) Infection sepsis — vitals q15min O2 SpO2 94% crackles maybe, large-bore IV fluids per order 500mL NS reassess, wound and blood cultures before antibiotics but antibiotics within 1hr if sepsis per protocol, lactate, I&O hourly daily weight, offload reposition q2h 30-degree lateral pressure redistribution low-air-loss mattress offload heels pillow under calves, notify provider STAT wound care rapid response if hypotension worsens. 2) Wound care — measure 5x6x1.2cm undermining 3cm at 9 o'clock photo PUSH, debridement per order collagenase vs surgical except stable eschar heels not applicable, moist healing foam alginate per order, pain analgesic 30min before dressing change per order, no massage no donut no heat no wet-to-dry, moisture barrier zinc oxide change briefs q2h perineal hygiene. 3) Nutrition perfusion glucose — nutrition consult protein 1.2-1.5g/kg vitamin C citrus zinc meat fluids if not contraindicated, glucose control insulin per order HbA1c <7, labs WBC CRP albumin prealbumin BUN/Cr glucose, cap refill pulses, device check, teach caregivers.

c) Improvement: Temp 101→99F HR 110→88 BP 92/58→112/70, WBC 13k→8k, pain 7→2, wound slough decreased granulation red moist increased size 5x6x1.2→4x5x0.8cm foul odor decreased drainage scant serosanguineous periwound erythema decreased, albumin 2.7→3.1 weight stable, glucose 180→140, Braden 10→13 moderate risk. Teaching: reposition q2h 30-degree lateral if bedbound q1h if chairbound shift weight q15min if able, pressure redistribution mattress offload heels, moisture barrier change briefs perineal hygiene, skin check daily bony prominences device areas, nutrition protein 1.2-1.5g/kg vitamin C zinc fluids if not contraindicated, glucose control <180, smoking cessation, no massage no donut no heat no wet-to-dry moist healing per order, daily weight same scale/time, when to seek emergency fever foul odor purulent periwound erythema hypotension confusion oliguria rapid spread pain out of proportion crepitus bullae. Follow-up wound care dietitian PT/OT provider labs.

Key Takeaways

Braden ≤18 = risk → bundle: reposition q2h 30-degree lateral, pressure redistribution surface, offload heels, moisture barrier zinc oxide, skin check daily, nutrition protein 1.2-1.5g/kg, manage friction shear HOB ≤30, device check q2h.
Stage 1 non-blanchable erythema intact no open, Stage 2 shallow open pink partial thickness blister no fat, Stage 3 fat visible may have slough undermining, Stage 4 muscle bone tendon visible, unstageable slough/eschar covered can't stage, DTPI purple maroon intact or blood blister deep damage may evolve.
No massage Stage 1-2, no heat, no donut cushions, no wet-to-dry for pressure injuries — moist healing hydrocolloid hydrogel foam alginate per order.
Granulation red moist bumpy healthy, slough yellow tan non-viable, eschar brown black except stable eschar heels dry adherent do NOT debride protect.
Infection: increasing pain foul odor purulent periwound erythema warmth fever tachy hypotension confusion oliguria = sepsis — cultures wound and blood before antibiotics but antibiotics within 1hr, offload, wound care, labs WBC CRP lactate.
Nutrition protein 1.2-1.5g/kg vitamin C zinc calories glucose <180 HbA1c <7 hydration if not contraindicated, perfusion cap refill <3 sec, daily weight PUSH decreasing good.

References

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline (3rd ed.). EPUAP/NPIAP/PPPIA.
Jarvis, C. (2020). Physical examination and health assessment (8th ed.). Elsevier.
Hinkle, J. L., Cheever, K. H., & Overbaugh, K. J. (2022). Brunner & Suddarth's textbook of medical-surgical nursing (15th ed.). Wolters Kluwer.
Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2020). Medical-surgical nursing (11th ed.). Elsevier.
National Pressure Injury Advisory Panel. (2020). Pressure injury stages. NPIAP.
Centers for Medicare & Medicaid Services. (2023). Hospital-acquired conditions: Pressure injuries.
Wound, Ostomy and Continence Nurses Society. (2022). Guideline for prevention and management of pressure injuries. WOCN.
Silvestri, L. A., & Silvestri, A. E. (2023). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier.
Assessment Technologies Institute. (2023). ATI RN fundamentals and medical-surgical review modules (12th ed.). ATI Nursing Education.

Pressure Injuries & Wound Healing

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Clinical Judgment Practice

Prioritization Practice

Delegation Practice

Lab Values

Final Review