Skin Integrity And Pressure Injury Prevention - NCLEX-PN

Sustained pressure causing ischemia and tissue necrosis. Prolonged compression over bony areas restricts blood flow, leading to oxygen deprivation and subsequent cell death in vulnerable tissues.

Nonblanchable erythema of intact skin. Indicates initial tissue damage where pressure impairs perfusion, preventing the reddened area from paling under light fingertip pressure.

Partial-thickness skin loss with exposed dermis. Represents superficial ulceration involving loss of epidermis and partial dermis, often appearing as a shallow crater or ruptured blister.

Full-thickness skin loss; adipose visible; no bone/tendon. Involves tissue destruction through the dermis into subcutaneous layers, exposing fat but not reaching muscle, tendon, or bone.

Full-thickness loss with exposed bone, tendon, or muscle. Signifies extensive destruction penetrating to musculoskeletal structures, heightening risks like infection and delayed healing.

Depth obscured by slough or eschar. Necrotic tissue obscures the wound base, preventing determination of the true extent of tissue loss until debridement occurs.

Persistent nonblanchable deep red/maroon/purple discoloration. Reflects underlying soft tissue damage from intense pressure or shear, often progressing to reveal full-thickness injury.

Slough. Represents devitalized, adherent tissue that must be removed to promote healing and assess the underlying wound bed.

Eschar. Forms a dry, adherent crust of necrotic tissue that protects but can harbor infection if not appropriately managed.

Moist, beefy red or pink tissue. Signifies active healing as new vascular tissue fills the wound defect with collagen and capillaries.

Immobility or significantly limited mobility. Prevents independent pressure relief, allowing continuous compression on bony prominences and increasing ischemia risk.

Incontinence-associated dermatitis from urine or stool. Prolonged exposure to irritants macerates skin, reducing its barrier function and heightening vulnerability to pressure damage.

Cleanse promptly and apply a moisture barrier protectant. Immediate cleansing removes irritants, while barriers shield skin from moisture, preventing maceration and breakdown.

Reposition at least every 2 hours. Frequent position changes alleviate sustained pressure, restoring circulation and minimizing tissue ischemia over time.

Pressure relief at least every 1 hour while seated. Seated postures concentrate higher pressure on smaller areas like ischia, necessitating more frequent relief to prevent injury.

Keep head of bed at or below $30^\circ$ when possible. Lower elevations minimize sliding forces that create shear stress on sacral and coccygeal tissues during bed elevation.

Use a drawsheet or lift device; do not drag the patient. Lifting eliminates dragging-induced friction and shear, protecting skin integrity during patient repositioning in bed.

Pressure-redistributing mattress or mattress overlay. Specialized surfaces evenly distribute weight, reducing peak pressures on vulnerable bony prominences to prevent injury.

Avoid donut cushions; they increase localized pressure. Ring designs concentrate pressure peripherally, potentially causing ischemia in the central area intended for protection.

Blanching erythema (redness turns white with pressure). Demonstrates intact perfusion as pressure displaces blood temporarily, distinguishing reactive hyperemia from true injury.

Assess temperature, firmness, and pain rather than blanching. Pigmentation masks color changes, so tactile and sensory cues better detect early pressure damage in darker skin tones.

Float heels off the bed with pillows or a heel suspension device. Suspends heels to eliminate direct contact with surfaces, reducing pressure and promoting blood flow to prevent ulcers.

Protein-calorie malnutrition. Deficiencies impair collagen synthesis, immune response, and tissue repair, delaying healing and increasing breakdown risk.

Stage, location, size, drainage, wound bed, and periwound skin. Detailed recording tracks wound progression, informs care planning, and ensures continuity among healthcare providers.