Nursing Foundation - Wound And Pressure Injury Complete Notes

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Wound and Pressure Injury – Complete Nursing Notes

Wound and Pressure Injury are important topics in Nursing Foundation, Medical-Surgical Nursing and clinical nursing practice. Proper assessment, prevention, wound-bed care, infection prevention, pressure redistribution and documentation are essential for safe patient care.

These complete notes cover wound definition, classification, wound healing, factors affecting healing, wound assessment, pressure injury definition, risk factors, common sites, stages, prevention, nursing management, dressing principles, complications, documentation, patient education, FAQs and MCQs.

Useful for BSc Nursing, GNM Nursing, ANM, NORCET, NCLEX, Nursing Foundation and Medical-Surgical Nursing examinations.

1. Introduction

Skin is the largest organ of the human body and acts as an important barrier against mechanical injury, microorganisms, fluid loss and environmental hazards.

Loss of skin integrity can occur because of trauma, surgery, infection, vascular problems, pressure, moisture, friction, shear, burns or underlying disease.

A wound can range from a small superficial break in the skin to a complex injury involving deeper tissues. Pressure injuries are a specific category of tissue injury associated with pressure and/or shear, usually over a bony prominence or related to a medical device.

Nursing Focus:

Assess early → Identify cause → Protect tissue → Control contamination → Promote healing → Prevent complications → Document accurately.

2. Definition of Wound

A wound is a disruption or damage to the normal structure and integrity of body tissue, most commonly involving the skin and sometimes extending into deeper tissues.

Wounds may result from trauma, surgery, pressure, burns, vascular disease, infection or other pathological processes.

Exam Definition:

A wound is a break or disruption in the continuity of body tissue caused by injury, disease or a therapeutic procedure.

3. Classification of Wounds

According to Cause

  • Traumatic wound
  • Surgical wound
  • Pressure-related wound
  • Burn wound
  • Vascular wound
  • Diabetic wound
  • Infectious wound

According to Skin Integrity

  • Open wound: Skin or mucosal integrity is disrupted.
  • Closed wound: Skin remains intact but underlying tissues may be damaged.

According to Duration

  • Acute wound: Usually progresses through healing in an expected sequence.
  • Chronic wound: Fails to progress normally through the expected healing process and may remain in a prolonged inflammatory state.

4. Types of Wounds

Type Description
Abrasion Superficial injury caused by rubbing or scraping of the skin.
Laceration A tear or cut in tissue caused by trauma.
Incision A wound produced by a sharp instrument, commonly during surgery.
Puncture wound A wound caused by a pointed object penetrating the tissue.
Contusion Blunt trauma causing tissue damage and bleeding beneath intact skin.
Avulsion Partial or complete tearing away of tissue.
Ulcer A localized area of tissue breakdown associated with underlying causes such as pressure, vascular disease or neuropathy.

5. Wound Healing

Wound healing is a complex biological process through which damaged tissue is repaired and tissue integrity is restored.

Healing requires coordinated activity involving blood vessels, inflammatory cells, growth factors, extracellular matrix, fibroblasts, collagen and epithelial cells.

Adequate perfusion + oxygenation + nutrition + infection control + protection from further trauma = favourable conditions for healing.

6. Phases of Wound Healing

Phase Main Events
Hemostasis Immediately after injury, blood vessels constrict and clotting mechanisms help control bleeding.
Inflammatory Phase Inflammatory cells remove damaged tissue and help control microorganisms. Typical features may include redness, warmth and swelling as part of the normal response.
Proliferative Phase Granulation tissue formation, fibroblast activity, collagen deposition and epithelialization occur.
Remodeling/Maturation Collagen is reorganized and the tensile strength of the healed tissue gradually improves.
Memory Trick:

H-I-P-R

H – Hemostasis
I – Inflammation
P – Proliferation
R – Remodeling

7. Factors Affecting Wound Healing

Local Factors

  • Infection
  • Poor tissue perfusion
  • Excessive pressure
  • Edema
  • Foreign material
  • Repeated trauma
  • Excessive moisture
  • Necrotic tissue

Systemic Factors

  • Malnutrition
  • Diabetes
  • Advanced age
  • Anemia
  • Immunosuppression
  • Smoking
  • Poor oxygenation
  • Peripheral vascular disease
  • Severe systemic illness
  • Certain medications, including some drugs that affect immune or inflammatory responses
Important:

Wound healing is influenced by the whole patient, not just the wound itself. Always assess systemic health, nutrition, perfusion, mobility and underlying disease.

8. Wound Assessment

A systematic wound assessment helps establish a baseline and allows the nurse to identify deterioration or improvement.

Assess the Following

  • Location
  • Cause/etiology
  • Length
  • Width
  • Depth
  • Wound bed
  • Wound edges
  • Drainage
  • Odor
  • Surrounding skin
  • Pain
  • Signs of infection
  • Undermining
  • Tunneling
  • Necrotic tissue
  • Granulation tissue
  • Exudate amount and character
Wound Assessment Principle:

Inspect and, when appropriate, palpate the wound and surrounding tissue. Compare findings with previous assessments and document changes clearly.

9. How to Describe a Wound

Parameter What to Document
Location Exact anatomical site.
Size Length × width and depth when appropriate.
Wound bed Granulation, slough, eschar, epithelial tissue or exposed structures.
Exudate Amount, color, consistency and odor.
Edges Attached, rolled, macerated, irregular or other relevant characteristics.
Surrounding skin Redness, warmth, edema, maceration, discoloration or other changes.
Pain Location, severity, quality and factors affecting pain.
Infection Local and systemic signs.

10. Signs of Wound Infection

Local Signs

  • Increasing redness or discoloration
  • Increasing warmth
  • Swelling
  • Increasing pain
  • Purulent drainage
  • Malodor
  • Delayed healing
  • Wound deterioration

Systemic Signs

  • Fever
  • Chills
  • Weakness
  • Confusion or altered mental status in vulnerable patients
  • Other systemic manifestations of infection
Clinical Alert:

Not every red or draining wound is automatically infected. Wound findings should be interpreted in the clinical context and assessed for signs of infection or inflammation.

11. General Wound Care Principles

  1. Assess the wound and patient.
  2. Identify the underlying cause.
  3. Control bleeding when present.
  4. Protect the wound from contamination and further trauma.
  5. Cleanse according to the wound type and clinical protocol.
  6. Remove devitalized tissue when clinically indicated and within scope of practice.
  7. Select an appropriate dressing based on wound characteristics.
  8. Manage exudate and protect surrounding skin.
  9. Address pain.
  10. Optimize nutrition and hydration.
  11. Address pressure, friction, shear and other mechanical causes.
  12. Monitor healing progress.
  13. Document findings and interventions.

12. Wound Dressing Principles

A dressing should be selected according to wound characteristics, exudate, infection status, tissue type, surrounding skin, patient comfort and the overall treatment plan.

Common Dressing Categories

Dressing Type General Purpose
Gauze Absorption, protection and packing in selected situations.
Foam Management of moderate exudate and protection.
Hydrocolloid Supports a moist wound environment for selected low-to-moderately exuding wounds.
Hydrogel Provides moisture and may be useful for selected dry wounds.
Alginate Absorbs exudate and may assist with hemostasis in selected wounds.
Antimicrobial dressings Used selectively when clinically indicated rather than automatically for every wound.
Remember:

There is no single "best dressing" for every wound. Dressing selection should be individualized.

13. Definition of Pressure Injury

A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device, resulting from intense and/or prolonged pressure or pressure in combination with shear.

Pressure injuries can occur in people of any age when risk factors and clinical circumstances are present.

Exam Point:

The preferred modern term is Pressure Injury rather than only "bed sore" or "pressure ulcer."

14. Pathophysiology of Pressure Injury

Pressure applied to tissue can impair blood flow and lymphatic drainage. Prolonged or excessive mechanical loading may result in tissue deformation, ischemia and cellular injury.

Pressure / Shear
↓
Tissue Deformation
↓
Reduced Perfusion
↓
Ischemia
↓
Cellular Damage
↓
Tissue Necrosis
↓
Pressure Injury

The severity of injury depends on factors such as magnitude and duration of loading, tissue tolerance, perfusion, mobility, sensation and overall health.

15. Risk Factors for Pressure Injury

Major Risk Factors

  • Immobility
  • Limited ability to reposition independently
  • Reduced sensation
  • Decreased level of consciousness
  • Malnutrition
  • Dehydration
  • Incontinence and excess moisture
  • Friction and shear
  • Poor tissue perfusion
  • Diabetes and other chronic illnesses
  • Advanced age
  • History of previous pressure injury
  • Edema
  • Critical illness
  • Medical devices
  • Spinal cord injury
  • Prolonged bed rest

16. Common Sites of Pressure Injury

Position Common Pressure Areas
Supine Occiput, scapulae, elbows, sacrum/coccyx, heels.
Side-lying Ear, shoulder, greater trochanter, knee, ankle.
Prone Forehead/face, shoulders, chest, knees, toes and other contact areas.
Sitting Ischial tuberosities, sacrum/coccyx, heels and areas affected by posture or equipment.
Important:

Pressure injuries can also occur beneath medical devices such as oxygen equipment, masks, tubes, splints, casts and other devices.

17. Pressure Injury Risk Assessment

Risk assessment should combine clinical judgment with an appropriate validated risk assessment tool when used by the institution.

Commonly Discussed Risk Assessment Tool

Braden Scale is widely used to assess pressure injury risk. It considers:

  • sensory perception
  • moisture
  • activity
  • mobility
  • nutrition
  • friction and shear
Braden Scale Memory:

S – Sensory perception
M – Moisture
A – Activity
M – Mobility
N – Nutrition
F – Friction & Shear

18. Comprehensive Skin Assessment

A comprehensive skin assessment involves systematic inspection of the skin and attention to areas at risk, particularly bony prominences and areas under medical devices.

Assess

  • Skin color/discoloration
  • Temperature
  • Moisture
  • Skin integrity
  • Edema
  • Induration or changes in firmness
  • Pain or tenderness
  • Non-blanchable discoloration
  • Open areas
  • Pressure from devices
Darkly Pigmented Skin:

Pressure-related injury may be more difficult to recognize visually. Changes in temperature, firmness, moisture, pain and discoloration should be assessed carefully rather than relying only on redness.

19. Pressure Injury Stages

The commonly used NPIAP staging system describes pressure injuries as Stage 1, Stage 2, Stage 3, Stage 4, Unstageable Pressure Injury and Deep Tissue Pressure Injury.

Important:

Pressure injury staging describes the extent of tissue damage. It is not a simple "healing scale," and a pressure injury should not be reverse-staged as it heals.

20. Stage 1 Pressure Injury

Stage 1 is characterized by intact skin with localized non-blanchable erythema or discoloration in the affected area.

Important Features

  • Skin remains intact.
  • Localized non-blanchable discoloration.
  • May be painful or tender.
  • Temperature may differ from surrounding tissue.
  • Texture or firmness may change.
Remember:

Stage 1 = Intact skin + Non-blanchable discoloration.

21. Stage 2 Pressure Injury

Stage 2 involves partial-thickness skin loss with exposed dermis. The wound bed is viable and may appear pink or red and moist.

Important Features

  • Partial-thickness skin loss.
  • Exposed dermis.
  • Pink/red and moist wound bed.
  • May appear as an intact or ruptured serum-filled blister.

Stage 2 pressure injury does not include exposed adipose (fat), granulation tissue, slough or eschar.

Remember:

Stage 2 = Partial-thickness skin loss + exposed dermis.

22. Stage 3 Pressure Injury

Stage 3 involves full-thickness skin loss. Adipose tissue may be visible and granulation tissue may be present. Undermining and tunneling may occur.

Possible Findings

  • Full-thickness skin loss.
  • Visible adipose tissue.
  • Granulation tissue.
  • Epibole/rolled wound edges may occur.
  • Undermining may be present.
  • Tunneling may be present.

Structures such as fascia, muscle, tendon, cartilage and bone are not exposed in Stage 3. If such structures are exposed, the injury meets the criteria for Stage 4.

Remember:

Stage 3 = Full-thickness skin loss + adipose may be visible.

23. Stage 4 Pressure Injury

Stage 4 involves full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, cartilage, bone or other deep structures.

Possible Features

  • Full-thickness tissue loss.
  • Exposed or palpable deep structures.
  • Slough and/or eschar may be visible.
  • Undermining may occur.
  • Tunneling may occur.
  • Potential osteomyelitis or other deep complications may occur.
Remember:

Stage 4 = Full-thickness tissue loss + exposed/palpable deep structures.

24. Unstageable Pressure Injury

An Unstageable Pressure Injury involves full-thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because it is obscured by slough and/or eschar.

If the obscuring material is removed and the depth can be determined, the injury can then be classified according to the visible tissue involvement.

Memory:

Unstageable = Depth obscured by slough and/or eschar.

25. Deep Tissue Pressure Injury

Deep Tissue Pressure Injury is characterized by persistent non-blanchable deep red, maroon or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister associated with underlying tissue damage.

Possible Features

  • Deep red, maroon or purple discoloration.
  • May be associated with pain or changes in temperature/firmness.
  • May progress rapidly.
  • May be difficult to identify in darkly pigmented skin.

A suspected deep tissue pressure injury requires prompt assessment and pressure redistribution/offloading.

26. Medical Device-Related Pressure Injury

Medical devices can create localized pressure, friction or shear and can cause pressure-related tissue damage.

Examples of At-Risk Areas

  • Oxygen tubing around ears
  • Non-invasive ventilation masks
  • Endotracheal tube-related areas
  • Urinary catheter-related pressure areas
  • Splints
  • Casts
  • Compression devices
  • Monitoring devices
Nursing Action:

Inspect skin beneath and around devices regularly, ensure appropriate fit, avoid unnecessary pressure and follow device-specific protocols.

27. Pressure Injury Prevention

Prevention is a major nursing responsibility. A prevention plan should be individualized according to risk, mobility, skin condition, nutrition, comorbidities and patient preferences.

Major Prevention Strategies

  • Perform regular skin assessment.
  • Assess pressure injury risk.
  • Reposition according to individualized need and clinical condition.
  • Use appropriate pressure-redistributing surfaces.
  • Protect heels and other high-risk areas.
  • Manage moisture and incontinence.
  • Reduce friction and shear.
  • Optimize nutrition and hydration.
  • Encourage safe mobility.
  • Inspect skin under medical devices.
  • Educate the patient and family.
  • Document the prevention plan.

28. Positioning and Repositioning

Repositioning reduces prolonged loading of vulnerable tissues. There is no single repositioning interval suitable for every patient.

The schedule should consider the patient's tissue tolerance, mobility, clinical condition, skin assessment, support surface and overall treatment goals.

Important Principles

  • Follow an individualized repositioning schedule.
  • Use appropriate lifting and repositioning equipment.
  • Avoid dragging the patient across the bed.
  • Reduce friction and shear.
  • Offload vulnerable areas.
  • Protect the heels when indicated.
  • Document repositioning according to policy.
Do Not Use a Universal "2-Hour Rule" for Every Patient.

Repositioning frequency should be individualized rather than treated as a one-size-fits-all number.

29. Support Surfaces

Pressure-redistributing support surfaces help reduce tissue loading in patients at risk.

Examples

  • Pressure-redistributing mattresses
  • High-specification foam mattresses
  • Alternating-pressure surfaces
  • Pressure-redistributing cushions
  • Heel offloading devices

Support surfaces should complement, not replace, regular skin assessment, repositioning and individualized pressure management.

30. Nutrition and Hydration

Adequate nutrition and hydration are important for maintaining skin integrity and supporting wound healing.

Assess

  • Weight and weight changes
  • Food intake
  • Fluid intake
  • Protein intake
  • Signs of nutritional deficiency
  • Relevant laboratory findings when ordered

Important Nutrients

  • Protein
  • Energy/calories
  • Vitamin and mineral requirements
  • Adequate fluids when not contraindicated
Important:

Do not automatically give supplements to every patient. Nutritional intervention should be based on assessment and clinical need.

31. Moisture and Incontinence Management

Excess moisture from urine, stool, perspiration or wound drainage can weaken the skin and increase susceptibility to damage.

Nursing Measures

  • Provide prompt cleansing after incontinence.
  • Keep skin clean and appropriately dry.
  • Use appropriate moisture-barrier products when indicated.
  • Manage excessive sweating.
  • Manage wound exudate appropriately.
  • Avoid excessive friction during cleansing.

32. Nursing Management of Wound and Pressure Injury

Assessment

  • Assess patient overall condition.
  • Assess wound characteristics.
  • Assess pain.
  • Assess infection risk.
  • Assess nutrition and hydration.
  • Assess mobility.
  • Assess pressure and shear factors.

Skin Protection

  • Maintain skin hygiene.
  • Control moisture.
  • Reduce pressure.
  • Use appropriate support surfaces.
  • Protect vulnerable areas.

Wound Care

  • Follow prescribed wound cleansing and dressing plan.
  • Maintain appropriate wound environment.
  • Manage exudate.
  • Monitor wound progression.
  • Report deterioration.

Pain Management

  • Assess pain before care.
  • Provide prescribed analgesia.
  • Use appropriate non-pharmacological measures.
  • Reassess pain after intervention.

Collaborative Care

  • Physician/medical team
  • Wound care specialist
  • Dietitian
  • Physiotherapist
  • Occupational therapist
  • Other specialists according to patient needs

33. Complications of Wounds and Pressure Injuries

  • Local infection
  • Cellulitis
  • Abscess
  • Delayed healing
  • Wound dehiscence
  • Bleeding
  • Necrosis
  • Osteomyelitis
  • Sepsis
  • Chronic pain
  • Reduced mobility
  • Psychological distress
  • Prolonged hospitalization
Emergency Warning Signs:

Rapidly spreading redness/discoloration, severe pain out of proportion, systemic deterioration, uncontrolled bleeding, rapidly worsening wound, significant tissue necrosis or signs of sepsis require urgent clinical assessment.

34. Wound and Pressure Injury Documentation

Accurate documentation provides a baseline for monitoring and supports continuity of care.

Document

  • Date and time of assessment
  • Location
  • Cause/etiology when known
  • Stage/category when applicable
  • Length
  • Width
  • Depth
  • Wound bed characteristics
  • Exudate
  • Odor
  • Wound edges
  • Surrounding skin
  • Pain
  • Undermining/tunneling
  • Signs of infection
  • Dressing applied
  • Patient tolerance
  • Pressure-relieving interventions
  • Repositioning plan
  • Nutrition interventions
  • Patient/family education

35. Patient Education

  • Explain the cause and risk factors of the wound.
  • Teach the importance of regular position changes.
  • Encourage safe mobility when possible.
  • Explain appropriate skin care.
  • Teach moisture and incontinence management.
  • Explain nutrition and hydration requirements.
  • Teach signs of infection.
  • Teach the patient to report new pain or skin discoloration.
  • Explain proper use of cushions and support surfaces.
  • Teach caregivers safe repositioning techniques.

36. Clinical Safety Points

  • Do not massage an area of suspected pressure injury.
  • Do not ignore persistent non-blanchable discoloration.
  • Inspect skin under medical devices.
  • Do not drag patients during repositioning.
  • Use appropriate pressure-redistributing equipment.
  • Assess nutrition and hydration.
  • Control moisture.
  • Assess pain regularly.
  • Document wound changes accurately.
  • Do not automatically classify every skin lesion as a pressure injury.
  • Identify and address the underlying cause.
  • Escalate rapidly worsening wounds or systemic deterioration.

37. Important Exam Points

  • Stage 1: Intact skin + non-blanchable discoloration.
  • Stage 2: Partial-thickness skin loss + exposed dermis.
  • Stage 3: Full-thickness skin loss; adipose may be visible.
  • Stage 4: Full-thickness skin and tissue loss with exposed/palpable deep structures.
  • Unstageable: Full-thickness tissue loss with depth obscured by slough and/or eschar.
  • Deep Tissue Pressure Injury: Persistent deep red, maroon or purple discoloration or characteristic blood-filled blister/epidermal separation.
  • Major prevention: Risk assessment + skin assessment + pressure redistribution + repositioning + moisture control + nutrition.
  • Braden Scale: Sensory perception, moisture, activity, mobility, nutrition, friction/shear.
  • Major complication: Infection and deeper tissue involvement can occur.
  • Medical devices: Can cause pressure injury.

38. Frequently Asked Questions

1. What is a pressure injury?

A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical device, resulting from pressure or pressure combined with shear.

2. What is Stage 1 pressure injury?

Stage 1 is intact skin with localized non-blanchable erythema or discoloration.

3. What is Stage 2 pressure injury?

Stage 2 involves partial-thickness skin loss with exposed dermis.

4. What is Stage 3 pressure injury?

Stage 3 involves full-thickness skin loss in which adipose tissue may be visible. Granulation tissue, undermining and tunneling may occur.

5. What is Stage 4 pressure injury?

Stage 4 involves full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, cartilage, bone or other deep structures.

6. What is an unstageable pressure injury?

It is full-thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because it is obscured by slough and/or eschar.

7. What is the Braden Scale?

The Braden Scale is a commonly used pressure injury risk assessment tool that considers sensory perception, moisture, activity, mobility, nutrition and friction/shear.

8. Can pressure injury occur in a young patient?

Yes. Pressure injury can occur at any age when sufficient risk factors are present, including immobility, reduced sensation, critical illness or medical-device pressure.

9. Why is nutrition important in wound healing?

Adequate energy, protein, fluids and appropriate micronutrients support tissue repair and overall health. Nutritional intervention should be based on individual assessment.

10. Should pressure injury areas be massaged?

Routine massage or rubbing of suspected pressure-injured areas is not recommended as a prevention strategy.

11. Can a pressure injury occur under a medical device?

Yes. Medical devices can create localized pressure and cause device-related pressure injury.

12. Is every wound with redness infected?

No. Redness can occur with inflammation, pressure, irritation or other conditions. Infection should be assessed using the complete clinical picture.

39. 10 MCQs for Practice

Q1. Which finding is characteristic of a Stage 1 pressure injury?

A. Exposed bone

B. Full-thickness tissue loss

C. Intact skin with non-blanchable discoloration

D. Exposed adipose tissue

Q2. Stage 2 pressure injury involves:

A. Exposed muscle

B. Partial-thickness skin loss with exposed dermis

C. Exposed bone

D. Full-thickness tissue loss with exposed tendon

Q3. Which finding is most consistent with Stage 3 pressure injury?

A. Intact skin

B. Partial-thickness skin loss only

C. Full-thickness skin loss with adipose tissue potentially visible

D. Only purple discoloration with intact skin

Q4. Which pressure injury category has its depth obscured by slough and/or eschar?

A. Stage 1

B. Stage 2

C. Stage 3

D. Unstageable

Q5. Which is included in the Braden Scale?

A. Blood pressure

B. Sensory perception

C. Heart rate

D. Body temperature

Q6. Which is an important pressure injury prevention measure?

A. Prolonged pressure on bony prominences

B. Routine massage of reddened areas

C. Individualized repositioning and pressure redistribution

D. Keeping the skin continuously moist

Q7. Which phase of wound healing involves granulation tissue formation?

A. Hemostasis

B. Proliferative phase

C. Immediate hemostatic phase only

D. Remodeling only

Q8. Which factor can delay wound healing?

A. Adequate nutrition

B. Good tissue perfusion

C. Infection

D. Appropriate wound protection

Q9. Which area should receive special attention during pressure injury prevention?

A. Only the hands

B. Bony prominences and areas beneath medical devices

C. Only the face

D. Only the abdomen

Q10. Which statement about repositioning is most appropriate?

A. Every patient must follow exactly the same repositioning schedule.

B. Repositioning is unnecessary when a pressure-relieving mattress is used.

C. Repositioning should be individualized according to patient and tissue tolerance.

D. Repositioning should be avoided in high-risk patients.

40. Answers to 10 MCQs

  1. C – Intact skin with non-blanchable discoloration.
  2. B – Partial-thickness skin loss with exposed dermis.
  3. C – Full-thickness skin loss with adipose tissue potentially visible.
  4. D – Unstageable pressure injury.
  5. B – Sensory perception.
  6. C – Individualized repositioning and pressure redistribution.
  7. B – Proliferative phase.
  8. C – Infection.
  9. B – Bony prominences and areas beneath medical devices.
  10. C – Repositioning should be individualized according to patient and tissue tolerance.

41. Quick Revision – Wound & Pressure Injury

Wound Healing

Hemostasis → Inflammation → Proliferation → Remodeling

Pressure Injury Stages

  • Stage 1: Intact skin + non-blanchable discoloration.
  • Stage 2: Partial-thickness + exposed dermis.
  • Stage 3: Full-thickness + adipose may be visible.
  • Stage 4: Full-thickness + deep structures exposed/palpable.
  • Unstageable: Depth hidden by slough/eschar.
  • Deep Tissue: Deep red/maroon/purple discoloration or characteristic deep tissue injury findings.

Prevention

Assess → Reposition → Offload → Protect Skin → Control Moisture → Optimize Nutrition → Inspect Devices → Document

Braden Scale

Sensory Perception + Moisture + Activity + Mobility + Nutrition + Friction/Shear

42. Conclusion

Wound care and pressure injury prevention are fundamental nursing responsibilities. Effective care begins with early assessment and continues with identification of the underlying cause, protection of tissue, appropriate pressure redistribution, infection prevention, nutritional support, pain management and accurate documentation.

Pressure injuries are preventable in many circumstances when risk is recognized early and an individualized prevention plan is implemented. However, prevention should never depend on a single intervention. Skin assessment, mobility, moisture control, nutrition, support surfaces and repositioning all work together as part of a comprehensive care plan.

Final Nursing Principle:

“Assess early, relieve pressure, protect the skin, treat the cause and document every important change.”

Continue Your Nursing Preparation

For more Nursing Foundation notes, clinical procedure notes, BSc Nursing study material, NORCET preparation, NCLEX practice questions and nursing MCQs, continue learning with Unity Medical Academy.

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Important Clinical Disclaimer

These notes are prepared for nursing education and examination preparation. Actual wound assessment, staging, dressing selection, debridement and other clinical interventions should be performed by appropriately trained healthcare professionals according to current institutional policies, patient-specific assessment, approved clinical guidelines and scope of practice. Wound care plans should be individualized because patients and wounds differ significantly.

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