Skin, Wounds, Ostomy, and Pressure Injury Care
Key Takeaways
- Skin care is patient safety: pressure injury, infection, moisture injury, impaired perfusion, and device injury can worsen quickly.
- Risk assessment must lead to interventions such as repositioning, support surfaces, nutrition support, moisture control, and device checks.
- Wound assessment should describe location, size, tissue, drainage, odor, edges, surrounding skin, pain, and signs of infection.
- Ostomy teaching focuses on stoma assessment, output, pouch seal, hydration, medication concerns, and when to call.
- Escalate ischemic tissue, rapidly spreading infection, new deep tissue injury, uncontrolled drainage, or stoma color change.
Skin, Wounds, Ostomy, and Pressure Injury Care
Case anchor
An 82-year-old adult with sepsis, diabetes, incontinence, and poor oral intake has a reddened sacrum, oxygen tubing marks on the ears, and a heel that is purple and boggy. The patient says, "I do not want to bother anyone, so I stay still." The CMSRN nurse sees multiple risks: pressure, shear, moisture, poor perfusion, malnutrition, neuropathy, and medical device injury.
Pressure injury prevention
Prevention starts at admission and changes with condition. Use a validated risk tool plus clinical judgment. Immobility, decreased sensation, moisture, malnutrition, anemia, edema, fever, vasopressors, diabetes, vascular disease, and prior pressure injury all increase risk. Interventions include turning and repositioning, heel offloading, pressure-redistribution surfaces, moisture barriers, prompt incontinence care, minimizing layers under the patient, avoiding massage over bony prominences, nutrition consult, and device padding or repositioning.
Do not wait for skin breakdown to act. Nonblanchable redness over a bony prominence is a stage 1 pressure injury. Purple or maroon intact skin or a blood-filled blister may indicate deep tissue pressure injury. Slough or eschar obscuring the wound base is unstageable until enough tissue is visible, except stable dry heel eschar may be left intact per wound specialist or provider plan.
Wound assessment language
| Element | What to document |
|---|---|
| Location and size | Length, width, depth, tunneling, undermining |
| Wound bed | Granulation, epithelial tissue, slough, eschar, exposed structures |
| Drainage | Amount, color, consistency, odor after cleansing |
| Edges and periwound | Maceration, erythema, warmth, induration, rolled edges |
| Symptoms | Pain, fever, functional impact, odor distress |
Precise documentation helps the next nurse detect change. Avoid vague terms such as "looks better" without objective findings. Take photographs only according to policy and consent requirements.
Infection, perfusion, and healing
Local wound infection may cause increasing pain, warmth, erythema, swelling, purulent drainage, odor, delayed healing, or friable tissue. Systemic infection may show fever, tachycardia, hypotension, confusion, or elevated white blood cell count. Diabetic foot wounds require extra caution because neuropathy can hide pain and peripheral arterial disease can impair healing. Check pulses, capillary refill, temperature, sensation, footwear, and offloading. A cold pale foot, black tissue, or sudden severe pain needs urgent escalation.
Healing requires oxygen, perfusion, protein, calories, glucose control, and moisture balance. Teach patients that a moist wound bed is different from wet macerated skin. Dressings should match wound goals: absorb drainage, donate moisture, protect from contamination, manage odor, or support debridement as ordered. The nurse should not pack tightly; packing should fill dead space without pressure.
Ostomy assessment and teaching
A new stoma should be pink to red and moist. Mild edema is common early. A dusky, purple, black, dry, or severely bleeding stoma is urgent. Assess stoma size, protrusion, mucocutaneous junction, peristomal skin, pouch fit, output amount and character, odor, gas, pain, and patient coping. Ileostomy output is often liquid and can cause dehydration and electrolyte loss. Colostomy output varies by location.
Teach pouch emptying when one-third to one-half full, skin barrier sizing, gentle skin cleaning, avoiding oily products that prevent adhesion, and tracking output. For ileostomy, emphasize fluids, signs of dehydration, high-output reporting, and medication forms because extended-release or enteric-coated tablets may not absorb well. Include body image, clothing, intimacy, travel supplies, and follow-up with a wound ostomy continence nurse.
Moisture and device injuries
Moisture-associated skin damage from urine, stool, sweat, or wound drainage is not staged as pressure injury, but it can coexist with pressure. Use barrier products, containment devices when appropriate, breathable briefs, and frequent skin checks. Medical devices such as oxygen tubing, masks, cervical collars, compression devices, splints, casts, and urinary tubing can create pressure. Assess under and around devices at routine intervals and whenever condition changes.
Patient safety and education
For discharge, confirm the patient or caregiver can demonstrate dressing or pouch changes, explain hand hygiene, identify infection signs, obtain supplies, and follow weight-bearing or offloading instructions. Teach pressure injury prevention in plain terms: change position, protect heels, keep skin clean and dry, eat protein as allowed, and report redness that does not fade.
Escalation cues
Escalate a new deep tissue injury, rapidly spreading redness, crepitus, fever with wound change, severe pain out of proportion, loss of pulses, black or cold tissue, uncontrolled bleeding, wound dehiscence or evisceration, high-output ileostomy with dizziness, or stoma color change. CMSRN questions favor early prevention, objective assessment, and urgent action for perfusion or infection threats.
A patient's heel is intact but purple, boggy, and painful. How should the nurse interpret this finding?
A new ileostomy patient has 1800 mL output in 24 hours and reports dizziness when standing. What is the priority nursing concern?
During ostomy assessment, which stoma finding requires urgent notification?