10.3 Wounds, Skin Breakdown, and Chronic Conditions
Key Takeaways
- Pressure injuries are staged 1 through 4, from non-blanchable redness of intact skin to full-thickness tissue loss exposing muscle or bone
- The biggest risk factors are immobility, moisture, poor nutrition and hydration, fragile aging skin, and friction or shearing
- Prevention is the CNA's daily work: reposition at least every 2 hours, keep skin clean and dry, support nutrition and hydration, and lift — never drag — during moves
- Observe and report wound changes precisely: amount and color of drainage, odor, redness or warmth at the edges, and size
- In chronic conditions such as arthritis, osteoporosis, Parkinson's disease, and cancer, the CNA adapts care for comfort, safety, and dignity rather than treating the disease
Pressure Injuries: Stages 1 Through 4
A pressure injury (also called pressure ulcer, bedsore, or decubitus ulcer) is damage to skin and underlying tissue caused by unrelieved pressure, usually over a bony area — the tailbone (sacrum), hips, heels, ankles, elbows, shoulder blades, and back of the head. Pressure squeezes capillaries shut, starving the tissue of blood. Injuries are staged by depth:
| Stage | Description |
|---|---|
| Stage 1 | Intact skin with non-blanchable redness — the area stays red when pressed and does not blanch (turn white); may feel warm, firm, or painful |
| Stage 2 | Partial-thickness skin loss — a shallow open ulcer, blister, or abrasion with a red-pink wound bed |
| Stage 3 | Full-thickness skin loss — fat may be visible, but bone, tendon, and muscle are not exposed |
| Stage 4 | Full-thickness loss with exposed muscle, tendon, or bone; risk of serious infection |
Two more categories matter: unstageable injuries, where the wound bed is covered by slough or eschar (dead tissue) so depth cannot be judged, and deep tissue injury, intact dark purple or maroon skin signaling damage underneath. The exam point: Stage 1 is still-intact skin that stays red — catching breakdown here, before the skin opens, is the whole goal.
Who Is at Risk
- Immobility: residents who cannot reposition themselves in bed or a chair — the single biggest factor
- Moisture: incontinence of urine or stool, sweat, and wound drainage soften (macerate) skin so it breaks easily
- Poor nutrition and hydration: without protein, vitamins, and fluids, skin cannot repair itself
- Age: older skin is thinner, drier, and has less fat and blood flow
- Friction and shearing: dragging skin across sheets, or sliding down in a raised bed, tears tissue layers apart
- Reduced sensation or awareness (diabetes, stroke, sedation), poor circulation, and chronic illness
Prevention: The CNA's Daily Work
Most pressure injuries are preventable, and prevention is squarely in the nursing assistant role:
- Reposition at least every 2 hours (q2h) in bed — or more often per the care plan — and every hour for chair-bound residents; teach or assist small weight shifts in between. Use pillows and wedges to keep pressure off bony prominences, and keep heels floated off the mattress
- Keep skin clean and dry: cleanse promptly after incontinence, use moisture-barrier creams as ordered, change wet or soiled linens and briefs right away, and avoid hot water and harsh soap
- Avoid friction and shearing: lift with a draw sheet during moves instead of dragging; keep the head of the bed at 30 degrees or less when the resident is lying flat, since sliding down causes shearing; protect heels and elbows
- Support nutrition and hydration: encourage meals and fluids, record intake accurately, and report poor eating
- Inspect the skin every time you give care: bath time, toileting, and repositioning are your inspection windows. Report any redness that does not fade — especially over bony areas — immediately
Wound Observation and Reporting
When a resident has a wound, the nurse assesses it clinically — but you see it during every episode of care and report changes precisely and factually:
- Drainage: amount (none, scant, moderate, large), color (clear, bloody/serosanguineous, yellow, green), and thickness
- Odor: a new or foul odor suggests infection
- Surrounding skin: redness, warmth, swelling, or the wound edges pulling apart
- Size and appearance: any increase in length, width, or depth, and new pain
Report in objective terms — "quarter-sized red area on the left heel that does not blanch" — not interpretations. Healing factors to remember: good protein and vitamin C intake, hydration, circulation, keeping pressure and moisture off the site, stable blood sugar, and freedom from infection all speed healing; smoking, poor nutrition, diabetes, pressure, and age slow it.
While repositioning a resident, the nursing assistant notices a reddened area over the tailbone that stays red when pressed. The skin is intact. How is this classified?
Common Chronic Conditions: What the CNA Observes and Does
Arthritis is joint inflammation causing pain, stiffness, and reduced motion — worst in the morning for osteoarthritis and rheumatoid arthritis alike. Support joints during care, allow extra time for dressing and bathing, use gentle range-of-motion as the care plan directs, apply warm or cold packs only if ordered, and let the resident do what they can to preserve independence.
Osteoporosis is thinning, porous bone that fractures easily — especially the hip, wrist, and spine. Handle and transfer residents gently, never pull on limbs, keep pathways clear to prevent falls, and encourage weight-bearing activity and calcium-rich foods per the care plan. A fall for this resident can mean a broken hip even from standing height.
Parkinson's disease is a progressive brain disorder causing tremor at rest, muscle rigidity, slow movement (bradykinesia), a shuffling gait, poor balance, and a masked facial expression. Fall prevention is paramount; allow plenty of time for every task, serve meals adapted for swallowing difficulty (dysphagia is common later in the disease), and understand that slurred, soft speech does not mean confusion.
Cancer and comfort care: wherever a resident is in a cancer journey, your role is comfort, observation, and dignity — gentle mouth care for sores from treatment, careful skin care, positioning for comfort, reporting nausea, pain, fatigue, or poor intake, and respecting the emotional weight the resident and family carry.
Across all chronic conditions the pattern is the same: you do not treat the disease, but your pacing, gentleness, safety measures, and prompt reporting of change are the care.
Which action best helps prevent shearing injury when caring for a resident in bed?