Nursing study guide
Integumentary nursing
Protect the barrier, identify the cause, support healing, and recognize wounds or burns that threaten life or function.
Nursing filter
Assess the patient first, recognize time-sensitive change, prevent harm, and trend the response.
Connect systems
Symptoms, laboratory patterns, medications, nutrition, function, and psychosocial needs interact.
Safety boundary
Use current orders, facility policy, clinical supervision, and emergency pathways.
Skin assessment
Describe what you see and what the patient feels
Document objective location, size, tissue, drainage, surrounding skin, pain, and change.
Risk
Mobility, sensation, perfusion, moisture, nutrition, friction/shear, devices, diabetes, age, medicines, and care access.
Inspect
Color across the patient skin tone, temperature, moisture, turgor context, integrity, rash/lesion, pressure areas, folds, feet, and devices.
Escalate
Rapid spread, severe pain, crepitus, systemic illness, necrosis, compartment concern, mucosal involvement, or airway/facial burn.
Wound healing
Perfusion, moisture balance, pressure relief, nutrition, and infection control work together
A dressing cannot correct an untreated cause.
Assess the cause
Surgical, traumatic, pressure, arterial, venous, neuropathic, inflammatory, moisture, or malignant wounds need different plans.
Measure consistently
Use the approved method for length, width, depth, undermining/tunneling, tissue, drainage, odor after cleansing, edge, and surrounding skin.
Support healing
Offload pressure, optimize perfusion and glucose, meet nutrition/hydration needs, manage edema/moisture, and use ordered wound products.
Pressure injuries
Prevent pressure and shear before tissue fails
Stage only after identifying pressure as the etiology and follow current staging guidance.
Prevention bundle
Risk and skin assessment, individualized repositioning/offloading, support surface, moisture care, nutrition, mobility, device checks, and patient/caregiver teaching.
Do not reverse-stage
A healing deeper injury is documented as healing at its deepest known stage, not relabeled as a shallower stage.
Escalate
New nonblanching change, deep tissue discoloration, device injury, exposed structures, undermining, infection, or rapid deterioration.
Burns
Airway, breathing, circulation, temperature, and exposure come first
Depth and surface area matter, but mechanism and location can make a small burn high risk.
| Priority | Assess | Nursing action |
|---|---|---|
| Airway / inhalation | Enclosed-space exposure, facial/oral burns, soot, hoarseness, stridor, altered status | Give emergency support and escalate early because edema can progress. |
| Circulation | Shock, circumferential injury, distal perfusion, associated trauma | Monitor perfusion, obtain access, give ordered resuscitation, and report restriction/compartment signs. |
| Wound / temperature | Depth, extent, location, contamination, pain, tetanus status | Stop the burning process, remove constricting items, cover appropriately, prevent hypothermia; avoid ice on major burns. |
Infection + pain
A changing wound can signal infection, ischemia, or treatment injury
Colonization and drainage do not alone define invasive infection.
Infection clues
Increasing pain, erythema, warmth, swelling, purulence, odor after cleansing, delayed healing, systemic change, or exposed/deep tissue findings.
Pain plan
Assess background, incident, procedural, and neuropathic pain; premedicate when ordered and reassess function and adverse effects.
Asepsis
Use clean or sterile technique according to wound type, order, and policy; protect supplies and avoid cross-contamination.
Delegation + teaching
Skin care is team work with RN evaluation
Routine prevention can be delegated; assessment and treatment decisions cannot.
Delegate
Repositioning, hygiene, moisture care, nutrition assistance, routine observation, and device checks may be assigned with exact frequency and reporting triggers.
RN retains
Risk and wound assessment, staging, interpretation, unstable burns, care-plan changes, teaching, and evaluation.
Teach
Pressure relief, dressing protection, infection signs, glucose/nutrition, smoking cessation support, sun/heat safety, and follow-up.
Sources
Reference notes
Current wound, burn, device, and facility guidance controls care.