Wound Care Nursing for NCLEX: Assessment, Staging & Dressing Selection
Complete NCLEX review of wound care nursing. Learn pressure injury staging, wound assessment, dressing types, and documentation standards.
Wound Care Essentials for NCLEX Preparation
Wound care is a fundamental nursing skill tested on the NCLEX. Questions often focus on pressure injury staging, appropriate dressing selection, and wound assessment documentation.
Pressure Injury Staging
Stage 1: Non-blanchable erythema of intact skin. The area may be painful, firm, or warmer than surrounding tissue. Stage 2: Partial-thickness skin loss involving the epidermis and possibly dermis. Presents as a shallow open ulcer with a red-pink wound bed or intact or ruptured serum-filled blister. Stage 3: Full-thickness skin loss involving damage to subcutaneous tissue that may extend to but not through the fascia. Presents as a deep crater. Stage 4: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Unstageable: Full-thickness skin loss with base covered by slough or eschar. Deep Tissue Injury (DTI): Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration.
Wound Assessment Parameters
Document wound location, size (length x width x depth), wound bed appearance (granulation, slough, eschar), exudate (type, amount, color, odor), wound edges, and surrounding skin condition. Use the MEASURE acronym: Measure, Exudate, Appearance, Suffering, Undermining, Re-evaluate, Edge.
Dressing Selection
Hydrocolloid dressings are appropriate for stage 2 wounds with minimal drainage. They promote autolytic debridement and maintain a moist environment. Foam dressings absorb moderate to heavy exudate. Alginate dressings are ideal for wounds with heavy drainage as they absorb up to 20 times their weight. Hydrogel dressings add moisture to dry wounds and promote autolytic debridement. Silver-containing dressings provide antimicrobial properties for infected or at-risk wounds.
Key Nursing Interventions
Reposition patients every 2 hours to prevent pressure injuries. Use the Braden Scale for risk assessment. Ensure adequate nutrition including protein and vitamin C for wound healing. Practice proper hand hygiene and aseptic technique during dressing changes. For more clinical nursing review, visit our clinical nursing flashcards and explore wound care topics.