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newSchoolWorks.com › VoTechWorks › Health & Personal Services › Practical Nursing (LPN) › Clinicals: Supervised Patient Care Skills › Lesson 7
HLT-LPN37-06 · Lesson 7 · 18 clock hours · practice

Wound Assessment, Dressing Changes, and Pressure Injury Prevention

Objective. Students will assess a simulated wound using the correct staging or classification system, perform a sterile dressing change, and document findings using standard wound-care terminology.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

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Wound Assessment, Dressing Changes, and Pressure Injury Prevention

Accurate wound assessment and proper dressing technique are core practical nursing skills. Every wound encounter gives you information that guides treatment decisions, alerts the team to complications, and protects the patient. Your documentation is the legal and clinical record of what you observed and what you did.

Types of Wounds

Wounds are broadly classified as acute or chronic. Acute wounds—surgical incisions, lacerations, abrasions—follow a predictable healing timeline. Chronic wounds—pressure injuries, venous ulcers, diabetic foot ulcers—stall in one healing phase and require ongoing management.

Wounds also differ by how they close. Primary intention means wound edges are brought together (sutured or stapled). Secondary intention means the wound is left open and fills in with granulation tissue from the base up. Tertiary (delayed primary) intention occurs when a wound is intentionally left open for a period, then closed later.

Pressure Injury Staging (NPIAP)

The National Pressure Injury Advisory Panel (NPIAP) defines pressure injuries as localized damage to skin and underlying soft tissue, usually over a bony prominence, caused by pressure or pressure combined with shear. Use the NPIAP staging system to classify depth and tissue involvement:

Safety note: Never reverse-stage a healing pressure injury. A healing Stage 3 does not become a Stage 2; document it as a "healing Stage 3."

Wound Assessment Parameters

A complete wound assessment includes every element below, documented in consistent terms:

1. Location — anatomical site (e.g., right lateral malleolus)

2. Size — length × width × depth in centimeters; measure longest axis, then widest axis perpendicular to it

3. Wound bed — color and tissue type: red/pink (granulation), yellow (slough), black (eschar)

4. Exudate — amount (none, scant, moderate, large) and color/consistency (serous, serosanguineous, sanguineous, purulent)

5. Wound edges — attached or unattached, undermining or tunneling (measure with a cotton-tipped applicator in centimeters using clock-face orientation)

6. Periwound skin — intact, macerated, erythematous, indurated, or calloused

7. Odor — none, faint, or strong (note after irrigation to distinguish wound odor from dressing odor)

8. Pain — patient-reported pain scale rating at rest and during dressing change

Pressure Injury Prevention

Prevention is always preferable to treatment. Key interventions include:

Performing a Sterile Dressing Change

Maintaining sterile technique protects the patient from healthcare-associated infection. Follow these key principles:

1. Explain the procedure to the patient; assess pain and offer analgesic per order before starting.

2. Perform hand hygiene and don clean gloves to remove the old dressing. Assess and discard.

3. Remove clean gloves, perform hand hygiene, then open sterile supplies onto a sterile field without contaminating them.

4. Don sterile gloves.

5. Irrigate the wound with normal saline (or ordered solution) using gentle pressure—enough to cleanse without damaging new tissue.

6. Pat the wound dry with sterile gauze; assess the wound fully at this point.

7. Apply the prescribed dressing — match dressing type to wound needs (e.g., foam for moderate exudate, transparent film for superficial low-exudate wounds, antimicrobial dressings per order).

8. Secure the dressing without causing skin trauma; avoid circumferential taping on an extremity.

9. Remove gloves, perform hand hygiene, and label the dressing with date, time, and your initials.

10. Document immediately after the procedure.

Safety note: If you contaminate the sterile field at any point, stop, discard contaminated items, and restart. Never compromise sterility to save time or supplies.

Documentation

Use objective, measurable language. Avoid vague terms like "small" or "looks better." A model wound note reads: "Right sacral pressure injury, Stage 3. Wound measures 3.5 cm × 2.0 cm × 0.8 cm. Wound bed 80% red granulation tissue, 20% yellow slough. Moderate amount of serosanguineous exudate. Periwound skin intact with mild erythema 1 cm border. No odor after irrigation. Patient rates pain 3/10. Wound irrigated with normal saline; foam dressing applied. Patient tolerated procedure."

Accurate, complete documentation protects the patient, informs the care team, and demonstrates professional accountability—all qualities that will serve you well on the NCLEX-PN and throughout your nursing career.

Key terms9

NPIAP StagingThe classification system developed by the National Pressure Injury Advisory Panel that describes pressure injury severity from Stage 1 (intact skin, non-blanchable erythema) through Stage 4 (full-thickness loss exposing bone, muscle, or tendon), plus Unstageable and Deep Tissue Pressure Injury categories.
Granulation tissueNew connective tissue and tiny blood vessels that form on the surface of a healing wound; appears beefy red or pink and indicates a wound is progressing toward healing.
SloughYellow, tan, or gray necrotic tissue that is moist and loosely or firmly adherent to the wound bed; its presence may impede healing and requires debridement.
EscharDry, thick, leathery black or brown necrotic tissue; covers wound depth, preventing accurate staging until removed (debrided), unless it is stable, dry, and intact on a heel.
ExudateFluid produced by a wound; described by amount (none, scant, moderate, large) and type (serous—clear watery; serosanguineous—pink tinged; sanguineous—bloody; purulent—thick, cloudy, often malodorous).
UnderminingTissue destruction that extends under intact skin beyond the visible wound edges; measured in centimeters using clock-face orientation.
Sterile fieldA designated area—typically a sterile drape—that is free of microorganisms; only sterile items may touch it, and it must be maintained throughout a sterile procedure.
Periwound skinThe skin immediately surrounding a wound; assessed for maceration (soggy, white from excess moisture), erythema, induration (firmness), or other changes that indicate complications.
Braden ScaleA validated tool used to assess a patient's risk for developing a pressure injury; evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Worked examples4

1. Measure wound dimensions: The longest straight-line measurement of a wound is 4.2 cm. Perpendicular to that line, the widest measurement is 3.0 cm. A sterile cotton-tipped applicator inserted into the deepest point of the wound bed, then measured against a ruler, reads 1.5 cm. How do you document wound size?
  1. Identify the three measurements: length (longest axis) = 4.2 cm, width (widest axis perpendicular to length) = 3.0 cm, depth = 1.5 cm.
  2. Arrange in standard order: length × width × depth.
  3. Confirm units are all in centimeters for consistency.
Answer: Document as: 4.2 cm × 3.0 cm × 1.5 cm (length × width × depth).
2. Measure tunneling: During a wound assessment, you insert a cotton-tipped applicator into a tunnel at the 6 o'clock position of the wound. The applicator reaches 2.8 cm before resistance. How do you document this finding?
  1. Note the clock-face position where the tunnel is located: 6 o'clock (toward the patient's feet if the patient is supine).
  2. Record the measured depth of the tunnel from the wound edge: 2.8 cm.
  3. Use standard documentation language combining position and measurement.
Answer: Document as: Tunneling present at 6 o'clock position, 2.8 cm in depth.
3. Classify wound bed tissue: A wound has a bed that is 60% red and moist, 30% yellow and loosely adherent, and 10% black and hard. What terms describe each portion, and what is the priority concern?
  1. Identify the 60% red moist tissue: this is granulation tissue — healthy, healing tissue.
  2. Identify the 30% yellow loosely adherent tissue: this is slough — non-viable tissue that can impede healing.
  3. Identify the 10% black hard tissue: this is eschar — necrotic tissue that must be assessed and may require debridement.
  4. Determine priority: the presence of necrotic tissue (slough and eschar) in 40% of the wound bed is the primary concern; report to the supervising nurse or provider, as debridement may be indicated.
Answer: Document: Wound bed 60% granulation (red, moist), 30% slough (yellow, loosely adherent), 10% eschar (black, hard). Necrotic tissue covers 40% of the wound bed; notify supervising nurse for wound care orders review.
4. Braden Scale subscale scoring: A patient is assessed as having 'very limited' sensory perception (score 2), 'occasionally moist' skin (score 3), 'chairfast' activity (score 2), 'very limited' mobility (score 2), 'probably adequate' nutrition (score 3), and 'potential problem' friction/shear (score 2). What is the total Braden score, and how is this generally interpreted?
  1. Add each subscale score: 2 + 3 + 2 + 2 + 3 + 2.
  2. Calculate total: 2 + 3 = 5; 5 + 2 = 7; 7 + 2 = 9; 9 + 3 = 12; 12 + 2 = 14.
  3. Interpret the total: A Braden Scale total of 14 or below generally indicates the patient is at risk for pressure injury development; lower scores indicate higher risk. Implement prevention interventions per facility protocol.
Answer: Total Braden score = 14. This score falls in the at-risk range; initiate or intensify pressure injury prevention measures (repositioning schedule, pressure-redistribution surface, skin care, nutrition support).

The math in this lesson1

Learners measure and record wound length, width and depth in centimeters, e.g., 4.2 x 3.0 x 1.5 cm.
N-Q.3
Brush up in the math halls at newSchoolWorks.com:
In class: Examine five simulated wound photographs or moulage wounds and classify each by type and, for pressure injuries, by NPIAP stage; discuss classifications with the group and reconcile discrepancies with instructor. · Perform a sterile dressing change on a wound care task trainer, including irrigation, application of appropriate dressing, and secure taping, narrating each step aloud. · Write a wound assessment note using correct terms (location, size in cm, wound bed color, exudate amount/color, surrounding skin, odor, pain) and compare with instructor's model note for accuracy.
Materials: Wound care task trainer or moulage kit, sterile dressing supplies (gauze, transparent film, foam dressings), normal saline irrigation, sterile gloves, wound measurement guide, NPIAP pressure injury staging chart, wound documentation template
Check: Wound staging accuracy 80% or higher on classification exercise; dressing change checklist scored by instructor with 85% minimum; wound note graded against rubric with all required elements present for pass.

Practice check7

Answer each question, then check it. Nothing is recorded; this is your own practice.

Physiological Integrity: Basic Care and Comfort
1. A nurse assesses a patient's sacral wound and finds full-thickness skin and tissue loss with visible subcutaneous fat but no exposed bone, tendon, or muscle. Slough is present in approximately 20% of the wound bed. Which NPIAP pressure injury stage does this describe?
Safe and Effective Care Environment: Safety and Infection Control
2. During a sterile dressing change, the nurse accidentally touches the sterile gauze with an ungloved hand. What is the most appropriate action?
Physiological Integrity: Reduction of Risk Potential
3. A nurse documents wound exudate as 'purulent.' Which finding best supports this description?
Safe and Effective Care Environment: Coordinated Care
4. A patient with limited mobility and incontinence is admitted from a long-term care facility. Which action is the highest priority to prevent pressure injury development?
Physiological Integrity: Basic Care and Comfort
5. A wound assessed two weeks ago as a Stage 3 pressure injury now shows granulation tissue filling the wound bed and reduced size. How should the nurse document the current stage?
Physiological Integrity: Reduction of Risk Potential
6. A nurse assesses a patient's heel and finds a dark purple, intact area of discoloration that is painful and firm compared to surrounding tissue. The area does not blanch with fingertip pressure. This finding is most consistent with which NPIAP category?
Safe and Effective Care Environment: Coordinated Care
7. Which element is required in a complete wound assessment documentation note?
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