Skin Assessment, Wounds, Pressure Injury Prevention, Nursing Process, and Documentation (Vocabulary Cards)

A comprehensive set of vocabulary flashcards covering skin assessment, wound care, pressure injuries, and the nursing process and documentation.

Skin functions

The skin acts as the body's first line of defense; it protects against injury, fluid and electrolyte loss, and infection; it also provides sensation, helps regulate temperature, excretes wastes, and produces vitamin D.

Wound dressing

A sterile covering placed over a wound to protect it, keep it intact, and promote healing; moisture level may be kept as ordered.

Moist wound healing

Maintaining a moist wound environment to support faster healing.

Sterile field

A designated area kept free of microorganisms used during sterile procedures.

Reverse isolation

PPE used to protect a patient from healthcare providers when the patient is immunocompromised.

Standard precautions

Core infection-control practices applied to all patients to minimize transmission risk.

Isolation precautions

Measures to prevent transmission of infectious agents (e.g., contact, droplet, airborne).

Intake and Output (I&O) monitoring

Tracking all fluid intake and urine/output to assess hydration and renal function.

Temperature regulation in the room

Adjusting room environment/temperature to help regulate the patient’s body temperature.

Normal skin assessment findings

Thinning skin, decreased elasticity, loss of subcutaneous fat, reduced blood supply, hydration issues, and changes in hair; decreased sweat and oil production.

Aging skin changes

Dry, loose, wrinkled skin with age spots; hair loss; itching; increased risk of skin tears, delayed healing, bruising, cancers, and pressure injuries.

Dark-skinned patient skin history questions

Ask about subtle skin changes in temperature, texture, or sensation and consider cultural practices and exposures.

Pallor

Paleness of the skin indicating reduced blood flow or anemia.

Erythema

Redness of the skin due to inflammation or increased blood flow (may be subtle on dark skin).

Jaundice

Yellowing of the skin (and sclera) due to elevated bilirubin; can be more noticeable in dark skin.

Cyanosis

Bluish discoloration from low oxygenation, often around the lips and mouth; a late sign.

Tan/Sunburn

Abnormal pigmentation from sun exposure; risk factor for skin cancer.

Hyperpigmentation

Increased pigment in skin, such as in scars or birthmarks.

Hypopigmentation

Depigmented patches or lighter areas of skin.

Hematoma

A collection of blood under the skin causing a lump or bump.

Ecchymosis

A bruise; large patch of bleeding under the skin.

Pitting edema (1+ to 4+)

Edema graded by indentation depth: 1+ 2 mm; 2+ 4 mm; 3+ 6 mm; 4+ severe with persistent indentation.

Non-pitting edema (Browning)

Edema where fluid cannot be displaced; skin is firm and shiny.

Generalized edema

Edema all over the body.

Dependent edema

Edema that worsens with dependent positioning (gravity).

Pedal edema

Edema located in the feet and ankles.

Bilateral edema

Edema present on both sides of the body.

Unilateral edema

Edema occurring on one side, often due to local trauma.

Signs of infection

Redness, warmth, drainage, swelling, pain/tenderness, fever, and chills.

Drainage (color, amount, consistency, odor)

Wound drainage characteristics; informs infection risk and healing stage.

Stage I pressure injury

Intact skin with non‑blanchable redness; may appear differently in darker skin tones.

Stage II pressure injury

Partial-thickness loss of skin involving epidermis and/or dermis; superficial ulcer or blister.

Stage III pressure injury

Full-thickness skin loss with visible subcutaneous tissue; possible fat exposure.

Stage IV pressure injury

Full-thickness skin and tissue loss with exposed bone, tendon, or muscle; may have tunneling.

Unstageable pressure injury

Full-thickness tissue loss with base obscured by slough/eschar.

Suspected Deep Tissue Injury

Localized area of purple or maroon intact skin or a blood-filled blister indicating underlying tissue damage.

Undermining

Tissue destruction extending under wound edges, not visible on surface.

Packing (wounds)

Filling dead space with gauze or other material to support healing and prevent abscess formation.

Braden Scale

Risk assessment tool for pressure injuries; score 6–23; ≤18 indicates higher risk; subscales: sensory, moisture, activity, mobility, nutrition, friction & shear.

Braden score interpretation

Lower scores indicate higher risk; guides preventive interventions.

Repositioning

Turning and repositioning every 2 hours to relieve pressure and prevent injury.

Nutritional and hydration support

Adequate protein, calories, and fluids to support wound healing and skin integrity.

Heel off-loading

Elevating heels off the bed using pillows or devices to prevent pressure injuries.

Wet-to-dry dressing

A dressing with moistened gauze that dries and mechanically debrides necrotic tissue during removal.

Chronic wounds

Wounds that persist or recur over time, often with necrotic tissue or persistent inflammation.

Wound VAC (negative pressure therapy)

Device applying negative pressure to promote wound drainage and healing.

Hyperbaric oxygen therapy

Treatment delivering 100% oxygen at high pressure to enhance wound healing.

Debridement

Removal of necrotic or devitalized tissue to promote healing.

Assessments within Braden scale (subscales)

Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear.

Nursing process stages (Assessment to Evaluation)

Assessment, Analysis (Diagnosis), Planning, Implementation, Evaluation.

Priority setting methods (ABC, Maslow)

Prioritize Airway, Breathing, Circulation; then safety vs risk; acute vs chronic; Physiologic needs per Maslow.

Concept maps in nursing

A visual diagram linking data, interventions, and outcomes to plan care.

Nursing process benefits

Structured, patient-centered care; supports critical thinking and evidence-based practice.

Concept map benefits

Enhances recall and problem-solving by organizing complex information visually.

Documentation basics (factual, accurate, complete, timely)

Records should be objective observations, precise measurements, full details of care, and timely entries.

Medical record purpose

Official, accessible record of a patient’s health history and care for communication among providers.

SBARR communication

Introductions, Situation, Background, Assessment, Recommendation, Read Back; used during handoffs.

ISHAPED reporting

Introduction, Story, History, Assessment, Plan, Error Prevention, Dialogue; structured incident communication.

Incident report

Filed after adverse events or near-misses; includes what happened, actions taken, contributing factors; completed promptly.

HIPAA

Health Insurance Portability and Accountability Act; protects patient privacy and confidentiality.

Confidentiality and EMR security

Log out when away; use unique passwords; do not access unrelated records; protect patient information.

Information sharing guidelines

Share with patient/family with consent and with other providers involved in care.

Reporting times and handoffs

Report off during shift changes or transfers; provide SBARR/ISHAPED as appropriate.

Documentation guidelines (what to document)

All actions taken: assessments, interventions, patient responses, and outcomes.

Independent, dependent, and collaborative interventions

Nurse-initiated (independent) actions; provider-initiated (dependent) orders; multidisciplinary collaboration.

ABC technique (prioritizing concepts)

Airway, Breathing, Circulation prioritized first; then other concerns.

Maslow’s Hierarchy of Needs

Prioritizes physiological needs before higher-level psychosocial needs.