Wound, Ostomy and Continence Nurses Society (WOCN) Practice Exam

What do you monitor for in a patient at risk for deep tissue injuries?

1. Only pain levels

2. Changes in skin color and tissue turgor

3. Just changes in blood pressure

4. Fatigue and weakness

The correct answer is: Changes in skin color and tissue turgor

Monitoring changes in skin color and tissue turgor is crucial for patients at risk for deep tissue injuries because these changes can indicate the early signs of pressure damage. Deep tissue injuries often start with alterations in the skin and underlying tissues, and observing skin color can reveal signs of ischemia or compromised blood flow. A dusky or discolored appearance can indicate that the underlying tissue is being damaged, and these early indicators can allow for timely interventions. Tissue turgor is another vital sign, as it reflects the hydration and elasticity of the skin. Healthy skin should have a certain degree of elasticity, and any changes in turgor can signal potential complications, such as dehydration or swelling, which can predispose the tissue to injury. By monitoring for these changes, healthcare providers can implement preventative measures, such as modifying the patient’s position, increasing mobility, or ensuring adequate nutrition and hydration, thereby reducing the risk of developing deep tissue injuries.