Skin Care & Wound Healing
This term means the removal of dead or necrotic tissue from a wound.
What is debridement?
These two commonly used assessment scales help nurses identify patients at risk for pressure injuries.
What are the Braden and Norton scales?
A child develops superficial facial lesions that rupture and leave honey-yellow crusts. This infection is the likely cause.
What is impetigo?
A nurse develops itching, burning, and redness of the hands after repeated exposure to a cleaning product. This inflammatory condition is the likely cause.
What is contact dermatitis?
A patient fears that a skin lesion is cancer, but testing identifies seborrheic keratosis. This is its classification: benign or malignant.
What is benign? Seborrheic keratosis is noncancerous.
This type of debridement uses the body’s own enzymes and a moist wound environment to break down necrotic tissue.
What is autolytic debridement?
Intact skin over the sacrum has persistent, nonblanchable erythema. This is the pressure injury stage.
What is a stage 1 pressure injury?
Small pustules appear around hair follicles in an area frequently irritated by shaving. This condition is the likely cause.
What is folliculitis?
Greasy, scaly patches affect the scalp, eyebrows, and nasolabial folds. This chronic inflammatory disorder is the likely cause.
What is seborrheic dermatitis?
A small, waxy nodule on the nose has rolled, translucent borders and central ulceration. This skin cancer is the likely cause.
What is basal cell carcinoma?
When choosing between a hydrogel dressing and an alginate dressing for a heavily draining wound, this dressing better absorbs the drainage.
What is an alginate dressing? Hydrogel dressings provide moisture to dry wounds.
A pressure injury has full-thickness skin loss with visible subcutaneous fat, but no exposed muscle, tendon, or bone. This is the stage.
What is a stage 3 pressure injury?
An abscess involves several adjacent hair follicles. This term distinguishes it from a furuncle involving one follicle.
What is a carbuncle?
A patient has raised, red plaques with silvery scales on the elbows and knees and asks whether family members can catch the condition. Name the disorder and explain its contagiousness.
knees and asks whether family members can catch the condition. Name the disorder and explain its contagiousness.What is psoriasis, a noninfectious condition? It does not spread through contact.
A rough, thickened, scaly tumor develops on sun-damaged skin. Because this cancer can metastasize, regional lymph nodes require assessment
What is squamous cell carcinoma?
An older adult with dry, itchy skin bathes in hot water and vigorously rubs the skin with a towel. These two changes would reduce irritation.
What are using lukewarm water and gently blotting the skin dry? Mild nonsoap cleansers and emollients also help.
A patient slides down in bed while the skin remains against the sheets. This force stretches blood vessels and disrupts circulation in the underlying tissue.
What is shear?
A teenager squeezes blackheads and picks at inflammatory acne lesions. Avoiding these actions helps prevent this lasting complication.
lesions. Avoiding these actions helps prevent this lasting complication.What is scarring? Manipulation can worsen inflammation and damage the skin.
Recurrent painful nodules in the axillae and groin rupture, drain, and leave scars or sinus tracts. This chronic disorder is the likely cause.
What is hidradenitis suppurativa?
A surgeon removes a skin tumor one layer at a time and examines each layer microscopically, conserving healthy tissue. This is the procedur
What is Mohs micrographic surgery?
An older adult receives a sedating antihistamine for nighttime itching and becomes drowsy and unsteady. This safety risk requires immediate nursing attention.
What is the risk for falls? Assist with mobility and implement fall precautions.
A nursing assistant begins massaging a reddened sacral area to “improve circulation.” These are the nurse’s immediate corrective actions.
What are stopping the massage and relieving pressure on the area? Massage can damage fragile capillaries. Reposition the patient and reassess the skin.
A family shares towels with a child who has impetigo and does not wash their hands after touching the lesions. These two teaching points address the transmission risk.
What are avoiding shared towels or washcloths and performing hand hygiene after contact with lesions?
A patient with psoriasis reports new joint pain and swelling in the hands. This associated complication should prompt further evaluation.
What is psoriatic arthritis? Report the findings and anticipate rheumatology evaluation.
A surgical defect has exposed tendon and a poorly vascularized wound bed. Between a skin graft and a flap, this option brings its own blood supply to the defect.
What is a flap? Its blood supply supports tissue survival and coverage of exposed structures.