Pressure Injuries
What causes pressure injuries to develop?
Compression of skin and soft tissue between a bony prominence and an external surface.
Name one common bacterial skin infection.
Cellulitis, folliculitis, or MRSA.
What is pruritus?
Itching; often due to irritation or allergic reaction.
What are the three phases of wound healing?
Inflammatory, proliferative, and maturation.
What is the ABCDE rule for melanoma?
Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolving lesion.
Name risk factors for pressure injuries.
Immobility, incontinence, malnutrition, diabetes, or decreased sensation.
What virus causes Herpes Zoster (shingles)?
Reactivation of the varicella-zoster virus (chickenpox).
How is contact dermatitis treated?
Identify and remove the causative agent; may use topical steroids or antihistamines.
Define first-intention wound healing.
Edges are approximated and aligned (surgical incision); minimal scarring.
Name one prevention strategy for skin cancer.
Avoid tanning beds, use sunscreen, wear protective clothing, perform monthly skin checks.
Describe a Stage 2 Pressure Injury.
Partial-thickness loss of skin with exposed dermis; pink, moist wound bed; may look like a blister
How is Candida albicans infection prevented?
Keep skin folds dry, practice good hygiene, and control blood glucose.
Describe atopic dermatitis (eczema).
Chronic, relapsing skin inflammation with dry, itchy patches often linked to allergies.
What is the priority nursing action for a burn patient with facial burns and soot around the mouth?
Maintain airway and assess for inhalation injury.
Which skin cancer type grows slowly and rarely metastasizes?
Basal cell carcinoma.
What are the priority nursing interventions for a patient with a Stage 1 pressure injury?
Relieve pressure, reposition at least every 2 hours, keep skin clean/dry, and monitor closely for progression.
What teaching do you give to a patient with MRSA?
Don’t share personal items, wash hands often, and complete prescribed antibiotics.
What triggers psoriasis flares?
Stress, infection, skin injury, medications, or cold weather.
Describe the difference between partial-thickness and full-thickness wounds
Partial-thickness: damage to epidermis/upper dermis, heals by re-epithelialization.
Full-thickness: extends into subcutaneous tissue, requires granulation tissue to heal.
What triggers Stevens–Johnson Syndrome (SJS) or Toxic Epidermal Necrolysis (TEN)?
Usually caused by a drug reaction.
How do you document the size and depth of a wound accurately?
Measure length, width, and depth in cm/mm using the “clock concept” and describe color, exudate, and tissue type.
A patient has strong wound odor when removing dressing. What should you do first?
Clean the wound and reassess before assuming infection.
List two treatment types for psoriasis.
Topical therapy (corticosteroids, vitamin D analogs), phototherapy, or systemic therapy (methotrexate, biologics).
What are the three phases of burn care?
Emergent (resuscitation), acute (healing), rehabilitative (restorative).
How are SJS and TEN managed?
Discontinue the offending drug and provide supportive care (fluids, wound care, infection prevention).