Skin Breakdown and Pressure Injuries
Earliest sign of a pressure injury
What is non-blanchable redness?
Burn affecting only the epidermis.
What is a superficial burn?
TBSA stands for this.
What is total body surface area?
Common nursing diagnosis for skin breakdown.
What is impaired skin integrity?
Silvery Scale plaques.
What is psoriasis?
A flat, non-palpable change in skin color.
What is a macule?
The most common type of skin cancer.
What is basal cell carcinoma?
Partial-thickness skin loss with blistering.
What is Stage 2 pressure injury?
Burn with blisters and severe pain.
What is partial-thickness burn?
What is the formula developed by Parkland?
What is 4m?l X weight in kg X %TBSA burned
Diagnosis related to burn fluid loss.
What is deficient fluid volume?
Mite infestation causing itching.
What is scabies?
A raised, solid lesion less than 1 cm.
What is a papule?
This skin cancer often appears as a scaly lesion.
What is squamous cell carcinoma?
Full-thickness skin loss with visible fat.
What is Stage 3 pressure injury?
Burn destroying all skin layers, possibly painless.
What is a full-thickness burn?
When is half the fluid given?
What is the first 8 hours?
Goal for wound healing.
What is no signs of infection?
Bacterial infection with honey-colored crust.
What is impetigo?
A fluid-filled lesion less than 1 cm.
What is a vesicle?
The most dangerous form of skin cancer.
What is melanoma?
Full-thickness skin loss with exposed bone, tendon, or muscle.
What is Stage 4 pressure injury?
Priority in the first 24 hours post-burn.
What is fluid resuscitation?
The remaining fluid is given over?
What is the next 16 hours?
Intervention to prevent infection.
What is aseptic technique?
Fungal infection with ring shape.
What is tinea?
A pus-filled lesion.
What is a pustule?
This rule helps assess suspicious moles.
What is the ABCDE rule?
Tool used to assess pressure injury risk.
What is the Braden Scale?
Most critical complication in facial/neck burns.
What is airway obstruction?
What fluid is commonly used in the Parkland formula?
What is Lactated Ringers?
Priority pain management route in major burns?
What is IV route?
Painful vesicular rash along nerves.
What is shingles?
A large fluid-filled blister greater than 1 cm.
What is a bulla?
Major risk factor for skin cancer.
What is UV exposure?
Priority intervention for a patient who is immobile and incontinent.
What is frequent repositioning and moisture management?
Why are burn patients at high risk for infection?
What is loss of protective skin barrier?
Why is urine output monitored closely during fluid resuscitation?
What is to assess kidney perfusion and fluid status?
Why avoid IM injections in burn patients?
What is unpredictable absorption?
Chronic itching inflammatory condition often lined to allergies.
What is eczema (atopic dermatitis)?
A deep loss of skin extending into the dermis.
What is an ulcer?
Why should you not massage reddened areas over bony prominences?
What is it can worsen tissue damage?
Expected urine output indicating adequate perfusion in burn patients.
What is at least 30 ml/hr?
60kg patient with burns to 10% of TBSA, how much fluid will be given over the first 24 hours?
What is 2400 ml?
Two interventions to prevent contractures in burn patients.
What is range-of-motion exercises and splinting?
A patient on antibiotics develops widespread rash, mucosal lesions, and fever, What is suspected?
What is Stevens-John Syndrome
A solid, elevated lesion greater than 1 cm.
What is a nodule?
A wound covered in slough where depth cannot be determined is classified as?
What is an unstageable pressure injury?
A burn patient develops dark urine and muscle pain after an electrical burn, what complication is suspected?
What is rhabdomyolysis?
If a patient arrives 2 hours after a burn, how does this affect fluid timing?
What is fluids are adjusted to be given in reference to the time of the burn.
A burn patient becomes confused with decreasing Blood Pressure, what is the priority nursing action?
What is notify provider and anticipate an order for an increase in IV fluid volume?
What is the nurse's first action if Steven Johnson Syndrome is suspected?
Stop the prescribed antibiotic.
Two priority nursing diagnoses in Stevens Johnson Syndrome.
What is impaired skin integrity or risk for infection?