Malignant Lesions
Small clusters of melanocytes, the cells that produce pigment in the skin, and typically appear as tan-to-brown spots.
What is a mole (nevus)
A pressure injury appears as a serum-filled blister or shallow open ulcer with a pink wound bed; despite the presence of fluid, it is not classified beyond this stage because dermal loss is only partial.
What is Stage II?
A client has pale, whitish nail beds. The nurse correlates this finding with this systemic condition rather than circulatory obstruction.
What is anemia?
These wounds can be classified as either intentional, like surgical incisions, or unintentional, like burns, punctures, or gunshot injuries, and their origin must guide the plan of care.
What is an acute wound?
A client presents with a clean surgical incision, but you notice redness around the edges. Because this wound was intentionally created, your priority is to monitor for this early complication.
What is infection?
They are the result of a specific triggering agent which causes a change to previously intact skin.
Primary lesions
A wound bed is completely obscured by slough and eschar, preventing visualization of the depth of tissue damage; staging cannot be determined until the wound is debrided.
What is an unstageable pressure injury?
A client’s nails are curved downward with spongy bases and widened fingertips. Instead of focusing on nail care, the nurse should prioritize assessment of this system.
What is the respiratory (or cardiopulmonary) system?
This type of skin damage occurs when the skin is exposed to irritants like urine, feces, or wound exudate and can cause pain, burning, and itching; the nurse’s priority intervention is to keep the skin clean and dry to prevent complications such as pressure injuries.
What is moisture-associated skin damage (MASD)?
This type of debridement uses a scalpel or scissors to remove necrotic tissue and biofilm, decreasing bacterial load and stimulating wound closure.
What is surgical debridement?
Larger (greater than 1 cm diameter) area of pigmentation change
Examples or causes: Birthmark, vitiligo, hormone changes
Patch
This stage presents with intact skin and nonblanchable erythema, but may be mistaken for a bruise due to discoloration and temperature changes.
What is Stage I?
A client’s nail beds appear bluish in color. Rather than focusing on cosmetic causes, the nurse should recognize this as a sign of this critical underlying problem.
What is cyanosis (lack of oxygen in the bloodstream)?
A client with poorly controlled diabetes presents with a plantar foot ulcer. Nurses recognize this wound as a type of chronic lower extremity wound primarily caused by:
What is neuropathic disease / diabetic neuropathy?
For a superficial wound with scant drainage, this type of dressing allows oxygen in, maintains a moist wound bed, and permits visualization without removal.
What is a film dressing?
This type of skin lesion is small (less than 1 cm), solid, and raised, commonly seen in warts, elevated moles, and skin tags.
What is a papule?
A client has a nonblanchable reddened sacral area with intact skin. The nurse’s priority action is to implement this intervention to prevent progression.
What is relieving pressure (repositioning the client at least every 2 hours)?
Transverse grooves or small pits in the nail surface can result from severe illness, trauma, or nutritional deficiencies. These linear depressions are sometimes associated with this vascular condition exacerbated by cold exposure.
What is Raynaud disease?
These wounds develop slowly due to impaired healing from conditions such as diabetes, peripheral artery disease, or chronic venous insufficiency, and risk is increased in older adults, smokers, the undernourished, or immunosuppressed clients.
What are chronic wounds?
This dressing is rarely used today because it removes both necrotic and healthy granulation tissue, increasing infection risk.
What is wet-to-dry gauze dressing?
This term refers to dried debris on the skin surface often composed of serum, blood, or purulent material forming what is commonly known as a scab; it may be seen in conditions like eczema and can follow repeated skin disruption.
What is a crust?
A client with a shallow Stage II pressure injury is incontinent of urine. Before applying any dressing, the nurse should prioritize this action to prevent further skin breakdown.
What is managing moisture and cleansing the skin promptly?
A light-skinned client develops a new, widening dark streak with irregular borders on a single nail. The priority nursing action is not reassurance, but this.
What is referring for evaluation of possible melanoma?
The nurse’s first priority intervention for a client with MASD focuses on this approach to protect the skin, minimize irritation, and reduce the risk of pressure injuries.
What is keeping the skin clean, dry, and protected from irritants?
A closed, active drain using negative suction for fluid collection is known as:
What is a Jackson-Pratt (JP) drain / portable wound bulb suction device?