wound stages
Risk factors for pressure injuries
Immobility • Incontinence • Poor nutrition • Decreased sensation • Age
What factors influence mobility
• Musculoskeletal health • Nervous system function • Pain, age, meds, posture issues
3. What are the main events in the inflammatory response
1. Vasodilation → redness, warmth
2. Fluid leaks → swelling, pain
3. WBCs arrive → phagocytosis
4. Exudate forms → pus, drainage
5. Tissue repair begins
Antifungal (yeast)
Nystatin
Stops protein synthesis
Azithromycin
watch for GI upset
Factors that affect healing?
Nutrition • Oxygenation • Infection • Age • Chronic illness
Major effects of immobility
Muscle atrophy • DVT risk • Constipation • Pneumonia • Skin breakdown • Depression
What are common causes and outcomes of HAIs
Causes: unwashed hands, invasive devices, resistant organisms Outcomes: longer stays, higher costs, complications, risk to staff
Antiviral (herpes)
Acyclovir
Breaks cell wall
Penicillin
check for allergies
Nursing care plan for pressure injury
• Reposition q2h • Keep skin clean/dry • Use support surfaces • Monitor wound • Nutrition support
How to prioritize care for limited mobility
• Prevent complications first (DVT, skin breakdown) • Promote movement • Address psychosocial needs
How can you differentiate localized vs. systemic infection
• Localized: Redness, swelling, pain at site • Systemic: Fever, fatigue, WBC ↑, malaise
Strong antifungal
Amphotericin B
monitor kidneys
Strong against MRSA
Vancomycin
monitor kidney function and trough levels
Examples of device-related injuries
• Oxygen tubing on ears • NG tube on nose • Foley catheter on thighs • Tracheostomy ties on neck
common meds
Warfarin: Prevents clots; monitor INR
Heparin: Fast-acting; monitor PTT
Enoxaparin: SubQ; fewer labs needed
What’s the difference between medical and surgical asepsis
Medical asepsis: Clean technique (hand hygiene, gloves)
Surgical asepsis: Sterile technique (no microbes allowed)
superinfections
Red man with vancomycin
take full course of meds
hypersensitivity
How to evaluate skin interventions?
• Wound size ↓ • Drainage ↓ • Skin intact • No new injuries
Interventions to prevent DVT
• Compression devices • Anticoagulants (heparin, enoxaparin) • Leg exercises • Early ambulation
How do isolation categories differ
• Contact: Gloves/gown (e.g., MRSA) • Droplet: Mask (e.g., flu) • Airborne: N95 + negative room (e.g., TB) • Protective: Protect immunocompromised (e.g., transplant)