skin -- exam 1

What causes a pressure injury?

Prolonged compression of skin/soft tissue between a bony prominence and an external surface, reducing perfusion and causing hypoxia/ischemia and tissue damage.

What are major pressure-injury risk factors?

Immobility, moisture/incontinence, poor nutrition, aging, cognitive impairment, vascular disease, and diabetes.

What does a lower Braden score mean?

Higher risk for pressure injury.

What are the six Braden subscales?

Sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

What is the Braden score range?

6–23; lower scores indicate greater vulnerability.

What Braden score is considered severe risk in the lecture?

≤9.

What defines a Stage 1 pressure injury?

Intact skin with nonblanchable erythema/hyperpigmentation, usually over a bony prominence.

What defines a Stage 2 pressure injury?

Partial-thickness skin loss with exposed dermis and a pink/red, moist, viable wound bed.

What defines a Stage 3 pressure injury?

Full-thickness skin loss with visible adipose and granulation tissue; slough/eschar may be present.

What defines a Stage 4 pressure injury?

Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, or bone.

What is an unstageable pressure injury?

Full-thickness tissue loss where the depth cannot be confirmed because slough or eschar obscures the wound bed.

What is a deep tissue pressure injury (DTPI)?

Persistent nonblanchable deep red, maroon, or purple discoloration; may include a dark wound bed or blood-filled blister.

What does granulation tissue look like?

Pink to beefy red healing tissue.

What is eschar?

Necrotic black, gray, or brown tissue.

What is cellulitis?

Inflammation of the skin/subcutaneous tissue extending beyond the original injury.

What is undermining?

Separation of skin layers at the wound margins from underlying tissue.

What should be documented when assessing a wound?

Location, size, color, tissue involvement, wound-base/margin characteristics, exudate, surrounding tissue, and length/width/depth.

What are key nursing interventions for wound care?

Routine assessment/measurement, pain management, appropriate cleansing, nutrition optimization, appropriate dressings, and frequent repositioning.

What is autolytic debridement?

The body's own fluids naturally break down nonviable tissue in a moist environment; hydrocolloids can facilitate it.

What is enzymatic debridement?

A topical agent such as collagenase loosens necrotic tissue.

What is mechanical debridement?

Removal of nonviable tissue using forces such as irrigation, pulsed lavage, or damp-to-dry dressings.

What is surgical debridement?

Sharp removal of nonviable tissue.

What is a major purpose of wound dressings?

Manage the wound environment based on exudate, wound characteristics, goals, and caregiver ability.

What does an alginate dressing do?

It is highly absorbent and gels when it contacts exudate.

What does a hydrocolloid dressing support?

A moist environment and autolytic debridement.

What should the nurse assess for with urticaria (hives)?

Angioedema involving the lips, eyelids, or airway; airway swelling is an emergency.

What causes urticaria?

Allergen exposure causes histamine release, vasodilation, and plasma protein leakage.

What is Stevens–Johnson syndrome (SJS)?

A life-threatening drug reaction involving rapidly spreading skin and mucosal lesions.

When does SJS commonly occur after starting a new medication?

Typically 1–3 weeks after starting the new medication.

What are early SJS symptoms?

Flu-like symptoms such as fever, sore throat, burning eyes, body aches, joint pain, and cough.

What is the priority action when SJS is suspected?

Withdraw the suspected medication immediately and provide supportive care.

What are the three phases of wound healing?

Inflammatory → Proliferative → Maturation.

What happens during the inflammatory phase?

Clotting occurs, then vasodilation/capillary permeability increase and WBCs/macrophages enter the wound.

What happens during the proliferative phase?

Fibroblasts/collagen and new capillaries form granulation tissue and the wound begins to contract.

What happens during the maturation phase?

Collagen reorganizes, tensile strength increases, and the scar becomes thinner and paler.

What is primary intention healing?

A clean wound with edges approximated/closed, such as a surgical incision.

What is secondary intention healing?

An open wound with greater tissue loss that fills gradually with connective tissue and granulation.

What is tertiary (delayed primary) intention?

A wound is left open initially because of infection risk and is closed later after inflammation/debris improve.

What does an elevated WBC count with increased bands indicate?

A bacterial infection pattern with a left shift.

What does MRSA stand for and what precautions are used?

Methicillin-resistant Staphylococcus aureus; Contact Precautions.

What does VRE stand for and what precautions are used?

Vancomycin-resistant Enterococcus; Contact Precautions.

What does an ESR above 20 mm/hr indicate according to the lecture?

Inflammation or infection.