A nurse is caring for a client who developed severe contact dermatitis from poison ivy exposure 3 days ago. The client has extensive vesicular lesions on both arms and legs with significant pruritus. Which nursing intervention should be the priority?
1Apply cool, wet compresses to affected areas for 15-20 minutes every 2-3 hours
2Administer prescribed oral antihistamines to reduce systemic allergic response
3Educate the client about proper wound care and prevention of secondary bacterial infection✓ 정답
4Encourage frequent cool baths with colloidal oatmeal to soothe irritated skin
해설
Priority is educating on wound care to prevent secondary bacterial infection from scratching. Cool compresses, antihistamines, and oatmeal baths are supportive but do not address the main complication risk.
Clinical Judgment
This question is a CJMM (Clinical Judgment Measurement Model) question focused on Prioritization and Prevention of Complication. While all options are appropriate interventions for poison ivy contact dermatitis, the clues 'severe blistering lesions' and 'severe itching' are key. When these two factors combine, the patient is at very high risk of scratching the lesions and causing a Secondary Bacterial Infection. Therefore, the nurse's top priority is to prevent the most serious potential complication. Symptom relief (options 1, 2, 4) is important, but infection prevention education (option 3) takes a more urgent priority.
Memory TipPrevent Infection Before Soothing (P.I.B.S): Remember the order—Prevent Infection comes before Soothing symptoms. Especially when Blisters and Severe itching are present together, the risk of infection is high.
KR vs US
In Korea, patient education may tend to be viewed as a 'supportive activity' rather than an 'intervention,' but in NGN and US nursing, Patient Education is recognized as an active and independent Nursing Intervention that prevents complications. In particular, infection prevention education is a core responsibility of the nurse.
임상 시나리오
Clinical Practice Guide
Poison ivy contact dermatitis is a T-cell mediated delayed hypersensitivity reaction. Initial interventions include decontamination (washing with soap and water), symptom management (antihistamines, topical steroids), and most importantly, prevention of secondary infection. Blisters contain urushiol in the exudate, and if popped, can spread to other areas.
Caution
A common pitfall in SATA (Select All That Apply) questions is when asked to "select all appropriate interventions," choosing only symptom management interventions (e.g., cold compresses, colloidal oatmeal baths) and missing infection prevention education. In 'Priority' questions, always consider Safety and complication prevention first.
핵심 개념
Contact Dermatitis (접촉성 피부염) — Skin inflammation that occurs when the skin comes into contact with a specific substance (allergen or irritant). In the case of poison ivy, it is a delayed hypersensitivity reaction (Type IV hypersensitivity) to urushiol.
Urushiol (우루시올) — Oily resin found in poison ivy, poison oak, and poison sumac. It binds to skin proteins, becoming a potent allergen that causes severe itching, redness, and blisters.
Secondary Bacterial Infection (이차 세균감염) — An infection that occurs when bacteria invade through existing skin lesions (e.g., blisters, abrasions). It can progress to impetigo or cellulitis caused by Staphylococcus or Streptococcus.
Pruritus (소양감, 가려움) — A strong urge to scratch the skin. It occurs when mediators such as histamine are released during allergic reactions or inflammation, and excessive scratching damages the skin barrier, becoming a major cause of secondary infection.
Vesicular Lesion (수포성 병변) — Small blisters (vesicles) filled with clear fluid characterize this skin lesion. When the lesions burst, they ooze fluid and become open wounds, making them highly susceptible to bacterial infection.