MS2: Chapter 25

Herpetic Whitlow

A type of herpes simplex that occurs on the fingertips of healthcare personnel it will come into contact with viral secretions This can be spread easily to other patients

Interventions for skin infection

avoidance of the offending organism, good hygiene, vaccination and example is zostavax

How is infection diagnosed

based on clinical indicators or systemic signs

Some nursing diagnoses for skin problems

compromised tissue integrity due to vascular insufficiency and trauma Potential for one deterioration due to insufficient with management

What does exfoliative psoriasis look like

explosively irruptive and inflammatory form Scaling no lesions

What are we in inspecting the skin wounds for

location, size, color, extent of tissue involvement and surrounding tissue, cell types in wound base and margins, exudate, foreign bodies

What factors might contribute to a high-risk skin issue patient

mental status changes, impaired motility, nutrition status, incontinence

Is there a cure for herpes Symplex virus

no after the first infection the virus remains in a dormant state in the nerve ganglia

Is the skin intact in a stage to pressure injury

no this is a partial thickness loss of epidermis or dermis

These types of loans are superficial with minimal loss of tissue integrity from the epidermis and upper dermal layers

partial thickness wounds

Implement aggressive intervention of prevention with...

pressure relief or reduction devices also pressure mapping

What is herpes zoster (shingles) caused by

reactivation of the vericella zoster virus also known as chickenpox

Cutaneous anthrax is an infection caused by

spores of bacillus anthracis

What triggers herpes to present

stress, trauma to the skin, fever, menses, fatigue

This intention has delayed closure, high-risk for infection and results in a scar

third intention

Dermatophytes

A type of fungi that causes skin, hair, and nail infections.

When does the maturation phase of wound healing begin

As early as three weeks after injury

When does the inflammatory phase of wound healing begin

At the time of injury

A chronic rash that occurs with allergies (Eczema)

AtopicDermatitis

What do we do to put a barrier between the skin and fluid

Barrier cream

These have a resistance to pesticides, they do not live on humans but they fear of human blood this type of bug hitchhikes from infested environment to others

Bedbugs

When does the proliferative phase of wound healing begin

Begins on the fourth day after injury

Risk for skin cancer

Chronic wounds that remain open for long periods of time, genetic predisposition, excessive exposure to UV light, presence of one or more precursor lesions that resemble unusual moles

Candida albicans Where does it occur? What environments does it favor?

Come in on theSkin mucous membranes and gross and warm moist environments

An acute or chronic rash thy occurs by Direkt content with an irritant or Allergen

Contact dermatitis

What does scabies look like on the skin and where is it most often seen on the body

Curved or linear White Ridge is most often seen on the fingers palms and inner aspects of the wrist

Where ever there is hair you can develop a...

Cyst

Superficial infections that different lesion appearance body location and species

Dermatophyte infections

tinea

Descriptive word meaning fungal infection Aka "tinea pedis" is athletes foot

If a patient has thick skin or lesions, bad nutrition, or as a mobile what should you do

Develop a plan to avoid pressure injuries

non-surgical management for wounds

Dressings mechanical, topical, natural, chemical debridement Physical, drug, nutrition, technology therapy

What does first intention look like

Edges are brought together with the skin lined up in correct anatomical position

This is a superficial infection that is often caused by staphylococcus it presents a small raised red pustules

Folliculitis

Do you stage four pressure injuries need to be packed

For sure

This is one skin is rubbed against the surface dragged or pulled

Friction

How can somebody contract herpes zoster also known as shingles

From patients with stress that haven't had the chickenpox vaccine if you plan to be pregnant stay away from them these patients need to be on droplet precaution

In these types of loans damage extends into the lower layers of the dermis and underlying subcutaneous tissue What do they need to heal

Full thickness wounds Need to be filled with granulation

This is also caused by a staphylococcus and Presents as large inflamed bombs usually with a pustular head

Furuncles\boils

What is the most common viral infection in adults

Herpes simplex virus

Exposed chronic wounds are colonized with micro organisms but not always...

Infected

For skin assessment we must identify the cause of tissue integrity loss and factors that may impair healing how we do this

Inspect the entire body

With a stage one pressure injury the skin is Where do these usually occur

Intact The area is usually over a bony prominence, the skin does not blanch with external pressure

What does second intention of wound healing require

It Requires gradual filling in of dead space with connective tissue

Assessment for skin cancer

Know their Family history, past surgery and growth removal's, recent changes in moles, occupational or recreational activities (sun exposure)

What number on the Braden scale is cause for worry

Less than 12

Where do dermatophytes live

Mainly in theSoil and on humans and animals

This is the result of gravity. Dependent tissue is in contact with a fixed surface

Mechanical pressure

I'are contact dermatitis and atopic dermatitis the same

No they're completely different

The bacterial infection go away on their own

NoThey just circulate

When will heel will lift boots not work

On the heel is not sitting in the whole

This form is pustules on the palms of hands and soles of feet

Palmoplantar pustulosis

What are some labs we might run for skin problems

Pre-albumin, albumin, total protein

Mechanical force is that create ulcers are

Pressure friction and sheer

Interprofessional collaborative care for wounds include

Primary care provider, nurse, plastics, dietitian

Become an auto immune disorder affecting the skin with exacerbation and remissions due to overstimulation of the immune system

Psoriasis

What are some health promotion and maintenance techniques for skin issues

Recognize risk, begin interventions early, identify high-risk patients early

This is a contagious skin infection caused by mite infestation

Scabies

This is sliding down in the bed or wheelchair

Shear

At this stage the ulcer is superficial and may appear as an abrasion blister or shallow crater at this point bruising is not present

Stage 2

At this stage subcutaneous tissue and underlying facia may be damaged or necrotic Bone, tendon, muscle or not exposed May have undermining and tunneling

Stage 3

This type of pressure injury is a full thickness skin loss with exposed or palpable muscle tendon or bone There is undermining and tunneling with sinus tracks possible Sloughing and eschar are often present

Stage 4

At this stage of a pressure energy there is. Full Thickness skin loss

Stage III

At this stage of pressure injury and you can see changes in healing quickly once the area pressure is off loaded

Stage one

With this syndrome the skin usually sloughs off, it's often a reaction to medication, it's deadly, and these people get treated like burn patients

Steven Johnson syndrome

This is a rare and serious disorder of the skin and mucous membranes. It's usually a reaction to a medication or an infection. It often begins with flu like symptoms followed by painful red or purple rash that spreads and blisters. Then the top layer of the affected skin dies, sheds, and heals,

Steven JohnsonSyndrome

These types of cultures help in identifying bacteria on the surface of the world

Swab

Where did bacterial skin infections usually start from

The hair follicle were bacteria easily collects and grows

Here is eating disorders often occur in who

The homeless population in those with poor hygiene

How do we document a wound

The location and size, length, width, depth also add photos

Lots of tissue integrity is caused when...

The skin and underlying soft tissue are compressed between a bony prominence an external service for extended period of time

Cellulitis can swell, why is this a problem?

The swelling could cut off circulation and cause compartment syndrome

What is important for the nurse to know when caring for patients with parasitic disorders such as lice scabies or bedbugs

ThesePatients need to be isolated

What do you stage III pressure injuries need

They need interventions immediately, wound VAC sometimes, they need to heal from the inside out, they may need packing

People with stage to pressure injuries need more than just turning what do they need

They need medication and the consult from plastics

What does a fungal infection look like and what type of med to these patients need

Thick white film on the tongue they need a Nystatin which is a swish and swallow

pediculosis Where do they occur and what is the treatment

This is lice and it occurs on the head body and pubic area and the treatment is chemical killing the parasites

What does herpes simplex virus type one look like versus type two

Type One is a recurring cold sore while type two is genital herpes and is recurrent

These are anything with necrosis on top

Unstageable ulcers they're called that because we can't see what's going on

What doesCellulitis feel like

Warm

How do we prevent infection and wound deterioration

We monitor the ulcers appearance or progress and we maintain a safe environment to prevent infection

If somebody has folliculitis what is the best action

We need to figure out why this is happening and culture them and get the meds

Can herpes transfer

Yes I can transfer from one person to the next and from one part of the body to the other

Cellulitis

diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling Secondary to boil, trauma, or MRSA

urticaria

hives

What are the three phases of wound healing

inflammation, proliferation, maturation

pruritus

itching

What is the most common type of psoriasis and what does it look like

psoriasis vulgaris it's thick red and papules or plaque and silvery scales with lesions

Reepithelialization

the movement of epithelial cells to form a covering over the wound