Unit XIV- Nursing Care of the Patient with Problems of the Integumentary System
C-reactive protein (CRP) elevation Erythrocyte sedimentation rate (ESR) elevation White blood cell (WBC) elevation CORRECT. CRP, ESR, and WBC elevation are all signs that may indicate inflammation or infection, but RBC and platelet elevation does not.
The nurse is reviewing the admission laboratory results for Louanne. Which of these laboratory findings are indicative of inflammation or infection? C-reactive protein (CRP) elevation Erythrocyte sedimentation rate (ESR) elevation White blood cell (WBC) elevation Red blood cell (RBC) elevation Platelet elevation
Answer: A Rationale: Obese patients frequently have increased moisture and friction under skin folds of the breasts, pannus, and back that may lead to full thickness wounds and infection.
When caring for an obese patient, which action represents a skin assessment technique that is unique for this population? A. Thorough inspection of all skin folds for the presence of lesions B. Functional ability to provide adequate self-care C. Gather data about recent skin changes or discomfort D. Personal motivation to lose weight
Wood's light examination
exposes some skin infections, produces a specific color such as blue-green or red in a darkened room. No discomfort with this exam. an ultraviolet light used to examine the scalp and skin for the purpose of observing fungal spores (used to check for circulation when assessing flap before closure)
Xerosis (Dryness)
• A common problem among older clients. • Fine flaking of the stratum corneum • Generalized pruritus (itching) • Scratching a result of secondary skin lesions, excoriations, lichenification, and infection
Pressure-Relieving Techniques
• Adequate pressure relief key to prevention of pressure ulcers • Capillary closing pressure (want to overcome this so the tissues can still get blood flow) • Pressure relief products and devices • Positioning away from mattresses and pillows
Ecchymoses
larger blue or purplish patches on the skin (bruises)
Palpation
• Palpation confirms the size of the lesions and determines whether they are flat or slightly raised • Macular: flat rash • Papular: raised rash • Skin temperature: assessed with the back of the hand • Turgor: the amount of skin elasticity (back of hand)
Third intention
A type of wound healing; delayed or secondary closure, such as a draining abdominal wound. (delayed closure)—high risk for infection with a resultant scar
Vesicles or Bullae
- Blisters filled with clear fluid- vesicles are < 1cm in diameter and bullae are >1cm in dia. • • 2nd degree burns
Papules
- Small firm raised lesions < 1cm in diameter • • Elevated moles or warts
Pustules
- Vesicles filled cloudy or purulent fluid • • Acne
Answer: C Rationale: The objective appearance and subjective symptoms are consistent with fungal infection. The recommended culturing method for fungal infection is to sterilely remove the roof of an intact pustule so that the tissue can be inspected using a KOH preparation.
A patient presents with a new-onset, erythematous rash that contains intact pustules. Subjective symptoms include itching and burning. Which diagnostic evaluation is most helpful in determining the underlying etiology? A. Excisional biopsy B. Skin scraping C. Sterile collection of pustule roof D. Cryosurgery
First intention
A type of wound healing (closure) for wounds with little tissue loss, such as a surgical incision. resulting in a thin scar
Second intention
A type of wound healing for wounds with tissue loss, as in pressure ulcers; the wound remains open and fills with scar tissue. (granulation) and contraction—a deeper tissue injury or wound
Wound care to the site. Functional assessment. Braden scale assessment. Positioning so that heal is not resting on the bed. Nutritional assessment. CORRECT. The wound site care should include a dressing and prevention of further injury. Both a functional assessment and Braden skin assessment are important to see her level of mobility and risk for further skin injury. The nutritional assessment will determine if she has a balanced diet with adequate protein. Nutritional planning may also help to control her blood sugars.
Because Louanne has a fever, the provider performs lab work and finds that her white blood cell count is elevated. Louanne is admitted to the hospital for intravenous antibiotics. What should the nurse include in the plan of care? Select all that apply. Wound care to the site. Functional assessment. Braden scale assessment. Positioning so that heal is not resting on the bed. Nutritional assessment.
Pediculosis corporis
Body lice, which is a parasite, microorganism, and arthropod
C-reactive protein and erythrocyte sedimentation rate
The nurse is admitting a client with a stage III pressure injury. Which serum lab values would the nurse expect to be drawn on the client during the hospital stay? B-type natriuretic peptide and lactic acid Prothrombin time/international normalized ratio and partial thromboplastin time (PTT) C-reactive protein and erythrocyte sedimentation rate Hemoglobin and hematocrit
Anemia Peripheral vascular disease Diabetes
The nurse is caring for a client with a pressure injury. Which comorbidities could the nurse expect to treat? Select all that apply. Anemia Varicose veins Peripheral vascular disease Diabetes Plantar fasciitis
Meat and dairy (protein)
The nurse is caring for a client with a stage IV pressure injury on the coccyx. The nurse advises the client to increase which types of foods in the diet to assist in the healing process? Bread and starches (carbohydrates) Meat and dairy (protein) Fats Fruits and vegetables
Answer: A, B, and D Rationale: This patient has a number of risk factors for developing skin damage. These include: excessive moisture caused by incontinence, immobility and increased fragility of the skin due to advanced age. Choices A, B, and D. are interventions that will help manage these risk factors
The nurse is teaching skin care guidelines to the caretaker of a 79-year-old incontinent female who has a total Braden score of 14 with a score of 2 in the mobility category. What are appropriate educational priorities? (Select all that apply.) A. Gently cleanse and dry the skin immediately after an incontinence episode. B. Utilize a toileting schedule to minimize episodes of incontinence. C. Aggressively clean the patient's skin after an incontinence episode. D. Assist the patient with repositioning at least every 2 hours. E. Use diapers for stool and urine containment.
Answer: D Rationale: In order to obtain the most accurate result, the culture should be completed before administration of the anti-infective agent or cleansing with an antiseptic solution
The nurse questions which intervention in the stable patient with the nursing diagnosis "impaired skin integrity related to draining skin lesions on right lower extremity"? A. Place patient on isolation precautions. B. Obtain a swab specimen from wound bed after cleansing with a non-antiseptic solution. C. Educate patient about wound and skin treatment regimen. D. Administer broad-spectrum antibiotic before obtaining a culture.
Keep the draw sheet and any other bedding material located under the client clean, dry, and without wrinkles. Develop and implement a turning schedule if the client is unable to turn independently. Use a skin risk assessment tool such as the Braden Scale per facility policy.
The nurse would implement which nursing interventions to decrease the chance of the client developing pressure injury? Select all that apply. Keep the draw sheet and any other bedding material located under the client clean, dry, and without wrinkles. Keep the client elevated to at least 45 degrees at all times. Develop and implement a turning schedule if the client is unable to turn independently. Use a skin risk assessment tool such as the Braden Scale per facility policy. Encourage client to sit in a chair for long periods of time.
Stage 2 pressure injury CORRECT. A stage 2 pressure injury is characterized by a partial thickness loss of the dermis with a shallow open ulcer. The bed of the wound is red or pink and usually without sloughing. An intact or ruptured serum-filled blister may be present.
The provider encourages Louanne to wear different shoes and return to the clinic in a week. When she returns, she has a low-grade fever and the heel has darkened in color. The red area now has a quarter-sized serum-filled blister. Louanne says "I tried some other shoes but they were not comfortable, so I went back to these." What stage pressure ulcer is now present? Stage 1 pressure injury Stage 2 pressure injury Stage 3 pressure injury Stage 4 pressure injury Unstageable pressure injury
Clients with advanced age Clients with malnutrition Clients with urinary or fecal incontinence Clients with dehydration
What clients are at risk for pressure injury? Select all that apply. Clients with advanced age Clients with malnutrition Clients with insomnia Clients with urinary or fecal incontinence Clients with dehydration
Answer: B Rationale: A new onset petechial rash indicates microvascular dysfunction. The underlying cause for this finding must be immediately identified to minimize risk for uncontrolled bleeding.
Which clinical finding requires additional investigation by the nurse? A. CRT less than 2 seconds B. New-onset petechial rash C. A macule with symmetrical shape, regular border, and uniform color D. Pale or cyanotic nailbed after exposure to cold temperatures
Answer: A, D, and E Rationale: In a teaching plan regarding treatment and prevention of melanoma, the nurse should emphasize guidelines regarding detection of new sites, pain management, and site care instructions to promote healing.
Which information should be included in the teaching plan for a patient diagnosed with melanoma? (Select all that apply.) A. Teach the ABCD tool for detecting abnormal skin lesions. B. Avoid wearing sun screen. C. Clothing is adequate to protective skin from sun exposure when outdoors. D. Discuss pain management plan for removal of skin lesions. E. Review biopsy or excisional site care instructions
Answer: D Rationale: The skin changes associated with peripheral vascular disease (PVD) often develop over time. New onset discoloration in the form of pallor, cyanosis, or ecchymosis of toe tips represents an acute change such as a blood clot that requires immediate intervention.
Which observation in a patient with peripheral vascular disease requires an immediate intervention by the nurse? A. Gradual hair loss on bilateral lower extremities B. Hemosiderin staining on bilateral ankles C. 2+ dorsalis pedis pulses bilaterally D. New-onset pallor, cyanotic or ecchymotic discoloration of distal toe tips
Answer: B Rationale: The patient described in B has the most significant risk factors including advanced age, mild-moderate risk for pressure ulcer development based on her Braden score, and excessive moisture caused by incontinence.
Which patient is at greatest risk for pressure ulcer formation? A. A 39-year-old male status post-mitral valve replacement with a Braden score of 18, who is NPO for procedure B. A 76-year-old female with an ICD pocket infection, Braden score of 15, incontinent of urine and stool C. A 52-year-old female heart transplant patient in rejection, Braden score of 15, one person assist to stand D. A 67-year-old male status post CABG x 4, Braden of 16, who needs assistance with repositioning when in the chair
Answer: A, C, D, and E Rationale: The maturation time of the epidermal keratinocytes and the replication of keratinocytes within the hair follicle impact the rate of wound closure. Langerhans cells, macrophages, and mast cells are part of the skin immune system, which play an important role in orchestrating the healing process. Blood vessels deliver oxygen and nutrients and remove waste products produced by the immune system cells.
Which properties of the epidermal and dermal layers contribute to wound healing? (Select all that apply.) A. The 30-day maturation time of epidermal keratinocytes B. Eccrine gland sweat production C. Melanocytes in a 1:36 ratio with keratinocytes D. Presence of Langerhans cells, macrophages, and mast cells E. Blood vessels in the dermis and subcutaneous tissue
Answer: C Rationale: While the skin has many protective features, the presence of Langerhans cells, which are the outermost cells of the immune system, triggers the immune system response to invading pathogens.
Which statement accurately describes the skin's protective capabilities? A. The epidermis can resist damage when exposed to continuous moisture. B. Melanocytes always provide adequate protection to underlying structures from UV exposure. C. Langerhans cells, located in the epidermis, often provide the initial signal to the immune system that pathogen invasion has occurred. D. Temperature is regulated by blood vessels and sweat glands.
Nodules
-Elevated, marble-like lesions >1cm deep/ wide (soft and can be moved around) • • Lipoma
Herpes Zoster- Shingles
a disease that involves a painful, blistering rash accompanied by headache, fever, and a general feeling of unwellness follow a dermatome and lays dormant until stressed (can cause blindness if it gets in the eye)
Petechiae
a small red or purple spot caused by bleeding into the skin.
Shave biopsy
a technique using a surgical blade to "shave" tissue from the epidermis and upper dermis
Pressure Ulcer- Stage 4
Full-thickness pressure ulcer involves all skin layers and extends into supporting tissue. Exposes muscle, tendon, or bone, and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue).
Pressure Ulcers- Stage 3
Full-thickness skin loss involving damage or loss of subcutaneous tissue
Warts (HPV)
Lesions causes by HPV (human papillomavirus) (genital or non genital) (very contagious)
Stage 1 pressure injury CORRECT. A stage 1 pressure injury has intact skin with non-blanching redness to a localized area, usually on a bony prominence.
Louanne is 70 years old and lives with her husband of 52 years in a small rural community. Louanne was diagnosed with diabetes 5 years ago and the disease is poorly controlled. She presented to the office today with a deep red bruise on the heel of her foot that doesn't seem to be healing. She tells the provider that "I think something bit me." The provider removes Louanne's shoe and sees an area the size of a half dollar on the heel of her foot that is bright read and does not blanch. The provider notes that the shoes Louanne is wearing are very tight and too small for her foot. What type of injury is Louanne demonstrating? Stage 1 pressure injury Stage 2 pressure injury Stage 3 pressure injury Stage 4 pressure injury Deep tissue injury
Protein CORRECT. The client should increase protein intake to assist in wound healing. The nurse should include this information in client education, along with examples of nutritious, protein-rich foods. Baseline lab work would be ordered during hospitalization to assess the client's protein status. A dietitian could be consulted per facility policy.
Louanne struggles to maintain a nutritious diet. What should the nurse encourage during the hospital stay for better wound healing? Carbohydrates Protein Fats Fruits Vegetables
Pressure Ulcers- Stage 1
nonblanchable erythema of intact skin
Cellulitis
diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling due to poor circulation treat with warm wraps and creams
Punch biopsy
removal of a small core of tissue using a hollow punch
Excisional biopsy
removal of tumor and a margin of normal tissue
Skin Grafts/ Pedicle Flaps
shaves off fine layer of tissue used for a skin graft to use on another site. the site where skin is removed will stay as a scar. What we use on burns
Folliculitis
superficial infection involving only the upper portion of the follicle
Sunburn (one too many times)
too much sun has damaged skin and turned to leather look, underlying damage has been done skin can be damaged in outside workers and truck driver, anyone who has consistent long-term sun exposure
Impaired Skin Integrity
• Interventions include: • • Individual client needs • • Nonsurgical management: dressings, physical therapy, drug therapy, diet therapy, new technologies, electrical stimulation, vacuum-assisted wound closure, and hyperbaric oxygen therapy
Risk for Infection and Wound Extension
• Interventions: • • Monitor the ulcer's progress. • • Provide timely treatment with topical and systemic antibiotics. • • Take steps to reduce introduction of pathogenic organisms to the ulcer through direct contact.
Prevention of Infection and Wound Extension
• Interventions: • • Report the following to the primary health care provider: • • • Sudden deterioration of the ulcer, increase in size or depth of the lesion • • • Changes in color or texture of the granulation tissue • • • Changes in the quantity, color, or odor of the exudate • • • Classic signs of wound infection
Partial-Thickness Wounds
• Involve damage to the epidermis and upper layers of the dermis • Heal by re-epithelialization within 5 to 7 days • Skin injury immediately followed by local inflammation
Inspect Skin
• Look for signs of: • • Edema • • Moisture • • Vascular markings • • • Petechiae (red freckles, can be all over, are little ruptured capillaries) • • • Ecchymoses (happens because of bruising) • • Integrity (looking for any skin breakdown, turning on schedule) • • Cleanliness
Common Skin Lesions
• Macules- flat lesions < 1cm in diameter • • Flat moles, freckles • Patches- Macules that are > 1cm in diameter • • Vitiligo • Papules- Small firm raised lesions < 1cm in diameter • • Elevated moles or warts • Plaques- Elevated, plateau-like lesions >1cm in diameter and don't extend to lower layers of skin. • • Psoriasis • Nodules-Elevated, marble-like lesions >1cm deep/ wide • • Lipoma • Cyst- Nodules that are liquid or semi-solid filled and can be expressed • • Sebaceous cyst • Vesicles or Bullae- Blisters filled with clear fluid- vesicles are < 1cm in diameter and bullae are >1cm in dia. • • 2nd degree burns • Pustules- Vesicles filled cloudy or purulent fluid • • Acne • Wheals- Elevated, irregularly shaped transient areas of dermal edema • • Urticaria or bug bites
Identification of High-Risk Clients
• Mental status/decreased sensory perception—client at risk for pressure ulcers • Activity/mobility • Nutritional status • Incontinence (anyone who does not know they need to move themselves, coma, Parkinson's, Alzheimer's, obese)
Collaborative Management (Xerosis)
• Nursing interventions aim to rehydrate the skin and relieve itching. • Bathing with moisturizing soaps, oils, and lotions may reduce dryness. • Water softens the outer skin layers; creams and lotions seal in the moisture provided by water. (needs to be done regularly and consistently)
Pediculosis
• Pediculosis—infestation by human lice • • Head lice: Pediculosis capitis • • Body lice: Pediculosis corporis • • Pubic or crab lice: Pediculosis pubis • Pruritus most common symptom • Drugs such as Bio-Well, Kwell, Kwellada, Ovide, Prioderm lotion, NIX • Laundering of clothing and bed linen
Trauma
• Phases of wound healing • • Inflammatory phase • • Fibroblastic, or connected tissue repair phase • • Maturation or remodeling phase
Surgical Management
• Preoperative care • • Dressing changes and prevention of infection (keep wound as clean as possible) • Operative procedures • • Debridement (clean to healthy tissue- bleeding) • • Possible closure/ skin grafts • • Pedicle flaps • Postoperative care • • Do not disturb dressing. • • Ensure complete rest of grafted area. • • Ensure care of pedicle flap. • • Provide postoperative care of donor sites. • • Ensure correct client positioning.
Wound Assessment
• Pressure ulcers and their features are classified and assessed in 4 stages: • • Stage I • • Stage II • • Stage III • • Stage IV
Skin Care
• Bathe daily with an antimicrobial soap. • Remove any pustules or crusts gently. • Apply warm compress twice a day to furuncles or areas of cellulitis. • Apply appropriate ointments (antibiotic, antifungals, antivirals) • Other treatments may be appropriate (cryosurgery, antipyretics, etc) • Avoid excessive moisture. • Ensure optimal client positioning.
Assessment (skin infection)
• Because most skin infections are contagious, take precautions to prevent the spread of infection. • Culture purulent material; obtain blood cultures. • A number of diagnostic tests can be run on skin: Diagnostic Tests of the Integumentary System (page 395)
Skin Assessment
• Color (appropriate for race, changes to note) • Lesions, primary and secondary • Assess each lesion (separately) for: • • ABCD features (for something cancerous) • • • A= Asymmetry of shape (is it the same shape on both sides) • • • B= Border irregularity (puts in a greater risk for cancer) • • • C= Color variation within one lesion (puts in a greater risk for cancer) • • • D= Diameter greater than 6mm (need to be referred to physician for further investigation)
Diagnostic Assessment
• Cultures for: • • Fungal infections • • Bacterial infections • • Viral infections • Skin biopsies • • Punch biopsy • • Shave biopsy (take a shaving off of lesion) • • Excisional biopsy (take whole lesion out) Wood's light examination
Full-Thickness Wounds
• Damage extends into the lower layers of the dermis and underlying subcutaneous tissue. • Removal of the damaged tissue results in a defect that must be filled with granulation tissue in order to heal. (may have secondary intention healing) • Contraction develops in healing process. (can get down to bone and tendon)
Fungal Infections
• Dermatophyte infections can differ in lesion appearance, anatomic location, and species of the infecting organism. • • The term tinea describes dermatophytoses. • • • Tinea capitis • • • Tinea corporis • • • Tinea pedis • Candidiasis infections caused by Candida albicans (yeastlike fungus) (in folds of skin, under breasts and can be caused by use on antibiotics)
Drug Therapy for Skin Disorders
• Drugs can be given topically or systemically, depending on need: • • Antibacterial drugs • • Antifungal drugs • • Antiviral drugs • • Anti-inflammatory drugs
Nail Assessment
• Dystrophic nails may occur with a serious systemic illness or local skin disease involving the epidermal keratinocytes (a sign of chronic illness either locally at nail site or systemic) • Evaluate fingernails and toenails for color, shape, thickness, texture, and presence of lesions (in and around) • Minor associations w/ the aging process include gradual thickening of nail plate, presence of longitudinal ridges, and yellowish-gray discoloration
Process of Wound Healing
• First intention resulting in a thin scar • Second intention (granulation) and contraction—a deeper tissue injury or wound • Third intention (delayed closure)—high risk for infection with a resultant scar
Sunburn
• First-degree, superficial burn • Cool baths (no hot water) • Soothing lotions (aloe Vera) • Antibiotic ointments for blistering and infected skin (prophylactically) • Topical corticosteroids for pain (need to protect skin from sun to keep from getting cancer and to keep skin healthy)
Bacterial Infections
• Folliculitis: superficial infection involving only the upper portion of the follicle • Furuncles: much deeper infection in the follicle • Carbuncles: A group of infected hair follicles • Cellulitis: generalized infection with either Staphylococcus or Streptococcus involving deeper connective tissue
Hair Assessment
• Inspect and palpate the hair for cleanliness, distribution, quantity, and quality. • Dandruff is an accumulation of patchy or diffuse white or gray scales that appear on the surface of the scalp. • Hirsutism is excessive growth of body hair, which is one manifestation of hormonal imbalances. (hair where there is not supposed to be hair) (alopecia- unusual balding) (will need to look for any damage that would need to be addressed to keep patient comfortable or may cause discomfort)
Functions of the Skin
• Protection • Homeostasis • Temperature regulation • Sensory organ • Vitamin synthesis (vit D) • Psychosocial (beauty industry shows importance)
Pruritus
• Pruritus is caused by stimulation of itch-specific nerve fibers at the dermal-epidermal junction. • Itching is a subjective symptom similar to pain. (cant see or rate) • Cool sleeping environment is helpful. • Fingernails should be trimmed short. (don't want itching to cause secondary lesions) • Balneotherapy is a therapeutic bath using colloidal oatmeal. • Therapy: • • Antihistamines • • Topical steroids (caused by scabies, head lice, (any lice) uric acid)
Scabies
• Scabies is a contagious skin disease caused by mite infestations. • • Transmitted by close and prolonged contact or infested bedding. • • Examine skin between fingers and on the palms. • • Infestation is confirmed by an examination of a scraping of a lesion under a microscope. • Scabicides include Kwell, Kwellada, or topical sulfur preparations. • Launder clothes and personal items.
Integrity of Skin
• Skin tears result from of flattening of the dermal-epidermal junction and are a common finding with aging. • Look for skin tears where constrictive clothing rubs the skin, on the upper extremities where the skin is grasped when assisting a client to move, and the areas where adhesive tapes or dressings have been used.
Anatomy and Physiology Review skin
• Structure of the skin • • Fat • • Dermis • • Epidermis • Hair • Nails • Glands Functions of the Skin • Protection • Homeostasis • Temperature regulation • Sensory organ • Vitamin synthesis • Psychosocial
Pressure Ulcer
• Tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period. • Mechanical forces that create ulcers: • • Pressure • • Friction • • Shear
Urticaria
• Urticaria: presence of white or red edematous papules or plaques of varying sizes • Removal of triggering substances • Antihistamines helpful • Avoidance of overexertion, alcohol consumption, and warm environments, which can worsen symptoms (need to find trigger and remove)
Viral Infections
• Warts: Lesions causes by HPV (human papillomavirus) (genital or non genital) • Herpes Simplex viruses • • HSV-1 Majority are above waist found on lips, waist, mouth (cold sore/ fever blister) • • HSV-2 Classified as sexually transmitted by physical contact, oral sex, or kissing • • • Will study later (Chp 52) • Herpes Zoster: Shingles
Structure of the skin
• • Fat • • Dermis • • Epidermis • Hair • Nails • Glands
Herpes Simplex Viruses
• • HSV-1 Majority are above waist found on lips, waist, mouth (cold sore/ fever blister) • • HSV-2 Classified as sexually transmitted by physical contact, oral sex, or kissing (must remove all warts to keep from spreading)
Skin Assessment techniques for Clients with Darker Skin
Assess for: • Pallor • Cyanosis • Inflammation (palpate with visualization) • Jaundice (sclera) • Skin Bleeding (on sheets, pillow case, socks) (look at mucous membranes, sclera, palms of hands)
"When your heels rest on the mattress, the continued pressure to the site creates injury." CORRECT. The response by the nurse should provide education as to why the pillow is necessary, since Louanne may not understand. B is the most direct response to the issue of concern.
Despite the nurse's attempts to keep Louanne's heels away from the pressure of the mattress, she continues to kick the pillow out from under her legs. She tells the nurse "It doesn't hurt me, I don't see what the big deal is." How should the nurse respond? "It's your decision since they're your feet." "When your heels rest on the mattress, the continued pressure to the site creates injury." "I'm glad it doesn't hurt, it looks like it would." "We'll have to ask your provider if we can get rid of the pillow, since she ordered it to be there." "Did you know you could end up with an amputation?"
The risk is high and referrals are needed for therapy services and wound care. CORRECT. The Braden scale scoreMild risk - 15 to 18Moderate risk - 13 to 14High risk - 10 to 12Very high risk - 9 or below
Louanne's Braden Scale score is an 11. What conclusions can the nurse make? Since she is ambulatory with assistance the skin score in insignificant. Today she's an 11, but it may be different tomorrow. The risk is minimal and not a concern. The risk is moderate so some interventions are important including a special mattress. The risk is high and referrals are needed for therapy services and wound care.
Pediculosis pubis
Pubic or crab lice
Pressure Ulcer- Stage 2
- Partial thickness (some skin loss or blistering)
Patches
- Macules that are > 1cm in diameter • • Vitiligo
Cyst
- Nodules that are liquid or semi-solid filled and can be expressed • • Sebaceous cyst
Wheals
- Elevated, irregularly shaped transient areas of dermal edema • • Urticaria or bug bites
Plaques
- Elevated, plateau-like lesions >1cm in diameter and don't extend to lower layers of skin. • • Psoriasis
Pediculosis capitis
- Head lice ** Nits shed into the environment and are able to hatch up to 7-10 days**
Macules
- flat lesions < 1cm in diameter • • Flat moles, freckles
Stage 4 pressure injury CORRECT. Stage 4 injury includes full thickness tissue sloughs with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often undermining and tunneling are present.
A few days later, the nurse performs a focused assessment and identifies that Louanne's pressure injury is now full thickness. There is some bone showing. There is eschar on the edges of the site along with some tunneling. What stage injury should the nurse document? Stage 1 pressure injury Stage 2 pressure injury Stage 3 pressure injury Stage 4 pressure injury Unstageable pressure injury
Answer: C Rationale: The need for stool containment should be based upon the severity of the incontinence symptoms, the patient's ability for self-care, and the severity of the skin damage. Invasive containment strategies should be considered in the presence of diffuse skin breakdown particularly when a patient has poor mobility.
In a patient with incontinence associated dermatitis caused by frequent, loose stools, the nurse includes which intervention in the plan of care? A. Vigorously scrub skin to remove contaminants. B. Use diapers to contain urine and stool. C. Use invasive containment devices in the presence of diffuse partial thickness wounds. D. Avoid using skin protectants.
