Integumentary Module
What is a furuncle?
"Boil" Infection of hair follicle that extends through dermis into subcutaneous tissue and forms a small abscess
Exudate may occur during a bacterial infection - what is this?
(wound drainage) that contains pus, odor, erythema, inflammation, and increased pain occurs in response to an infection.
How does pressure ulcers develop and why?
1. Decreased level of consciousness or sensation 2. Sedation or frequent analgesic dosing 3. Poor circulation 4. Elderly patients 5. Malnourished or dehydrated 6. Incontinence and diaphoresis 7. Impaired mobility
When assessing a pressure ulcer, what should you examine?
1. Location: anatomical position 2. Size: centimeters or millimeters 3. Depth: use sterile swab. 4. Undermining or tunneling 5. Tissue type: describe the wound bed. 6. Drainage 7. Wound margins: surrounding tissue—clean, dry, red 8. Drains and tubes
DMARDS (disease modifying anti-rheumatic drugs) are used to treat psoriasis but these have a lot of side effects. List 4.
1. Methotrexate 2. Humira 3. Enbrel 4. Remade
What are the 5 functions of the skin?
1. Protection 2. Temperature regulation 3. Vitamin D metabolism 4. Sensation 5. Excretion
How should a nurse provide patient education to a patient after a skin biopsy?
1. Teach to check incision daily 2. Ask health care provider about getting the incision wet or showering 3. Light dressing may be applied and can be changed daily 4. Antibiotic ointment can be used to prevent infection
Healing, whether it be from a traumatic injury or a surgical procedure, depends on nutritional status. Primarily what two things?
1. albumin 2. pre-albumin
What are the 11 types of wound dressings?
1. alginate 2. collagens 3. non adherent contact layers 4. foams 5. hydrocolloids 6. hydrogels 7. hydrofibers 8. semipermeable films 9. gauze 10. hydrofera blue 11. debridement
List the layers of the skin in order.
1. epidermis 2. dermis 3. subcutaneous
What are the 3 layers of skin?
1. epidermis 2. dermis 3. subcutaneous
List the 4 stages of wound healing.
1. hemostasis 2. inflammatory 3. proliferative 4. maturation
What are the 4 stages of wound healing?
1. hemostasis 2. inflammatory phase 3. proliferative phase 4. remodeling phase
Patients who have had reconstructive surgery are at high risk for what two things?
1. infection 2. loss of vascularity
How do you treat pressure ulcers?
1. nutrition 2. wound care
Who takes longer to heal?
1. older adult 2. especially diabetics 3. smokers
What are the 3 types of surgical incisions?
1. primary intention 2. secondary intention 3. tertiary intention
What does the Braden Scale look at?
1. sensory perception 2. moisture 3. activity 4. mobility 5. nutrition 6. friction and shear
How do you treat skin cancer?
1. surgical excision 2. curettage and electrodessication 3. Moh's micrographic surgery 4. photodynamic therapy 5. cryotherapy 6. radiotherapy 7. topical chemotherapy
What are the treatment options for skin trauma?
1. surgical/ sharp 2. autolytic 3. mechanical 4. maggot larvae 5. enzymatic
List the 4 age-related changes of the integumentary system.
1. xerosis 2. eczema 3. psoriasis 4. herpes zoster (shingles)
Describe the scoring for the Braden Scale.
15 to 18 = mild risk 13 to 14 = moderate risk 10 to 12 = high risk 9 or below = very high risk
What percentage of patients with psoriasis will develop psoriatic arthritis? What is this?
30%; an inflammation and pain in their joints
Describe pressure ulcers.
A break in skin integrity Acute or chronic Partial thickness involves epidermis and dermis. Full thickness involves epidermis, dermis, and subcutaneous tissue. - May involve muscle, tendon, ligaments, and bone
Describe wound care.
A circumferential assessment for undermining (tissue destruction or pressure injury extending under the wound edges, making the injury larger at its base than at the skin surface) and inspection and measurements of tunneling (a passageway under the skin surface that is also known as a sinus tract that results in dead space that can increase the risk for abscess formation) are included in each wound assessment.
What is a carbuncle?
A furuncle that extends into adjacent follicles
What is a laceration?
A laceration is a break in the skin caused by penetration of a sharp object or high shearing forces that exert a diagonal force on the skin, causing damage. The wound edges of abrasions may be smooth or jagged. Lacerations are superficial (near the skin surface) or extend into the deeper tissues such as the nerves, muscle, bone, or tendon. Lacerations that are superficial and do not involve the underlying tissues are usually treated in the primary healthcare provider's office.
What are the worst possible complications for a bacterial infection?
A major complication of skin and soft tissue infections is the overuse and misuse of systemic antibiotics. Some providers resort to using antibiotics when some uncomplicated skin and soft tissue infections can be treated simply with warm compresses or incision and drainage without follow-up antibiotics. However, incorrect wound-culturing techniques can lead to further complications, such as misidentification of the virulent bacteria, worsening infection, and bacteremia (bacteria in the bloodstream). Complicated soft tissue infections, such as necrotizing soft tissue infection, present another set of complications because it is often not possible to diagnose these infections on initial presentation.
What is a punch biopsy?
A punch biopsy, which is the most frequently used technique, removes a circular, continuous section that contains epidermis, dermis, and upper layers of subcutaneous tissue. The sample is approximately 3 to 4 mm wide, and local analgesia is administered. Closure of the site may require minimal suturing.
What is an abrasion?
Abrasions, occurring as a result of friction and shear from external forces, are usually minor injuries involving only the epidermis. Some abrasions involve part or all of the dermis. Minor abrasions do not usually require treatment by healthcare personnel, leading to difficulty in determining incidence and prevalence rates because these injuries are not consistently reported.
What is actinic keratosis?
Actinic keratoses are considered precancerous lesions. Formed by atypical keratinocytes (epidermal squamous cells), they proliferate in the epidermis. Without treatment, they evolve into squamous cell carcinoma.
Describe the evaluating outcomes for skin trauma and healing.
Acute traumatic wounds usually heal without consequence. Educating the patient and family about the clinical manifestations of infection is important in managing wounds. Additionally, because aging skin is at even greater risk of trauma, awareness of potential environmental hazards can minimize traumatic injuries. Ensuring that wheelchairs are in good repair, floors are clear from clutter, beds are kept in their lowest position, and patients are positioned with the head of the bed at less than 30 degrees when possible are ways to minimize environmental risks. Lastly, evaluating and maximizing nutrition for a patient with an open wound supports wound healing.
Describe the evaluating outcomes for psoriasis.
Address emotional and psychological stress because physical clinical manifestations have proven to be crucial in the management of psoriasis. Providing emotional support, allowing the patient to verbalize concerns, and referral to the appropriate providers and support groups can improve overall quality of life. Educating the patient and family about medication side effects, including frequent skin assessment during phototherapy, is essential for the patient's health and safety.
Describe nutrition.
Adequate nutrition plays a significant role in healing pressure injuries, and patients require supplementary nutritional support. Appropriate amounts of calories, protein, fluids, vitamins, and minerals are necessary for tissue repair and the prevention of pressure injuries.
What is tinea corporis?
Affects the entire body Annular patches or plaques with advancing, raised border and central clearing
What is tinea crusis?
Affects the face Annular rash with rasied margins Pruritus
What is tinea pedis?
Affects the feet Maceration of interdigital skin of feet Diffuse dry scaling of soles of feet
What is oral thrush (oropharyngeal candidiasis)?
Affects the mouth: tongue, inner cheek (buccal mucosa), inner lip, and occasionally hum (gingiva) Creamy white plaques on erythematous mucous membranes. Thick white coating of tongue, inner cheeks, inner lips, or gums
What is vulvovaginal candidiasis?
Affects vagina and vulva Thick, cottage cheese-like vaginal discharge Pruritus
What is an excision biopsy?
An excision biopsy removes a relatively large, deep section of tissue. This technique may be used to remove an entire lesion, so sutures, a graft, or even a flap may be required to close the area.
What is an excoriation?
An excoriation is a superficial abrasion. It can be self-induced through repetitive scratching and is usually linear in appearance. Excoriations are commonly seen in disorders of the skin that cause pruritus (itching), such as insect bites, scabies, dermatitis (inflammation of the skin from an allergic reaction), and chicken pox (varicella-zoster virus). The term excoriation is also used to describe the loss of epithelium in response to prolonged exposure to urine and feces in an individual who is incontinent.
How do you treat a patient after reconstructive surgery?
Antibiotics may be ordered prophylactically for initial treatment; however, culture and sensitivity information must be evaluated and antibiotic therapy targeted to treat any identified pathogens. Lastly, nutrition must be optimized for healing to occur.
How do you treat a fungal infection?
Antifungal agents are the primary agents used to treat fungal infections. Not every antifungal medication is the same, and what is an appropriate treatment for one infection may not be for another. Therefore, research recommends better healthcare provider education concerning the diagnosis, management, and prevention of fungal skin infections.
Body distribution of malignant melanoma?
Anywhere on the body, especially where there are existing moles; upper back, lower legs, soles of feet, and palms of hands in dark-skinned individuals
Clinical features of malignant melanoma?
Appearance can follow the ABCDE rule: A: Asymmetric appearance B: Irregular borders C: Variation of color (brown, black, tan, blue, red, white, or any combination) D: Diameter greater than 6 mm E: Elevation or an evolving, enlarging, and changing existing lesion
What are the symptoms of a fungal infection?
Areas that are occluded, such as the toe spaces, are most at risk of infection, and an identifiable characteristic of dermatophyte infections is an active, raised border. Yeasts, on the other hand, multiply by budding and thrive in warm, moist environments on the skin and mucous membranes of the gastrointestinal tract and vagina. Fungal infections may present as scaling rashes, plaques, vesicles, or pustules.
What is the worst possible complication for skin trauma and healing?
As with any breach in the integrity of the skin, patients with traumatic skin injuries are at high risk for infection. Clinical manifestations of infection include increasing erythema, increased temperature of surrounding tissues, odor, purulent drainage, increased swelling, increased pain, and fever. Depending on the depth of the injury, an individual can be at further risk of damage to underlying structures of muscle, tendon, bone, and nerve, requiring deep lacerations to be explored down to the wound bed to determine the involvement of these structures. Lastly, scarring from skin injuries that are on the face or other apparent surfaces can be psychologically traumatic and can affect self-image and interpersonal relationships.
What is the worst possible complication for pressure ulcers?
As with any open wound, infection is the main complication. Assessing for local clinical manifestations of wound infections (erythema, increased warmth, swelling, increase in injury size or depth, increased pain, purulent exudate, and odor) should occur on a regular basis.
What is the worst possible complication of reconstructive surgery?
As with any surgery, reconstructive surgery runs a high risk of infection. A close assessment of the surgical site and donor sites of skin grafts and free tissue transfers for erythema, increased warmth, purulent drainage, approximation of the incision line, swelling, increased pain, and local lymphadenopathy is essential. For flaps and free tissue transfer, hematoma formation, induration, and signs of decreased vascularity are indications that may require further surgical interventions. Additionally, attention to frequent laboratory values such as CBC values and serum electrolyte panels is essential in monitoring for hemorrhage, fluid and electrolyte imbalances, and infections.
What is basal cell carcinoma?
Basal cell carcinomasarise from the basement membrane of the epidermis. Although these are rarely metastatic, they can significantly damage adjacent tissue secondary to large excisions and damage vital structures.
How do you treat psoriasis?
Because there is no cure for psoriasis, the goal in treating this disorder is to reduce the clinical manifestations, control the disease, and improve quality of life. There are several therapies available, including topical creams and ointments and UV light therapy, as well as systemic medications.
Describe hemostasis.
Begins at onset of injury/after surgery Objective is to stop bleeding Blood clotting system activated Primarily about coagulation, lasts approximately 24 hours
Describe the appearance of herpes zoster (shingles).
Blistering and erythema along a dermatome.
Clinical course of squamous cell carcinoma?
Can invade fatty tissue beneath the dermis and spread via the lymph nodes to other parts of the body (although this is not that common); recurrence rate within 3 years is 18%.
Diagnostic for tinea crusis?
Clinical appearance KOH microscopy
Diagnostic for tinea corporis?
Clinical appearance KOH microscopy A fungal culture, used as an adjunct to KOH for diagnosis, is more specific than KOH for detecting a dematophyte infection. If clinical suspicion is high, yet the KOH result is negative, a fungal culture should be obtained.
Diagnostic for tinea pedis?
Clinical appearance KOH microscopy if needed
What are the symptoms for the herpes simplex virus?
Clinical manifestations of primary infection occur within 2 weeks of viral transmission and can include fever; malaise; myalgias; anorexia; irritability; cervical or inguinal lymphadenopathy; and lesions that can involve the lip, face, mucous membranes of the mouth, pharynx, or genitals. Typically, the secondary infection is milder than the primary infection and is usually preceded by a prodrome of a burning, itching, or tingling sensation where the lesion eventually occurs. May people who get HSV 1 (oral) get prodromal symptoms before the eruption - tingling, burning, headache, malaise, then the area may get red about 2 days before eruption Most people with HSV 2 (genital herpes) don't even know they have it
Diagnostic for vulvovaginal candidiasis?
Clinical signs and symptoms
Diagnostic for oral thrush (oropharyngeal candidiasis)?
Clinical signs and symptoms Visual inspection of the area
Clinical manifestations of a carbuncle?
Coalescent inflammatory lesion' pus drains from multiple follicles; typically, on back and neck
Describe integumentary in older adults.
Collagen and elastic begin to steadily break down which weakens the strength of the skin making it at risk for injuries such as skin tears. Skin becomes very fragile Teach them to use mild soap, may not need to bathe every day, avoid hot baths and showers because they will dry skin out more Apply moisturizers twice a day to prevent from drying out Pruritusis known as itching
Describe the maturation phase.
Collagen fibers increase the tensile strength of the scar tissue. 70% to 80% of the skin's original strength is attained when the wound is healed •
What are necrotizing soft tissue bacterial infections?
Complicated skin and tissue infections and necrotizing soft tissue infections are usually polymicrobial. In complicated (non-necrotizing) skin and soft tissue infections, gram-positive bacteria such as methicillin-sensitive Staphylococcus aureus (MSSA) and S. pyogenes are isolated about 50% of the time.
What is the worst possible complication for a fungal infection?
Complications of fungal infections occur when they are not treated promptly and are allowed to proliferate, especially in the critically ill and immunocompromised patient. Prompt diagnosis of Candida infections in an ICU is difficult because of the time needed for finalization, thus delaying treatment and increasing the risk of mortality.
Describe Moh's Micrographic Surgery.
Considered the "gold standard" for the treatment of non-melanoma skin cancers, Mohs' micrographic surgery is a highly specialized surgical approach completed only by surgeons specifically trained in this procedure. The surgeon excises horizontal sections of the tumor, leaving a minimal margin of normal tissue. Each layer of tissue is histologically examined by frozen section and microscopically analyzed during surgery. Excision continues until all residual tumor is removed. This allows the surgeon to explore all of the margins to reduce the risk of incomplete excision or removal of too much tissue, possibly causing unfavorable cosmetic outcomes. Horizontal sections are removed and looked at - frozen and histologically examined during the surgery until they get to the point where all the tumor is removed. You will hear the term "frozen sections."
Describe maggot larvae.
Consume necrotic tissue and bacteria
Clinical features of squamous cell carcinoma?
Crusted papules and plaques that can become indurated and ulcerated. Larger lesions can become painful and bleed. Also, squamous cell carcinomas can arise from chronically open wounds, burn scars, or leg ulcers because of chronic inflammation.
What is necrotic tissue?
Dead or avascular or devitalized tissue
What is a fungal infection?
Dermatophytes, which reproduce by the formation of spores, cause superficial cutaneous fungal infections and do not spread beyond the epidermis. Found living in soil, on animals, and on humans, dermatophytes are aerobic fungi that feed on the dead keratin of the skin, hair, and nails.
Describe the proliferative phase.
Development of collagen, new blood vessels, and connective tissue creates granulation tissue. Wound edges contract Clinical findings: beefy red and shiny, rainy or bumpy, epithelialization results in scar
What is cellulitis?
Diffuse infection of the dermis and subcutaneous tissue; usually occurs through breaks in the skin Sometimes with cellulitis, we will draw an outline around the erythematous area to be able to measure improvement or worsening of the infection
Describe xerosis.
Dry skin that is very uncomfortable. Patients often describe pruritus or burning.
Describe autolytic.
Endogenous enzymes present in wound fluid interact with moist dressings to soften and remove necrotic tissue
Describe enzymatic.
Enzymes degrade and remove necrotic tissue
Describe the appearance of eczema.
Erythema, weeping, crusting, scales, and severe pruritus.
Risk factors for necrotizing soft tissue bacterial infections?
Factors influencing the patient's susceptibility to infection include acute or chronic skin ulcerations, fungal infections, venous stasis disease and alterations in venous drainage, obesity, arterial compromise to the skin, lymph node resection, and immunocompromised state. Additional factors that put individuals at risk for necrotizing soft tissue infection, such as necrotizing fasciitis, include diabetes mellitus, trauma, alcohol or injection drug use, and the use of nonsteroidal anti-inflammatory medications because of their immunosuppressant effect. Methicillin-resistant S. aureus infections are frequently associated with poor hygiene, overcrowded living conditions, skin-to-skin contact, sharing of contaminated objects, previous infection with MRSA, and trauma. I Therefore, demographic groups at higher risk of MRSA infections include children, young adults, minorities, low-socioeconomic groups, homosexual men, athletes, prisoners, daycare workers, and tattoo recipients.
Clinical course of malignant melanoma?
Favorable outcome if diagnosed and treated early; rapid metastasis can occur; 5-year survival rate of 91% and 10-year survival rate of 89%
Describe necrotizing soft tissue infections.
Flesh eating bacteria Typically, resistant to antibiotics Grows very quick
What is a friction blister?
Friction blisters commonly occur on the feet of long-distance runners or on individuals with poor-fitting shoes, as well as on the palms of athletes who play racquet sports. Friction is a force that is applied parallel to a surface, resulting in a rubbing motion. This causes the cells of the epidermis to separate, and increased hydrostatic pressure causes plasmalike fluid to accumulate between the cells. Moisture on the surface increases the risk of blistering. Most commonly, blisters occur on the feet and palms where the skin is thick; however, blisters can occur on other parts of the body because of the external forces of friction and shear.
Describe a stage 3 wound.
Full-thickness loss of skin, in which adipose tissue is visible in the ulcer and granulation tissues and epibole (rolled wound edges) are often present Slough and/or eschar may be visible The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds Undermining and tunneling may occur Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure ulcer
Describe a stage 4 wound.
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer Slough and/or eschar may be visible o Epibole, undermining, and/or tunneling often occur Depth varies by anatomical location If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury
How do you prevent a fungal infection?
Generally, the prevention of fungal skin infections requires avoidance of the causative factors, which include wearing tight shoes for prolonged periods, moisture and perspiration, contact of surfaces with bare skin, and sharing of contaminated personal items. Meticulous hand washing and eliminating the sharing of personal items are the primary methods of preventing infection transmission. For hospitalized patients, prevention of superficial fungal infections can be achieved by keeping skinfolds dry and clean, frequent turning of bed-bound patients to enhance airflow, and timely cleansing and drying of incontinence and wound exudates.
What is the herpes simplex virus?
Herpes simplex viral infections can occur on the skin, mucous membranes, central nervous system, and genital tract. There are two phases of reactivity of the herpes virus, primary and secondary infections. A primary HSV infection describes the first time an individual is infected with the herpes virus. Primary infection can occur through direct contact with an individual with HSV who is asymptomatic; is in a prodromal (early) stage of the disease; or has active oral or genital infections, secretions, or lesions. Secondary (or recurrent) HSV infections occur following an exogenous or endogenous trigger that reactivates the dormant virus. Triggers are individually specific but commonly occur in response to ultraviolet (UV) light exposure, febrile illnesses, and stress, for example. The virus is then transferred from the ganglia back to the initial site of inoculation via the peripheral nerve. The number of lesions and the nature of the outbreak depend on the individual's immune status at the time, and in general, genital recurrences occur more frequently than oral recurrences. Recurrences of GH caused by HSV-1 occur less frequently than those caused by HSV-2.
Typically, why does herpes spread?
Herpes spreads because people can be asymptomatic at the time or even unaware that they have it and they engage in sexual activity and it spreads
Describe herpes zoster.
History of chicken pox; reactivation of the varicella-zoster virus Nerves around the chest and back, facial (trigeminal nerve) is affected Not good if it gets in the eyes Contagious to people who have never had chickenpox or have not been vaccinated There is also a vaccination for shingles (Zostavax) which is recommended for patients >60
What is hyper granulation tissue?
Hyperplasia of granulation tissue recognized by its friable red appearance usually in response to a prolonged inflammatory phase
Describe the inflammatory phase.
Immediately after wound occurs Vasoconstriction, platelet aggregation, and fibrin deposition, phagocytosis Clinical findings: erythema, edema, pain
Describe biologic treatment for psoriasis.
Immunomodulatory medications (e.g., Humira, Enbrel, Remicade)
What is the worst possible complication for skin cancer?
In addition to the physical complications of the treatments, the psychosocial aspects of skin cancers can have far-reaching effects on both the patient and family.
What is the worst possible complication for psoriasis?
In addition to the side effects of medications, patients with psoriasis are at high risk of developing other diseases (i.e., cancer, cardiovascular disease, Crohn's disease, diabetes, metabolic syndrome, uveitis, and liver disease). PsA occurs in approximately 30% of those individuals diagnosed with psoriasis. Those with PsA experience pain, soft tissue swelling, and limitations in movement for 6 weeks or longer, and this can be a debilitating consequence of psoriasis. Research demonstrates an increased risk of malignancy among patients with psoriasis. Non-melanoma skin cancer; lymphoma; and cancer of the lung, larynx, pharynx, liver, pancreas, female breast, penis, vulva, bladder, and kidney are among the most common malignancies found to develop. Research also suggests that patients with psoriasis may be at greater risk of developing cardiovascular disease. Some forms of psoriasis are associated with recent streptococcal infections among patients who complained of sore throat symptoms 1 to 2 weeks prior to the psoriatic eruption. Additionally, patients with psoriasis are at increased risk of systemic infections, mainly related to the immunosuppressant therapies used to treat the disease. Therefore, immunizations against influenza and pneumonia are highly recommended. Lastly, psoriasis can have a significant impact on an individual's quality of life. Depression leading to suicidal ideation occurs in more than 5% of those with psoriasis.
What are the symptoms for guttate psoriasis?
In guttate psoriasis, small plaques 2 to 10 mm in diameter appear in a centripetal distribution (starting from the face and extremities and moving toward the trunk). Erythroderma, another form of psoriasis, can involve most or all of the skin. Erythroderma can occur when psoriatic plaques become confluent and extensive or may be an indication of unstable psoriasis exacerbated by infection, medications, or corticosteroid withdrawal. This may lead to the skin's inability to thermoregulate, causing hypothermia and heart failure.
What are the symptoms of a bacterial infection?
In the absence of clinical manifestation of infection, the quantity of organisms is believed to be the best indicator of infection The clinical manifestations observed in patients with bacterial skin infections are related to the bacteria involved, the depth and composition of tissues involved, the temporal association of clinical manifestation onset and presentation to the healthcare provider, existing comorbidities of the patient, and the age of the patient.
What is hyper metabolism?
Increased metabolic rate causing an increased need for calories in response to trauma, severe illness, infection, or pressure injuries, for example Energy pulled from glycogen stores first, then visceral protein stores Results in anorexia, muscle wasting, decreased nitrogen retention, impaired albumin synthesis
Clinical manifestations of a furuncle?
Inflammatory nodule with overlying pustule with hair follicle in the center; outbreaks can occur in families or settings with close personal contact (sports); chronic furunculosis with nasal colonization of MRSA
Describe cellulitis.
Introduction of bacteria onto your skin Typically starts out very red and warm and it grows The best thing you can do when you're a nurse is to take a skin pen and mark the initial inflammation and monitor it
Medical management for tinea pedis?
Keep feet dry and ventilated Topical antifungal Severe: oral antifungal
Describe the medical management of herpes zoster (shingles).
Lidocaine patch to affected area. Antiviral medications.
Describe cryotherapy.
Liquid nitrogen is used for cryotherapy. It creates temperatures between -50°F (-45.6°C) and -60°F (-51.1°C), which freeze the vasculature, leading to cell death and tissue destruction. The freezing of the tissues is nonselective, and the microcirculation becomes impaired, causing pain that usually requires local anesthesia. As the tissues thaw, patients experience increased tenderness. In the days following the procedure, the patient may experience blistering and sloughing at the site, requiring local wound care. Slough is soft, moist devitalized tissue that may be white, yellow, tan, or green. Healing occurs with minimal scarring. o Uses liquid nitrogen to freeze the lesion - slough off
What is cachexia?
Loss of muscle and weight loss with or without loss of fat mass Is a metabolic syndrome associated with underlying illnesses
Clinical course of actinic keratosis?
May begin as erythematous, scaly plaques that exfoliate with toweling off or the rubbing of clothes during the day; induration at the base, cutaneous horn, ulceration, or pain may indicate transformation to squamous cell carcinoma.
How do you treat bacterial infections?
Medical management of skin trauma begins with a thorough wound and medical history, including immunization status. Tetanus is a potentially life-threatening disease that can occur following penetrating injury with an object contaminated with Clostridium tetani bacteria. Nutritional status is another important indicator of wound healing and should be incorporated into the treatment plan to promote wound healing and decrease the length of treatment. When it is not possible to wean patients from steroids, providers use high doses of vitamin A to counteract the steroids' detrimental effects. Vitamin A works by boosting the immune response and enhancing the early inflammatory phase of wound healing. Controlling or eliminating external factors, such as exposure to urine and feces, and decreasing the mechanical forces of friction and shear are necessary in the healing and prevention of traumatic skin injury.
Describe traditional systemic medications to treat psoriasis.
Methotrexate, cyclosporine, acitretin
Describe the medical management of xerosis.
Mild, pH-balanced soaps are used for bathing. Limit bathing time to 10 minutes and use warm water. Twice daily use of moisturizers is encouraged.
Describe topical treatment for psoriasis.
Moisturizing ointments, gels, creams Coal tar: creams and shampoos Corticosteroids Vitamin D analogues (calcipotriene, calcitriol) Retinoids (vitamin A) Salicylic acid (in combination with other topical therapies)
What are the symptoms of psoriasis?
Nail involvement is common and presents as pitting, onycholysis (lifting of the nail away from the nail bed), and splinter hemorrhages under the nail.
Describe phototherapy treatment for psoriasis.
Narrow-band ultraviolet therapy (NB-UVB) phototherapy PUVA photochemotherapy: uses oral psoralens to sensitive cells to ultraviolet A (UVA) radiation; can be combined with other therapies
Describe surgical/sharp.
Necrotic tissue is removed using a scalpel, scissors, forceps, or curette
What is a needle aspiration culture?
Needle aspiration cultures pinpoint the types of infective organisms that have invaded tissues surrounding the wound bed. This process involves inserting a needle into the periwound to aspirate fluid from surrounding tissues.
Describe a stage 1 wound.
Non-blanchable erythema of intact skin Intact skin with localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
What is a bacterial infection?
Non-necrotizing cellulitis occurs when microorganisms, especially streptococcal and staphylococcal species, find a portal of entry through breaches in skin integrity. Initial presentation of bacterial skin infections can include erythema, warmth, edema, and localized pain. Cellulitis is identified by rapidly spreading erythema, warmth, localized pain, and edema with possible inflammation of regional lymph nodes. Necrotizing soft tissue infections are very serious, potentially life-threatening infections that spread rapidly and destroy a significant amount of tissue. They can penetrate and spread throughout the dermis, subcutaneous tissues, fascia, and muscle.
Describe an unstageable wound.
Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed
Describe the diagnostics of skin.
Obtain when S & S of infection Fluid biopsy, wound biopsy, surface culture Clean and irrigate with normal saline before swabbing the wound. Gently roll the swab starting at 12 o'clock position moving zigzag down to the 6 o'clock position.
What are the worst possible complications for herpes simplex virus?
One of the most significant complications of HSV infections is its effect on quality of life due to the psychosocial stress of a diagnosis of GH. Infection with HSV-2 is a major risk factor for the acquisition and transmission of HIV as well. Also, because of a loss of skin integrity, open epithelial lesions carry the risk of secondary bacterial infections. The most devastating time to acquire GH is during pregnancy because the complication of disseminated neonatal herpes carries a mortality rate of up to 30%.
Medical management for oral thrush (oropharyngeal candidiasis)?
Oral antifungal liquids (swish and swallow) or lozenge such as Nystatin May be either treated topically or ingested in liquid form
Clinical manifestations of cellulitis?
Painful, edematous, warmth with poorly demarcated borders of erythema on any part of the body; usually unilateral; lymphadenitis, lymphangitis; fever may be present
Describe a stage 2 wound.
Partial-thickness skin loss with exposed dermis The wound bed is viable, pink or red, and moist and may also present as an intact or ruptured serum-filled blister Adipose (fat) and deeper tissues are not visible Granulation tissue, slough, and eschar are not present These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions)
Clinical features of basal cell carcinoma?
Pearly, translucent, flesh-colored papules; superficial telangiectasias(broken blood vessels) are usually visible; may have rolled edges or ulcerations
Describe a deep tissue pressure injury (DPTI).
Persistent non-blanchable deep-red, maroon, or purple discoloration or epidermal separation revealing dark wound bed or blood-filled blister Pain and temperature change often precede skin color changes Results from intense and/or prolonged pressure and shear forces at the bone - muscle interface The wound may rapidly evolve to reveal the actual extent of tissue injury or may resolve without tissue loss
Clinical manifestations for folliculitis?
Presents as multiple or single pustules with hair follicle in center on any skin bearing hair
What are pressure ulcers?
Pressure injuries are a common health problem among individuals who are physically limited or bedridden. A pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. In other words, a pressure injury can develop in less time with a higher intensity of pressure or in a longer period of time with a lesser degree of pressure. Therefore, the use of pressure-redistribution surfaces and frequent repositioning of the patient are equally important. Pressure-related tissue damage is not only associated with the surface involved but also the type of tissue involved. The epidermis and the dermis can withstand a lengthier exposure to ischemia without incurring irreversible damage. Commonly, the occiput (back of the head), ears, scapulae, sacrum and coccyx, ischium and buttocks, greater trochanters of the hips, and the heels of the feet are affected. An individual who sits for prolonged periods of time is exposed to higher pressures in the coccyx and ischial areas (and possibly the heels or even the lateral surfaces of the feet if a wheelchair is not adjusted to the patient's body).
How do you diagnose pressure ulcers? How do you determine the risk for pressure ulcers?
Pressure injury risk assessments are important in identifying patients at greatest risk of pressure injury development. The Braden scale, the most widely utilized pressure injury risk assessment tool, guides clinicians in medical management decisions to modify treatment parameters and reduce a patient's pressure injury risk.
Describe evaluating outcomes for pressure ulcers.
Prevention of pressure injuries is an important nursing intervention, and surveillance and assessment of risk factors contribute to decreasing the incidence. Pressure injury diagnosis, management, treatment, and prevention require an interprofessional approach to care. Initial and consistent ongoing skin assessment is crucial to the management of pressure injuries. It is essential to include the patient, family, and caregivers in the treatment plan. Careful assessment of risk factors, skin, wound, and nutrition guide the clinical decision-making process. Uncomplicated wound healing and prevention of further tissue damage are the ultimate goals in treating pressure injuries.
Describe primary intention.
Primary intention is the approach used with typical surgical incisions with well-approximated edges that are closed with sutures or staples. These are nice clean wounds (like a simple laceration) or surgical incisions. The edges can be approximated and secured with staples or sutures.
What is undernutrition?
Protein and energy deficiency Consequences can be reversed completely with the administration of nutrients Contributing conditions include increased dependence on others for eating, decreased oral intake of food and fluids, unintentional weight loss, and aging
What is psoriasis?
Psoriasis is a lifelong inflammatory disorder characterized by exacerbations and remissions of raised, scaling, erythematous plaques usually seen on the extensor surfaces of the body. Although there is no cure for psoriasis, there is a variety of treatments available that can control symptoms. Although the cause of psoriasis remains unknown, current research suggests that it results from an interaction of multiple genes, the immune system, and environmental influences. New epithelial cells are continually made in the basal layer of the epidermis, and it takes approximately 28 days for these new cells to reach the surface of the skin and shed. Psoriasis is not always limited to the skin. Psoriatic arthritis (PsA) is a common manifestation of psoriasis, and there is evidence to suggest that there is a genetic component to PsA.
What is granulation tissue?
Red/pink moist granular tissue composed of new blood vessels Healthy, healing tissue
Describe herpes zoster (shingles).
Results from resurgence of varicella virus. Subjective symptoms include burning and pain.
Describe pre-albumin.
Reviewed to evaluate the adequacy of nutrition Normal: 19.5-35.8 mg/dL Malnutrition: Less than 19.5 g/dL
Describe serum albumin.
Reviewed to evaluate the adequacy of nutrition Normal: 3.4-5.1 g/dL Malnutrition: Less than 3.5 g/dL
What is a shave biopsy?
Shave biopsy is used to collect superficial tissue samples of the epidermis and dermis. A sterile blade is used to remove a small piece of skin tissue, and healing occurs through tissue regeneration.
Describe the appearance of xerosis.
Skin appears rough and scaly; it may be erythematous and cracked. Frequently located on extremities.
Describe a biopsy.
Skin biopsy is a key diagnostic tool that allows for microscopic examination of skin conditions or infections. Biopsy is indicated for ulcers and nodules ensuring that all skin layers are scrutinized. When skin biopsy is completed in a timely fashion, it assists with diagnosis as well as identification of an appropriate treatment.
Describe eczema.
Skin inflammation (or dermatitis) that may become chronic with scratching and rubbing.
Describe a category 1 skin tear.
Skin tear without tissue loss: the epidermal flap either completely cover the dermis or covers the dermis to within 1mm of the wound margin Ia: linear type Ib: flap type
What are skin tears?
Skin tears are traumatic wounds usually caused by minor trauma that primarily affect older adults.
Describe a category 3 skin tear.
Skin tears with complete tissue loss - epidermal flap is absent
Describe a category 2 skin tear.
Skin tears with partial tissue loss IIa: scant tissue loss - partial-thickness wound in which less than or equal to 25% of the epidermis flap is lost and greater than or equal to 75% of the dermis is covered by the flap IIb: moderate to large tissue loss - partial-thickness wound in which greater than or equal to 25% of the epidermal flap is lost and greater than or equal to 25% of the dermis is exposed
Clinical features of actinic keratosis?
Skin-colored to reddish-brown macules, papules, or plaques; range from a few millimeters up to 2 cm; usually occur as multiple lesions
What is the best way to treat a furuncle?
Small furuncle is treated with moist heat Large furuncle is treated with an incision and drainage and antibiotics Furunculosis is treated with mupirocin (Bactroban) ointment intranasally
What is slough?
Soft, moist devitalized tissue that may be white, yellow, tan, or green May be loose, stringy
What is macerated tissue?
Softened tissue in response to prolonged exposure to moisture
What is squamous cell carcinoma?
Squamous cell carcinoma is mostly attributed to cumulative exposure to UVB rays over an extended period of time and is a cancer that arises from epidermal squamous cells (keratinocytes). These atypical squamous cells intermix with the normal squamous cells and can invade the underlying dermis. Squamous cell carcinomas can cause significant damage to adjacent tissue and can metastasize within a few months. Many times, actinic keratoses are within or adjacent to the squamous cell carcinomas.
Body distribution of actinic keratosis?
Sun-exposed areas (particularly cheeks, temples, forehead, anterior and posterior neck, ears, backs of hands, and forearms)
Body distribution of basal cell carcinoma?
Sun-exposed areas, especially head, neck, and trunk
Body distribution of squamous cell carcinoma?
Sun-exposed skin, especially the top of the head, neck, and lips
What is folliculitis?
Superficial inflammation and infection of hair follicles
What is primary intention?
Surgical wound or lacerations Sutures, staples, or glue
What is a swab culture?
Swab cultures collect fluid from the most superficial tissue layers. Although this process has minimal risk factors for bleeding or additional infection, it represents the least accurate type of culture. Swab cultures identify the correct infecting organism approximately 60% of the time.
Describe complicated bacterial infections.
Systemic symptoms: fever (or hypothermia), hypotension, tachycardia, confusion/ disorientation, sepsis Spreading area of cellulitis with swelling of regional lymph nodes Edema, ischemia, tissue necrosis with resulting anesthesia to the involved area Moderate pain to paint that is disproportionate with clinical manifestations Blood work: elevated white blood cell count, elevated C-reactive protein Later stages: bullae, skin ecchymosis; CT scan shows gas in subcutaneous tissues
Describe tertiary intention.
Tertiary intention often uses skin grafts for wound closure, after a period of observation following initial surgical debridement. Usually a dirty wound also, it may require debridement of dead tissue and then skin grafts may be used for closure, or it may be allowed to heal by secondary intention for a while then closed. Many pressure ulcers are healed this way.
How do you treat the herpes simplex virus?
The basis of medical treatment of GH is systemic antiviral chemotherapy. Treatment can be directed at first or recurrent episodes as well as daily suppressive therapy, and options need to be discussed with the patient. In counseling patients, it is important to stress that the medications do not eradicate the latent virus. Also, decreased frequency and severity of recurrences are based on continued use of suppressive therapy. Additionally, suppressive therapy has shown to decrease the risk of transmitting HSV-2 to sexual partners. Three antiviral medications, acyclovir, valacyclovir, and famciclovir, tested in randomized trials, have shown clinical benefit in the treatment of GH.
How do you diagnose a fungal infection?
The diagnosis of tinea infections is usually made with a focused history, physical examination, and potassium hydroxide (KOH) microscopy, but sometimes Wood's lamp examination, fungal culture, or histological tissue evaluation is necessary to confirm the diagnosis. Potassium hydroxide microscopy, which has a 76.5% sensitivity and an 81.6% negative predictive value, makes it more sensitive than a fungal culture. To perform KOH microscopy, the scraping of skin from the affected area is placed on a slide and viewed through a microscope after adding a drop of 10% to 20% KOH solution. The presence of hyphae confirms the diagnosis. A Wood's lamp examination that uses a UV light held close to the skin in a darkened room is helpful in diagnosing tinea versicolor. This fungus fluoresces a pale yellow to white.
What is skin trauma and healing?
The explanation of the pathophysiology of skin trauma and the acute wound must include a discussion of the structure and function of the skin, a definition of wound tissues, wound healing, and the influence of age. There are many functions of the skin, including protection from bacterial invasion and external elements; perception of the environment through the senses of touch, pain, temperature, and pressure; retention of water; absorption; thermoregulation; immune surveillance; and metabolism of vitamin D.
How do you treat a carbuncle?
The first treatment option for a carbuncle is an IND Antibiotics are required
How do you diagnose bacterial infections?
The initial diagnostic evaluation includes blood culture and sensitivity, complete blood count with differential, serum electrolytes, and C-reactive protein to monitor inflammation and the effects of treatment. Blood cultures, needle biopsies, and punch biopsies are usually not necessary for localized skin and soft tissue infections such as cellulitis. Nasal colonization of MRSA has been associated with recurrent MRSA skin and soft tissue infections, and there is a high correlation between nasal swab cultures positive for MRSA and wound infections resulting from MRSA.
What are the symptoms of plaque psoriasis?
The most common type of psoriasis is plaque psoriasis, affecting approximately 80% to 90% of those with the disease. Patients with this type of psoriasis present with well-circumscribed, thick, reddened papules or plaques, often covered with silvery scaling flakes.
What is malignant melanoma?
The most serious of all skin cancers are malignant melanomasthat originate from melanocytes found in the basement membrane of the epidermis. There are several different stages of malignant melanomas, depending on the thickness and depth of the tissue.
Describe the evaluating outcomes of reconstructive surgery.
The patient undergoing reconstructive surgery has many needs during the perioperative period. Success rates of skin grafts, muscle flaps, and free tissue transfer flaps can be tenuous and vary by the location of the flap, health status of the patient, presence of preoperative infections such as osteomyelitis, and postoperative care. Patients undergoing debridement with closure by secondary intention need dressing changes throughout the healing phase and will likely go home with an open wound. The patient and family/caregivers require support to help them meet the physical and psychosocial demands of wound healing and the prescribed course of treatment. The goal of treatment is a well-healed wound and improved functional status of the patient.
What is reconstructive surgery?
The plastic surgeon performs primary closure of the wound with minimal scarring if the edges of the wound are fairly straight. For wider wounds, surgical debridement and healing by secondary or tertiary intention may be required. Healing by tertiary intention includes the use of skin grafts, myocutaneous (skin, subcutaneous tissues, and muscle), fasciocutaneous (skin, subcutaneous tissues, and fascia), and free muscle flaps.
What is the worst outcome of cellulitis?
The worst outcome is that it is spread systemically; you could become septic and potentially lose your leg
What is tertiary intention?
The wound is left open to allow for infection and/or edema to resolve. The wound is packed or irrigated
How do you diagnose psoriasis?
There are no laboratory tests specific for psoriasis. Plaque psoriasis is usually diagnosed on the basis of a patient's clinical manifestations. However, some forms of psoriasis mimic other skin disorders, such as bacterial and fungal infections, making it sometimes necessary for a dermatologist to perform a skin biopsy for a definitive diagnosis. If PsA is suspected, serum inflammatory markers such as C-reactive protein and an erythrocyte sedimentation rate (ESR) usually are elevated.
Describe psoriasis.
These lesions emerge from overproduction of epidermal cells. These sites may not be pruritic.
Describe psoriasis.
Thick raised red patches- silvery, flakey scales- plaques No cure- treatment is aimed at controlling the clinical manifestations.
Describe the appearance of psoriasis.
Thick, flaky, silvery skin covering circumferential red patches; skin, hair, and nails may be affected.
What is eschar?
Thick, leathery, devitalized tissue; black or brown; hard, soft, or boggy Loose or firmly attached to wound bed
Describe the evaluating outcomes for herpes simplex virus.
To prevent transmission of the virus, it is paramount to teach safe sex practices to individuals with or without an HSV infection, including the use of a condom as well as not engaging in sexual contact during an outbreak. Teenagers and young adults must be made aware of the risk of contracting HSV-1 through orogenital sex. Referring an individual for counseling with a new diagnosis of HSV may be essential in helping him or her cope with feelings of isolation, depression, and anger and can help him or her develop and maintain social and intimate relationships.
Medical management for vulvovaginal candidiasis?
Topical and intravaginal antifungals
Medical management for tinea crusis?
Topical antifungals Topical antifungal agents
Medical management for tinea corporis?
Topical antifungals for infections Topical azoles Topical therapy should be applied to the lesion and at least 2 cm beyond this area once or twice a day for at least 2 weeks
How do you treat psoriasis?
Topical creams- coal tar- corticosteroids, retinols (vitamin A), UV light therapy, methotrexate some biologics used will effect the immune system: Humira, Enbrel, Remicade
Describe the medical management of eczema.
Topical steroids
Describe the medical management of psoriasis.
Topical steroids
Describe the evaluating outcomes for a fungal infection.
Treating fungal infections in the community has a high success rate as long as the correct antifungal medication is prescribed. Educating the patient about clinical manifestations and causes of fungal infections can decrease occurrences and the severity of the infection. For the hospitalized patient, keeping the skin and skinfolds dry and cleaning incontinence episodes as soon as they occur is an appropriate goal to decrease the incidence of fungal infections. The healthcare provider must keep in mind that critically ill and immunocompromised patients with a fungal infection of the skin are at high risk of developing a bloodstream infection that could prove to be fatal. Therefore, close monitoring of the patient's status, including vital signs and blood work, is essential in his or her care.
What is the best way to treat a carbuncle?
Treatment by incision and drainage; systemic antibiotics
Describe the evaluating outcomes for skin cancer.
Treatment for skin cancers begins with teaching about risks and ways to prevent the development of skin cancers. Certainly, the prognoses of actinic keratosis, basal cell carcinomas, and most squamous cell carcinomas are much better than those for patients with malignant melanoma. Education for patients treated for actinic keratosis and basal carcinomas includes an explanation of prognosis as well as ways to decrease risk factors. Emotional support and connecting the patient and his or her family with appropriate community resources significantly helps the patient with a new diagnosis of melanoma.
What is the best way to treat folliculitis?
Treatment is most heat; topical mupirocin (Bactroban) ointment; Clindamycin 1% lotion or gel; alternatively, benzoyl peroxide 5% wash may be used when showering for 5 to 7 days.
What is skin cancer?
Ultraviolet radiation from sunlight is composed of UVA and UVB rays. Ultraviolet radiation is the main cause of all types of skin cancers. Ultraviolet B rays do not penetrate deep into the skin and are responsible for sunburns that occur from prolonged periods in the sun. Ultraviolet B rays cause direct damage to DNA within the skin cells, whereas UVA rays penetrate deeper into the skin and are responsible for indirect damage that disrupts the cellular membranes. Researchers hypothesize that UV radiation energy is absorbed by the DNA of the epidermal cells and mediates immune suppression, leading to the development of cancerous cells.
What is secondary intention?
Unable to approximate wound edges due to significant tissue loss; increased risk for scar formation and infection
Describe uncomplicated bacterial infections.
Usually no systemic symptoms Localized signs: erythema/ cellulitis, furuncles, pustules, folliculitis, cutaneous abscess, purulent drainage if open wound Localized increased warmth to surrounding tissues Mild to moderate pain No changes in blood work
Clinical course of basal cell carcinoma?
Usually not metastatic but can become locally invasive; recurrence rate after excision is 44% in 3 years.
How do you diagnose the herpes simplex virus?
Virological testing is appropriate for a patient seeking medical attention because of the presence of mucocutaneous (a region of the body where mucosa transitions to skin) lesions or ulcers. Serological type-specific glycoprotein G-based assays obtained from capillary or serum blood samples accurately distinguish HSV-1 from HSV-2.
What is protein-energy malnutrition?
Wasting with excessive loss of lean muscle mass Results from untreated undernutrition and can be reversed with administration of nutrients Increased morbidity and mortality
Describe mechanical.
Wet-to-dry: moist dressing is applied to wound, allowed to dry, and removed with force Hydrotherapy: moving water dislodges loose debris Pulsed lavage: irrigation combined with suction
Describe cultures.
When a skin infection is suspected, microscopic examination of the tissue allows for identification of the pathogen. Methods of tissue collection vary depending on the lesion's characteristics but include the swab culture, needle aspiration culture, and biopsy. The method for collection varies depending on the appearance and extent of the affected area. Once the infective organism has been identified, the culture also determines the appropriate medication for treatment.
Describe secondary intention.
With secondary intention, the wound is left open and allowed to fill in with granulation tissue. Often, these wounds are packed with gauze and changed daily. The healing process with secondary intention can be slow, and scar tissue is more pronounced. These are your dirty wounds with irregular edges. A lot of softy tissue damage. Animal bites come to mind. Granulation of new tissue starts in the bed of the wound and eventually fills it - bigger scar than primary intension. Measure it - length, depth, tunneling, and undermining.
Describe evaluating outcomes for bacterial infections.
With the correct antibiotics verified by wound cultures, patients with bacterial skin infections can usually be successfully treated with antibiotics and wound care as needed in the outpatient setting. Care of the patient and family includes teaching about wound care, clinical manifestations of infection, and infection transmission. A rapid and thorough evaluation is essential to a positive prognosis with necrotizing soft tissue infections. Upon initial presentation and follow-up, a wound or cellulitic area that is causing pain out of proportion to the injury should be immediately referred for a surgical evaluation. With aggressive therapy including surgical debridement and specialized wound care, patients with necrotizing soft tissue infections can recover.
What is debridement?
Wound debridement removes necrotic tissue, reducing the risk of infection and facilitating healing. There are many different types of wound debridement, including surgical, autolytic, mechanical, maggot, and enzymatic. If conservative measures such as local wound care, including conservative debridement methods (autolytic, mechanical, maggot, and enzymatic), are not successful in removing the necrotic tissue, surgical/sharp wound debridement may be warranted. Surgical/sharp debridement can occur in an inpatient setting, outpatient setting, or operating room, depending on the extent and goals of debridement, and requires anesthetic medications (local or general). Healing by secondary intention or reconstructive flap surgery may be required following surgical debridement of pressure injuries.
How do you treat a furuncle?
You treat a furuncle by using warm compresses (always try a warm compress first) If a warm compress doesn't help we can do a small incision and drainage (IND)
What is a quantitative tissue biopsy?
an invasive test in which a piece of tissue below the surface of the wound is obtained and sent for quantitative Gram stain and culture, is considered the gold standard in identifying wound pathogens. infection is present if the quantitative culture is greater than or equal to 105 colony-forming units per gram of tissue and/or beta-hemolytic streptococci are present
How do you treat cellulitis?
antibiotics
How do you treatment HSV?
antiviral meds (acyclovir, valacyclovir, and famciclovir) vaccinations
Serosanguinous?
appears blood-tinged, straw to amber colored, reflecting presence of serum and red blood cells; normal during first 48 hours after injury
What is the dermis?
approximately 2 to 4 mm thick and encases blood vessels, nerves, immune system cells including macrophages and mast cells, dermal proteins including collagen and elastin, hair follicles, and sweat and sebaceous glands
Describe the nursing care for a patient with psoriasis.
assess skin; administer meds- and educate your patient, emotional support
What is the subcutaneous layer of skin?
below the other two layers of skin; contains adipose tissue, connective tissue, nerves, and blood supply
Aside from cultures, what diagnostic test examines deeper layers of the skin for infecting organisms and represents the GOLD STANDARD for wound culture?
biopsy
Cyanosis?
blue
What is a furuncle?
boil
Describe HSV 1.
can be transmitted through contact with bodily fluids will stay dormant and will come up in times of stress or weather changes occurs on the mouth, lips, or face aka "cold sore" or "fever blister" (can rarely be genital)
The most common reconstructive surgeries performed by a plastic surgeon are usually...
cancer reconstruction and wound repair and closure
How will you tell if it's lost vascularity or perfusion?
change in color and temperature
Purulent?
creamy yellow pus, greenish-blue with fruity odor, beige pus with fishy odor; colonization with Staphylococcus or Pseudomonas or Proteus
Which stage of wound healing is being described below? -Immediate -Activation of platelets and clotting factors -Fibrin deposition -Platelet release of cytokines -Fibroblasts activate production of collagen -Primarily about coagulation -Lasts approximately 24 hours -Expect sanguineous drainage
hemostasis
The vaccination that fights against herpes zoster is contraindicated in...
immunocompromised people should not get it - on steroids, chemo, HIV because it is a live virus
Which stage of wound healing is being described below? -Lasts anywhere from 24 hours to 2 weeks after injury -Surrounding vasculature begins to "leak" in response to mast cells -Neutrophils phagocytize bacteria and remove foreign material -Fluid escapes into the wound and causes edema -Macrophages remove additional bacteria, residual foreign bodies, and necrotic tissue -Macrophages secrete growth factors and cytokines that activate the synthesis of collagen and lay down extracellular matrix
inflammatory stage
What is vascularity?
is there enough blood flow/perfusion to keep the graft alive?
Which stage of wound healing is being described below? -Can last up to 2 years -Decreased fluid within wound -Decreased metabolic rate -Reorganization of collagen fibers -Continued collagen synthesis and degradation
maturation
Describe HSV 2.
most prevalent STD can be on your face and lips as well as the genital area
What is maceration?
occurs when skin has been exposed to moisture for too long
What is desiccation?
occurs when skin is dehydrated
What does the nurse need to take into consideration for a patient who has HSV?
pregnancy testing if appropriate; education about transmission (safe sex), viral cultures; administer and teach about the meds; pain management; psychological stress- counseling; vaccines
Which stage of wound healing is being described below? - Angiogenesis: growth of new blood vessels from previously existing ones -Epithelialization -Fibroplasia with formation of granulation tissue -Collagen deposition -Wound contraction
proliferative stage
What is the most important nutrition? What are some examples of this nutrition?
protein - lean meats - poultry - fish and seafood - eggs - dairy products
Erythema?
redness
What is a carbuncle?
same as a furuncle but it is a little bit deeper
Describe HSV 3.
shingles
---- is the first line of defense.
skin
Describe a graft.
skin taken from a donor site; vascularity
What is the best way to treat cellulitis?
systemic antibiotics
What type of contact precautions should be implemented for a patient with herpes zoster?
the lesions shed and they are contagious until vesicles are crusted over ad healing- they dry up; the pain will continue after the lesions heal
What is the epidermis?
the outermost layer of the skin that protects the body by forming a barrier that resist pathogen invasion
Describe a flap.
tissue that is partly detached and moved to cover a nearby wound skin flap may contain skin and fat, or skin, fat, and muscle usually vascularity is good, but watch for hematomas to form under the flap
Describe the relation between UV light therapy and psoriasis.
under the supervision of a dermatologist - be on the lookout for itching, burning skin, erythematous UV light therapy increases the risk for skin cancer.
Pallor?
white or pale
What should nurses take into consideration for reconstructive surgery?
wound care - most surgeons that do reconstruction are plastic surgeons and they are VERY precise about graft and flap care
Jaundice?
yellow
How will you educate patients about the herpes simplex virus?
· Actions of antiviral medications · Safe sex practices · Considerations related to HSV infection during pregnancy
What are the nursing priorities / plan of care for bacterial infections?
· Administer antibiotics based on culture results · Wound care as prescribed · Surgical evaluation
What are the nursing priorities/ plan of care for psoriasis?
· Administer ordered medications · Monitor for side effects of treatments · Topical preparations · Phototherapy · Biologicals (immunomodulatory medications) · Traditional systemic · Provide emotional support · Referral to counseling for psychological dysfunction administer analgesic as ordered for control of pain · Encourage patient and family to join a psoriasis support group
What are the nursing priorities/ plan of care for reconstructive surgery?
· Administer pain medications according to prescriptions · Assist patient in identifying alternative methods of pain control to supplement medications: distraction, imagery, relaxation, application of heat and cold · Obtain nutrition referral for nutrition assessment · Obtain a specialty bed if reconstruction was for a pressure injury · Position patient so that he or she is not lying on the newly reconstructed surgical area · Provide emotional support to the family/caregivers
What are the priority physical assessments for a fungal infection?
· Assess skin, paying close attention to creases and moist environments and noting any treated or untreated fungal infections · Pruritus · Current and recent medications · Liver function · Health history
How will you educate the patient about fungal infections?
· Avoid tight-fitting clothes, shoes, and communal washing (wear shower shoes) · Clinical manifestations of fungal infections · Complete antifungal infection medications as prescribed
How will you teach your patient about bacterial infections?
· Hand washing · Wound care · Clinical manifestations of infection
How will you educate your patient about pressure ulcers?
· Importance for turning and repositioning · Nutritional requirements (adequate intake of proteins and carbohydrates) · Importance of adequate fluid intake · Clinical manifestations of infection
How will you educate your patient about reconstructive surgery?
· Importance of following prescribed diet · Clinical manifestations of infection and decreased tissue perfusion to patient and family · Expected progression of healing · Wound care · Appropriate methods of off-loading, such as push-ups while sitting in the wheelchair and repositioning while lying down
How will you educate your patient about skin cancer?
· Limit sun exposure · Sunscreen use · Skin self-examinations · Wound care for postoperative incisions or effects of other skin cancer treatment · Information about different types of skin cancer · Providing patients and families with constant information for local chapters of the American Cancer Society
What are the nursing priorities/ plan of care for a fungal infection?
· Meticulous hand washing before and after patient contact · Perform cultures as needed · Administer antifungal medications as prescribed · Cleanse incontinent episodes as soon as they occur and keep the perineum as dry as possible; change moist bed linens and gowns · Separate skinfolds with gauze or other dressings and keep dry to decrease the risk of intertrigo · Meticulous cleanliness and application of antifungal medications
What are the priority physical assessments for herpes simplex virus?
· Pain and fever · Oral cavity lesions (questions about sore throat, dysphagia, anorexia, mouth pain) · Genital lesions · Sexual history · Skin and mucous membranes for presence and appearance of lesions · Knowledge of HSV and transmission of the virus · Assess serum human chorionic gonadotropin (hCG) levels · Ability to cope with diagnosis of HSV
What are the nursing priorities/ plan of care for herpes simplex virus?
· Perform viral cultures and/or serological testing · Administer antiviral medications as indicated · Administer analgesic medications as indicated and warm sitz baths for comfort · Collaborate with interprofessional team for psychological support
What are the nursing priorities / plan of care for skin trauma and healing?
· Perform wound care as prescribed (including cleansing and using appropriate dressings) · Administer pain medications as prescribed · Administer antibiotics as prescribed · Referral to nutritionist as needed · Referral for vascular evaluation with documented decreased perfusion · Provide emotional support
What are the nursing priorities/ plan of care for pressure ulcers?
· Positioning to decrease pressure on bony prominences · Keep the head of the bed at 30 degrees or less · Utilize draw sheets to reposition the patient · Control moisture, and cleanse the patient immediately after incontinence · Apply moisture barrier ointment to skin subject to incontinence · Obtain appropriate bed surfaces · Wound care: cleansing, dressings · Documentation of wound progression with each dressing change or at least weekly · Nutritional referral · Administer antibiotics as prescribed for infections · Physical therapy/ occupational therapy referrals · Provide emotional support to the patient, and refer to social work if needed · Provide emotional support to caregivers, and refer to social work if needed
How will you educate your patient about psoriasis?
· Proper hand washing before and after application of topical medications · Clinical manifestations of adverse reactions to specific therapies · Signs of skin infection (purulent drainage, erythema, increased warmth) · To limit the amount of sunlight exposure while taking systemic therapies · For phototherapy: daily examination of skin to look for signs of overexposure (erythema, tenderness on palpation, blisters)
How will you educate the patient about skin trauma and healing?
· Proper positioning · Need to cleanse incontinence as soon as possible and use moisture barrier creams · Minimize objects on the floor, and maintain the bed in the lowest position · Importance of nutrition and examples of nutritious foods to eat (increased protein intake) · Utilize mobility aids as prescribed, and ask for assistance
What are the nursing priorities/ plan of care for skin cancer?
· Provide pain medications as prescribed for post procedural pain · Provide emotional support · Refer to social work or psychologist
What are the priority physical assessments for skin cancer?
· Skin · Work history · Family and personal history · Psychosocial history
What are the priority physical assessments for reconstructive surgery?
· Vital signs · Pain · Baseline and ongoing wound/surgical incision assessments · Intake and output · CBC · Serum electrolytes · Medication history
What are the priority physical assessments for pressure ulcers?
· Vital signs · Pain · Functional assessment · Skin · Pressure-prone areas · Risk assessments (Braden scale) · Wounds nutritional status · Past medical history · Serum albumin and prealbumin · Blood values of C-reactive proteins and ESRs
What are the priority physical assessment for skin trauma and healing?
· Vital signs · Pain · Nutritional status · Skin · Peripheral vascular status · Fluid volume status
What are the priority physical assessments for psoriasis?
· Vital signs · Pain · Skin · Mood, affect
What are the priority physical assessments for bacterial infections?
· Vital signs · Wound and skin · Pain · Complete blood count (CBC) results · Nutritional status
