Tissue integrity

Candidiasis albicans: Yeast

(moniliasis) white, cheesy, curdlike patch on buccal mucosa due to superficial fungal infection ◦Affect superficial layers of skin and mucous membranes

The Impact of Pressure Injuries

> 60,000 patients die annually from complications related to this preventable occurrence. > The United States spends ~9-12 billion dollars annually on the treatment of pressure ulcers. >Hospitals are financially responsible for pressure ulcers that develop or worsen during impatient stays. Correct staging upon admission is crucial. >Pressure ulcers are very painful for our patients. Nurses can prevent this occurrence before it leads to infection and/or death.

An older adult has pruritis on the arms and legs and is scratching the affected areas. Which is the priority nursing care for this client? A. preventing infection B. instructing the client not to scratch C. increasing fluid intake D. avoiding social isolation

A. preventing infection

Bacterial Skin Infection Cellulitis

An acute streptococcal or staphylococcal infection of the skin and subcutaneous tissue

Pressure ulcers AKA

Pressure injuries, Decubitus ulcers, bedsores, pressure sore

Lesions Caused by Fungal Infections

Tinea infections: Tinea corporis Tinea cruris Tinea capitis Tinea pedis Tinea unguium Tinea versicolor Candidiasis: Affect superficial layers of skin and mucous membranes

Herpes Simplex

cold sores

Scabies

contagious skin disease transmitted by the itch mite, commonly through sexual contact

Stages of Pressure injuries Stage 4

full-thickness skin and tissue loss

Stages of Pressure injuries Stage 3

full-thickness skin loss; not involving underlying fascia

Pediculosis capitis

head lice

Folliculitis

inflammation/infections of the hair follicles

tunneling wound

insert and pinch then measure

Tissue integrity

refers to the state of skin or other tissue when it is healthy and intact. When tissue is wounded, its normal integrity and continuity are disrupted and its function of protection is compromised, making it vulnerable to invasion by organisms

Tinea corporis

ringworm

Tinea capitis

scaling and balding

Viral Infection:Herpes Zoster (Shingles)

•Condition caused by Varicella-Zoster Viruses (identical to virus that causes varicella, aka: Chicken Pox). •Characterized by painful vesicular eruption along the area of distributionof the sensorynerves from one or more dermatomes.

Tinea cruris

jock itch

Stages of Pressure injuries Stage 1

nonblanchable erythema of intact skin

Eczema

noninfectious, inflammatory skin disease characterized by redness, blisters, scabs, and itching

Stages of Pressure injuries Unstageable

obscured full-thickness skin and tissue loss

Stages of Pressure injuries Stage 2

partial-thickness skin loss with exposed dermis

Deep tissue pressure injury

persistent nonblanchable deep red, maroon, or purple discoloration

Tinea versicolor

Skin

Which change in the integumentary system is associated with normal aging? A. The outer layer of skin is replaced with new cells every 3 days. B. SQ fat and extracellular water decrease. C. The dermis becomes highly vascular and assists in the regulation of body temperature. D. Collagen becomes elastic and strong.

B. SQ fat and extracellular water decrease.

A 2 y/o child developed crusted lesions on her chin within the past three days. They started as a single blister that broke, discharging a honey-colored liquid that became a "stuck on" crust. New blisters and crusts have been forming in the adjacent skin area. The nurse determines that this clinical picture is consistent with which of the following? A. Impetigo B. Scabies C. Herpes implex D. Contact dermatitis

A. Impetigo

Carbunculosis

A carbuncle is a coalescence of several inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles

Which client should receive a shingles vaccine? A client who: A. has never had chickenpox B. is at risk for genital herpes C. is over 50 years old D. has a compromised immune system

C. is over 50 years old

The nurse is discharging the older adult to home after hospitalization for cellulitis of the right foot followed by an infection. After reviewing discharge instructions, which statement by the client indicates the need for further teaching by the nurse? All in quotes. A. I will eat lots of fruit and vegetables and take vitamin C to help this heal. B. I will be sure to wear shoes to protect my feet when I go out to get mail. C. I will manage my pain by putting this foot up on a pillow when it hurts. D. I will take the antibiotics until the redness goes away and my foot feels better.

D. I will take the antibiotics until the redness goes away and my foot feels better. (You take them as prescribed)

undermining wound

Direction according to a clock

Atopic dermatitis

Excess inflammation; dry skin, redness, and itching from allergies and irritants.

Tinea unguium

Onychomycosis; occurs on nails

Tinea pedis

athlete's foot

Cleaning a Pressure Injury/Wound

vClean with each dressing change. vUse new gauze for each wipe and clean from top to bottom and/or from the center to the outside. vUse 0.9% normal saline solution to irrigate and clean the injury. vOnce the wound is cleaned, dry the area using a gauze sponge in the same manner vReport any drainage or necrotic tissue.

Purposes of Wound Dressings

vProvide physical, psychological, and aesthetic comfort vPrevent, eliminate, or control infection vAbsorb drainage vMaintain moisture balance of the wound vProtect the wound from further injury vProtect the skin surrounding the wound vDebride (remove damaged/necrotic tissue), if appropriate vStimulate and/or optimize the healing response vConsider ease of use and cost-effectiveness

Presence of Infection

vWound is swollen. vWound is deep red in color. vWound feels hot on palpation. vDrainage is increased and possibly purulent. vFoul odor may be noted. vWound edges may be separated, with dehiscence present.

Herpes Zoster

viral disease affecting the peripheral nerves, characterized by painful blisters that spread over the skin following the affected nerves, usually unilateral; also known as shingles

Patients at risk for pressure injuries

ØConsider EVERY patient as "at risk." ØPatients with lengthy surgical procedures, altered mental status, spinal cord injury, peripheral neuropathy, over age 65 and post CVA. ØTubing from nasal cannulas, IV therapy, feeding tubes and SCDs can cause pressure ulcer development. ØPatients with poor nutritional status as evidenced by decreased pre-albumin levels are at increased risk. Normal values are 19-38mg/DL. ØPatients of all ages that are critically ill, including babies that cannot turn themselves.' ØNever use donut cushions . This type of device can lead to ischemia of the surrounding tissue.

Mechanical forces create ulcers

ØPressure ØFriction ØShear

Bacterial Skin Infection: Impetigo

•Highly contagious condition caused by various bacteria (commonly staphylococci aureus (MRSA) or streptococci pyogenes) that may spread through direct and indirect contact. •Affects skin previously damaged (bites, cuts, abrasions, etc.) •Common sites: body, face, neck, and extremities

Pressure Injuries: Risk Factors

•Immobility •Impaired sensory perception or cognition •Decreased tissue perfusion •Decreased nutritional status •Friction, shear •Increased moisture or Incontinence