MS2: Chapter 25
Herpetic Whitlow
A type of herpes simplex that occurs on the fingertips of healthcare personnel it will come into contact with viral secretions This can be spread easily to other patients
Interventions for skin infection
avoidance of the offending organism, good hygiene, vaccination and example is zostavax
How is infection diagnosed
based on clinical indicators or systemic signs
Some nursing diagnoses for skin problems
compromised tissue integrity due to vascular insufficiency and trauma Potential for one deterioration due to insufficient with management
What does exfoliative psoriasis look like
explosively irruptive and inflammatory form Scaling no lesions
What are we in inspecting the skin wounds for
location, size, color, extent of tissue involvement and surrounding tissue, cell types in wound base and margins, exudate, foreign bodies
What factors might contribute to a high-risk skin issue patient
mental status changes, impaired motility, nutrition status, incontinence
Is there a cure for herpes Symplex virus
no after the first infection the virus remains in a dormant state in the nerve ganglia
Is the skin intact in a stage to pressure injury
no this is a partial thickness loss of epidermis or dermis
These types of loans are superficial with minimal loss of tissue integrity from the epidermis and upper dermal layers
partial thickness wounds
Implement aggressive intervention of prevention with...
pressure relief or reduction devices also pressure mapping
What is herpes zoster (shingles) caused by
reactivation of the vericella zoster virus also known as chickenpox
Cutaneous anthrax is an infection caused by
spores of bacillus anthracis
What triggers herpes to present
stress, trauma to the skin, fever, menses, fatigue
This intention has delayed closure, high-risk for infection and results in a scar
third intention
Dermatophytes
A type of fungi that causes skin, hair, and nail infections.
When does the maturation phase of wound healing begin
As early as three weeks after injury
When does the inflammatory phase of wound healing begin
At the time of injury
A chronic rash that occurs with allergies (Eczema)
AtopicDermatitis
What do we do to put a barrier between the skin and fluid
Barrier cream
These have a resistance to pesticides, they do not live on humans but they fear of human blood this type of bug hitchhikes from infested environment to others
Bedbugs
When does the proliferative phase of wound healing begin
Begins on the fourth day after injury
Risk for skin cancer
Chronic wounds that remain open for long periods of time, genetic predisposition, excessive exposure to UV light, presence of one or more precursor lesions that resemble unusual moles
Candida albicans Where does it occur? What environments does it favor?
Come in on theSkin mucous membranes and gross and warm moist environments
An acute or chronic rash thy occurs by Direkt content with an irritant or Allergen
Contact dermatitis
What does scabies look like on the skin and where is it most often seen on the body
Curved or linear White Ridge is most often seen on the fingers palms and inner aspects of the wrist
Where ever there is hair you can develop a...
Cyst
Superficial infections that different lesion appearance body location and species
Dermatophyte infections
tinea
Descriptive word meaning fungal infection Aka "tinea pedis" is athletes foot
If a patient has thick skin or lesions, bad nutrition, or as a mobile what should you do
Develop a plan to avoid pressure injuries
non-surgical management for wounds
Dressings mechanical, topical, natural, chemical debridement Physical, drug, nutrition, technology therapy
What does first intention look like
Edges are brought together with the skin lined up in correct anatomical position
This is a superficial infection that is often caused by staphylococcus it presents a small raised red pustules
Folliculitis
Do you stage four pressure injuries need to be packed
For sure
This is one skin is rubbed against the surface dragged or pulled
Friction
How can somebody contract herpes zoster also known as shingles
From patients with stress that haven't had the chickenpox vaccine if you plan to be pregnant stay away from them these patients need to be on droplet precaution
In these types of loans damage extends into the lower layers of the dermis and underlying subcutaneous tissue What do they need to heal
Full thickness wounds Need to be filled with granulation
This is also caused by a staphylococcus and Presents as large inflamed bombs usually with a pustular head
Furuncles\boils
What is the most common viral infection in adults
Herpes simplex virus
Exposed chronic wounds are colonized with micro organisms but not always...
Infected
For skin assessment we must identify the cause of tissue integrity loss and factors that may impair healing how we do this
Inspect the entire body
With a stage one pressure injury the skin is Where do these usually occur
Intact The area is usually over a bony prominence, the skin does not blanch with external pressure
What does second intention of wound healing require
It Requires gradual filling in of dead space with connective tissue
Assessment for skin cancer
Know their Family history, past surgery and growth removal's, recent changes in moles, occupational or recreational activities (sun exposure)
What number on the Braden scale is cause for worry
Less than 12
Where do dermatophytes live
Mainly in theSoil and on humans and animals
This is the result of gravity. Dependent tissue is in contact with a fixed surface
Mechanical pressure
I'are contact dermatitis and atopic dermatitis the same
No they're completely different
The bacterial infection go away on their own
NoThey just circulate
When will heel will lift boots not work
On the heel is not sitting in the whole
This form is pustules on the palms of hands and soles of feet
Palmoplantar pustulosis
What are some labs we might run for skin problems
Pre-albumin, albumin, total protein
Mechanical force is that create ulcers are
Pressure friction and sheer
Interprofessional collaborative care for wounds include
Primary care provider, nurse, plastics, dietitian
Become an auto immune disorder affecting the skin with exacerbation and remissions due to overstimulation of the immune system
Psoriasis
What are some health promotion and maintenance techniques for skin issues
Recognize risk, begin interventions early, identify high-risk patients early
This is a contagious skin infection caused by mite infestation
Scabies
This is sliding down in the bed or wheelchair
Shear
At this stage the ulcer is superficial and may appear as an abrasion blister or shallow crater at this point bruising is not present
Stage 2
At this stage subcutaneous tissue and underlying facia may be damaged or necrotic Bone, tendon, muscle or not exposed May have undermining and tunneling
Stage 3
This type of pressure injury is a full thickness skin loss with exposed or palpable muscle tendon or bone There is undermining and tunneling with sinus tracks possible Sloughing and eschar are often present
Stage 4
At this stage of a pressure energy there is. Full Thickness skin loss
Stage III
At this stage of pressure injury and you can see changes in healing quickly once the area pressure is off loaded
Stage one
With this syndrome the skin usually sloughs off, it's often a reaction to medication, it's deadly, and these people get treated like burn patients
Steven Johnson syndrome
This is a rare and serious disorder of the skin and mucous membranes. It's usually a reaction to a medication or an infection. It often begins with flu like symptoms followed by painful red or purple rash that spreads and blisters. Then the top layer of the affected skin dies, sheds, and heals,
Steven JohnsonSyndrome
These types of cultures help in identifying bacteria on the surface of the world
Swab
Where did bacterial skin infections usually start from
The hair follicle were bacteria easily collects and grows
Here is eating disorders often occur in who
The homeless population in those with poor hygiene
How do we document a wound
The location and size, length, width, depth also add photos
Lots of tissue integrity is caused when...
The skin and underlying soft tissue are compressed between a bony prominence an external service for extended period of time
Cellulitis can swell, why is this a problem?
The swelling could cut off circulation and cause compartment syndrome
What is important for the nurse to know when caring for patients with parasitic disorders such as lice scabies or bedbugs
ThesePatients need to be isolated
What do you stage III pressure injuries need
They need interventions immediately, wound VAC sometimes, they need to heal from the inside out, they may need packing
People with stage to pressure injuries need more than just turning what do they need
They need medication and the consult from plastics
What does a fungal infection look like and what type of med to these patients need
Thick white film on the tongue they need a Nystatin which is a swish and swallow
pediculosis Where do they occur and what is the treatment
This is lice and it occurs on the head body and pubic area and the treatment is chemical killing the parasites
What does herpes simplex virus type one look like versus type two
Type One is a recurring cold sore while type two is genital herpes and is recurrent
These are anything with necrosis on top
Unstageable ulcers they're called that because we can't see what's going on
What doesCellulitis feel like
Warm
How do we prevent infection and wound deterioration
We monitor the ulcers appearance or progress and we maintain a safe environment to prevent infection
If somebody has folliculitis what is the best action
We need to figure out why this is happening and culture them and get the meds
Can herpes transfer
Yes I can transfer from one person to the next and from one part of the body to the other
Cellulitis
diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling Secondary to boil, trauma, or MRSA
urticaria
hives
What are the three phases of wound healing
inflammation, proliferation, maturation
pruritus
itching
What is the most common type of psoriasis and what does it look like
psoriasis vulgaris it's thick red and papules or plaque and silvery scales with lesions
Reepithelialization
the movement of epithelial cells to form a covering over the wound