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