Week 4
Which statements indicate that the patient understands the role of inflammation in wound healing?
-"Inflammation is responsible for the redness, heat, and swelling of my wound." -"The inflammatory response works to clean the wound of organisms and debris."
Wet-to-dry dressing
-A saline-soaked gauze or cotton sponge is placed within a wound with exudate or drainage. -As the dressing dries, it pulls exudate out of the wound
Formation of exudate (inflammation)
-Accumulation of fluid and leukocytes at the site of injury -Quantity and type of exudate depends on injury
The nurse is evaluating a patient's risk for developing a pressure ulcer. Which patient characteristics does the nurse consider?
-Age -Activity level -General health
Treatment of actinic keratosis
-Aggressive, nonsurgical procedures are the first-line treatment. -Chemical peel, laser resurfacing, or photodynamic therapy, cryosurgery
Actinic keratosis
-Also called solar keratosis and characterized by hyperkeratotic papules and plaques on sun-exposed areas -The most common of all precancerous skin lesions
The nurse is caring for a patient diagnosed with melanoma. The nurse is aware that which areas are common sites for this cancer?
-Back -Scalp -Trunk -Lower legs
Maturation phase of wound healing
-Begins as early as 3 weeks after injury -Lasts 1+ year -Reorganization of collagen -Formation of mature scar
Inflammatory phase of wound healing
-Begins at the time of injury -Lasts 3 to 5 days -Immediately: vasoconstriction and clot formation -After 10 minutes: vasodilation and increased capillary permeability/leakage of plasma into the surrounding tissue -Migration of white blood cells into the wound -Local edema, pain, erythema, and warmth
Proliferative phase of wound healing
-Begins the fourth day after injury -Lasts 2 to 4 weeks -Fibrin strands form a scaffold -Migration of mitotic fibroblast cells migrate into the wound to secrete collagen -Formation of scar tissue -Angiogenesis begins -Contraction of the wound
Common fungal infections
-Candidiasis (thrush) -Tinea corporis (ringworm) -Tinea cruris (jock itch) -Tinea pedis (athlete's foot) -Tinea unguium (nail fungus)
Verucca vulgaris
-Caused by human papillomavirus (HPV) -Possible spontaneous disappearance in 1-2 years -Mildly contagious -Response is body dependent -Prevalence greater in youth and with immunosuppression -Circumscribed, hypertrophic, flesh-colored papule on epidermis -Painful on lateral compression
Which integumentary findings does the nurse expect to find in a patient diagnosed with hypothyroidism?
-Cold, dry, pale skin -Dry, coarse hair -Brittle, slow growing nails
Wound excision
-Common for full-thickness and deep partial-thickness wounds -Surgeon makes an excision through the necrotic tissue until healthy tissue is encountered (identified by bleeding)
Wound contraction
-Decrease in wound size, leading to complete wound closure -Depends on fibroblasts pulling wound edges inward -Healing mechanism for full-thickness wounds
Patient populations at higher risk of pressure injuries:
-Decreased sensory perception -Increased moisture -Sedentary/decreased mobility -Poor nutrition (particularly regarding protein) -Friction & shearing forces
Hyperbaric oxygen therapy wound treatment
-Delivery of oxygen at increased atmospheric pressure -May be administered topically or systemically -Increases oxygen delivery to tissues and stimulates angiogenesis
Granulation
-Deposition of scar tissue -Healing mechanism for full-thickness wounds
A pressure ulcer prevention program consists of two steps:
-Early identification of high-risk patients -Aggressive implementation of interventions by nurses and ancillary staff to reduce pressure to areas of potential skin breakdown: physical therapy or occupational therapy department frequently implements special pressure-relieving devices and equipment
Cellular response (inflammation)
-First, NEUTROPHILS arrive to phagocytose foreign materials; dead neutrophils then accumulate as pus -Next, MONOCYTES arrive & transform into macrophages to phagocytose inflammatory debris; they "clean up" the area prior to the healing process -Later, LYMPHOCYTES arrive and have a role in cell mediated immunity
Common viral skin infections
-Herpes simplex virus types 1 & 2 -Herpes zoster (shingles) -Verucca vulgaris -Plantar warts
Nutritional therapy for wound healing
-High fluid intake to replace fluid loss -Diet high in protein, carbohydrate, and vitamins promotes healing -Vitamin C is necessary for capillary synthesis and collagen production -B vitamins promote metabolism -Parenteral and enteral feedings may be indicated
Cellulitis
-Hot, tender edematous, and erythematous area with diffuse border -May be associated with chills, malaise, and fever -Deep inflammation of subcutaneous tissues -Secondary complication or primary infection -Follows a break in skin, with Staphylococcus aureus and streptococci as the causative agents -May progress to gangrene if left untreated
Common bacterial skin infections
-Impetigo -Falliculitis -Furuncle -Cellulitis -Erysipelas
The nurse caring for a patient diagnosed with squamous cell carcinoma knows that which patient findings are risk factors for the development of skin cancer?
-Inability to tan -Celtic ancestry -Infrequent use of sunscreen
Stages of wound healing
-Inflammatory phase -Proliferative phase -Maturation/Remodeling phase
Vascular response (inflammation)
-Initial momentary vasoconstriction -Vasodilation and increased capillary permeability facilitate movement of fluid into the tissue Causing erythema, heat, swelling -Fibrin strengthens the blood clot, and platelets release growth factors to initiate healing
seborrheic keratosis
-Irregularly round or oval papules or plaques well defined in shape -Pigmentation increases with time -Multiple, itchy papules
After the biopsy, important patient teaching points include:
-Keep the biopsy site clean and dry. -Have stitches taken out 3 to 14 days after the biopsy, depending on the site. -Leave adhesive bandages in place until they fall off (7-14 days). -Take any prescribed antibiotics until the course of treatment has been completed. -Avoid activities that may stretch the skin and promote bleeding. -Notify the HCP immediately about excessive bleeding or drainage from the biopsy siteIncreased tenderness, pain, redness, or swelling at the biopsy siteFever
Systemic manifestations of wounds
-Leukocytosis (elevated WBC) -Malaise -Nausea -Anorexia -Increased pulse -Increased respiratory rate -Fever
The nurse understands that which clinical manifestations are consistent with a diagnosis of shingles?
-Linear rash with red pustules -Burning & itching on the trunk or lumbar area
Electrical stimulation for pressure injuries
-Low-voltage pulses are applied to the wound to promote increased blood vessel growth and granulation tissue, thereby encouraging healing. -This procedure may be performed by a physical therapist
Basal cell carcinoma
-Most common form of nonmelanoma skin cancer -Related to excessive sun exposure, radiation, scars, certain nevi, and genetics -Small slowly enlarging papules that have "pearly" borders -Rarely metastasizes, but if left untreated may result in massive tissue destruction
For deeper wounds, monitor every 24 hours for:
-Necrotic tissue -Foul odor -Erythema -Swelling -Increased tenderness at margins
Squamous cell carcinoma
-Nonmelanoma skin cancers, which can become malignant tumors, that have invaded the dermis and surrounding skin -Most commonly found on sun-exposed areas (face and hands) -Highly aggressive; may metastasize and lead to death
The patient on anticoagulant therapy has a pressure ulcer on the right foot that has a foul odor to the drainage. The patient has good peripheral pulses. The nurse anticipates the health care provider will prescribe which interventions?
-Obtain a wound drainage specimen for culture and sensitivity -Cushion foot to prevent contact between the ulcer and the bed -Have a dietitian evaluate nutrition needs and create a new diet plan
Shingles
-Occurs in people who have had the varicella zoster virus -Activation of a latent virus -Incidence increases with age -Contagious to anyone who has not had varicella or is immunosuppressed -Linear distribution along a dermatome -Grouped vesicles and pustules (looks like chicken pox) -Unilateral on trunk, face, and lumbosacral areas with burning, itching, pain, and neuralgia preceding breakouts
Furuncle
-Painful, tender erythematous area that drains pus and necrotic debris when ruptured -Common sites: face, back of neck, axillae, breasts, buttocks, perineum, thighs -Characterized by malaise, regional adenopathy, and elevated body temperature -Deep infection by staphylococci around hair follicles often associated with severe acne or seborrheic dermatitis -Often recurs with scarring
Physical therapy for pressure injuries
-Physical therapists can debride wounds by using whirlpool treatments. -The warm water with a cleansing agent swirls around the wound, softening necrotic tissue. -The wound is abraded with gauze, and loose tissue that remains is removed using debriding instruments.
The nurse performing a focused wound assessment will document which findings?
-Presence of exudate in the wound base -Measurement of the greatest depth of the wound -Presence of erythema for 1cm around the wound edges
Re-epithelialization
-Production of new skin cells by undamaged epidermal cells -Healing mechanism for partial-thickness wounds
Nutritional therapy for pressure injuries
-Proper nutritional intake is essential to wound healing. -Adequate protein, vitamins, minerals, and water are required. -Nutritional deficiencies result in inhibited healing and impaired infection defenses. -Dietician may be consulted as part of the team to perform a nutrition assessment and give dietary recommendations.
Which nursing interventions are most appropriate for a patient receiving psoralen therapy?
-Provide skin moisturizers since it may cause sunburn -Give Zofran PRN for nausea -Recommend use of emollient because it may cause itching
A patient diagnosed with basal cell carcinoma is being treated with radiation therapy. The patient is complaining of a sore mouth. Which nursing actions are appropriate?
-Provide the patient with hard candies for dry mouth -Encourage consumption of cool/cold food & drink -Avoid hot/spicy foods
Impetigo
-Pruritic vesicular lesions with thick honey-colored crusts surrounded by erythema -Group A β-hemolytic streptococci, staphylococci, or a combination -Associated with poor hygiene -Primarily seen on face -Contagious
Phototherapy (UV therapy) treats ___
-Psoriasis -Atopic dermatitis -Vitiligo -Pruritis
Pathophysiology of wound healing
-Re-epithelialization -Granulation -Wound contraction
Patient age can affect the efficiency of wound healing due to:
-Re-epithelialization and contraction are slower -Replacement of connective tissue is reduced -Higher risk for development of pressure ulcers (incontinence, immobility, poor nutrition)
Herpes simplex virus
-Recurrent and lifelong -Exacerbated by sunlight, trauma, menses, stress, and systemic infection -Contagious -Transmitted by respiratory droplets or virus-containing fluid (i.e., bodily fluids) -Infection in one area is easily transmitted to another HSV-1 generally affects the mouth area HSV-1 and HSV-2 affect the genitals -Symptoms occur 2 days to 2 weeks after contact -Painful local reaction -Single or grouped vesicles on erythematous base -Systemic symptoms (flu-like symptoms) or none
Local manifestations of wounds
-Redness, resulting from vasodilation -Heat, resulting from increased metabolism -Pain, resulting from pH changes, swelling, and nerve stimulation -Swelling, resulting from fluid accumulation -Loss of function due to swelling and pain
Positioning considerations to prevent pressure injuries
-Reposition Q2H in bed or Q1H in chair -Use contact surfaces with foam, silicone gel, or air pads -Use supportive tension-reducing material between bony surfaces -Elevate the bed 30 degrees -Avoid dragging or sliding a patient -Avoid contact between patient's skin and plastic surfaces -Elevate patient's heels
The nurse knows that which bacteria are responsible for primary and secondary skin infections?
-S. Aureus -group A beta-hemolytic streptococci
Adhesions
-Scar tissue that forms around organs. -These can be in the abdominal cavity or lungs and pleura. -Complications of adhesions include intestinal obstruction.
Erysipelas
-Sharply demarcated plaque that is red, hot, indurated, and painful -May cause bacteremia; toxic signs are fever increased white blood cell count, headaches, and malaise -Commonly found on face and extremities -Caused by superficial cellulitis involving the dermis Group A β-hemolytic streptococci
Upon the initial home visit, the home health nurse notes the patient has a pressure ulcer that is red with a purulent discharge. Which patient information is vital for the home health nurse to obtain from the discharging hospital nurse to properly perform an initial assessment of the patient's pressure ulcer?
-Skin condition at discharge -Successful pressure relief measures used -Measurements of the wound prior to discharge
Folliculitis
-Small, tender to touch, pustule at hair follicle that presents with mild erythema and eventually crusts over -Common sites: scalp, beard, and extremities in men -Usually staphylococci -Increased incidence in individuals with diabetes -Present in areas where friction, moisture, or rubbing occurs -Heals without scarring unless lesions are extensive and deep
The top layer of skin contains 3 cell types:
-Squamous cells, which lie just below the outer surface -Basal cells, which lie beneath the squamous cells and produce new skin cells -Melanocytes, which are located in the lower part of the epidermis and produce melanin
Treatments for basal cell carcinoma
-Surgical excision -Electrodessication -Curettage -Cryosurgery -Radiation therapy -Topical or systemic chemotherapy -Photodynamic therapy
Wound classifications
-Surgical or non-surgical -Superficial (epidermis) -Partial thickness (epidermis and dermis) -Full thickness (subcutaneous tissue and sometimes the fascia and underlying structures)
Monitor wounds at least every 24 hours until sutures are removed for:
-Tenderness -Swelling -Erythema -Heat -Purulent drainage -Fluctuance
Treatments for squamous cell carcinoma
-This cancer is highly aggressive; it may metastasize and in rare cases lead to death. -Squamous cell cancers are usually treated with a surgical procedure such as excision, cryosurgery, or electrosurgery. Chemotherapy and radiation may also be used for treatment. -The cure rate is high with early detection and treatment
The nurse is taking care of a patient with impetigo. Which methods are appropriate for management of the skin lesions and discomfort?
-Topical antibiotics -Warm saline soaks
Topical therapy for pressure injuries
-Under certain circumstances, (such as presence of necrotic tissue or lowered immunity), topical antibacterial agents are needed to ensure the wound bed does not get infected. -Topical growth factors are normal body substances that are lacking in the wound bed and once applied stimulate cell movement and growth. -Nursing staff usually applies topical therapy
Negative pressure wound therapy
-Used for acute and chronic wounds -Vacuum source is used to clean wound -Tubing is attached to wound dressing, which uses a vacuum to create pressure -Dressing changed every 5-7 days -Negative pressure wound therapy is not to be used for patients on anticoagulant therapy, with reduced tissue health around the wound, or with exposed organs
Autograft
-Used for large full-thickness wounds (typically burns) -Skin from another part of the patient's body is transplanted to cover the wound -Graft sites require 3-5 days undisturbed recovery to allow vascularization of the grafted skin
Dehiscence
-Usually occurs during primary healing when a previously joined wound separates. -Possible causes are infection, tension on the wound greater than the granulation tissues can withstand, obesity, or fluid collection under the wound edges. -Dehiscence extensive enough to allow intestines to protrude through the wound is an evisceration.
Kaposi's sarcoma
-Usually starts within the deeper layers of the skin but can also form in internal organs -Manifests as bluish red or purple lesions -Occurs in individuals with compromised immune systems, such as those with human immunodeficiency virus infection or acquired immunodeficiency syndrome and transplant recipients who are receiving immunosuppressive drugs
Atypical or dysplastic nevi (moles)
-Variegated color (tan, brown, black, red, or pink) within a single mole -Most commonly found on back but may be found on the scalp or buttocks -Most often noncancerous
Components of inflammatory response
-Vascular response -Cellular response -Formation of exudate
Nutritional factors that delay wound healing include:
-Vitamin C deficiency, which delays collagen formation -Protein deficiency, which decreases supply of amino acids -Zinc deficiency, which impairs epithelialization
A patient just underwent a surgical dermatologic procedure. Which statements indicate the nurse fully understands the foundations of proper healing when providing patient teaching?
-Your sutures will be removed in 4-14 days -Topical antibiotics will help prevent infection while promoting healing -Mild analgesics with anti inflammatory properties should be encouraged
Cutaneous T cell lymphoma
-localized, chronic, slowly progressing disease that may be related to environmental toxins and chemical exposure -presentation involves three stages: patch (early), plaque (middle), and tumor (advanced)
Altered cellular proliferation can affect wound healing by:
-prolonged inflammatory response, leading to further tissue damage -Impaired collagen synthesis, leading to decreased wound contraction
Altered immune response can affect wound healing by:
-reduced tissue circulation -ischemia -impaired white blood cell response -increase risk for infection
Plantar warts
-sometimes caused by HPV
Skin cancer staging
0- Cancer cells are confined to the epidermis (the top layer of the skin) and have not spread I- Cancer cells have grown deeper into the skin but have not spread to the lymph nodes or other parts of the body II- Cancer cells have grown deeper into the skin or have high-risk features but have not spread to the lymph nodes or beyond III- Cancer cells have spread to nearby lymph nodes but not to distant organs IV- Cancer cells have spread beyond the skin and regional lymph nodes to distant organs such as the liver, lungs, or brain or to distant lymph nodes
Patients should report moles that are more than ___ in diameter
1/4 inch
The nurse understands that it will take how long for a toenail, which was entirely removed, to grow back to its normal size?
12-24 months -toenails grow at a rate of 30-50% slower than fingernails
Acne vulgaris
Caused by buildup in & inflammation of the sebaceous glands
A patient with psoriasis of the upper arms is being treated while in the hospital with a diagnosis of lupus. Which medication order should the nurse question?
Ceftriaxone
A patient being treated for a large pressure ulcer on the heel reports new inflammation in the surrounding subcutaneous tissue. Which term describes the condition the patient is experiencing?
Cellulitis -cellulitis can occur due to untreated pressure ulcers and involves the spreading of inflammation to the subQ tissue
Secondary intention wound healing
Deeper injury with loss of tissue integrity Ex. Venous stasis ulcer, chronic pressure ulcer
Third intention wound healing
Delayed primary closure Purposefully left open to heal Ex. Grossly contaminated and infected wound
Monitor wounds once a week for ___
Depth & size
Chemotaxis
Directional migration of WBCs to the site of cellular injury
Electrodessication and electrocoagulation
Electrical energy is converted into heat at the tip of an electrode, and the heat burns and destroys tissue.
A patient admitted with cellulitis of the left foot may present with which clinical manifestations?
Erythema (redness) and swelling
The nurse is caring for a patient with a pressure ulcer determined to be unstageable. What characteristics would the nurse expect?
Eschar covering the wound bed
Contractures
Excessive contraction of a wound results in deformity, including shortening of muscle, or scars because of excessive fibrous tissue formation
Treatment of atypical or dysplastic nevi
Excisional biopsy for lesions suggestive of cancer and a detailed family history related to melanoma and atypical or dysplastic nevi
The nurse is caring for a patient with an uninfected surgical wound. How would the nurse expect this wound to heal?
First intention healing -A clean laceration or an uninfected surgical wound would heal by first intention
Which practice should the nurse emphasize as being the single most important means of preventing secondary skin infections?
Hand washing
The nurse is providing care to a patient who is experiencing delayed healing of a surgical wound. The nurse asks which question to assess for nutritional deficiencies?
How much protein do you eat with each meal?
The nurse is concerned that a patient is experiencing complications of long-term oral corticosteroid use. Which finding indicates a possible complication?
Hyperglycemia -common incidence in prolonged/overuse of corticosteroids
Lentigo (liver spots)
Hyperpigmented brown to black macule or patch on sun-exposed areas
Which wound-related task can the RN delegate to the unlicensed assistive personnel (UAP)?
The UAP is able to measure the volume of fluid in a wound drainage container and empty its contents
A patient is scheduled to undergo a biopsy of a 4-cm deep wound to determine the source of the wound infection. The patient asks the nurse, "Why can't you just collect some of this stuff with a cotton swab?" What is the nurse's best response?
A biopsy works best to determine the source of infection for deeper wounds
Curettage
A curette (small spoon-like instrument with sharp edges) is used to remove and scoop away tissue; the targeted area is anesthetized, lesion is removed, and skin is cauterized
The nurse is most concerned about the administration of psoralen to which patient?
A patient with alcohol-related liver disease
A patient presents to the emergency department with a small, plaque-like lesion on the right arm. The patient states, "I don't know what this is, but I want it removed." Which order by the health care provider should the nurse anticipate?
A skin scraping to obtain samples of surface cells for microscopic inspection and diagnosis
Expected outcomes for a patient with a wound is to have complete wound healing:
A) Presence of granulation tissue, re-epithelialization, and scar formation B) Decrease in wound size C) Absence of any new pressure ulcers
A nurse is reviewing the electronic medical record of a patient with a stage 2 pressure ulcer to the iliac crest and notices the following entry: "Wound bed is pink with noticeable slough. It measures 2 cm * 2 cm. Packed with normal saline wet-to-damp dressing and covered with dry sterile dressing." Which data is missing from the documentation entry?
Absence or presence/type of drainage
A young adult female was recently prescribed oral birth control pills. The patient states that since she started taking the pills, her skin has become "problematic." The nurse understands that which skin disorder is a common side effect of oral contraceptives?
Acne flare ups are common with birth control and corticosteroids
Most common form of nonmelanoma skin cancer
Basal cell carcinoma
The nurse is preparing to administer psoralen to a patient diagnosed with cutaneous T-cell lymphoma. Which action should the nurse teach the patient to perform while taking this medication?
Wear protective eyewear -this medication sensitized the body to UV light
The nurse is assessing a wound noted to have skin and some underlying tissue loss. Which is the appropriate frequency for the nurse to assess the size of this wound?
Weekly
First intention wound healing
Wound without loss of tissue Ex: clean laceration, surgical incision
Mohs micrographic surgery
involves shaving off skin from the affected area, sending it to the laboratory for evaluation, and continuing to shave and submit skin samples to the laboratory until it has been determined that all cancer cells have been removed
Enzyme debriding ointments should only be applied to ___
necrotic or eschar tissue, not to healthy tissue
Acute wounds normally heal within ___
3 months
Wet-to-damp saline moistened gauze dressing
As with the wet-to-dry technique, necrotic debris is mechanically removed. The dressing should be damp when it is removed and causes less trauma to healing tissue than the wet-to-dry technique.
ABCDEs of melanomas
Asymmetry Border Color Diameter Evolving
A patient in the clinic states, "I found this reddish brown mole on my scalp. It can't be cancer: I only sunbathe twice a year." The nurse understands that this characteristic finding is common in which type of skin cancer?
Atypical nevi -A single atypical nevus (mole) can include a variety of colors and is commonly found on the back, scalp, or buttocks
Which cosmetic procedure improves the appearance of both acne scarring and actinic and seborrheic keratoses?
Chemical peel
A patient has been diagnosed with malignant melanoma. The health care provider orders adjuvant therapy after surgery for this patient. Which medication does the nurse anticipate administering to the patient?
Cisplatin -this is a type of chemo drug often used for melanomas
The wound care nurse is preparing to dress a wound. The nurse notes increased granulation at the site. Which dressing should the nurse prepare to use?
Clear plastic dressing (ie Tegaderm)
Atopic dermatitis
Clinical manifestations -Acute stage: bright erythema, oozing vesicles -Subacute stage: scaly, light red to red-brown plaques -Chronic stage: lichenification, with possible hypo/hyperpigmentation Common in antecubital and popliteal spaces Caused by a type I hypersensitivity response
Tinea pedis (athlete's foot)
Clinical manifestations -Interdigital scaling and maceration with scaly plantar surfaces -Erythema, pruritus, and painful blistering
Candidiasis (thrush)
Clinical manifestations -Mouth: white, cheesy plaque -Vagina: vaginitis with red edematous, painful vaginal wall, white patches, discharge, and pruritus -Skin: diffuse papular erythematous rash This is a fungal yeast infection caused by Candida albicans, which appears in warm, moist areas such as the groin, oral mucosa, and submammary folds. 50% of adults are symptom-free carriers.
Tinea corporis (ringworm)
Clinical manifestations -Ring-like erythematous scaly appearance -Appearance anywhere on the body A dermatophyte fungus that requires keratin to grow, such as that found in hair, nails, and skin
Tinea unguium (nail fungus)
Clinical manifestations -Scaly skin under distal nail plate -Incidence increases with age -A few nails on only one hand may be affected -Toenails more commonly affected -Brittle, thickened, broken, or crumbling nails with yellowish discoloration
Tinea cruris (jock itch)
Clinical manifestations -Well-defined scaly plaque -Does not affect mucous membranes A dermatophyte that presents in the groin area
Allergic contact dermatitis
Clinical manifestations -Appearance of lesions 2-7 days after contact -Red papules and plaques, usually pruritic -Area of dermatitis frequently takes shape of causative agent
Beige pus with "fishy" odor
Colonization with Proteus
Greenish-blue pus with "fruity" odor
Colonization with Pseudomonas
Creamy yellow pus
Colonization with Staphylococcus
Brownish pus with fecal odor
Colonization with aerobic coliform and Bacteroides (usually occurs after intestinal surgery)
A patient with an arm sprain asks the nurse about the benefit of heat application. Which rationale does the nurse provide?
It localizes inflammatory agents by increasing circulation to the heated site
Phototherapy for a patient with atopic dermatitis has been effective when the nurse notes which assessment finding?
Itching has resolved
The nurse suspects a patient receiving topical immunomodulatory therapy is experiencing a side effect of the treatment if which finding is noted?
Itching, burning, warmth
A patient shares with the nurse a concern about a skin tag on the inner thigh. The patient is becoming worried that the skin tag is cancerous. How should the nurse respond?
Most skin tags are harmless and won't require any treatment, unless they are irritating and you want them removed
The patient taking anticoagulants would not be a candidate for ___
Negative pressure wound therapy, because they could begin bleeding into the wound vac canister
A patient arrives at the primary care clinic. The patient expresses concern about a "new mole" on the upper thigh. The nurse anticipates which initial order from the primary care provider?
Prepare the patient for a biopsy
Most common form of skin cancer
Nonmelanoma
Which base used for topical agents produces a drying effect of the skin?
Pastes -pastes are made from a mix of ointment and powder; the ointment is absorbed by the skin, leaving the dried powdery feeling
A patient has returned to the dermatology office to review results of a repeat skin biopsy. The provider is unable to determine the results of the biopsies on microscopic examination. Which data found in the patient's record would be most significant to report to the provider?
Patient is taking ibuprofen -certain anti inflammatory agents can alter the appearance of biopsy specimens
___ are small, pink/purple non-blanching macular pinpoint lesions
Petechiae -usually caused by minor hemorrhage of capillaries
___ are potent vasodilators involved in the inflammatory response cascade
Prostaglandins
Topical enzyme preparations
Proteolytic (a process in which water added to the peptide bonds of proteins breaks down the protein molecule into simpler substances) action on thick, adherent eschar causes breakdown of denatured protein and more rapid separation of necrotic tissue
___ are red/purple discolorations of the skin which do not blanch when pressure is applied
Purpura -associated with bleeding under the skin
marion lab wound classification system
Red: -Pale, pink, beefy red granulation tissue -Protect wound and surrounding tissue; Maintain warm, moist environment; Use transparent dressing Yellow: -Moist yellow slough, varies in adherence -Clean and remove yellow layer; Debride necrotic tissue; Protect periwound; Cover with moisture-retentive dressing Black: -Thick, black, adherent eschar —Debride necrotic tissue for wounds with adequate blood supply; Use enzymatic product
Nonsurgical wound management
Removing surface debris -Mechanical debridement: mechanical detachment of dead tissue -Chemical debridement: topical enzymes loosen dead tissue -Natural debridement: natural enzymes loosen dead tissue Protecting healthy tissues Creating a barrier Various types of dressings
A 24-year-old sustained a laceration to the lower leg and is having a difficult time healing. Which meal would be appropriate for the nurse to order for the patient?
Scrambled eggs and sausage with orange juice -Scrambled eggs and sausage are high in protein sources that promote wound healing. Orange juice has vitamin C that also helps wounds heal.
Acrochordons (skin tags)
Small skin-colored, soft, pedunculated papules that may or may not become irritated
Moisture retentive dressings
Spontaneous separation of necrotic tissue is promoted by autolysis.
Cryosurgery
Subfreezing temperatures (usually in the form of liquid nitrogen applied topically) are used to destroy epidermal lesions. Cell death and necrosis of the treated tissue occur, the skin lesion sloughs off with a scab, and new skin growth follows
The nurse caring for a patient with a stage 2 pressure ulcer expects to prepare the patient for which diagnostic assessment?
Swab culture -Swab cultures can be obtained for stages 2, 3, and 4 wounds to determine the presence of infection
Continuous wet gauze
The wound surface is continually bathed with a wetting agent of choice, promoting dilution of viscous exudate and softening of dry eschar.
A patient with a new diagnosis of actinic keratosis is admitted to the unit. On assessment, which clinical manifestations would the nurse expect to find?
Thickened papules on sun exposed skin
Fitzpatrick Classification of Skin Types
Types I-III most at risk for skin cancer -Type I very fair, always burns/never tans -Type II fair/pale, usually burns, rarely tans -Type III beige/golden undertones, mild burns, gradually tans -Type IV olive skin, rarely burns, tans with ease -Type V light to dark brown skin, rarely burns, tans easily -Type VI very dark skin, never burns, always tans
The nurse is preparing to change the dressing to an ischial wound. The order has been changed from a wet-to-dry dressing to a wet-to-damp dressing. The patient asks the nurse why there is a change to a wet-to-damp dressing. What is the nurse's best response?
Using a wet-to-damp dressing keeps the wound bed moist and protects it from trauma during dressing changes.
Telangiectasia
Visibly dilated superficial cutaneous small blood vessels commonly found on face and thighs
Psoralen
sensitizes the skin to ultraviolet light therapy; damages cellular DNA; decreases cell division
Corticosteroid use impairs ___
white blood cell (WBC) function and depresses formation of granulation tissue
Vitiligo
white patches on the skin caused by the destruction of melanocytes associated with autoimmune disorders
