Deck 05_Integument/Skin Flashcards
Define these primary lesions: macules, papules, pustules, nodules and vesicles?
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Macules – Non-palpable, skin color change, < 1 cm
- Ex. Freckles
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Nodules/tumor– Palpable, circumscribed, 0.5cm or more
- Ex. Wart
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Papules– Palpable, circumscribed, < 0.5cm
- Ex. Elevated moles
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Pustules– Pus-filled (colored),
- Acne
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Vesicles– Serous fluid-filled, < 1 cm
- Ex. Small blister
What are the changes that occur with the integumentary system as a result of aging?
- Increased transparency & fragility
- Decreased collagen
- Structure changes
- Slower healing
- Thinning dermis
- Increased risk for skin tearing
- Slowed inflammatory response
- Increased risk for sun-related damage
- Temperature regulation & excretion less efficient
- Increased risk for exposure related injury (heat stroke & hypothermia)
- Sensations changes
- Decreased perception of injury
Give examples of bacterial skin infections
Bacterial skin infections are categorized by depth of infection, tissues involved & interventions
Impetigo
- Inflammatory skin infection
- Localized
- Contagious
- Presentation:
- Vesicles
- Pustules
- honey crusted sores
- No systemic symptoms
- Medical management: Topical mupirocin
Cellulitis
- Diffuse infection of dermis & subcutaneous tissue
- Presentation:
- Unilateral
- Painful, edematous, warmth
- Poorly, demarcated borders
- Associated symptoms
- Lymphadenitis – enlarged lymph nodes
- Lymphangitis – inflamed lymphatic channel
- Fever
- Medical management: Systemic antibiotics
Folliculitis
- Like shave rash
- Superficial inflammation/infection of hair follicles
- Multiple or single pustules
- Hair follicle in center
- Medical management: Moist heat & topical antibiotics
Furuncles (Boil)(bacteria)
One hair follicle infected
Carbuncles( bacteria)
Multiple hair follicles infected; in a cluster
MRSA
Typically nosocomial (hospital acquired)
Precautions are used to prevent the spread of MRSA skin infections
Avoid close contact
Do not share personal items
Take all antibiotic
Keep area clean & covered
Shower
Wash area with MRSA LAST – after other body parts; clean to dirty
Clean surfaces with bleach
Give examples of fungal skin infections
Examples of fungal skin infections:
Dermatophyte (tinea) or ring-worm
Various lesions, body location & species
Annular patches/plaques
Raised border
Central clearing – flesh colored center
Locations: Body, feet, genital areas, scalp, toenails (Onychomycosis aka toe fungus)
Direct contact
Fomite (objects or materials that are likely to carry infection, such as clothes, utensils, and furniture)
Candida albicans (yeast infection)
Common organism
Like warm, moist environment
Candidiasis:
Maceration from moisture
Erythema
Itching & burning
Satellite lesions
Give examples of viral skin infections
Examples of viral skin infections:
Herpes simplex virus (HSV)
Type 1 (HSV-1)
Type 2 (HSV-2)
Primary infection
First time infected
Asymptomatic or fever, malaise, myalgias anorexia, irritability, lymphadenopathy & lesions (lip, face, mucous membranes mouth, pharynx or genitals).
Secondary (recurrent) infection
Endogenous or exogenous trigger
Prodrome of burning, itching or tingling
Multiple fluid filled vesicles
What are the different types of wound surface tissues? What is the basic description of each type of wound tissue?
Epithelialization
- Pink and dry
- Seals & protects
- Extremely fragile
Granulation
- Red and moist
- Wound healing
Slough
- Yellow
- Liquefying & separating necrotic tissue
- Rough & stringy texture
- Must be debrided
Eschar
- Black or brown
- Soft or hard
- Wet or dry
- Full thickness tissue destruction
Necrotic Tissue
- Dead or avascular or devitalized tissue, black in color
What parts of the body are susceptible to skin breakdown as a result of external pressure?
- BONY PROMINENCES
- Occiput (back of head)
- Ear
- Scapula
- Elbow
- Sacrum
- Ischial tuberosities
- AKA the sit bones, or as a pair the sitting bones is a large swelling posteriorly on the superior ramus of the ischium
- Greater trochanter (of the femur)
- Medial condyle of tibia
- Fibular head
- Medial malleoluS: the prominence on the inner side of the ankle, formed by the lower end of the tibia
- Lateral malleolus: found at the foot end of the fibula
- Heel
What is the difference between friction and sheering?
Friction
· Back and forth rubbing
· Ex. Moving a patient and a sheet, friction occurs and rubs against the patient’s body
Sheering
· Almost like tearing
· Like rug burn
· Ripping of the skin, skin breakdown
· Ex. Dragging a sheet under a patient’s bottom
DIAGONAL FORCE. Shearing between muscular structure and skin
Define and identify stage 1, stage 2, stage 3, stage 4 and unstageable pressure ulcers.
Stage I
- Skin intact
- Non-blanchable
- Possibly painful
- Different from adjacent skin
Stage II
- Partial thickness loss of dermis
- Skin not intact
- Skin color/Light colored
- Open/ruptured serum filled blister
Stage III
- Full thickness tissue loss
- Subcutaneous fat may be visible
- Bone, tendon or muscle not exposed
- Slough present but does not obscure the depth
- May include undermining and tunneling
- Undermining: Tissue destruction along wound margins
- Tunneling: Destruction extends from wound base into tissue
Stage IV
- Full thickness tissue loss
- Exposed bone, tendon or muscle
- Undermining and tunneling
- Slough or eschar
Unstageable
- Base of ulcer covered
- Inability to see the base of PU
- Slough
- Eschar
- Full thickness tissue loss
Suspect deep tissue injury (sDTI)
- Purple, burgundy, or maroon
- Bruise-like
- Intact skin
- Blood-filled blister
- Preceded by tissue
- Painful, firm, mushy
- Firm
Identify pressure ulcer preventive interventions.
- Avoid positioning on area of erythema
- Keep skin clean & dry
- Do not massage or vigorously rub high risk areas
- Implement continence management plan
- Clean skin promptly post incontinence
- Use barrier product to reduce risk of damage
- Reposition
- Lift – do not drag
- Nutrition assessment:
- Energy & protein intake, hydration, vitamins & minerals
- Consider adults with medical devices at risk
- Medical devices – nasogastric (NG) tubes, oxygen nasal cannula, endotracheal tube, bedpans, urinary catheters
- Reposition to prevent heel pressure ulcers
- Heels free of the bed surface
- Elevate full length of calves
- Slight flexion of knees
- Mattress and bed support surfaces
- Limit amount of linen & pads
Identify pressure ulcer treatment.
- Follow orders for wound care
- Medication orders from MD
- Assess, prevent & manage pressure ulcer pain
- Use lift or transfer sheet to minimize friction/shear
- Avoid positions that increase pressure
- Fowler’s position greater than 30 or 90 degrees
- Side-lying position
- Coordinate pain medication with dressing changes
- WOCN would help here
- Keep wound bed covered and moist, use non-adherent dressing
- Use non-pharmacological pain management strategies
