objective 2 (2) Flashcards
general itching
Common symptom of dermatological disorders
Occurs with rash or lesion but may without
pruritis
what are the S&S of pruritis?
Altered skin integrity, redness, raised areas (wheals), infection
what is the medical management of pruritis?
Identify and treat the cause, cold compresses, corticosteriods, antihistamines
Inflammatory reaction of the skin
Absorbed agent –nickel and gold jewellery, Balsam of Peru (found in perfumes)
allergic contact dermatitis (ACD)
most frequently used antibiotic to treat skin, ear and eye infections. Found in OTC creams/lotions
neomycin
most likely antibiotic to cause anaphylaxis
bacitracin
Impetigo
Folliculitis, furuncles, and carbuncles
bacterial infections
tinea pedis, tinea corporis, tinea capitis, tinea cruris, tinea unguium
fungal infections
Herpes Simplex Virus, Herpes Zoster, Plantar Warts Bacterial, Fungal and Viral Infections
viral infections
Infection of the skin caused by staph, strep or multiple bacteria
Usually on exposed areas of the body
impetigo
bacterial (staph) or fungal infection of the hair follicles (razor rash) bacterial (staph) or fungal infection of the hair follicles (razor rash)
folliculitis
(boil) acute inflammation deep in one or more hair follicles and spreads to surrounding dermis (back of neck, axillae and buttocks)
furuncles
abscess of the skin and subcutaneous tissue that represents an extension of the furuncle (back of neck and buttocks)
carbuncle
fungal infection of the foot
tinea pedis
Ringworm of the body – ringed lesions appear on the face, neck, trunk and extremities (contact with pets)
tinea corporis
Ringworm of the scalp – round scaling patches on the scalp
tinea capitis
Ringworm of the groin (jock itch)
tine cruris
Most common infectious cause of limb swelling
Entry point through the skin allows bacteria to enter
cellulitis
Chronic, noninfectious inflammatory disease of the skin
Hereditary defect that causes overproduction of keratin
Genetic makeup and environmental stimuli may trigger
Improves and recurs; a lifelong condition
May be aggravated by stress, trauma, and seasonal and hormonal changes
psoriasis
Infection caused by the varicella-zoster virus
Reactivation of latent varicella virus infection and reflects lowered immunity
shingles
Infestation of the skin by the itch mite
Mites involve the fingers and hand contact may spread infection
Rash on elbows, knees, edge of feet, nipples, axillae, groin
scabies
Most common types of skin cancer
Diagnosed by biopsy and histologic evaluation
basal cell carcinomas and squamous cell carcinomas
Most lethal of all skin cancers
Cancerous neoplasm in the pigment cells
Ultra violet rays are suspected to play role
malignant melanoma
what are the diagnostic studies?
Careful history
Physical examination
Inspection of individual lesions
what are the collaborative care?
Phototherapy
Radiation therapy
Laser technology
what are the drugs used for drug therapy>
Antibiotics -
Corticosteroids –
Antihistamines –
Topical fluorouracil –
Immunomodulators –
infection
antibiotics
anti-inflammatory
corticosteroids
helps with allergic reactions
antihistamines
used for treatment of premalignant and malignant skin diseases
topical fluorouracil
suppresses an overactive immune system
immunomodulators
what is the diagnostic and surgical therapy?
Skin scraping – obtain surface cells using scalpel
Electrodesiccation and electrocoagulation – tissue destroyed by burning
Curettage – removal and scooping away of tissue
Punch biopsy – cores out a small cylinder of skin
Cryosurgery – using subfreezing temperatures to destroy epidermal lesions
Excision – removal of tissue in thin layers
what do we do for ambulatory and home care?
Wet dressings
Baths
Topical medications
Control of pruritus
Prevention of spread
Prevention of secondary infections
Specific skin care
Psychological effects of chronic dermatological problems
Physiological effects of chronic dermatological problems
Caused by a transfer of energy from a heat source to the body
Most burns occur in the home
Young children & elderly are at high risk
Also occur from work-related injuries
Can lead to fluid loss, infection, hypothermia, scarring, and compromised immunity * Described according to depth of the injury and the extent of body surface area injured
burns
what are the types of burns?
Thermal burns
Chemical burns
Smoke inhalation injury
Electrical burns
Cold thermal injury
Caused by flame, flash, scald, or contact with hot objects
Most common type of burn
thermal burns
Result from tissue injury and destruction from acids, alkalis, and organic compounds
Alkali (Not neutralized by tissue) burns are hard to manage because they cause protein hydrolysis and liquefaction… oven / drain cleaners
chemical burns
Result from inhalation of hot air or noxious chemicals
Cause damage to respiratory tract
Major predictor of mortality in burn clients
Need to be treated quickly
smoke inhalation injuries
Result from coagulation necrosis caused by intense heat generated from an electric current
May result from direct damage to nerves and vessels, causing tissue anoxia and death
electrical burns
what does the severity of electrical burns depend on?
amount of voltage.
tissue resistance.
current pathways.
surface area.
duration of the flow.
what is the severity of an injury determined by?
depth of burn.
extent of burn in percent of TBSA.
location of burn.
client risk factors.
Minimal epithelial damage
Erythema, dark pink, pain & mild edema – 3-5 days
Sunburn
Healing time 5-10 days
superficial (first degree)
Epidermis/minimal dermis
Hot liquids; flash flame
Supersensitive to pain
Moist, blisters, pink or mottled red
Healing time 21-28 days , minimal scarring
superficial partial thickness burn (second degree)
Entire epidermis, part of dermis, hair and sweat glands intact
Hot liquids, flame, chemicals, electrical
Sensitive to pressure
Dry, pale, waxy
Healing time 30 days months – scarring, marked contracture
deep partial thickness (second degree)
Complete epidermis, complete dermis, portion of subcutaneous fat, may involve tissue, muscle, bone
Sustained flame, electrical, chemical, steam
Limited/no pain
Leathery, cracked, avascular, white, cherry red, black
Cannot self regenerate/ needs grafting
full thickness (third degree)
what are the 2 commonly used guides for determining the toal body surface area?
lund-brower chart
rule of nines
what are the phases of burn management?
Pre-hospital care
Emergent (resuscitative)
Acute (wound healing)
Rehabilitative (restorative)
is the period of time required to resolve immediate problems resulting from the injury.
Usually lasts up to 72 hours
Primary concerns are onset of hypovolemic shock and edema.
Phase begins with fluid loss and edema formation and continues until fluid mobilization and diuresis begin
emergent phase
what are the clinical manifestations of the emergent phase?
Shock from pain and hypovolemia
Blisters
Adynamic ileus - paralysis of intestinal motility.
Shivering
Altered mental status
provide temporary wound closure and protects granulation tissue until autografting is possible
biologic dressings
tissue from a living or recently deceased human or heterografts
homografts
composed of nylon, silastic membrane with collagen derivative. Useful for intermediate to long term closure of wounds until an autograft becomes available.
briobane
artificial skin (Integra) becomes a permanent structure. Consists of an epidermal and dermal layer
dermal substitutes
Patient’s own skin is used
autografts
begins with the mobilization of extracellular fluid and subsequent diuresis. (intravascular fluid deficit)
The acute phase is concluded when the burned area is completely covered by skin grafts, or when the wounds are healed.
Focuses on respiratory and circulatory status
acute phase
what are the acute phase manifestations?
Partial-thickness wounds form eschar.
Once eschar is removed, re-epithelialization begins.
Full-thickness wounds require debridement.
burn wounds are healed.
client is able to resume a level of self-care activity.
rehabilitation phase
what are the emotional needs of the client and family?
A common emotional response is regression.
Early psychiatric intervention
Assess psychoemotional cues.
Issue of sexuality must be met with honesty.
Family and client support groups
what are the special needs of the nursing staff?
The nurse may find it difficult to cope with burn injuries.
The nurse will know that he/she can provide care that makes a critical difference. * Practice good self-care.
S/S purulent drainage, pain, redness around wound, edema, increased temp, elevated WBC
infection
S/S slimy top, no advancement in healing edges, low level erythema: DEBRIDE
biofilms
S/S large amounts sanguineous drainage + other symptoms of hypovolemic shock. Check UNDER clients
hemorrhage
S/S wound edges pulling away; not well-approximated. Early sign = increasing serosanguineous drainage
dehiscence
S/S wound opens revealing internal organs. Emergency rx = sterile NS gauze to cover; prepare for OR
evisceration
Encourage verbalization of feelings; encourage self-care as tolerated by client, explore reasons no any non-adherence to treatment regime or lifestyle factors affecting healing
psychosocial impact
what are the types of wounds?
Surgical
Pressure (Classification system)
Trauma
Burns (Classification system)
Healthy red tissue is observed and is deposited during the repair process. It presents as pinkish/red colored moist tissue and comprises of newly formed collagen, elastin and capillary networks. The tissue is well vascularized and bleeds easily.
granulating
is a process by which the wound surface is covered by new epithelium, this begins when the wound has filled with granulation tissue. The tissue is pink, almost white, and only occurs on top of healthy granulation tissue.
epithelializing
The presence of devitalized yellowish tissue is observed and is formed by an accumulation of dead cells. Must not be confused with the presence of pus.
sloughy
Describes a wound containing dead tissue. The wound may appear hard, dry and black. Dead connective tissue may appear grey. The presence of dead tissue in a wound prevents healing.
necrotic/eschar
This is observed when granulation tissue grows above the wound margin.
hyper granulation
Wound undermining occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound’s edge
undermining
Similar to undermining, however usually occurs in only one direction and can be much deeper
tunneling
what is the scale for measuring the amount of exudate?
- None visible
- Scant: moist, few dots, smears
- Small- < 25% of dressing covered
- Moderate- approx. 50% of dressing
- Large/Copious- Saturates entire dressing
what are the types of wound edges?
Approximation / Dehiscence
Jagged
Wound Edges Attached/Detached
Macerated
what are the factors affecting infection>
characteristics of the individual
characteristics of the wound
characteristics of the environment
Poorly controlled diabetes
Radiation or chemo (Immunosuppression)
Hypoxia, anemia, arterial/vascular disease)
Malnutrition, alcohol, smoking, drug abuse
characteristics of the individual
Contaminated wounds, Penetrating wounds over 4 hours
acute wound
Duration of wound, large wound area, deep wound, located near a site of potential contamination (perineum, sacrum)
chronic wound
Interwoven matrix of bacteria and fungi embedded in a thick slimy barrier of sugars and proteins that begins to form within minutes of skin breakdown.
They are resistant to antibiotics (including topical)
The organisms within the biofilm cannot be detected using a normal wound culture method.
Are present in the majority of chronic wounds (60 to 90%) and have the potential to delay healing;
biofilms
