Skin Disorders Flashcards

Question

stage III pressure ulcer

Answer 1

Skin loss is full thickness and damage extends down to but not through the underlying fascia; bone, tendon, and muscle are not exposed Subcutaneous tissues may be damaged or necrotic Undermining and tunneling may or may not be present

Answer 2

Skin loss is full thickness with exposed or palpable muscle, tendon, or bone Often includes undermining and tunneling Slough and eschar are often present on at least part of the wound

Answer 3

The intact skin area appears purple or maroon Blood-filled blisters may be present The area may have felt more firm, boggy, mushy, warmer, or cooler than the surrounding tissue before the color change occurred

Answer 4

Skin loss is full thickness, and the base is completely covered with slough or eschar, obscuring the true depth of the wound

Answer 5

Assess wounds for location, size, color, extent of tissue involvement, cell types in the wound base and margins, exudate, condition of surrounding tissue, tunneling, undermining and presence of foreign bodies Document this initial assessment to serve as a starting point for determining the intervention plan and its effectiveness Assess the wound at each dressing change, comparing the existing wound features with those documented previously to determine the current state of healing or deterioration

Answer 6

Beneath the dead tissue, granulation tissue appears Early granulation is pale pink, progressing to a beefy red color as it grows and fills the wound Palpate the wound to determine the granulation texture Healthy granulation tissue is moist and has a slightly spongy texture

Answer 7

Assist with major position changes every 2 hours in bed, every 1 hour in a chair Pad contact surfaces with foam, silicon gel, air pads, or other pressure-relieving pads Do not keep the head of the bed elevated above 30 degrees to prevent shearing Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or her When positioning a patient on his or her side, do not position directly on the trochanter Place pillows or foam wedges between two bony surfaces Keep the patient's skin directly off plastic surfaces Help the patient maintain an adequate intake of protein and calories and a fluid intake of 2 – 3L/day Perform a daily inspection of the patient's entire skin and document all sores and signs of infection Use moisturizers daily on dry skin, and apply when skin is damp Keep moisture from prolonged contact with skin Keep areas dry where two skin surfaces touch, such as the axillae and under the breasts Place absorbent pads under areas where perspiration collects Use moisture barriers on skin areas where wound drainage or incontinence occurs Clean the skin as soon as possible after soiling occurs and at routine intervals Use a mild, heavily fatted soap or gentle commercial cleanser for incontinence with tepid rather than hot water While cleaning, use the minimum scrubbing force necessary to remove soil and gently pat dry

Answer 8

have only a protective function and maintain a moist environment for natural healing; they just cover that area and may remain in place for several days DuoDERM, Tegaderm

Answer 9

capable of absorbing wound exudate while maintaining a moist environment in the area of the wound and allowing the surrounding skin to remain dry Hydrocolloids, alginates, hydrogels

Answer 10

improve the healing process and decrease healing time Skin grafts, biologic skin substitutes

Answer 11

removal of necrotic tissue and skin grafting or use of muscle flaps to close wounds that do not heal by re-epithelialization and contraction Those with poor blood flow are unlikely to have successful graft take and heal The procedures are very similar to the surgical management of burn wounds

Answer 12

can reduce or even close chronic ulcers by removing fluids or infectious materials from the wound and enhancing granulation This technique requires that a suction tube be covered by a special sponge and sealed in place Per manufacturer's instructions, the foam dressing is changed every 48 to 72 hours (or at least 3 times weekly). Continuous low-level negative pressure is applied through the suction tube Duration of the treatment is determined by the wound's response

Answer 13

Characterized by red macules that become thin-walled vesicles that rupture and become covered with honey-yellow crust May have formation of bullae (large fluid-filled blisters) from original vesicles, then the bullae rupture leaving red raw areas Exposed areas of the body, face, hands, neck and extremities are most frequently involved Contagious and may spread to over parts of the body or to other people

Answer 14

Isolated erythematous pustules occur singly or in groups; hairs grow from centers of many of the lesions Occasional papules are present There is little or no associated discomfort There is no residual scarring Areas of hair-bearing skin, especially areas of shaving, thighs, buttocks, and axillae are affected

Answer 15

Small, tender, erythematous nodules become pus filled Lesions may be single or multiple and also recurrent May progress and involve the skin and subcutaneous fatty tissue, causing tenderness, pain, and cellulitis Occasional scarring results

Answer 16

Localized area of inflammation may enlarge rapidly if not treated Redness, warmth, edema, tenderness, and pain are present On rare occasions, blisters are present Cellulitis is often accompanied by lymphadenopathy and fever Lower legs, areas of persistent lymphedema, and areas of skin trauma (e.g., leg ulcer, puncture wound) are affected

Answer 17

Lesions are similar in appearance to herpes simplex and also progress with weeping and crusting Grouped lesions present unilaterally along a segment of skin following the pathway of a spinal or cranial nerve (dermatomal distribution) Eruption is preceded by deep pain and itching Postherpetic neuralgia is common in older adults Areas of the anterior or posterior trunk following the involved dermatome; face, sometimes involving trigeminal nerve and eye are affected

Answer 18

Grouped vesicles are present on an erythematous base Vesicles evolve to pustules, which rupture, weep, and crust Older lesions may appear as punched-out, shallow erosions with well-defined borders Lesions are associated with itching, stinging, burning or pain Type 1 classically occurs on the face and type 2 on the genitalia, but either may develop in any area where inoculation has occurred

Answer 19

The erythematous macular eruption occurs with isolated pustules or papules at the border (satellite lesions) Candidiasis is associated with burning and itching Oral lesions (thrush) appear as creamy white plaques on an inflamed mucous membrane Cracks or fissures at the corners of the mouth may be present Skinfold areas: perineal and perianal region, axillae, beneath breasts, and between the fingers; under wet or occlusive dressings can all be affected along with the oral or vaginal mucous membranes

Answer 20

Pediculosis capitis (head lice) Pediculosis corporis (body lice) Pediculosis pubis (pubic, or crab, lice) Pruritus and excoriation from scratching Matting and crusting of the scalp and a foul odor indicate a probable secondary infection

Answer 21

A contagious skin infection caused by mite infestations, transmitted by close contact with an infested person or infested bedding

Answer 22

Intense itching Red pruritic eruptions Small raised burrows created by the mites Usually affects between the fingers, wrists, elbows, knees, edges of feet, axillary folds, under breasts, near the groin, or penis / scrotal areas

Answer 23

This parasite does not live on humans; however, it feeds on human blood The insect bites a human host at night and sucks blood for 3 to 10 minutes The bite area resembles a mosquito or flea bite with a raised bite mark surrounded by a wheat

Answer 24

The bite causes an itchy discomfort Clustered bite marks

Answer 25

is a chronic, autoimmune disorder that results from overstimulation of the immune system (Langerhans' cells) in the skin that target keratinocytes, causing increased cell division (because some degree of cellular regulation is lost) and plaque formation Chronic condition with exacerbations and remissions

Answer 26

Reddened papules or plaques covered by silvery white scales Bilateral distribution Borders between the lesions and normal skin are sharply defined Lesions thicken during exacerbations and extend to new body areas

Answer 27

Nonpharmacological Urge patients and families to consider support groups Pharmacological Topical steroids Phototherapy / ultraviolet light Systemic biologic & immunomodulating agents

Answer 28

occurs as a result of failure of cellular regulation over cell division Current estimates are that one in five Americans will develop skin cancer in their lifetime It is estimated that approximately 9,500 people in the U.S. are diagnosed with skin cancer every day Basal cell and squamous cell carcinomas, the two most common forms of skin cancer, are highly curable if detected early and treated properly Five-year survival rates for regional and distant stage melanomas are 63 percent and 20 percent, respectively

Answer 29

Cheeks, temples, forehead, ears, neck, backs of hands, and forearms May disappear spontaneously or reappear after treatment; slow progression to squamous cell carcinoma is possible

Answer 30

Small (1-10 mm) macule or papule with dry, rough, adherent yellow or brown scale Base may be erythematous Associated with yellow, wrinkled, weather-beaten skin Thick, indurated keratoses more likely to be malignant

Answer 31

Sun-exposed areas, especially head, neck, and central portion of face Metastasis is rare; may cause local tissue destruction; 50% recurrence rate related to inadequate treatment

Answer 32

Pearly papule with a central crater and rolled, waxy borders Telangiectasias and pigment flecks visible on close inspection As it grows, it undergoes central ulceration and sometimes crusting

Answer 33

Sun-exposed areas, especially head, neck, ears, nose and lower lip; sites of chronic irritation or injury (e.g., scars, irradiated skin, burns, leg ulcers) Rapid invasion with metastasis via the lymphatics occurs in 10% of cases; larger tumors are more prone to metastasis

Answer 34

Rough, thickened, scaly tumor (may involve bleeding) Indurated margins Fixation to underlying tissue with deep invasion

Answer 35

Can occur anywhere on the body, especially where nevi (moles) or birthmarks are evident; commonly found on upper back and lower legs; soles of feet and palms in dark-skinned people Radial growth phase followed by vertical growth phase; rapid invasion and metastasis with high morbidity and mortality

Answer 36

Irregularly shaped, pigmented papule or plaque Variegated colors, with red, white, and blue tones

Answer 37

A: asymmetry of shape B: border irregularity C: color variation within one lesion D: diameter greater than 6mm E: evolving or changing in any feature (shape, size, color, elevation, itching, bleeding, or crusting)

Answer 38

Avoid sun exposure between 11am and 3pm Use sunscreen with the appropriate skin protection factor for your skin type Wear a hat, opaque clothing, and sunglasses when you are out in the sun Keep a “body map” of your skin spots, scars, and lesions to detect when changes have occurred Examine your body monthly for possibly cancerous or precancerous lesions Seek medical advice if you note any of the ABCDE changes

Answer 39

Nonsurgical management Topical or systemic chemotherapy, biotherapy or targeted therapy Radiation therapy Surgical management Cryosurgery Curettage and electrodesiccation Excisional biopsy Mohs’ surgery Wide excision

Answer 40

caused by a burn injury leads to local and systemic problems that affect: Fluid and electrolyte balance Protein losses Sepsis development Changes in metabolic, endocrine, respiratory, cardiac, hematologic, and immune functioning

Answer 41

Have the least damage because the epidermis is the only part of the skin that is injured

Answer 42

Redness, pain, tingling and increased sensitivity to heat occurs as a result; desquamation (peeling of dead skin) occurs 2 to 3 days after the burn

Answer 43

rapidly in 3 to 6 days without a scar or other complication

Answer 44

Caused by injury to the upper third of the dermis, leaving a good blood supply The small vessels bringing blood to this area are injured, resulting in the leakage of large amounts of plasma, which in turn lifts the heat-destroyed epidermis, causing blister formation

Answer 45

Pink to red, painful, blisters

Answer 46

10 to 21 days with no scar, but some minor pigment changes may occur

Answer 47

Extend deeper into the skin dermis, and fewer healthy cells remain Blisters usually do not form because the dead tissue layer is thick, sticks to the underlying dermis, and does not readily lift off the surface

Answer 48

Red and dry with white areas in deeper parts (dry because fewer blood vessels are patent) with moderate edema

Answer 49

2 to 6 weeks, but scar formation results

Answer 50

Destruction of the entire epidermis and dermis, leaving no skin cells to repopulate This wound does not regrow, and areas not closed by wound contraction require grafting

Answer 51

Hard, dry, leathery eschar forms from coagulated particles of destroyed skin; with severe edema May be waxy white, deep red, yellow, brown, or black

Answer 52

can range from weeks to months depending on establishing a good blood supply

Answer 53

Extend beyond the skin and damages muscle, bone, and tendons All full-thickness burns need early excision and grafting

Answer 54

Charred, blackened and depressed, with sensation completely absent

Answer 55

Grafting may not be successful. Amputation may be needed when an extremity is involved

Answer 56

Circulation to the burned skin is disrupted immediately after injury by blood vessel occlusion Fluid shift occurs after initial vasoconstriction as a result of blood vessels near the burn dilating and leaking fluids into the interstitial space Leakage of fluid and electrolytes from the vascular space continues, causing extensive edema, even in areas that were not burned, leading to weight gain Hypovolemia, metabolic acidosis, hyperkalemia, and hyponatremia occur in the first 24-36 hours Fluid remobilization starts at about 24 hours after injury, when the capillary leak stops. The diuretic stage begins at about 48 to 72 hours after the burn injury

Answer 57

nurses should do a primary survey and monitor circulation. As the taut, burned tissue becomes unyielding to the edema underneath its surface, it begins to act like a tourniquet, especially if the burn is circumferential. As edema increases, pressure on small blood vessels in the distal extremities causes an obstruction of blood flow and consequent tissue ischemia and compartment syndrome

Answer 58

Respiratory problems are caused by superheated air, steam, toxic fumes, or smoke Respiratory damage from an inhalation injury can occur in the upper and major airways and the lung tissue and can cause edema that leads to obstruction The lining of the trachea and bronchi may slough 48 to 72 hours after injury and obstruct the lower airways Leaking capillaries cause alveolar edema, which can occur immediately or up to a week after the injury

Answer 59

Heart rate increases and cardiac output decreases because of the initial fluid shifts and hypovolemia that occur after a burn injury Workload of the heart and oxygen demands increase with decreased perfusion, oxygen delivery and BP  shock Cardiac output may remain low until 18 to 36 hours after the burn injury Cardiac output improves with fluid resuscitation and reaches normal levels before plasma volume is restored completely Proper fluid resuscitation and support with oxygen prevent further complications

Answer 60

The sympathetic nervous system stress response increases secretion of epinephrine and norepinephrine, which inhibit GI motility and further reduce blood flow to the area Secretions and gases collect in the GI tract, causing abdominal distention Peristalsis decreases, and a paralytic ileus may develop The increased production (and loss) of heat breaks down protein and fat (catabolism), rapidly uses glucose and calories, and increases the metabolic rate and calorie needs If there is inadequate blood flow, acute kidney injury can occur

Answer 61

Thinner skin, sensory impairment, decreased mobility Slower healing time More likely to have cardiac impairments Reduced inflammatory and immune responses Reduced thoracic and pulmonary compliance More likely to have pre-existing medical conditions such as diabetes mellitus, kidney impairment, or pulmonary impairment

Answer 62

Assess the airway for patency Administer oxygen as needed Cover the patient with a blanket and cover the wound with a clean dry cloth Keep the patient on NPO status Elevate the extremities if no fractures are obvious Obtain vital signs Initiate an IV line and begin fluid replacement Administer tetanus toxoid for prophylaxis Perform a head-to-toe assessment

Answer 63

Inspect the mouth, nose, and pharynx Burns of the lips, face, ears, neck, eyelids, eyebrows, and eyelashes are strong indicators that an inhalation injury may be present Burns inside the mouth and singed nasal hairs also indicate possible inhalation injury Black particles of carbon in the nose, mouth, and sputum; edema of the nasal septum; and a “smoky” smell to the patient's breath indicate smoke inhalation

Answer 64

Progressive hoarseness or brassy cough; drool or difficulty swallowing; audible wheezing, crowing or stridor, dyspnea in supine position

Answer 65

Changes in the cardiovascular system begin immediately after the burn injury and include shock as a result of disrupted fluid and electrolyte balance At first, cardiac manifestations are from hypovolemia and decreased cardiac output Monitor the degree of edema, and assess cardiac status by measuring central and peripheral pulses, blood pressure, capillary refill, and pulse oximetry Obtain baseline ECG tracings at the time of admission, and continue the ECG monitoring throughout the resuscitation phase

Answer 66

Although the GI tract usually is not directly injured, changes in function occur in all burn patients The decreased blood flow and sympathetic stimulation reduce GI motility and promote development of a paralytic ileus Bowel sounds are usually reduced or absent in a patient with severe burns; nausea, vomiting, and abdominal distention may also be present if there is an ileus Patients with burns of 25% TBSA or who are intubated generally require a nasogastric (NG) tube inserted to prevent aspiration and remove gastric secretions

Answer 67

Changes in kidney function with burn injury are related to decreased blood flow and cellular debris. During the fluid shift, blood flow to the kidney may not be adequate for filtration When muscle damage occurs from a major burn or electrical injury, myoglobin is released from damaged muscle and circulates to the kidney, along with other proteins from damaged blood cells; which can contribute and cause kidney failure Assess kidney function and monitor intake and urine output hourly

Answer 68

Nonsurgical management Airway maintenance Promotion of ventilation, gas exchange and oxygen therapy Drug therapy Positioning and deep breathing Surgical management Tracheostomy Escharotomy Chest tubes

Answer 69

Nonpharmacological Priority nursing interventions are carrying out fluid resuscitation and monitoring for indications of effectiveness or complications Monitor any invasive cardiac monitoring devices Pharmacological IV fluid resuscitation Drug therapy Surgical Escharotomy

Answer 70

Initiate and maintain at least one large-bore IV in an area of intact skin (if possible) Coordinate with physicians to determine the appropriate fluid type and total volume to be infused during the first 24 hours postburn Administer one half of the total 24-hour prescribed volume within the first 8 hours postburn and the remaining volume over the next 16 hours 2mL NS or LR x patients weight in kg x % TBSA Assess IV access site, infusion rate, and infused volume at least hourly Monitor vital signs at least hourly Assess for fluid overload Measure and assess strict intake and output at least hourly

Answer 71

Nonsurgical Drug therapy with analgesics and opioids Complementary therapy Environmental manipulation Surgical Early excision

Answer 72

about 36 to 48 hours after injury, when the fluid shift resolves, and lasts until wound closure is complete

Answer 73

Cardiovascular and respiratory systems GI and nutrition status Burn wound care and infection control Pain control Musculoskeletal contractions and promoting mobility Psychosocial interventions

Answer 74

Provide a safe environment Use of asepsis, ensure daily cleaning of the room and unit Do not share equipment among patients; use disposable items as much as possible Detect problems early Continually assess and monitor these patients carefully Perform dressing changes as ordered Avoid musculoskeletal problems, such as contractions, with proper positioning Ensure adequate diet and fluids Tetanus prophylaxis given

Answer 75

The psychosocial adjustment of the patient The prevention of scars and contractures The resumption of preburn activity, including resuming work, family, and social roles This phase may take years or even last a lifetime as patients adjust to permanent limitations