Skin Problems Flashcards
STAND bundle
-Score (using the Braden Scale for predicting pressure injury risk)
-Turn (repositioning tubes and decides, turn the pt)
-Apply (bordered foam dressing or barrier cream)
-Nutrition (attention given to nutrition status)
-Discuss (involvement of specialists)
Assessment: Recognize Cues
History
-conduct with risk factors in mind
-assess cardiovascular status, cognition/mental status
-identify cause of tissue integrity loss and factors that may impair healing
-Contributing factors
(bedrest, immobility, incontinence, DM/ PDV, malnutrition, decreased sensory perception or cognition problems)
Stage 1 Pressure Injury
-intact skin with localized area of non-blanchable erythema (may appear differently in skin with darker pigmentation)
-may be preceded by changes in sensation, temp, or firmness
-color changes are not purple or maroon
Stage 2 Pressure Injury
-partial-thickness loss of skin with exposed dermis
-wound bed us viable, pink, or red and moist
-may look like intact or ruptured serum-filled blister
Stage 3 Pressure Injury
-full-thickness skin loss with adipose (fat) visible in the ulcer
-granulation tissue and rolled wound edges are often present
-slough/ or eschar may be present
-undermining and tunneling may be present
-subq tissues may be damaged or necrotic
Stage 4 Pressure Injury
-full-thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone
-may have slough or eschar
-rolled edges, undermining, tunneling may be present
Arterial Ulcers
History:
-pt reports claudication after walking about 1-2 blocks
-rest pain usually present
-pain at ulcer site
-2-3 risk factors prevent
Location:
-end of toes, between toes, deep, ulcer bed pale, with even edges, little granulation tissue
Assessment Findings:
-cool or cold foot
-decreased or absent pulses
-hair loss
-pallor w elevation
-possible gangrene
-when acute, neurologic deficits noted
Treatment:
-treat underlying cause (surgical, revascularization)
-prevent trauma and infection
-pt education, stressing foot care
Venous Ulcers
History:
-chronic nonhealing ulcer
-no claudication or rest pain
-moderate ulcer discomfort
-pt reports of ankle or leg swelling
Location:
-ankle area
-brown pigmentation
-ulcer bed pink
-usually superficial, with uneven edges
-granulation tissue present
Assessment Findings:
-ankle discoloration and edema
-full veins when leg slightly dependent
-pulses present
-may have scarring from previous ulcers
Treatment:
-long-term wound care
-elevate extremity
-pt education
-prevent infection
Diabetic Ulcers
History:
-diabetes
-peripheral neuropathy
-no reports of claudication
Location:
-plantar area of foot
-metatarsal heads
-pressure points on feet
-deep
-pale, with even edges
-little granulation tissue
Assessment:
-pulses usually present
-cool or warm foot
-painless
Treatment:
-rule our major arterial disease
-control diabetes
-pt education regarding foot care
-prevent infection
Pressure Injuries: Assessment-Recognize Cues
Laboratory Assessment
-Clinical indications of infection (cellulitis, exudate changes, increase in injury size or depth)and systemic signs of bacteremia (fever, elevated WBC)
-wound culture is not routinely performed (to see if septic)
-if performed, tissue culture is done (not just wound swab)
Other Diagnostic Assessments:
-arterial blood flow studies is arterial occlusion is suspected
-duplex ultrasound imaging
-blood tests for nutritional deficiencies (prealbumin, albumin, total protein)
Pressure Injuries: Analysis
-compromised tissue integrity due to vascular insufficiency and trauma
-potential for infection due to insufficient wound managment
Alginate: Wound Dressing
Highly absorbent fabrics or yarns that are derived from natural polysaccharide fiber or seaweed; may be combined with collagen. Alginate forms a gel when it comes in contact with the pressure injury
-Indication: stage 3 and 4 pressure injuries with moderate exudate
Antimicrobial: Wound Dressing
Impregnated with antimicrobial agents, such as medical-grade honey, chlorhexidine, or silver ions
-Indication: for pressure injuries with infection
Collagens: Wound Dressing
Gels, pads, particles, pastes, powder, sheets, or solutions. Made from bovine, equine, porcine, or avian sources, Used with secondary dressings
Indication: stage 3 or 4 pressure injuries
Foam (including hydropolymers): Wound Dressing
Sheets or other shapes of foamed, polymer solutions (usually polyurethane) that have open cells that can hold fluid. May be impregnated or layered
Indication: stage 2 and greater pressure injuries with moderate or heavy exudate
