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
Gauze (moist): Wound Dressing
Dry, woven, or nonwoven sponges and wraps made of cotton, polyester, or rayon
Indications: pressure injuries that cannot be dressed with an advanced wound dressing, yet need a moist environment
Hydrocolloid (3M Tegaderm hydrocolloid dressing): Wound Dressing
Wafers, powders, or pastes (powder and pastes need a secondary dressing). Used in areas that require contouring (heels)
Indications: noninfected stage 2 pressure injuries
Hydrogel: Wound Dressing
Amorphous, impregnated, or in sheet form. Designed to maintain a moist environment
Indications: Noninfected stage 2 pressure injuries, noninfected stage 3-4 pressure injuries with minimal exudate
Superabsorbent(3M Tegaderm superabsorbent dressing)
Highly absorptive fiber layers (cellulose, cotton, rayon). Minimizes adherence to the wound while collecting exudate
Indications: heavily exuding pressure injuries
Transparent films (3M Tegaderm): Wound Dressing
Polymer membranes that are impermeable to liquid, water, and bacteria. Can see through the dressing. (also used to cover IV sites, lacerations, second degree-burns)
Indications: noninfected stage 2 pressure injuries; also for pressure injuries as a secondary dressing when advanced wound dressings are not an option
Wet-to-damp saline moistened gauze
as with the wet-to-dry technique, necrotic debris is mechanically removed but with less trauma to healing
Continuous wet gauze
the wound surface is continually bather with a wetting agent of choice, promoting dilution of viscous exudate and softening of dry eschar
Topical enzyme preparations
proteolytic action on thick, adherent eschar causes breakdown of denatured protein and more rapid separation of necrotic tissue
Moisture-retentive dressing
spontaneous separation of necrotic tissue is prompted by autolysis
Pressure Injuries: Planning and Implementation: Generate Solutions & Take action
Nonsurgical Management:
-Physical therapy
-Drug therapy
-Nutrition therapy
-Adjuvant therapies: electrical stim, negative-pressure sound therapy, therapeutic ultrasounds
Surgical Management:
-remove necrotic tissue and skin grafting or use of muscle flaps to close wounds that do not heal by re-epithelialization and contraction
Preventing Infection
-monitor for S/S on infection (fever, elevated WBC, positive blood cultures)
-report change to Dr.
-sudden deterioration of the wound, with an increase in the size or depth of the lesion
-change in the color or texture of the granulation tissue
-changes in the quantity, color, or odor of exudate
-maintain safe emviromanet
-teach all personnel to use standard precautions and to proper;y dispose of solid dressings and linens
Pressure Injuries: Evaluation
-experience progress toward wound healing by second intention as evidenced by granulation, epithelialization, contraction, and reduction solution of wound size
-re-establish skin tissue integrity and restore skin barrier function
-remain free from local or systemic infections
