Test #7 Study Guide Flashcards
How do you document pressure ulcers/injuries?
Date, time, site, stage, blanching and intervention performed. As the pressure ulcers heals continue documentation as notated above along with the PUSH tool to demonstrate healing.
What are pressure ulcers/injuries risk factors?
Confinement, immobilization, incontinence, malnutrition, decreased LOC, confusion, DM, dehydration, edema, excessive sweating and extreme age.
What are ways to prevent pressure ulcers/injuries?
Pressure relief, padding, positioning, use of pressure relief devices, adequate nutrition (protein, hydration), excellent skin care: clean, dry and moisturized
What are some nursing interventions for skin tears?
Clense with sterile saline water, debride, approximate, steri-strips and dress with non adhering dressing, provide medication as prescribed (ie. Antibiotics)
What are some special considerations to prevent pressure ulcers in an elderly patient?
Keep skin clean, dry and moisturized, frequent repositioning, prevent skin shearing, be cautious with skin( thin tears easy), keep nurished and hydrated, ambulate.
What are diagnostic test for skin conditions?
All done diagnosed by a professional doctor.
Fungus: Microscopic examinations of skin scrapings
Skin Cancer: examinations of skin, biopsy and pathology results
All other skin conditions are diagnosed by physical examination of skin, review of medical history
Basal Cell Carcinoma
growth or sore that doesn’t heal, a skin-colored bump that’s translucent, or a white, waxy, scar-like lesion without a clearly defined border most commonly seen in the face and the trunk.
Squamous Cell Carcinoma
a firm bump, flat sore, or raised area on the skin. It can appear as a rough, scaly patch, wart-like growth, or sore that won’t heal
Malignant Melanoma
Changes in the size, shape, color, or feel of a mole or skin lesion. It is the least common, but most dangerous because it can lead to death if not treated. Genetic predisposition.
Superficial Spreading Melanoma
on the surface, that usually starts as a dark spot with irregular edges, often on a sun-exposed part of the body.
Nodular melanoma
a firm, raised, discolored growth on your skin that may look like a blood blister, that grows downward through the skin that can lead to a formation of a nodule.
Lentigo Malignant Melanoma
a flat, tan, or brown patch with an uneven border. It can also look like a freckle that changes in size, shape, or color.
How to monitor for skin cancers
Have yearly skin checks, if a new mole, or u healing lesion appears get it checked ASAP, watch for uneven borders, changing moles.
Dermatitis types
Contact: allergic response due coming in contact with something
Atopyc: eczema
Stasis: rash due to venous stasis
Seborrheic: crusty yellow build up in scalp,ears, neck
Dermatitis s+s
Itching
Dermatitis treatment
Contact: avoid touching irritant, antihistamine, corticosteroid.
Atopic: avoid soaps or other irritants (creams, ointments), antihistamines, medicated creams.
Stasis: compressir stockings, medicated creams, treat underlying cause
Seborrheic: self care, medicated shampoos
Dermatitis patient education
Avoid irritants, do not take long hot showers, trial and error to identify self care products that do not irritate skin, Do not rub skin to dry, pat dry instead.
Stage I pressure ulcer
A non blanchable, intact area of the skin that is reddened, deep pink or mottled
Stage II pressure ulcer
Partial thickness skin loss involving the epidermis, or dermis, or both, blistered or abraded or has a shallow crater. The area surrounding the damaged skin is reddened and probably will feel hot or warmer than normal
Stage III pressure ulcer
The skin is ulcerated. There is a crater-like ulcer, and the underlying subcutaneous tissue is involved in the destructive process. The ulcer may or may not be infected. Bacterial infection is almost always present at this stage, however, and accounts for continued erosion of the ulcer and the production of drainage
Stage IV pressure ulcers
deep ulceration and necrosis involving deeper underlying muscle and possibly bone tissue. The ulcer can be dry, black, and covered with a tough accumulation of necrotic tissue, or it can be made up of wet and oozing dead cells and purulent exudates. Depth can’t be determined
Prevention and Treatment for skin cancer?
Prevention: wear sunscreen/sunblock, UV protective clothing, stay out of sun during peak sunlight hours, wear hats, get yearly skin checks.
Treament: Removal of lesion, chemotherapy, radiation.
Acne s+s
uninflamed blackheads to pus-filled pimples or large, red, and tender bumps.
Acne types
Acne vulgaris: during puberty
Acne rosacea: during adulthood 30- 50 yo look like ruptured veins or spiderveins
Acne treatment
Treatment: retinol A, Benzoyl peroxide: lots of acne face washes, azelaic acid, antibiotics.Accutane should only be used for severe cystic acne resistant to other treatment, cystic acne are going to be big and painful acne Photodynamic therapy: can be used for severe acne, and skin cancers. Dermabrasion: removal of first layer of skin, watch out for infection, do not perform on regular basis.
Acne patient teaching
Wash hands before caring for acne
Wash face
Do not pop pimples
Diet, hydration
Psoriasis s+s
Noncontagious, chronic, inflamed, edematous skin lesions covered with white flaking scales that can cause itching and pain.
Psoriasis treatment
Mild cases: keep moist with good moisturizing lotion
Tar preparations: ie. Medicated shampoo
Antimetabolites: methotrexate is most common, injections remicade: they keep skin from over proliferatin, it stops it from overgrowing.
Psoriasis patient teaching
Keep skin moist and pliable, do not dry out. Use humidifiers, if skin is dry.
Be cautious to prevent injury, which can increase psoriasis growth
Steven- Johnson-Syndrome s+s
Allergic reaction with skin manifestations. Fever, sore throat/mouth, fatigue, burning eyes, widespread skin pain, a rash that spreads, blisters, shedding of skin
Commonly caused by: Anticonvulsants carbamazepine (Tegretol) and phenytoin (Dilantin), the antimalarial med: sulfadoxine–pyrimethamine (Fansidar), and the antibiotic trimethoprim–sulfamethoxazole (Bactrim, Septra)
Steven-Johnson-Syndrome treatment
First action if this is suspected: Discontinue the drug causing this.
Provide supportive care. Medical Emergency!
Provide wound care. They will need wound care.
Steven-Johnson-Syndrome patient teaching
Remember medication that caused this reaction add it to allergy list, recovery may take months, ways to cleanse mouth. Therapy to prevent weakness and contractures due to being in bed., rest.
Cellulitis s+s
Swollen, red, hot skin caused by infection of the dermis and subcutaneous tissue
Furuncles: boils infected nodule turnes red that turns into a large tender cyst(Whitehead like nodule)
Carbuncles: group of furuncles.
Cellulitis treatment
Warm compresses, Incision and drainage ,if really big. Systemic antibiotics, depending on severity.
Cellulitis patient teaching
Rinse well after bathing, avoid cosmetics on affected areas, use clean washcloths and linens.
Hepres simplex s+s
HSV-1: lesion on lip, nares- often called ”cold sores”
HSV-2: lesions on perineal area
Herpes simplex treatment
Topical and oral Zovirax, Famvir, Valtrex
Abreva-OTC. Tincture of benzoin or spirits of camphor – dry lesions and aids in healing
Herpes simplex patient teaching
Good personal hygiene
Prevent spread
Reduce stress
Sunscreen for lips I herpes
Herpes zoster (shingles) s+s
Aching or discomfort along the nerve pathway, very painful localized blisters
Herpes zoster (shingles) treatment
Symptomatic treatment, oatmeal baths, no overheat, it will spread if overheated
Antibiotics, Zovirax, Famvir, Valtrex,
Systemic corticosteroids
Herpes zoster (shingles) patient teaching
Cold compresses, calamine lotion, and Rest and adequate nutrition. Imagery, deep muscle relaxation, or use of distraction activities. Isolation during active phase, before lesions crust over.
Fungal infection types
Tinea pedis (athletes foot)
Tinea cruris (jock itch)
Tinea of the scalp (ringworm)
Tinea barbae (barbers itch)
Moniliasis (thrush)
Onychomycosis (nail fungus)
Fungal infection treatment
Topical medicated ointments, antifungals, tea tree oil Vicks vaporub
