Week 2 Flashcards
Name 6 types of dressings for burn wounds.
Silver impregnated (antimicrobial) - common & effective against staph
Alginate - moderate to high exudate
Hydrocolloid & foam - moderate to low exudate
Light dressings over joints - allows ROM and minimises compartment syndrome
Paraffin gauze
Antimicrobial impregnated - skin grafts, left on 3-5 days
What are the early signs of wound infection?
Pain
Redness
Oedema
Heat
What are the 4 wound classifications?
Acute/chronic*
Damage (burns)
Stages (pressure sores)
Colour
- Acute refers to surgical or traumatic injury, the wound is not usually colonised with bacteria
Chronic refers to long term wound; e.g. Leg ulcer. Microbial colonisation
What are the 2 principal layers of the skin?
Dermis and epidermis
When conducting an integumentary assessment, what questions are asked regarding the patients health history?
Allergies Previous skin conditions Family Hx of skin conditions Presenting problem Symptoms Medical Hx (cardiac and respiratory) Current medications Nutritional status
When assessing the skin, what is the nurse looking for?
Skin colour (general appearance, buccal mucosa, tongue, lips, nails)
Cyanosis
Erythema
Petechiae
Pallor
Jaundice
Alopecia to lower limbs
Nail clubbing (indicates endocarditis, COPD, cancer, cirrhosis of liver, hyperthyroidism)
What is herpes simplex, the signs and symptoms, treatment and management?
True primary infection
Type 1 - mouth (cold sores)
Type 2 - genital area
Signs and symptoms are pain, itchiness, burning, tingling, appearance of vesicles
Treatment and management
Type 1 - topical antiviral agent
Type 2 - dependent on severity, frequency and psychological impact of recurrence. Immunosuppressant therapy is effective in 85% of patients
What is herpes zoster, the signs and symptoms and treatment?
Shingles caused by the varicella-zoster virus.
Red coloured rash Swelling to rash area Pain Malaise GI upsets
Patient is contagious until rash develops cysts.
Oral or IV antiviral medication Analgesia Corticosteroids for neuralgia Pain management Dressings Patient education on dressings, ointment and hand hygiene
Prevention - varicella virus vaccination
What is the usual dose of vancomycin?
For specific infections
125 - 500mg four times a day PO
15-20mg/kg
Endocarditis
500mg four times a day or 1g BD
What is the route of administration for vancomycin?
Typical route is IV
Oral route used for clostridium defficile
What are the precautions and side effects of vancomycin?
Allergy to tecioplanin
Inflammatory GI conditions (affect absorption/can cause toxicity)
Renal impairment (increase the dose interval, reduce dose or both)
Surgery (GA increases adverse effects)
Elderly (toxicity)
Pregnancy (B2 drug category)
Breastfeeding (can cause loose bowel motions in baby)
Oral route - indigestion, nausea, vomiting, diarrhoea, chills
IV - local pain, thrombophlebitis, interstitial nephritis, serious skin reactions, chemical peritonitis, nausea, hypersensitivity (fever, chills, itch, rash, Steven-Johnsons syndrome, toxic epidermal necrolysis)
Why are specific infection control procedures required when MRSA+ve patients are hospitalised?
Prevent transmission to unaffected patients who may be at risk of opportunistic infection (eventually leading to death)
Why are limited antibiotics available for MRSA+ve patients?
Due to bacteria being resistant to most antibiotics traditionally used to treat infection (penicillin, methicillin, flucoxacillin)
What medication is used for MRSA+ve and how does it work?
Vancomycin; stops growth of bacteria
What is the treatment for a burns patient?
Fluid resuscitation (rule of nines) Early wound debridement and resurfacing Specialised dressings Antibiotics Nutrition/fluid balance Analgesia Surgical intervention (grafts)
What are the 3 types of burns? (Classification by damage)
Superficial (epidermis)
Partial thickness (epidermis & dermis)
Full thickness (epidermis, dermis and extends into subcutaneous tissue, muscle or bone)
Mortality rate is highest in elderly, young and 60%+ of body)
Describe the 4 stages of wounds.
Stage I
Pressure related alteration of the skin
Skin not yet broken
Erythema does not disappear
Damage can be reversed at this stage
Stage II
Partial thickness skin loss involving epidermis and dermis
Ulcer is superficial; presents as abrasion, blister or shallow crater
Stage III
Full thickness skin loss
Ulcer presents as deep crater
Haemoserous exudate
Necrosis or slough may be present
Stage IV
Full thickness skin loss Extensive destruction Tissue necrosis or damage to muscle, bone supporting structures Dermis and subcutaneous tissue destroyed Muscle and bone may be involved HIGH RISK OF INFECTION
Describe the classification of wounds by the following colours:
Black Yellow Green Red Pink
Black - necrotic tissue
Yellow - usually moist and sloughy
Green - moist, sloughy, query infection
Red - healthy granulating wound
Pink - epithelialising wound, translucent in appearance
What are four causes of decubitus (pressure) sores?
Reduced blood supply
Reduced oxygen supply
Reduced nutrition
Reduce immune response
What is the purpose of a wound care dressing?
Provide protection
Reduce microorganisms
Reduce patient discomfort
Reduce further trauma
Improve/speed up healing time by keeping wound moist
When attending to wound care, what is assessed and documented?
Pain Colour Exudate Odour Location Size of wound Integrity of surrounding skin Type of dressing used
What is the nursing care for burns?
Cool burn with tepid, running water for at least 20 minutes
Fluid replacement/balance
NGT above 20% RON
Assessment of total body surface area affected
IDC
Enteral feeding
Wound management
What is the wound management for burns?
Administer analgesia prior to wound care
Clean the wound
Observe for chilling, fatigue and pain (ability to thermoregulate is diminished)
Topical antibacterial therapy for non-surgical burn wounds
What are the 3 phases of wound healing?
Haemostasis
Vasoconstriction
Platelet response
Biochemical response
Inflammation
Capillaries contract and thrombose
Vasodilation of surrounding tissue
Release of immune cells
Reconstruction
Epithelial cells migrate over granulation tissue from surrounding wound edges
Epithelium begins to thicken
Wound contraction
Maturation
Matrix of collagen cells reorganised and strengthened - can take up to a year
What are the 3 intentions of wound healing?
Primary (first) intention
Wound has minimal tissue loss and edges can be brought together by sutures or clips
Secondary intention
Wound cannot be brought together
Granulation tissue fills the wound until epithelialisation occurs
Third intention
Primary wound healing is delayed so infected/contaminated wound can be debrided and cleaned
What are the factors that affect wound healing?
Wound infection Wound dehydration Age Underlying disease (diabetes, CVD) Obesity Drugs Allowing maceration of wound Not treating underlying cause Inappropriate dressings Temperature variances Disorders of sensation and movement Friction/shearing forces Psychological state Nutritional state Radiation therapy Keloid Foreign bodies
What is impetigo and what is the nursing management?
Highly contagious, superficial, bacterial infection caused by staphylococci, streptococci of multiple bacteria.
Occurs as fluid-filled blisters (bullae) on the neck, face, hands or extremities
Bullae rupture, leaving raw red areas that may be itchy.
Patient is contagious until no more crusts.
Treatment is antibiotic therapy.
Good hand hygiene
Isolate from other patients to minimise cross contamination
Adopt Contact Standard Precautions
What are the 5 functions of the skin?
Protection
Keratin, melanin, sebum and nerve endings
Thermoregulation
Controls body temperature by convection, evaporation, conduction and radiation
Sensation
Perceives stimuli - heat, cold, pain, pressure, touch
Metabolism
Provides insulation; helps produce and use vitamin D
Emotions
Portrays emotions - flushing, sweating, pallor
What is a BCC?
Basal Cell Carcinoma
Most common form of skin cancer Good prognosis Recurrence common Rarely metastasises Mainly on face
What is a SCC?
Squamous Cell Carcinoma
Malignant proliferation of epidermis cells
Seen on sun damaged skin; face, ear, lower lip, scalp, neck, hands, arms, legs
Invasive and can metastasise
Prognosis dependent on nature and presence of metastasis
What is a malignant melanoma?
Third most common skin cancer (3% of cancer related deaths)
Involves epidermis and dermis
Poor prognosis if metastasises present
What is the Rule of Nines and why is it important?
Estimation of total body surface area that is burnt.
Areas of body are divided into head and neck (front and back), trunk (front and back) arms and legs (front and back) and perineum and given a percentage. Percentages are calculated using multiples of 9.
Anterior and posterior head & neck 9%
Anterior and posterior upper extremities 18%
Anterior and posterior lower extremities 36%
Anterior and posterior trunk 36%
Perineum 1%
Guides treatment decisions including fluid resuscitation.
What is the treatment for a BCC?
Surgical removal of the tumour layer by layer - MOHs micrographics surgery
Most accurate method
Electrosurgery - destruction and removal by electrical energy
Cryosurgery - deep freezing of cancerous tissue using liquid nitrogen
Name two types of skin infections, the symptoms and treatment.
Candida (thrush)
Ringworm (tinea)
Itching, burning and inflammation to the affected area.
Anti-fungal ointment/cream
Pessaries
Oral or IV preparations
What are the 8 steps of a skin assessment?
Health history Assess skin colour Assess for signs of rash Skin temperature Vascularity and hydration Nails Hair Diagnostic evaluation (blood samples, patch treats, skin scraping)
