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Pressure ulcers - staging and dressing selection -9 questions;DefinitionA pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.Partial thickness: inflammatory response, epithelial proliferation and migration, reestablishment of epidermal layersFull thickness: inflammatory phase, proliferative phase, and remodelingStage 1 – Nonblanchable erythema of intact skin; reddened area doesn’t dissipate 30 min p removal of pressureAppropriate support surfacePosition patient off the affected area Gently apply moisturizing cream to areaAvoid massaging over the reddened areaApply film forming skin prepApply transparent film dressing or hydrocolloid dressingRemove q 5-7 days or when redness resolves, or when dsg is compromisedStage 2 – Partial thickness skin loss involving epidermis, dermis or both; Partial thickness skin loss involving epidermis, dermis or both (blister)Position patient off the affected areaGently cleanse with NS or wound cleanserApply skin prep to periwound/let dryApply transparent film dsg ? (tegaderm) tension or wrinklingChange only when dsg compromised or blister has re-absorbedMay also change is blister broken and leaking, or soiledFilm can stay on 5-7 days(abrasion/shallow crater) Appropriate support surfacePosition pt off affected areaGently cleanse ? NS or wound cleanserSaturate gauze with hydrogel Skin prep to periwound areaApply hydrocolloid wafer dsg.Change q 3-4 days et prn if leaksStage 3 – Full thickness skin loss involving damage to, or necrosis of Subcutaneous tissue No necrosis, Minimal ExudatePosition patient off the affected areaGently cleanse with NS or wound cleanserSaturate gauze with hydrogel Apply loosely to wound bedCover c nonstick pad/secure ? tapeChange q1-3 days, depending on drainageMust assess et use this for moist/dry wounds Necrosis, Minimal ExudateAppropriate support surfacePosition pt off affected areaGently cleanse ? NS or wound cleanserSaturate gauze with hydrogel Apply loosely to wound bedSecure ? transparent film dsg.Change q1-2 days depending on drainagePromotes autolytic debridementUse of a film dsg will trap wound drainage which helps keep the wound bed moist and rehydrate necrotic tissue Necrosis and Moderate to Heavy ExudateAppropriate support surfacePosition pt off affected areaCleanse wound ? NSSkin prep to periwound areaPlace calcium alginate in woundCover with gauze or foam dsg.Change q 1-2 days depending on drainageIf the dressing needs to be changed more than once daily due to excess wound drainage, use of foam dsg (such as allevyn) will usually prolong the interval between dsg changesAlso may use Aquacel (hydrofiber) r/t alginate (twice as absorbent)Do not use in dry or moist woundsStage 4 – Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures Primary dressing is the one that actually touches the wound. Secondary dressing would be the one that covers the wound No necrosis, no tunneling, Minimal or no UnderminingPosition patient off the affected areaGently cleanse with NS Apply skin prep to periwound/let drySaturate gauze ? hydrogel Loosely place in woundHydrogel to undermined areas if presentCover ? non-stick dsg Change q 1-2 days, depending upon drainageBe sure dsg is touching all wound base surfaces With Necrosis & Possible Tunneling/Undermining Moderate to Heavy ExudateAppropriate support surfacePosition pt off affected areaCleanse wound ? NSSkin prep to periwound areaPlace calcium alginate in woundUse calcium alginate rope for tunneling (don’t want to leave tunnels without packing them.)Cover with foam dsg Change q 1-3 days depending on drainageTunneled areas should be cleansed, probed*,et repacked at each dsg changeAlso may use Aquacel (hydrofiber) r/t alginate (twice as absorbent)May need to secure foam with tape if it is not adhesive Necrosis, Deep Cavity Moderate to Heavy ExudateAppropriate support surfacePosition pt off affected areaCleanse wound ? NSSkin prep to periwound areaLoosely pack wound ? cavity dsg Cover with foam dsg/Secure ? tapeChange q 1-3 days depending on drainageTunneled areas if present should be cleansed, probed*,et repacked at each dsg changeUse calcium alginate rope for tunnelingMay use alginate sheets or other wound filler if cavity dsg not availableAlso may use Aquacel (hydrofiber) r/t alginate (twice as absorbent)May need to secure foam with tape if it is not adhesiveNew Pressure Ulcer Stages Suspected Deep Tissue InjuryPurple or maroon localized area of discolored intact skin or blood-filled blister due to underlying soft tissue injury from pressure/shear. May be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared with adjacent tissue Unstageable 100% covered with slough and/or eschar (dead tissue)Treatment OverviewNutritional assessment: what are they eating? Management of pressure load (offloading) make sure pt has appropriate support surface. Ulcer care Debridement PRNmanagement of bacterial colonizationMoist wound care Wound ManagementPrevent and manage infectionCleanse the wound (normal saline or appropriate wound cleanser) Remove nonviable tissue: appropriate dressing selection, chemical removals, wet to dryManage exudate: absorb the drainage if too much and make moist if dry. Want the wound to be MOIST. Not dry/wetProtect the woundClient educationNutritional support: extra protein if not a renal patient. Know what your pt needs. Wound Healing Hierarchy of NEEDSPromote Re-EpithelializationPromote Granulation & ContractionPrevent premature Wound closure or contractureOptimize exudate control Remove necrotic tissuePrevent/Control InfectionOptimize Systemic ConditionsDiane Krasner, Wound Care, 2nd Ed. Benefits of moist wound dressings. If moist, Maintain moistureIf dry, moistenIf wet, reduce moisture Phases of Normal Healing ProcessInflammatory (Reaction)Proliferative (Regenerative)Maturation (Remodeling): collagen fibers disorganize and form a softer scar.Dressing choicesBased on Classification, % Red, Yellow, Black tissueSelecting an Appropriate DressingSelect a dressing that will:Maintain a moist wound environmentKeep the surrounding skin dryAbsorb excess wound exudate without desiccating the wound bedNot require frequent dsg. ’s *every 2-4 days*Effectively seal the wound to risk of bacterial contaminationNot require frequent dsg. Changes ’s (potential for cross infection and frequent alterations in wound temperature.Optimal is to select a dressing that can be changed q 48-72 hours. (TQ)Moisture Providing DressingsGel Amorphous or in tubeSheet (may have borders or film covering)Impregnated gauzeUsed to add moisture to dry woundsDressings to Maintain MoistureHydrocolloidsFilmsMoist SalineCompositesContact LayersModerately Absorbing DressingsFoamsComposites (2 layers)Heavily Absorbing DressingsAlginateSeaweed base sheet or rope Becomes GEL as it absorbs moistureWound fillersFoam filled pouchesDon’t forget: Wound Cleanser or Normal SalineSkin sealants (protects healthy tissue)VAC dressing/vacuum systemDebridment agentsAutolytic Enzymatic debriding agents;Skin ConditionsSmeltzer Bare Chapter 56Managing Dermatologic ProblemsConstant annoyance Often primary reason for seeking health careProvide *understanding *explanations *teaching to patientPruritusItching- most common complaintFound with rashAssociated with systemic disease (early diabetes, lots of endocrine disorders)Scratching > histamine release > itchingSearch for underlying causeCorticosteroids/non-steroidal meds Pt. teaching Tepid water bathsShake & blotavoid vasodilationAvoid long, hot baths (take lukewarm baths)Avoid excessive scrubbing or brisk toweling (blot dry) Lukewarm short bathsApply moisturizing lotions (avoid high oil products)Use soap free products for sensitive skin (make sure it is right for YOUR skin) Skin Conditions Spr08/Fall0810Health PromotionEnvironmental hazardsSun exposure- teach pts to avoid the tanning beds!!Irritants and allergensRadiationRest and sleepExerciseHygieneNutritionSelf-treatmentSun exposure is a real and present danger, worse where sun is closer.Wind is also a factor, esp in West Tx DirtIrritants - Allergens - esp in hosp LATEXThink about baby products c LatexSunsmart - UK teaching programRadiation from Xrays , other radiation tx Rest is Restorative -important for healthy skinSo is exercise, 20% of body wt - skin, don’t lose excess skin with excess wt lossNutrition, especially vitamins, proteins, waterSelf -tx - sun screen, lotions, TANNING!assessment (of conditions) and lesions – 8 questions Skin LesionsPremalignant:Actinic Keratosis: flat top scaly lesionBenign:Solar keratosis: doesn’t have the likelyhood to lead to squamous cellsWarts: caused by virus, Nevi: also known as moles, caused by virusAngiomas: little tumors of blood origincancer and pruritus – 5 questions; Skin CancerFrequently related to sun exposure; prevention involves use of sunscreen and avoidance of sun exposure (babies need more protection) Incidence is increasing-Prevention of all types of skin cancer involves protection from excessive sun exposureBasal cell carcinoma- 75%Most common type and most successfully treated because tumors remain localizedEtiology – type of cell, dna damage from sunincidence 80, 20assessment – BCC pearly borders, telangiectasia (spider type looking) , cSCC rusty, wound doesn’t heal, assessment by dermatologistprogression – Basal doesn’t metastasize, squamous cantreatments – Excision, mohs (excision of tumor and surrounding skin, path exam during procedure,) curretage (scraping of the layers to remove it) chemotherapy (can be done topically) , radiationSquamous cell carcinoma- 20%Prognosis depends upon presence of metastasisTreatment involves eradication of the tumor5% of skins cancer is melanoma---the deadly typeMalignant melanoma (rare occurs in less than 5% of people with skin cancer) Risk factors: see Chart 56-8 (MED/SURG BOOK)Worldwide incidence and mortality rate are increasingPeak incidence occurs between ages 20 to 45Types: superficial spreading, lentigo-maligna melanoma, and nodular melanomas (just know there are multiple types) 20% can arise from dyspastic nevi -aytypical nevi; morphologically between nevi (mole) and melanoma (some char of each)Melanoma - arises from melanocytes, invasion and widely metastisizes, ABCD(E) asymetric side to side, border irregular, color variation inside , red white,blue, brown, black, diameter gr than 6 mm.Treatment: surgical excision and other therapies (radiation, pet scan) ABCDE of Malignant MelanomaFig. 24-3 LewisA = asymmetry (different from side to side0B = border irregularity often notched, irregularC = color changes within lesion (multicolored) red, white, blue, brown, black, tanD = diameter >6 mm, size of pencil eraserE = (some add) elevation above ground Multi colored lesions. Not only brown and black, but also red/white/blue. Irregular boards, symmetrical on the sides.Medical and Nursing Mgmt of Skin CancersClinical ManifestationsMedical Management: immune therapy, more aggressive in assessment for surrounding nodes. Melanoma: biological therapy stimulates T and B cells. Nursing ManagementTeachingAssessment of the Patient With Malignant MelanomaInspect the skin carefullyAsk specific questions about pruritus, tenderness, pain, changes in moles, and new pigmented lesionsAssess knowledge level and risk factorsAssess coping and anxiety Kaposi’s Sarcoma (KS)A malignancy of endothelial cells that line the blood vessels: dark reddish-purple lesions of the skin (look like grapes), oral cavity, GI tract, and lungsCategoriesClassic KS (people with DNA damage, didn’t occur frequently)Endemic (African) KSImmunosuppression: associated KSOccurs in transplant recipients and people with AIDSMuch more aggressive form that involves multiple body organs Malignant Skin Neoplasms Risk factorsFair skinned (Red or blonde hair, light eyes)- can also appear in darker individuals. Chronic sun exposure Family hx of skin ca Environmental: exposure to tar and arsenicFor melanoma don’t forget areas hidden from sunLiving near the equator (harsher sun) Nonmelanoma Skin CancersActinic keratosis - premalignantBasal cell carcinomaSquamous cell carcinomaActinic keratosis = precursor of SCC; Manifestation - fat or elevated, hyperkeratotic scaly papule, may have adherent scale, may return when removed, may be rough scale on erythematous base on sun-exposed areasTx; - cryosurgery, topical 5FU2-3 wksBCC - ca arising from basal cell, related to sun exposure, often > 5mmBoth nodular and ulcerative, small, slowly enlarging papule, often semitranslucent or pearly borders, overlying telangiectasia, erosion and ulceration my develop in depressed centerRecurs but doesn’t metastesize, tx excisionSCC - tumor of squamous cell of epidermis, occurs on sunexposed areas, superficial - thin, scaly, erythematous plaqueEarly firm borders, indistinct edges, Tx - excision, sx excision, cyrosx, radiation, may metastisize, high cure rate with early detectionInfectious conditions - 9; Bacterial infectionscellulitis (staph or strep)inflammation of subcutatneous tissue, may be 2nd complication of primary infeciton, Hot, tender, erythmatous, edematous area diffuse borders, chill malaise feverTx moist heat, immobiliaztion, elevation, systemic abx, can progress to gangrene if untx Impetigo superficial skin infection; self limiting group a-beta hemolytic strep.Vesicle pustular lesions c honey colored crust surrounded by erythema, often on face, make sure to remove crusty lesions before apply Triple antibiotic ointment. Folliculitis, furuncles, and carbuncles : boilsFolliculitis - (staphylococcus) sm pustule at hair follicle opening c minimal erythema, crusting,On Scalp, beard, extremities in men, tender to touchFuruncle (boil) Furuncle (Carbuncles): Boil (carbuncle---collection of boils treated w/ antibiotics) persist longer than 2 weeks. Deep infection c staphylococciTx - - incision & drainage, packing abx, meticulous skin care, warm, moist compresses. Draining pus, necrotic debree, may recur despite abx Patient Teaching —Bacterial InfectionsImpetigo is contagious and may spread to other parts of a patient’s body or to other personsPatient teaching regarding antibiotics, hygiene, and skin and lesion care (treat with doxycyline, topical if there is just a single lesion.)Do not share towels, combs, etc. (personal hygiene products)Remove crusty parts before applying antibiotic ointments.Bathe daily with antibacterial soapTeach preventionFuruncles, boils, or pimples should never be squeezed Viral infectionsHerpes zoster (shingles, chicken pox)(Type 1 and Type 2) genital disease is more chronic.Herpes simplex: orolabial and genital (fever blisters, Melissa’s ass)archiform or zosteriform lesions is how you would chart. Characteristic of shingles. Not an elevated lesion, so its patch form lesion. You can see fluid filled vesicle. Narcotics and supportive treatments..extremely painful since it includes the nerves. Antiviral---ZoviraxHPV (Verruca Vulgaris liquid nitrogen to treat- Wart, Plantar wart- if they occur on the plantar surfaces of the foot. ) Usually only a physical problem unless they are on pressure pointsPatient Teaching Viral infectionsHerpes zoster: provide instruction regarding prescribed antiviral medications, lesion care, dressings, and hand hygiene Herpes simplex: provide instruction regarding prescribed use of antiviral and prophylactic medications, information about the spread of herpes, and measures to reduce contagion of partner or of neonates born to mothers with genital herpesFungal infections: yeast or dermatophytes tinea pedis, tinea corporis, tinea capitis, tinea cruris, tinea unguium; see Table 56-5Tineas - foot, body, groincan take 6 weeks for treatment or on the nails could take up to 4 months of treatmentCandidiasis - It is characterized by pruritus, a white exudate, peeling, and easy bleeding. Mouth- white cheese plaque, resembles milk curds\\ (yeast infection or thrush)Vagina - vaginitis c red, edematous, painful vaginal wall with white patches, pruritus (itching)Pain with urination & with intercourseTx – nystatin: swish & swallow, vaginal suppositiories, oral lozanges, powder on skin (nystatin also) Patient Teaching—Fungal InfectionsInstruction regarding medications, use of oral and topical agents, and shampoos Instructions regarding hygiene; use clean towels and washcloths every day Do not share towels, combs, etc.Keep skin folds and feet dryWear clean, dry, cotton clothing including underwear and socks; avoid synthetic underwear, tight-fitting garments, wet bathing suits, and plastic shoesAvoid excessive heat and humidity Hair loss associated with tinea capitus is temporary Infestations and insect bitesPediculosis (lice): pediculosis capitus, pediculosis corporus, and phthirius pubis Patient TeachingHead lice may infest anyone and are not a sign of uncleanliness Provide instruction in use of shampoo (pyrethrin: RID; RID, NIX, elimite, lindane: Kwell;) and combing of hair with fine-tooth comb dipped in vinegar to remove all nitsNote lindane may have toxic effects and must be used only as directed (could cause seizure and death) All articles of clothing and bedding must be disinfected, washed in hot water, or dry cleaned; furniture and floors should be frequently vacuumedDo not share combs, hats, etc. All family members and close contacts must be treated Patient Teaching—Pediculosis Corporis and PubisPediculosis corporis is a disease related to poor hygiene and occurs in those who live in close quartersPediculosis pubis is common and spread chiefly by sexual contact Bathe in soap and water; apply prescription scabicide or an OTC permethrin, such as NIX; mechanically remove any nits; if eyelashes are involved, Vaseline may be applied twice a day for 8 days All family members and sexual contacts must be treated and instructed regarding personal hygieneAll clothing and bedding must be washed in hot water or dry cleanedPatient and partner should be scheduled for a medical checkup to assess for coexisting sexually transmitted diseaseScabies (mites): Sarcoptes scabiei Patient Teaching—ScabiesMites frequently involve fingers and hands; contact may spread infection; health care personnel should wear gloves when providing care until infection is ruled out Instruct patient to take a warm, soapy bath; allow skin to cool; apply the prescription scabicide lindane, crotamiton, or 5% permethrin to entire body, not including the face or scalp; leave on for 12 to 24 hoursWash clothing and bedding in hot water and dry in a hot dryerTreat all contacts at the same timePruritus may continue for several weeks and does not mean retreatment is required Tickspsoriasis – 4 questions.Psoriasis - Chronic dermatitis, rapid cell turnover, silvery scalesChronic dermatitisExcessive Rapid turnover of epidermisSilvery scaled plaques on erythematous base (skin replaces every 4-5 days---way to fast)Intermittent or continuousTx with steroids, tar, sunlight, UV light, to Remicade (immune modifying drugsA chronic, noninfectious inflammatory disease of the skin in which epidermal cells are produced at an abnormally rapid rateAffects about 2% of the population, primarily those of European ancestry Improves and recurs; a life-long condition May be aggravated by stress, trauma, and seasonal and hormonal changesTreatment: baths to remove scales and medications; see PUVA therapy (Table 56-6 )Nursing Process—Assessment of the Patient With PsoriasisAppearance of the skinCoping of the patient with conditionNote impact of the disease on the patient activities and interactions (daily lives)Cardinal signs of psoriasis---silvery scales ................
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