Upgrade to remove ads
Only $2.99/month

Client with Integumentary Condition

Terms in this set (58)

What should be looked at with a physical assessment?
Color and temperature
Hydration
Integrity
Odor
What are diagnostic tests used to check skin condition?
Complete blood cell count (WBC)
Erythrocyte sedimentation Rate
Biopsy
Potassium hydroxide prep
Culture
Patch, scratch, skin testing
What are pressure ulcers?
Bedsores, decubitus ulcer, pressure sore
What causes pressure ulcers?
Incontinence, poor nutrition, friction/shear, immobility
What is a stage one pressure ulcer like?
Unblanchable red skin over a bony prominence
What is a stage 2 pressure ulcer like?
Partial thickness
Loss of dermis
Shallow ulcer with pink bed
Blistering
What is a stage 3 pressure ulcer like?
Full thickness
Loss of dermis/epidermis
Subcutaneous fat visible
Bone tendons are not visible
Undermining tunneling maybe present
What is a stage 4 pressure ulcer like?
Full thickness Loss
Bone exposed
Tunneling and undermining
What is an unstageable pressure ulcer like?
Eschar,
Covered
What are nursing diagnosis for pressure ulcers?
Impaired skin integrity
Acute pain
Risk for infection
Disturbed body image
Risk for fluid volume deficit
Altered nutrition
What does the Braden score assess?
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear
What does it mean if someone's Braden score is below 18?
They are at risk
What can a nurse do to prevent pressure ulcers?
Float heels
Keep patient dry
Bed cradles
Reposition
Turn patient every 2 hours
Increase protein in diet
Bed should be at 30 degrees or less
How can you manage pressure ulcers?
Assess for complications: Fistulas, Abscess, Osteomyelitis, Bacteremia
Monitor ulcers daily
Manage pain
Treat with debridement and products
Document
List the five types of debridement:
Mechanical: Wet-Dry
Autolytic: Transparent dressing
Enzymatic: Proteolytic enzymes
(Papain, urea, Collagenase, Trypsin)
Sharp, Scalpel, or lazer
Biosurgery
List Products used to treat pressure ulcers:
Hydrocolloid dressings
Alginate Dressings
Hydrofibers
Hydrogel dressing
Transparent adhesive dressing Vacuum assisted closure (VAC)
List what must be documented with a pressure ulcer:
Location of ulcer
Estimation of stage
Dimension of ulcer
Tunneling
Undermining
Presence of wound bed
Odor
How do you treat frost bite?
Re-warming
Bed rest
Pain meds
What are non melanoma skin cancers?
Basal cell cancer
Squamous cell cancer
What are risk factors for basal cells?
Appearance
Family history
Exposure to sun
What do basal cells look like?
Nodular
White/Yellow
Smooth and shiny
Superficial
Good prognosis
What do squamous cells look like?
Firm
Scaly
Erythromatous or ulcerated
Invasive
Prognosis depends on metastaic incidence.
What is used to treat non-melanoma skin disorders?
Surgical excision
Moh's Surgery
-Removing thin layers of the tumor
Curettage- Scrapping
Electrodesiccation- Damaging the base of the tumor
Cryosurgery
Radiation therapy
Health promotion
What do we know about malignant melanoma?
Arises from melanocytes
Greatest mortality
-Poor prognosis
Risk factors are Nevi and UV sunlight
How can malignant melanoma be diagnosed?
Biopsy
Tests for metastasis:
Liver function test
CT of liver
Complete blood cell count
Chest X ray
Bone scan
CT scan of head
How can malignant melanoma be treated?
Surgical excision
Immunotherpay
Radiation therapy
Biological therapy
What are nursing interventions for Malignant melanomas?
Assess patients coping mechanisms
Include family for teaching
Be knowledgeable about current therapy
Monitor for signs and symptoms of metastasis: lung, bone, liver
Teach prevention
What are defining factors for moles?
Asymmetry
Borders
Color
Diameter
Evolving or changing
What is plastic surgery?
Alteration, replacement or restoration
What is Cosmetic surgery?
Aesthetic surgery to enhance attractiveness
What is reconstructive surgery?
Improves function or appearance or parts that were damaged
What is a split thickness skin graft?
Epidermis and only a portion of the dermis
What is a full thickness skin graft?
The epidermis and dermis.
What is pruritis?
Itching
What is Xerosis?
Dry skin
Often seen with older adults
It manifests as itchy or flaking skin
What are interventions for Dry skin and Pruritis?
Apply skin lubricants after shower
Increase fluids
Cotton gloves
Cold relief/pressure
Distraction
Mild soap and detergents
Bath oils after bath
What are cysts?
Closed sac in or under the skin
What are Keloids?
Progressively enlarging scars
What are Nevi?
Moles
What are angiomas?
Hemangiomas or birthmark
What are skin tags?
Soft papules
What are Keratoses?
Benign overgrowth and thickening of cornified epithelium.
What is Psoriasis?
A chronic immun inflammatory skin disorder
Erythromatous plaques that shed silvery to white scales
Remission and exacerbation
What are triggers for psoriasis?
Stress
Sunlight
Weather
Strep throat
Skin Trauma
Medications
What are complications of psoriasis?
Psoriasis arthritis
What medications are used to manage psoriasis?
Corticosteriods
Tar prep
Methotrexate
Retinoids
Laser therapy
Ultraviolet B light
What are nursing interventions for psoriasis?
Life time managment
Exacerbation: stress and illness
Avoid scratching
Do not wash frequently
Do not remove the scales
Warm water
Emollients
Education and support
What is folliculitis?
Superficial inflammation of the hair follicle
Manifests as pain, itching, and burning
Complications: abcess
What are Furuncles?
Acute inflammation within the hair follicle
Manifests as a raised painful pimple developing into a cyst
What are Carbuncles?
A group of infected hair follicles
Abscess is located in subcu and dermis
Manifests as pain, swollen mass
Systemic manifestations can be chills and fever
What is cellulitis?
Localized skin infection of dermis and subcutaneous tissues
-Extension for furuncle or carbuncles
Manifests as red, swollen, painful, chills, headache, swollen lymph glands
Complications are Ostomyelitis, sepsis
What is Impetigo?
Bacterial infection following skin trauma
Manifests as papules to vesicles with honey colored crust
Educate family about hygiene
What are treatments for bacterial infections:
Handwashing
Obtain cultures from drainage
Antibiotics
Warm compresses
Do not rupture
Cover draining lesions with dressing
Impetigo
Soak crust with cool compress
Remove crust
Topical antibiotic or oral.
What is the stage of the following? Heel; Reddened and nonblanching
Stage 1
Reasoning: Stage ones are unblanchable with redness
What is the stage of the following? Coccyx: Deep opening with tunneling to adjacent tissue
Stage 3
Reasoning: The tendons and bone are not visible yet, but there is a deep opening and it has tunneled into the dermis. Undermining or tunneling could be present
What is the stage of the following? Ankle with leathery scab
Unable to stage
Reasoning: Eschar is covering the ulcer
What is the stage of the following? Elbow with blister
Stage 2
Reason: It is a blister that is intact there is some loss of dermis but not all
What is the stage of the following? Heel: Purulent drainage, visible bone
Stage 4
Reasoning: Bone is visible
THIS SET IS OFTEN IN FOLDERS WITH...