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Ch 25: Care of Patients with Skin Problems
Terms in this set (80)
(itching) is a distressing condition caused by stimulation of itch-specific nerve fibers. It may or may not occur with skin disease. Physical or chemical agents can directly trigger the nerve fibers or can activate chemical mediators (i.e., histamine), which then act on the itch receptors.
-Priority nursing interventions focus on increasing patient comfort and preventing skin injury with loss of TISSUE INTEGRITY
-Encourage patients to keep the fingernails trimmed short, with rough edges filed to reduce damage from scratching and secondary INFECTION. Wearing mittens or splints at night can help prevent scratching during sleep.
-A cool sleeping environment and comfort measures (e.g., cool shower, moisturizers) may help promote sleep
-effectiveness of topical steroid preparations and other topical agents is increased if the drug is applied to slightly damp skin. Using topical drugs under an occlusive dressing increases the dose being delivered. Avoid occluding treated areas unless specifically prescribed by the health care provider.
Prevention of Dry Skin
• Use a room humidifier during the winter months or whenever the furnace is in use.
• Take a complete bath or shower only every other day (wash face, axillae, perineum, and any soiled areas with soap daily).
• Use tepid water.
• Use a superfatted, nonalkaline soap instead of deodorant soap.
• Rinse the soap thoroughly from your skin.
• If you like bath oil, add the oil to the water at the end of the bath.
• Take care to avoid falls; oil makes the tub slippery.
• Pat rather than rub skin surfaces dry.
• Avoid clothing that continuously rubs the skin, such as tight belts, nylon stockings, or pantyhose.
• Maintain a daily fluid intake of 3000 mL unless contraindicated for another medical condition.
• Do not apply rubbing alcohol, astringents, or other drying agents to the skin.
• Avoid caffeine and alcohol ingestion.
(hives) is a rash of white or red edematous papules or plaques of various sizes. This problem is usually caused by exposure to allergens, which releases histamine into the skin
-common causes of urticaria include drugs, temperature extremes, foods, INFECTION, diseases, cancer, and insect bites
Management focuses on removal of the triggering substance and relief of manifestations. Because the skin reaction is caused by histamine release, antihistamines such as diphenhydramine (Benadryl) are helpful. Teach the patient to avoid overexertion, alcohol consumption, and warm environments, which further dilate blood vessels and make urticaria worse
A wound without tissue loss, such as a clean laceration or a surgical incision, can be closed with sutures, staples, or adhesives. The wound edges are brought together with the skin layers lined up in correct anatomic position (approximated) and held in place until healing is complete. -closed wound eliminates dead space and shortens the phases of tissue repair
Deeper tissue injuries with greater loss of TISSUE INTEGRITY, such as a chronic pressure ulcer or venous stasis ulcer, result in a cavity that requires gradual filling in of the dead space with connective tissue.
-prolongs the repair process
-granulation and contraction
Wounds at high risk for INFECTION, such as surgical incisions into a nonsterile body cavity or contaminated traumatic wounds, may be intentionally left open for several days. After debris (dead tissues) and exudate have been removed (débrided) and INFLAMMATION has subsided, the wound is closed by first intention.
-This type of healing represents delayed primary closure and results in a scar similar to that found in wounds that heal by first intention.
Damage to epidermis, upper layers of dermis
Heal by re-epithelialization within 5 to 7 days
Skin injury immediately followed by local inflammation
the production of new skin cells by undamaged epidermal cells in the basal layer of the dermis, which also lines the hair follicles and sweat glands
Damage extends into lower layers of dermis, underlying subcutaneous tissue
Must be filled with granulation tissue to heal
Contraction develops in healing process
Removal of the damaged tissue results 436in a defect that must be filled with scar tissue, for healing to occur
Fibroblasts also begin to pull the wound edges inward along the path of least resistance (contraction). This causes the wound to decrease in size at a uniform rate of about 0.6 to 0.75 mm/day
Compression of skin and underlying soft tissue between bony prominence and external surface for extended period
occurs when surfaces rub the skin and irritate or directly pull off epithelial tissue. Such forces are generated when the patient is dragged or pulled across bed linen.
are generated when the skin itself is stationary and the tissues below the skin (e.g., fat, muscle) shift or move
-pulling skin layers away from deeper tissue. The skin is "bunched up" against the back of the mattress while the rest of the bone and muscle in the area presses downward on the lower part of the mattress. Blood vessels become kinked, obstructing circulation and leading to tissue death.
usually occurs when a patient is in a wheelchair or in bed in a semi-sitting position and gradually slides downward
-leads to soft-tissue ischemia and deep tissue injury
a commonly used valid skin risk assessment tool. Using it helps the nurse assess and document risk categories for pressure ulcer formation (e.g., mental status, activity and mobility, nutritional status, incontinence).
includes laboratory studies; evaluation of weight and weight change; ability of the patient to consume an adequate diet; and the need for vitamin, mineral, or protein supplementation
-Serum prealbumin levels are often used to monitor nutrition status. Nutrition is considered inadequate when the serum prealbumin level is less than 19.5 g/dL, albumin level is less than 3.5 g/dL, or the lymphocyte count is less than 1800/mm3
A positive nitrogen balance
requires an intake of 30 to 35 calories per kilogram of body weight daily with a protein intake of 1.25 to 1.5 g/kg/day.
Nursing Safety Priority
Teach all nursing care personnel and family members not to massage reddened skin areas directly or use donut-shaped pillows for pressure relief. These actions can damage capillary beds and increase tissue necrosis.
Capillary closing pressure
which is the pressure needed to occlude skin capillary blood flow in a body area
normal 12 to 32 mm Hg
alternate inflation and deflation of the device
made of gel, water, foam, or air are in a constant state of inflation that distributes the patient pressure load over a larger area and reduces the pressure experienced by any particular area.
Inadequate nutrition or hydration
Altered mental status
Peripheral vascular disease
Stage 1 Pressure Ulcer
Area usually over bony prominence, does not blanch with external pressure
Observable pressure-related alterations of intact skin
Stage 2 Pressure Ulcer
Skin not intact
Partial-thickness skin loss of epidermis or dermis
Ulcer is superficial, may appear as abrasion, blister, or shallow crater
Bruising not present
Stage 3 Pressure Ulcer
Full-thickness skin loss
Subcutaneous tissue and underlying fascia may be damaged or necrotic
Bone, tendon, muscle NOT exposed
May have undermining and tunneling
Stage 4 Pressure Ulcer
Full-thickness skin loss with exposed or palpable muscle, tendon, or bone
Undermining and tunneling common with sinus tracts possible
Slough and eschar often present
INFLAMMATION of the skin and subcutaneous tissue
Deep, extensive tissue damage may be present under normal-appearing skin surrounding the wound, with separation of the skin layers from the underlying granulation tissue
Blood-tinged amber fluid consisting of serum and red blood cells
Normal for first 48 hr after injury
Sudden increase in amount precedes wound dehiscence in wounds closed by first intentio
Creamy yellow pus
Colonization with Staphylococcus
Greenish blue pus causing staining of dressings and accompanied by a "fruity" odor
Colonization with Pseudomonas
Beige pus with a "fishy" odor
Colonization with Proteus
Brownish pus with a "fecal" odor
Colonization with aerobic coliform and Bacteroides (usually occurs after intestinal surgery)
size at greatest length and width using a disposable paper tape measure or, for asymmetric ulcers, by tracing the wound onto a piece of plastic film or sheeting (plastic template) at least weekly or more often if the wound shows signs of deterioration.
Cleanse the ulcer
with saline or a prescribed solution (after diluting it as per manufacturer's directions or prescriber's instructions).
An exposed wound is always contaminated but not always infected!
Presence of organisms without infection
Pathogenic organisms grow and spread, cannot be controlled by body's immune defenses
is the application of a low-voltage current to a wound area to increase blood vessel growth and promote granulation
The voltage is delivered in "pulses" that may cause a "tingling" sensation. Usually this technique is performed for 1 hour a day, 5 to 7 days a week
It is not used with patients who have a pacemaker or a wound over the heart.
vacuum-assisted closure [VAC] system
negative pressure wound therapy
-as a method of increasing the rate of wound healing for open fractures. This device allows quicker wound closure, which decreases the risk for INFECTION.
Nursing Safety Priority
Do not use a continuous negative pressure wound therapy device with any patient who is on anticoagulant therapy; has reduced tissue health near the wound (e.g., with radiation therapy or poor nutrition); or has any exposed blood vessels, nerves, or organs in the wound area.
Hyperbaric oxygen therapy (HBOT)
is the administration of oxygen under high pressure, raising the tissue oxygen concentration.
-This type of therapy is usually reserved for life- or limb-threatening wounds such as burns, necrotizing infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers.
-Treatment usually lasts from 60 to 90 minutes
-are applied directly over an open wound to promote local tissue oxygenation; however, their effectiveness in promoting wound healing requires further study
(nonabsorbent, waterproof) material is useful when the wound has little drainage and needs to be protected from external contamination.
(absorbent) material draws excessive drainage away from the ulcer surface, preventing maceration.
mechanical entrapment and detachment of dead tissue
topical chemical débridement
topical enzyme preparations to loosen necrotic tissue
natural chemical débridement
promoting self-digestion of dead tissues by naturally occurring bacterial enzymes [autolysis]
Topical growth factors
are normal body substances that stimulate cell movement and growth
-engineered products that aid in the closure of different types of wounds.
-These products vary widely in design and application
-are used mainly for surgically débrided wounds before reconstruction with grafts or muscle flaps.
Wound Management: Surgical
A full-thickness pedicle flap of skin is separated and rotated to cover the wound. Blood vessels are left intact. The resultant defect is either primarily closed or covered with skin grafts. The flap is held in place with staples or sutures
(boils) are also caused by Staphylococcus, but the infection is much deeper in the follicle
-This larger, sore-looking, raised bump may or may not have a pustular "head" at its point
a superficial INFECTION involving only the upper portion of the follicle and is often caused by Staphylococcus.
-The rash is raised and red and usually shows small pustules.
often occurs as a generalized infection with either Staphylococcus or Streptococcus and involves the deeper connective tissue.
Methicillin-resistant Staphylococcus aureus (MRSA)
It is easily spread to other body areas and to other people by direct contact with infected skin and by contact with clothing, linens, athletic equipment, and other objects used by a person with MRSA
-highest among adults living in communal environments, such as dormitories or prisons, and among patients in hospitals or other health care settings.
Herpes zoster (shingles)
is INFECTION caused by reactivation of the varicella-zoster virus (VZV) in patients who have previously had chickenpox.
- It is contagious to people who have not previously had chickenpox and have not been vaccinated against the diseas
Herpes simplex virus (HSV) INFECTION
is the most common viral infection of adult skin and has two types. Type 1 (HSV-1) infections cause the classic recurring cold sore
The clinical picture of HSV-1 INFECTION is isolated or grouped painful vesicles on a red base. The infection can occur anywhere on the skin and may be spread by respiratory droplets or by direct contact with an active lesion or virus-containing fluid (e.g., saliva).
Tinea is used to describe dermatophytoses
Tinea pedis involves the foot (athlete's foot)
Tinea manus involves the hands
tinea cruris involves the groin (jock itch)
tinea capitis involves the head*
tinea corporis involves the rest of the body (ringworm)*
Dermatophyte infection of the nails resulting in onycholysis*
also known as yeast infection, is a common fungal INFECTION of skin and mucous membranes
for superficial INFECTION involves topical agents. Mild bacterial infections of the skin usually resolve with topical antibacterial treatment.
-patients infected with MRSA or other drug-resistant organisms, drug therapy may involve IV vancomycin or oral linezolid or clindamycin.
Acyclovir (Zovirax), valacyclovir (Valtrex), or famciclovir (Famvir) is used for the treatment
Single louse clearly enough to count its six legs, and a number of egg capsules (nits) attached to the hairs
Pediculosis is a lice infestation: pediculosis capitis (head lice), pediculosis corporis (body lice), and pediculosis pubis (pubic, or crab, lice).
a contagious skin INFECTION caused by mite infestations. It is transmitted by close contact with an infested person or infested bedding. Infestation is common among patients with poor hygiene or crowded living conditions.
A common parasite is the bedbug, Cimex lectularius
it feeds on human blood. The bite causes an itchy discomfort. The most common mode of infestation is carrying the "hitch-hiking" bug home from an infested environment such as a hotel room
a chronic, autoimmune disorder affecting the skin with exacerbations and remissions. It results from overstimulation of the immune system (Langerhans' cells) in the skin that activates T-lymphocytes
have anti-inflammatory actions. When applied to psoriatic lesions, corticosteroids suppress cell division. The effectiveness of a topical steroid depends on its potency and ability to be absorbed into the skin.
applied to the skin suppress cell division from impaired CELLULAR REGULATION and reduce INFLAMMATION. These drugs are available as solutions, ointments, lotions, gels, and shampoos.
occurs as a result of failure of CELLULAR REGULATION over cell division.
Overexposure to sunlight is the major cause of skin cancer, although other factors also are associated
cell destruction by the local application of liquid nitrogen (−200° C) to isolated lesions, causing cell death and tissue destruction.
Curettage and electrodesiccation
removal of cancerous cells with the use of a dermal curette to scrape away cancerous tissue, followed by the application of an electric probe to destroy remaining tumor tissue.
total surgical removal of small lesions for pathologic examination.
a specialized form of excision usually for basal and squamous cell carcinomas. Tissue is sectioned horizontally in layers, and each layer is examined histologically to determine the presence of residual tumor cells.
deep skin resection often involving removal of full-thickness skin in the area of the lesion. Depending on tumor depth, subcutaneous tissues and lymph nodes may also be removed.
is often a drug-induced skin reaction caused by an immunologic mechanism, similar to toxic epidermal necrolysi
A patient presents to the ED with urticaria of the legs and arms after hiking in the woods. In addition to applying a topical antihistamine, what nursing intervention would provide symptom relief?
Taking a cool shower
Taking a warm shower
Applying alcohol to the lesions
Applying used tea bags over the lesions
Rationale: Management of urticaria (hives) focuses on removing the triggering substance and relieving symptoms. Because the skin reaction is caused by histamine release, antihistamines such as diphenhydramine (Benadryl) are helpful. Teach the patient to avoid overexertion, alcohol consumption, and warm environments such as warm or hot showers, which contribute to blood vessel dilation and make the symptoms worse. Alcohol and tea bags would irritate the lesions further.
Upon removing a dressing from a wound, the nurse notices a strong odor. What is the appropriate nursing action?
No action is necessary at this time.
Notify the physician of a possible wound infection.
Clean the wound and reassess for presence of infection.
Culture the wound and anticipate an order for antibiotics.
Rationale: Wound fluid and debris often interact with the dressing and may result in an odor when the dressing is removed. Gently clean the wound and reassess. Signs of infection are most frequently stalled wound healing, presence of purulent exudate, increased wound size or depth, fever, elevated WBC count, and increased pain
An elderly patient with a long history of congestive heart failure is being treated for a pressure ulcer over the coccyx that is 3 cm wide and 4 cm long, with eschar present. Which is the safest technique that can be used to remove the necrotic tissue?
Continuous dry gauze dressing
Dressings along with a topical enzyme preparation
Rationale: Although surgical removal of necrotic tissue may be indicated for some patients, those who are older but too ill or debilitated for surgery will require a nonsurgical approach to ulcer débridement. A biologic dressing is appropriate once the eschar has been removed. A continuous dry gauze dressing is not appropriate for débridement. Topical enzyme preparations help soften and remove eschar.
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