Skin Disorders Flashcards
skin
plays a major role in protection by acting like the first line of defense, as well as helps regulate body temperature and maintains fluid and electrolyte balance
hair
differs in type and function in various body areas
nails
are useful for grasping and scraping and have cosmetic value
changes in epidermis related to aging
Physical changes: decreased epidermal thickness skin transparency and fragility
Nursing interventions: handle patients carefully to reduce skin friction and shear; assess for excessive dryness or moisture; avoid taping the skin
Physical changes: decreased cell division delayed wound healing
Nursing interventions: avoid skin trauma, and protect open areas
Physical changes: decreased epidermal mitotic homeostasis skin hyperplasia and skin cancers (especially in sun-exposed areas)
Nursing interventions: assess non–sun-exposed areas for baseline skin features; assess exposed skin areas for sun-induced changes
Physical changes: increased epidermal permeability increased risk for irritation
Nursing interventions: teach patients how to avoid exposure to skin irritants
Physical changes: decreased immune system cells decreased skin inflammatory response
Nursing interventions: do not rely on degree of redness and swelling to correlate with the severity of skin injury or localized infection
Physical changes: decreased melanocyte activity increased risk for sunburn
Nursing interventions: teach patients to wear hats, sunscreen, and protective clothing; teach patients to avoid sun exposure from 10amto 4pm
Physical changes: hyperplasia of melanocyte activity (especially in sun-exposed areas) changes in pigmentation (e.g., liver spots, age spots)
Nursing interventions: teach patients to keep track of pigmented lesions; teach them what changes should be evaluated for malignancy
Physical changes: decreased vitamin D production increased risk for osteomalacia
Nursing interventions: urge patients to take a multiple vitamin or a calcium supplement with vitamin D
Physical changes: flattening of the dermal-epidermal junction increased risk for shearing forces, resulting in blisters, purpura, skin tears, and pressure-related problems
Nursing interventions: avoid pulling or dragging patients; assist patients confined to bed or chairs to change positions at least every 2 hours; avoid or use care when removing adhesive wound dressings
changes in the dermis related to aging
Physical changes: decreased dermal blood flow increased susceptibility to dry skin
Nursing interventions: teach patients to apply moisturizers when the skin is still moist and to avoid agents that promote skin dryness
Physical changes: decreased vasomotor responsiveness increased risk for heat stroke and hypothermia
Nursing interventions: teach patients to dress for the environmental temperatures
Physical changes: decreased dermal thickness paper-thin, transparent skin with an increased susceptibility to trauma
Nursing interventions: handle patients gently, and avoid the use of tape or tight dressings; use lift sheets when positioning patients
Physical changes: degeneration of elastic fibers decreased tone and elasticity
Nursing interventions: check skin turgor on the forehead or chest
Physical changes: benign proliferation of capillaries cherry hemangiomas
Nursing interventions: teach patients that these are benign
Physical changes: reduced number and function of nerve endings reduced sensory perception
Nursing interventions: tell patients to use bath thermometer and to lower the water heater temperature to prevent scalds
changes in the subcutaneous layer related to aging
Physical changes: thinning subcutaneous layer increased risk for hypothermia and increased risk for pressure injury
Nursing interventions: teach patients to dress warmly in cold weather; assist patients confined to bed or chairs to change positions at least every 2 hours
skin inspection
observe and document these features:
Obvious changes in color and vascularity
Presence or absence of moisture
Edema
Skin lesions
Skin integrity
Skin assessment techniques for patients with darker skin
Pallorcan be detected in people with dark skin by first inspecting the mucous membranes for an ash-gray color
Cyanosis can be detected in the lips and tongue appearing gray and the palms, soles, conjunctivae, and nail beds have a bluish tinge
Inflammationin dark-skinned patients appears as excessive warmth and changes in skin consistency or texture
Jaundiceis best assessed by inspecting the oral mucosa, especially the hard palate, for yellow discoloration
Ecchymoses appear darker than normal skin; they may be tender and easily palpable
Primary lesions
are an initial reaction to a problem that alters skin components
Secondary lesions
changes in the appearance of the primary lesion; these changes occur with progression of an underlying disease or in response to a topical or systemic therapeutic intervention
Annular
circular
Circumscribed
well-defined with sharp borders
Clustered
several lesions grouped together
Coalesced
lesions that merge with one another and appear confluent
Linear
occurring in a straight line
Serpiginous
with wavy borders, resembling a snake
Universal
all areas of the body involved, with no areas of normal-appearing skin
Skin palpation
use palpation to gather additional information about skin lesions, moisture, temperature, texture, and turgor
Palpation confirms lesion size and whether they are flat or slightly raised
Consistency of larger lesions can vary from soft and pliable to firm and solid
Subtle changes, such as the difference between a finemacular rash and apapular rash, are best determined by palpating with your eyes closed
Ask the patient whether skin palpation causes pain or tenderness
diagnostic labs/tests
cultures
Skin biopsy
Wood’s light examination
Diascopy
pressure ulcer
is a loss oftissue integritycaused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period
Tissue compression from pressure restricts blood flow to the skin, resulting in reduced tissue perfusion and oxygenation and, eventually, leading to cell death
Complications include sepsis, kidney failure, infectious arthritis, and osteomyelitis
assess for any contributing factors for pressure ulcers
Prolonged bedrest
Immobility
Incontinence
Diabetes mellitus
Inadequate nutrition or hydration
Decreased sensory perception or cognitive problems
Peripheral vascular disease
Friction and sheering forces
Inspect the whole body
Incontinence associated dermatitis (IAD)
Skin damage associated with exposure to urine or stool
It is a type of irritant contact dermatitis
Once IAD occurs, there is a high risk for pressure ulcer development as well as an increased risk of infection and morbidity
Stage I pressure ulcer
Skin is intact, red and does not blanch with external pressure
For patients with darker skin that does not blanch:
Observe for changes compared with an adjacent or opposite area for:
Skin color darker or lighter than the comparison area
Skin temperature (warmth or coolness)
Tissue consistency (firm or boggy)
Sensation (pain, itching)
Stage II pressure ulcer
There is partial-thickness skin loss of the epidermis or dermis and skin is not intact
Ulcer is superficial and may be characterized as an abrasion, a blister (open or fluid-filled), or a shallow crater
Bruising isnotpresent
stage III pressure ulcer
Skin loss is full thickness and damage extends down to but not through the underlying fascia; bone, tendon, and muscle arenot exposed
Subcutaneous tissues may be damaged or necrotic
Undermining and tunneling may or may not be present
Stage IV pressure ulcer
Skin loss is full thickness with exposed or palpable muscle, tendon, or bone
Often includes undermining and tunneling
Slough and eschar are often present on at least part of the wound
Deep tissue injury
The intact skin area appears purple or maroon
Blood-filled blisters may be present
The area may have felt more firm, boggy, mushy, warmer, or cooler than the surrounding tissue before the color change occurred
Unstageable pressure ulcer
Skin loss is full thickness, and the base is completely covered with slough or eschar, obscuring the true depth of the wound
assessment and document for pressure ulcers
Assess wounds for location, size, color, extent of tissue involvement, cell types in the wound base and margins, exudate, condition of surrounding tissue, tunneling, undermining and presence of foreign bodies
Document this initial assessment to serve as a starting point for determining the intervention plan and its effectiveness
Assess the wound at each dressing change, comparing the existing wound features with those documented previously to determine the current state of healing or deterioration
assess for signs of healing
Beneath the dead tissue, granulation tissue appears
Early granulation is pale pink, progressing to a beefy red color as it grows and fills the wound
Palpate the wound to determine the granulation texture
Healthy granulation tissue is moist and has a slightly spongy texture
Nursing interventions for pressure-relieving and pressure reducing techniques
Assist with major position changes every 2 hours in bed, every 1 hour in a chair
Pad contact surfaces with foam, silicon gel, air pads, or other pressure-relieving pads
Do not keep the head of the bed elevated above 30 degrees to prevent shearing
Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or her
When positioning a patient on his or her side, do not position directly on the trochanter
Place pillows or foam wedges between two bony surfaces
Keep the patient’s skin directly off plastic surfaces
Help the patient maintain an adequate intake of protein and calories and a fluid intake of 2 – 3L/day
Perform a daily inspection of the patient’s entire skin and document all sores and signs of infection
Use moisturizers daily on dry skin, and apply when skin is damp
Keep moisture from prolonged contact with skin
Keep areas dry where two skin surfaces touch, such as the axillae and under the breasts
Place absorbent pads under areas where perspiration collects
Use moisture barriers on skin areas where wound drainage or incontinence occurs
Clean the skin as soon as possible after soiling occurs and at routine intervals
Use a mild, heavily fatted soap or gentle commercial cleanser for incontinence with tepid rather than hot water
While cleaning, use the minimum scrubbing force necessary to remove soil and gently pat dry
passive wound dressing
have only a protective function and maintain a moist environment for natural healing; they just cover that area and may remain in place for several days
DuoDERM, Tegaderm
interactive wound dressing
capable of absorbing wound exudate while maintaining a moist environment in the area of the wound and allowing the surrounding skin to remain dry
Hydrocolloids, alginates, hydrogels
active wound dressings
improve the healing process and decrease healing time
Skin grafts, biologic skin substitutes
Surgical management of a pressure ulcer includes
removal of necrotic tissue and skin grafting or use of muscle flaps to close wounds that do not heal by re-epithelialization and contraction
Those with poor blood flow are unlikely to have successful graft take and heal
The procedures are very similar to the surgical management of burn wounds
Negative pressure wound therapy
can reduce or even close chronic ulcers by removing fluids or infectious materials from the wound and enhancing granulation
This technique requires that a suction tube be covered by a special sponge and sealed in place
Per manufacturer’s instructions, the foam dressing is changed every 48 to 72 hours (or at least 3 times weekly). Continuous low-level negative pressure is applied through the suction tube
Duration of the treatment is determined by the wound’s response
Impetigo
Characterized by red macules that become thin-walled vesicles that rupture and become covered with honey-yellow crust
May have formation of bullae (large fluid-filled blisters) from original vesicles, then the bullae rupture leaving red raw areas
Exposed areas of the body, face, hands, neck and extremities are most frequently involved
Contagious and may spread to over parts of the body or to other people
Folliculitis
Isolated erythematous pustules occur singly or in groups; hairs grow from centers of many of the lesions
Occasional papules are present
There is little or no associated discomfort
There is no residual scarring
Areas of hair-bearing skin, especially areas of shaving, thighs, buttocks, and axillae are affected
Furuncle (boil)
Small, tender, erythematous nodules become pus filled
Lesions may be single or multiple and also recurrent
May progress and involve the skin and subcutaneous fatty tissue, causing tenderness, pain, and cellulitis
Occasional scarring results