How are skin lesions primarily assessed?
Color.
How else are they assessed?
Irregular border, shape, diameter > 5-6mm.
What signs do you look for when inspecting the skin?
Edema, moisture, petechiae, ecchymoses.
What signs do you look for when inspecting the skin in a darker skinned patient?
Pallor (ask grey of mucous membranes), Cyanosis (lips, tongue, nail beds, palms, soles), Inflammation (warmth and redness), Jaundice (hard palate), Skin bleed (darker).
Where do you look for skin tears, especially on the elderly patients?
Where their clothing rubs, upper extremities where the skin is grasped, under tapes and dressings.
What is the difference between a macular rash and a papular rash?
Macular rashes are flat and papular rashes are raised.
Where is it best to assess skin temperature?
On the forearm with the back of you hand.
Describe the differences between 1st, 2nd, and 3rd intention healing.
1st = clean cut, sewed shut, thin scar. 2nd = deep, wide, granulated, not swen. 3rd = delayed closure, granulation, risk for infection, scar.
When skin and underlying tissue are pressed against a bony prominence or external surface for a period of time it can cause a _____, or tissue _____.
Pressure ulcer. Anoxia.
Name all 9 risk factors for pressure ulcers.
Impaired mental status, sensory deficits, immobility, elderly, very thin or obese, mechanical, shearing or friction, moisture or secretions, impaired nutritional status.
What is the best way to prevent pressure ulcers?
Shift your weight (even the slightess mvmt) q15mins.
Should you massage reddened areas or the legs of those at risk for DVT?
No!
In the clinical setting, how often should you turn a patient?
Every 2 hours minimum.
What are the scoring ranges on the Braden scale?
11 or under = severe, 12-14 = moderate, 15-16 = mild.
What does black, yellow, and red tissue indicate?
Black = necrosis, yellow = infection, red = healing.
What are the 4 stages of pressure ulcers? Describe them.
Stage 1 = red, unblanchable, skin intact. Stage 2 = Partial thickness skin loss. Stage 3 = Full thickness skin loss, may have some eschar. Stage 4 = Damage to muscle, bone, and/or support.
Which method of debridement is NON-selective?
Mechanical.
Which type of debridement is selective? What are its advantages and disadvantages?
Some enzymatic debriders are selective, but not all. Advantages - it is fast acting with minimal damage to healthy tissue. Disadvantages - expensive, need prescription, must be carefully applied, may have discomfort.
How does the autolytic method of debridement work and when is it used?
It uses the body's own enzymes. Best used in stage 3 or 4 with light to moderate exudate.
What method of debridement is fastest?
Surgical
What does negative pressure wound therapy provide and what DON'T you use on it?
It provides drainage and vascularization, and you should NEVER put it over healthy tissue. Usually used on ST3 or ST4.
What changes to an ulcer should you inform the provider of?
Sudden deterioration or increase in size or depth. Changes in color or texture of granulated tissue.
What albumin level is considered a sign of impaired nutritional status? Lymphocytes?
Albumin < 3.5mg/dL. Lymphocytes < 1800mm3.
What % weight loss is considered INS?
Greater than 15% of body weight.
What is cellulitis?
Inflammation or infection of the skin, connective tissue by staph or strep.
What causes cellulitis?
Open wound or trauma or may be unknown.
What are s/s of cellulitis and what can it mimic?
Warmth, redness, edema, pain, tender, fever, lymphadenopathy. Can mimic DVT, but no fever in DVT.
What is Lymphadenopathy?
Swollen lymph gland.
How is cellulitis diagnosed?
Tissue and/or blood cultures.
What can be done about cellulitis?
Antibiotics and/or debridement.
Describe the difference between Herpes 1 and 2.
Same virus. 1 above the waist and 2 is below the waist.
What is autoinoculation?
The transfer of a pathogen from one part of the body to another.
What usually brings on a recurrence of herpes 1?
Stress
What are the stages of a herpes 1 breakout?
Prodromal - burning, tingling then vesicles, pustules. Contagious until scabbed.
What drug is used for herpes 1?
Acyclovir (Zovirax).
What is shingles?
Herpes Zoster. A disease caused by reactivation of the chicken pox virus.
What causes it to activate?
Occurs with reduced immune function. More common in the elderly, AIDs patients.
What are the s/s of Herpes Zoster?
Vesicles and/or plaques along a nerve, itching, fever, malaise, pain.
What is defined as burning, pain along a nerve?
Postherpetic neuralgia.
What is defined as burning, pain at a nerve ending?
Persistant dermatomal pain. A dermatome is an area of skin that is mainly supplied by a single spinal nerve.
Define Hyperesthesia.
Hypersensitivity.
What nerve does opthalmic herpes zoster affect?
Opthalmic branch of the trigeminal nerve.
What can be done about a case of shingles? What are the steroids for? Antihistamines?
Acyclovir, antibiotics for secondary infections, analgesics, steroids, antihistamines. Pain. Burning and itching.
What is dermatophytosis?
Fungal skin infections.
What type of environment do fungi need?
Warm and moist.
Name and describe the 4 types of fungal infections?
Tinea pedis (athlete's foot), tinea capitas (head), tinea corporis (body), tinea cruris (groin).
What are some interventions for fungal infection?
Keep it clean and dry, topical and/or oral antifungals, steroids, teaching.
Name 2 common inflammatory conditions of the skin.
Dermatitis and psoriasis.
What is dermatitis of the skin and what causes it?
Inflammation. Allergens, irritants, heredity, stress.
What type of dermatitis is eczema?
Atopic dermatitis.
Name some s/s of eczema.
Crusts, fissures, lesions, macules, pustules, papules.
What are its complications?
Infection, sepsis.
What are some interventions?
Antihistamines, analgesics, antipruritics, colloidal oatmeal baths, steroids, wet dressings.
What is psoriasis?
An inflammatory disorder of the skin with a proliferation of epithelial cells and scaling.
How long does psoriasis last?
Lifelong with exacerbations and remissions.
What are some causes of psoriasis?
Cold weather, hormones, skin trauma, drugs, stress, strep pharygitis.
What are some s/s of psoriasis?
Papules, plaques, scales, itching, yellow fingernails.
What are some complications of psoriasis?
Infection, fever, chills, lymphadenopathy, yellowing of the nails.
What are some therapeutic interventions for psoriasis?
Tub baths, steroids, aspirin, keratolytics, coal tar, UV light, chemotherapy, occlusive dressings.
What are venous stasis ulcers?
Ulcers caused by venous stasis. Lack of venous blood flow in the legs causes tissue death, often at the ankle, or in some cases at the kankle.
What are some s/s of venous stasis?
Edema, brownish hardened skin.
What is the #1 way to diagnose Psoriasis?
Physical assessment.
Name some therapeutic interventions for venous stasis?
Decrease edema and/or heal ulcerations, compression wraps and/or unna boot, skin grafts, walk, avoid standing, bedrest with the legs elevated.
What are some nursing interventions for venous stasis?
Elevate and protect legs, do not cross your legs, avoid heat, compression from foot upward.
Where should eschar not be removed from?
The heels.
What is the difference between a strain and a sprain?
Sprains involve ligaments. Strains just involve muscle and tendons.
What is a strain?
Excessive stretching of a muscle or tendon when it is weak or unstable.
What do you do for a strain?
Cold and heat, limit activity, high dose NSAIDs (600-800mg), muscle relaxant, possible surgery.
How many degrees of sprains are there?
3.
Define a 1st degree sprain.
Only a few ligament fibers are damaged.
Define a 2nd degree sprain.
Refers to a more extensive damage to the ligament with associated swelling.
Define a 3rd degree sprain.
Refers to a complete rupture of the ligament with swelling and a possible joint dislocation.
What is done for a first-degree sprain?
Rest, ice for 24 to 48 hr, compression bandage, and elevation.
What is done for a second-degree sprain?
Immobilization, partial weight bearing as tear heals.
What is done for a third-degree sprain?
Immobilization for 4 to 6 weeks, possible surgery.
What is Carpal Tunnel Syndrome?
Common condition in which the median nerve in the wrist becomes compressed causing pain & numbness
What causes Carpal Tunnel Syndrome?
Common repetitive strain injury via occupational or sports motions. Occurs with swelling in tunnel.
Where does the pain/numbness occur in carpal tunnel?
Fingers, hand, arm
What can be done for carpal tunnel?
Rest it, splint it, relieve it (anti-inflammatory meds), surgery
What finger (or fingers) is not innervated by the median nerve?
The pinkie finger.
What does R.I.C.E. stand for and what is it Nursing care for?
Rest, Ice, Compression, & Elevation. Nursing care for sprains and strains.