objective 2 (2) Flashcards by Kaitlyn Dominie

general itching
Common symptom of dermatological disorders
Occurs with rash or lesion but may without

pruritis

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what are the S&S of pruritis?

Altered skin integrity, redness, raised areas (wheals), infection

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what is the medical management of pruritis?

Identify and treat the cause, cold compresses, corticosteriods, antihistamines

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Inflammatory reaction of the skin
Absorbed agent –nickel and gold jewellery, Balsam of Peru (found in perfumes)

allergic contact dermatitis (ACD)

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most frequently used antibiotic to treat skin, ear and eye infections. Found in OTC creams/lotions

neomycin

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most likely antibiotic to cause anaphylaxis

bacitracin

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Impetigo
Folliculitis, furuncles, and carbuncles

bacterial infections

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tinea pedis, tinea corporis, tinea capitis, tinea cruris, tinea unguium

fungal infections

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Herpes Simplex Virus, Herpes Zoster, Plantar Warts Bacterial, Fungal and Viral Infections

viral infections

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Infection of the skin caused by staph, strep or multiple bacteria
Usually on exposed areas of the body

impetigo

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bacterial (staph) or fungal infection of the hair follicles (razor rash) bacterial (staph) or fungal infection of the hair follicles (razor rash)

folliculitis

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(boil) acute inflammation deep in one or more hair follicles and spreads to surrounding dermis (back of neck, axillae and buttocks)

furuncles

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abscess of the skin and subcutaneous tissue that represents an extension of the furuncle (back of neck and buttocks)

carbuncle

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fungal infection of the foot

tinea pedis

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Ringworm of the body – ringed lesions appear on the face, neck, trunk and extremities (contact with pets)

tinea corporis

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Ringworm of the scalp – round scaling patches on the scalp

tinea capitis

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Ringworm of the groin (jock itch)

tine cruris

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Most common infectious cause of limb swelling
Entry point through the skin allows bacteria to enter

cellulitis

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Chronic, noninfectious inflammatory disease of the skin
Hereditary defect that causes overproduction of keratin
Genetic makeup and environmental stimuli may trigger
Improves and recurs; a lifelong condition
May be aggravated by stress, trauma, and seasonal and hormonal changes

psoriasis

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Infection caused by the varicella-zoster virus
Reactivation of latent varicella virus infection and reflects lowered immunity

shingles

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Infestation of the skin by the itch mite
Mites involve the fingers and hand contact may spread infection
Rash on elbows, knees, edge of feet, nipples, axillae, groin

scabies

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Most common types of skin cancer
Diagnosed by biopsy and histologic evaluation

basal cell carcinomas and squamous cell carcinomas

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Most lethal of all skin cancers
Cancerous neoplasm in the pigment cells
Ultra violet rays are suspected to play role

malignant melanoma

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what are the diagnostic studies?

Careful history
Physical examination
Inspection of individual lesions

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what are the collaborative care?

Phototherapy Radiation therapy Laser technology

what are the drugs used for drug therapy>

Antibiotics - Corticosteroids – Antihistamines – Topical fluorouracil – Immunomodulators –

infection

antibiotics

anti-inflammatory

corticosteroids

helps with allergic reactions

antihistamines

used for treatment of premalignant and malignant skin diseases

topical fluorouracil

suppresses an overactive immune system

immunomodulators

what is the diagnostic and surgical therapy?

Skin scraping – obtain surface cells using scalpel Electrodesiccation and electrocoagulation – tissue destroyed by burning Curettage – removal and scooping away of tissue Punch biopsy – cores out a small cylinder of skin Cryosurgery – using subfreezing temperatures to destroy epidermal lesions Excision – removal of tissue in thin layers

what do we do for ambulatory and home care?

Wet dressings Baths Topical medications Control of pruritus Prevention of spread Prevention of secondary infections Specific skin care Psychological effects of chronic dermatological problems Physiological effects of chronic dermatological problems

Caused by a transfer of energy from a heat source to the body Most burns occur in the home Young children & elderly are at high risk Also occur from work-related injuries Can lead to fluid loss, infection, hypothermia, scarring, and compromised immunity * Described according to depth of the injury and the extent of body surface area injured

burns

what are the types of burns?

Thermal burns Chemical burns Smoke inhalation injury Electrical burns Cold thermal injury

Caused by flame, flash, scald, or contact with hot objects Most common type of burn

thermal burns

Result from tissue injury and destruction from acids, alkalis, and organic compounds Alkali (Not neutralized by tissue) burns are hard to manage because they cause protein hydrolysis and liquefaction… oven / drain cleaners

chemical burns

Result from inhalation of hot air or noxious chemicals Cause damage to respiratory tract Major predictor of mortality in burn clients Need to be treated quickly

smoke inhalation injuries

Result from coagulation necrosis caused by intense heat generated from an electric current May result from direct damage to nerves and vessels, causing tissue anoxia and death

electrical burns

what does the severity of electrical burns depend on?

amount of voltage. tissue resistance. current pathways. surface area. duration of the flow.

what is the severity of an injury determined by?

depth of burn. extent of burn in percent of TBSA. location of burn. client risk factors.

Minimal epithelial damage Erythema, dark pink, pain & mild edema – 3-5 days Sunburn Healing time 5-10 days

superficial (first degree)

Epidermis/minimal dermis Hot liquids; flash flame Supersensitive to pain Moist, blisters, pink or mottled red Healing time 21-28 days , minimal scarring

superficial partial thickness burn (second degree)

Entire epidermis, part of dermis, hair and sweat glands intact Hot liquids, flame, chemicals, electrical Sensitive to pressure Dry, pale, waxy Healing time 30 days months – scarring, marked contracture

deep partial thickness (second degree)

Complete epidermis, complete dermis, portion of subcutaneous fat, may involve tissue, muscle, bone Sustained flame, electrical, chemical, steam Limited/no pain Leathery, cracked, avascular, white, cherry red, black Cannot self regenerate/ needs grafting

full thickness (third degree)

what are the 2 commonly used guides for determining the toal body surface area?

lund-brower chart rule of nines

what are the phases of burn management?

Pre-hospital care Emergent (resuscitative) Acute (wound healing) Rehabilitative (restorative)

is the period of time required to resolve immediate problems resulting from the injury. Usually lasts up to 72 hours Primary concerns are onset of hypovolemic shock and edema. Phase begins with fluid loss and edema formation and continues until fluid mobilization and diuresis begin

emergent phase

what are the clinical manifestations of the emergent phase?

Shock from pain and hypovolemia Blisters Adynamic ileus - paralysis of intestinal motility. Shivering Altered mental status

provide temporary wound closure and protects granulation tissue until autografting is possible

biologic dressings

tissue from a living or recently deceased human or heterografts

homografts

composed of nylon, silastic membrane with collagen derivative. Useful for intermediate to long term closure of wounds until an autograft becomes available.

briobane

artificial skin (Integra) becomes a permanent structure. Consists of an epidermal and dermal layer

dermal substitutes

Patient’s own skin is used

autografts

begins with the mobilization of extracellular fluid and subsequent diuresis. (intravascular fluid deficit) The acute phase is concluded when the burned area is completely covered by skin grafts, or when the wounds are healed. Focuses on respiratory and circulatory status

acute phase

what are the acute phase manifestations?

Partial-thickness wounds form eschar. Once eschar is removed, re-epithelialization begins. Full-thickness wounds require debridement.

burn wounds are healed. client is able to resume a level of self-care activity.

rehabilitation phase

what are the emotional needs of the client and family?

A common emotional response is regression. Early psychiatric intervention Assess psychoemotional cues. Issue of sexuality must be met with honesty. Family and client support groups

what are the special needs of the nursing staff?

The nurse may find it difficult to cope with burn injuries. The nurse will know that he/she can provide care that makes a critical difference. * Practice good self-care.

S/S purulent drainage, pain, redness around wound, edema, increased temp, elevated WBC

infection

S/S slimy top, no advancement in healing edges, low level erythema: DEBRIDE

biofilms

S/S large amounts sanguineous drainage + other symptoms of hypovolemic shock. Check UNDER clients

hemorrhage

S/S wound edges pulling away; not well-approximated. Early sign = increasing serosanguineous drainage

dehiscence

S/S wound opens revealing internal organs. Emergency rx = sterile NS gauze to cover; prepare for OR

evisceration

Encourage verbalization of feelings; encourage self-care as tolerated by client, explore reasons no any non-adherence to treatment regime or lifestyle factors affecting healing

psychosocial impact

what are the types of wounds?

Surgical Pressure (Classification system) Trauma Burns (Classification system)

Healthy red tissue is observed and is deposited during the repair process. It presents as pinkish/red colored moist tissue and comprises of newly formed collagen, elastin and capillary networks. The tissue is well vascularized and bleeds easily.

granulating

is a process by which the wound surface is covered by new epithelium, this begins when the wound has filled with granulation tissue. The tissue is pink, almost white, and only occurs on top of healthy granulation tissue.

epithelializing

The presence of devitalized yellowish tissue is observed and is formed by an accumulation of dead cells. Must not be confused with the presence of pus.

sloughy

Describes a wound containing dead tissue. The wound may appear hard, dry and black. Dead connective tissue may appear grey. The presence of dead tissue in a wound prevents healing.

necrotic/eschar

This is observed when granulation tissue grows above the wound margin.

hyper granulation

Wound undermining occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound’s edge

undermining

Similar to undermining, however usually occurs in only one direction and can be much deeper

tunneling

what is the scale for measuring the amount of exudate?

0. None visible 1. Scant: moist, few dots, smears 2. Small- < 25% of dressing covered 3. Moderate- approx. 50% of dressing 4. Large/Copious- Saturates entire dressing

what are the types of wound edges?

Approximation / Dehiscence Jagged Wound Edges Attached/Detached Macerated

what are the factors affecting infection>

characteristics of the individual characteristics of the wound characteristics of the environment

Poorly controlled diabetes Radiation or chemo (Immunosuppression) Hypoxia, anemia, arterial/vascular disease) Malnutrition, alcohol, smoking, drug abuse

characteristics of the individual

Contaminated wounds, Penetrating wounds over 4 hours

acute wound

Duration of wound, large wound area, deep wound, located near a site of potential contamination (perineum, sacrum)

chronic wound

Interwoven matrix of bacteria and fungi embedded in a thick slimy barrier of sugars and proteins that begins to form within minutes of skin breakdown. They are resistant to antibiotics (including topical) The organisms within the biofilm cannot be detected using a normal wound culture method. Are present in the majority of chronic wounds (60 to 90%) and have the potential to delay healing;

biofilms

objective 2 (2) Flashcards

(81 cards)