Test #7 Study Guide Flashcards
How do you document pressure ulcers/injuries?
Date, time, site, stage, blanching and intervention performed. As the pressure ulcers heals continue documentation as notated above along with the PUSH tool to demonstrate healing.
What are pressure ulcers/injuries risk factors?
Confinement, immobilization, incontinence, malnutrition, decreased LOC, confusion, DM, dehydration, edema, excessive sweating and extreme age.
What are ways to prevent pressure ulcers/injuries?
Pressure relief, padding, positioning, use of pressure relief devices, adequate nutrition (protein, hydration), excellent skin care: clean, dry and moisturized
What are some nursing interventions for skin tears?
Clense with sterile saline water, debride, approximate, steri-strips and dress with non adhering dressing, provide medication as prescribed (ie. Antibiotics)
What are some special considerations to prevent pressure ulcers in an elderly patient?
Keep skin clean, dry and moisturized, frequent repositioning, prevent skin shearing, be cautious with skin( thin tears easy), keep nurished and hydrated, ambulate.
What are diagnostic test for skin conditions?
All done diagnosed by a professional doctor.
Fungus: Microscopic examinations of skin scrapings
Skin Cancer: examinations of skin, biopsy and pathology results
All other skin conditions are diagnosed by physical examination of skin, review of medical history
Basal Cell Carcinoma
growth or sore that doesn’t heal, a skin-colored bump that’s translucent, or a white, waxy, scar-like lesion without a clearly defined border most commonly seen in the face and the trunk.
Squamous Cell Carcinoma
a firm bump, flat sore, or raised area on the skin. It can appear as a rough, scaly patch, wart-like growth, or sore that won’t heal
Malignant Melanoma
Changes in the size, shape, color, or feel of a mole or skin lesion. It is the least common, but most dangerous because it can lead to death if not treated. Genetic predisposition.
Superficial Spreading Melanoma
on the surface, that usually starts as a dark spot with irregular edges, often on a sun-exposed part of the body.
Nodular melanoma
a firm, raised, discolored growth on your skin that may look like a blood blister, that grows downward through the skin that can lead to a formation of a nodule.
Lentigo Malignant Melanoma
a flat, tan, or brown patch with an uneven border. It can also look like a freckle that changes in size, shape, or color.
How to monitor for skin cancers
Have yearly skin checks, if a new mole, or u healing lesion appears get it checked ASAP, watch for uneven borders, changing moles.
Dermatitis types
Contact: allergic response due coming in contact with something
Atopyc: eczema
Stasis: rash due to venous stasis
Seborrheic: crusty yellow build up in scalp,ears, neck
Dermatitis s+s
Itching
Dermatitis treatment
Contact: avoid touching irritant, antihistamine, corticosteroid.
Atopic: avoid soaps or other irritants (creams, ointments), antihistamines, medicated creams.
Stasis: compressir stockings, medicated creams, treat underlying cause
Seborrheic: self care, medicated shampoos
Dermatitis patient education
Avoid irritants, do not take long hot showers, trial and error to identify self care products that do not irritate skin, Do not rub skin to dry, pat dry instead.
Stage I pressure ulcer
A non blanchable, intact area of the skin that is reddened, deep pink or mottled
Stage II pressure ulcer
Partial thickness skin loss involving the epidermis, or dermis, or both, blistered or abraded or has a shallow crater. The area surrounding the damaged skin is reddened and probably will feel hot or warmer than normal
Stage III pressure ulcer
The skin is ulcerated. There is a crater-like ulcer, and the underlying subcutaneous tissue is involved in the destructive process. The ulcer may or may not be infected. Bacterial infection is almost always present at this stage, however, and accounts for continued erosion of the ulcer and the production of drainage
Stage IV pressure ulcers
deep ulceration and necrosis involving deeper underlying muscle and possibly bone tissue. The ulcer can be dry, black, and covered with a tough accumulation of necrotic tissue, or it can be made up of wet and oozing dead cells and purulent exudates. Depth can’t be determined
Prevention and Treatment for skin cancer?
Prevention: wear sunscreen/sunblock, UV protective clothing, stay out of sun during peak sunlight hours, wear hats, get yearly skin checks.
Treament: Removal of lesion, chemotherapy, radiation.
Acne s+s
uninflamed blackheads to pus-filled pimples or large, red, and tender bumps.
Acne types
Acne vulgaris: during puberty
Acne rosacea: during adulthood 30- 50 yo look like ruptured veins or spiderveins
