Pressure Injuries & Skin Disorders (V 2.0) PDF

Pressure injury -- injuries to intact and ulcerated skin. 1. Skin breakdown -- variety of causes 2. Needs to be addressed immediately. 3. Classification i. Staged 1 -- Stage 4 Stages of Pressure Injury 4. Stage I -- localized area of skin ii. Over bony prominence (typical) i...

Pressure injury -- injuries to intact and ulcerated skin. 1. Skin breakdown -- variety of causes 2. Needs to be addressed immediately. 3. Classification i. Staged 1 -- Stage 4 Stages of Pressure Injury 4. Stage I -- localized area of skin ii. Over bony prominence (typical) iii. Non-blanchable intact skin with redness iv. Darker skin tone- lack visible blanching (but color may differ from surrounding area) v. Wound characteristics (in comparison to adjacent tissue). a. Painful b. Firm c. Soft d. Warm e. Cool 5. Stage II -- Partial-thickness loss of dermis vi. Appears to be a shallow open injury. vii. Shiny or dry viii. Red-pink wound bend (without slough or bruising) ix. Intact or ruptured skin x. Serum-filled blisters 6. Stage III -- Full-thickness tissue loss xi. Subcutaneous fat (sometimes) xii. Bone, tendon, and muscle are NOT exposed. xiii. Slough (may be present) f. Does not obscure the depth of tissue loss. xiv. Possible features: g. Undermining h. Tunneling i. Depth of the wound (variable) -- depends on anatomical location. xv. Extremely deep Stage III injuries- j. Develop in areas with significant layers of deep adipose tissue. 7. Stage IV- Full-thickness tissue loss with, xvi. Exposed bone, tendon, cartilage, or muscle. xvii. Slough or eschar (sometimes) xviii. Undermining xix. Tunneling xx. Vary depending on location. xxi. Patient is at risk for osteomyelitis (local or generalized infection of bone and bone marrow) 8. Unstageable/Unclassified xxii. Involves full-thickness tissue loss. xxiii. Wound base covered in slough and eschar. k. Slough -- yellow, tan, gray, green, or brown l. Eschar- usually tan, brown, or black xxiv. True depth of wound cannot be determined. xxv. Stable eschar (on heels) m. Natural biologic cover -- Do NOT remove it. 9. Suspected Deep Tissue Pressure Injury xxvi. Appearance n. Localized purple or maroon area. o. Skin is intact. p. May have a blood-filled blister. xxvii. Cause: Soft tissue damage from pressure or shear. xxviii. Characteristics (compared to adjacent tissue) q. Painful r. Firm s. Mushy t. Boggy u. Warm to cool to touch. xxix. May become covered with thin eschar. 10. Nursing Interventions: xxx. Ongoing assessment and evaluation xxxi. Assess v. Size and depth w. Amount and color of exudate x. Presence of pain or odor y. Color of exposed tissue z. Plan of care - consistent and evaluate for effectiveness. 11. Medical Management xxxii. Wound care a. Skin is the body's first defense. b. Injury is portal to infection. c. Treatment is determined on type and size of the wound. 12. Characteristics and Uses of Wound-Dressing Materials -- xxxiii. Discuss Table 43.2, p. 1287, Foundations and Adult Health Nursing, 8^th^ Ed., Cooper and Gosnell (2019). a\. Herpes Simplex (Viral): caused by the herpes virus hominis. \(1) Two types of the virus are known: 1\) Areas are usually reddened and edematous. 2\) The vesicles ulcerate and crust over. 3\) General malaise is common, upon rupture-it burns. 4\) Self-limiting with no cure. \(b) Type 2: Characterized by vesicles in the genital area of both male and female. Known as genital herpes. Transmitted primarily through sexual contact. 1\) Vesicles rupture and encrust causing ulcerations. Lesions may be present for 2 to 3 weeks and are most painful during the first week. 2\) Headache, fatigue, myalgia and elevated temperature, or flu-like symptoms occur 3-4 days after the vesicles erupt. \(2) Assessment includes both an inspection of the skin and a thorough history. \(3) Diagnostic testing includes cultures of the lesions supported by a thorough assessment. \(4) Medical Management: \(a) There is no cure for the herpes virus but treatment is aimed at relieving \(b) Analgesics (Tylenol) and topical anesthetics may be prescribed for pain. \(c) May require a local anesthetic such as lidocaine (Xylocaine). \(d) Daily suppressive therapy with valacyclovir (Valtrex) can be used to make breakouts less frequent. \(5) Nursing interventions are directed toward treating the symptoms, and preventing the spread of the disease: \(a) Keep lesions dry and avoiding direct contact. \(b) Wear gloves and practice good hand washing. \(c) Warm compresses, sitz baths to relieve pain and severe pruritus. \(6) Patient education: \(a) Stress that HSV remains in dormant state in the body after initial infection. Periodic recurrences are expected and may be triggered by stress, fever, trauma or fatigue. Patient may be able to identify triggers and try to avoid or minimize them. \(b) To prevent transmission of infection instruct patient to avoid sexual or direct contact while lesions are present. Encourage condom use. Patients can transmit the infections as long as the lesions are present despite antiviral therapy. \(c) To prevent secondary infections by implementing good personal hygiene. b\. Herpes Zoster (Shingles) (Viral): \(1) Caused by the varicella-zoster virus that causes chicken pox. \(2) Characterized by lesions along the nerve fibers of spinal ganglia causing inflammation. First symptoms are pain, itching, and heightened sensitivity along the nerve pathway. \(a) Vesicle formation follows and then crusting of the skin. \(b) Severe pain is characteristic and lasts 7 to 28 days but the disease is not permanently disabling but temporary neuralgia may result in some cases. \(c) The infection is contagious to people who have not had previous exposure to the virus. \(d) Immunosuppressed people are at greater risk and can have serious systemic complications, even death. \(3) Assessment includes an inspection of the skin and a thorough history. a. Subjective: a. Sharp, burning pain (usually one side) b. Pruritus of the lesions c. Malaise d. Hx of chickenpox b. Objective: e. skin excoriation (from scratching) f. patches of vesicles on the trunk/following nerve pathways g. tenderness to touch \(5) Management: 1. Acyclovir, an antiviral medication given orally and IV within 72 hours of onset may reduce the pain and duration. 2\) Lotions (Kenalog/Lidex) are used to relieve pruritus and decrease Inflammation. 3. Corticosteroids may be used to relieve pruritus and inflammation 4\) Herpes Zoster vaccine (for patients over 60 years old), Zostavax \(6) Nursing interventions are directed at relieving the patient\'s symptoms of pain and pruritus and prevention of secondary complications. \(a) Use tranquilizers (Ativan or Atarax) to decrease anxiety. \(b) Analgesics for pain. \(c) Medicated baths and warm compresses. \(d) Aseptic technique. \(7) Patient Teaching: \(a) Methods for controlling pain. \(b) Application of medication and wet dressings. \(c) Methods for inhibiting spread of disease. \(d) Techniques to prevent secondary infection. \(e) Proper diet with vitamin C to promote healing. c\. Pityriasis Rosea 1. Can affect people of any age -- noted most often in young adults. 2. Caused by a virus- not clear which virus. 3. May be linked to herpes virus (not Type I). 4. Rash generally disappears without treatment within 4 to 8 weeks. 5. Clinical Manifestations a. Single lesion -- (herald patch). Scaly area up to 4 inches in diameter with raised border and pink center. i. Resembles ring worm (a fungal infection) b. Smaller matching spots become widespread on both sides of the body. c. Rash appears mainly on, ii. Chest iii. Abdomen iv. Back v. Groin vi. Axilla 6. Assessment d. Skin inspection e. Health History f. Subjective data assessment 7. Diagnostic Tests g. Diagnosis is based on skin inspection. h. No specific laboratory tests. 8. Medical management i. No treatment required. j. Preventative interventions can control secondary infections. k. If skin is dry- moisturize. l. Pruritis -- 1% hydrocortisone cream two to three times a day. m. Ultraviolet light. 9. Nursing Interventions n. Symptomatic relief o. Analgesics p. Oatmeal baths q. Antihistamines r. Topical steroids 10. Prognosis- self-limiting and resolves in a few weeks. d\. Cellulitis: (Bacterial) \(1) Caused by staphylococcus aureus, streptococci or Haemophiles influenzae B bacterial infection of the skin underlying tissues. \(a) risk increases with other disease process such as diabetes, venous stasis, lymphedema, chemo, autoimmune disease, \(b) develops edematous, erythematous areas of skin caused by bacteria entering through breaks in the skin (cut, scratch, insect bite). \(c) superficial and can occur on any part of the skin, however, usually affects the lower extremities, and can be spread. \(2) Assessment: \(a) Subjective data: will include symptoms of pruritus, pain, malaise limited use of extremities \(b) Objective data: erythema, pruritic area, orange peel looking skin, vesicles may appear, and lymph node may enlarge \(3) Diagnostic test: positive culture for streptococcus or Staphylococcus aureus. CBC reveals leukocytosis (high WBC count), x-rays, CT MRI, ultrasound to see if abscess had formed \(4) Management: \(a) Medical Management: \(b) Nursing interventions: 1\) Focus of nursing care to disrupt the course of the disease and prevent the spread of infection. a\) Clean the area with antiseptics, then remove dry exudates\ using special instruments & sterile technique. b\) Apply topical antibiotics several times a day. c\) Don gloves when providing care or in direct patient contact. \(5) Patient Teaching: \(a) Principles of hygiene-include patient and family. \(b) Stress the importance of taking entire prescription antibiotics. \(c) Seek further medical attention if red streaks, or blistering occur d\. Impetigo: (Bacterial) \(1) Caused by staphylococcus aureus, streptococci or a mixed bacterial infection of the skin. \(a) Lesions start as macules that develop in pustulant vesicles. These rupture and form a crust. As the crust drops off, the skin underneath is smooth and red. \(b) It is highly contagious from contact. May spread by touching personal articles, linens and clothing of the infected person. \(2) Assessment: \(a) Subjective data: will include symptoms of pruritus, pain, malaise, spread to other parts of the body and the presence of diseases. \(b) Objective data: erythema, pruritic area, honey-colored crust over the dried lesions and smooth, red skin under the crust, low grade fever, leukocytosis. \(3) Diagnostic test: positive culture for streptococcus or Staphylococcus aureus. \(4) Management: \(a) Medical Management: 2. Topical antibiotics (Bactroban) started early in the treatment. 3. Antiseptic soaps to remove crusted exudate and thoroughly cleanse the area before applying topical treatments \(b) Nursing interventions: 1\) Focus of nursing care to disrupt the course of the disease and prevent the spread of infection. a\) Clean the area with antiseptics, then remove dry exudates\ using special instruments & sterile technique. b\) Apply topical antibiotics several times a day. c\) Don gloves when providing care or in direct patient contact. \(5) Patient Teaching: \(a) Principles of hygiene-include patient and family. \(b) Stress the importance of preventing the spread of the disease by contact. e\. Folliculitis, Furuncles, Carbuncles: a bacterial inflammation of the skin and caused by staphylococcus aureus infection of a hair follicle. Felons are infections under and around the finger or toenails. \(1) Clinical Manifestation: \(a) Sudden onset of red, tender, and hot skin around the hair follicle, which spreads to the surrounding skin. \(b) The center forms pus, and the core may need to be excised. \(2) Treatment: \(a) Isolation procedures for wound and drainage/ secretion precautions. \(b) Surgical intervention may include draining the lesion \(c) Administer systemic antibiotics if a carbuncle (series of furuncles(boils)) appear. \(d) Warm compresses to speed up production of purulent material. f\. Fungal Infections (Dermatophytoses): Superficial infections of the skin. \(1) Etiology and Clinical Manifestations: \(2) Assessment: thorough skin assessment. \(3) Diagnostic Tests: diagnosis is primarily by visual inspection. A Wood\'s light is an ultraviolet light used to diagnose Tinea capitis (infected hairs become brilliantly fluorescent) \(4) Management: \(a) Medical Management: 1. Topical (Tinactin, Lotrimin AF, Mentax and Desenex) or oral (Fulvicin and Griseofulvin) antifungal drugs. 2. Antifungal soaps and shampoo 3\) Treatment may last from 2 to 6 weeks. \(b) Nursing Interventions: to protect the involved area from trauma and Irritation by keeping it clean and dry; and proper application of medications and warm compresses to alleviate the fungus. 1\) Keep the affected areas clean and dry. 2\) Loose-fitting clothes/wear sandals. 3\) Treat: Tinea pedis with warm soaks using Burrow's solution and topical antifungal medication to alleviate the fungus \(5) Patient Education: \(a) Proper skin care and comfort measures to relieve pruritus. \(c) Discuss that the infection may take months to heal. \(d) Clarify any misconceptions of athlete's foot **Inflammatory Disorders of the Skin** a\. Contact Dermatitis: \(1) Etiology: \(b) Common causes are detergents, soaps, industrial chemicals and plants such as poison ivy. \(2) Clinical Manifestations: \(a) Lesions appear at point of contact with the irritant. \(b) Epidermis becomes inflamed and papules form. \(c) Vesicles appear most often on the dorsal surfaces. \(d) There is burning, pain, pruritus and edema. \(3) Assessment: get a history of the patient\'s activities and assess the skin. a. Subjective: a. Try new soap b. New personal items c. Working with plants or flowers b. Objective: d. Erythema e. Papules and vesicles, clear exudate f. Scratches from pruritis g. Edema \(4) Diagnostic Tests: \(a) Primary test is an accurate health history to identify the agent. \(b) Intradermal skin testing may be done to identify allergies. \(c) Labs: IgE levels and eosinophils are elevated. \(5) Management: \(b) Nursing Interventions: goal is to identify the agent and protect the rest of the skin from further damage. 1\) Identify the cause of the dermatitis. Wash the area before applying\ topical medication. 2\) Wet dressings with burrow's solution and cold compresses to induce\ vasoconstriction at the site. 3\) Calamine lotion is used to reduce itching. 4\) Therapeutic baths using colloid solution, lotions, and ointments also help relieve the pruritis. 4\) Emotional support is necessary. The patient's appearance is difficult for the patient and family members to accept b\. Other Inflammatory Disorders: \(2) Urticaria: commonly called hives. The presence of wheals caused by an allergic reaction from drugs, food, insect bites, inhalants, emotional stress or exposure to heat or cold. Patient should wear medical alert bracelet if they have anaphylactic reactions. 3. Acne vulgaris: an inflammatory papulopustular skin eruption that involves the c\. Psoriasis: \(1) Etiology: a noninfectious disease where skin sloughing and generation of new skin cells occurs more rapidly than the normal 28 days. A chronic, hereditary disease involving the epidermis. No specific predisposing factors are known. \(2) Clinical Manifestation: lesions appear as raised, erythematous, silvery, scaling plaques located on the scalp, elbows, knees, chin and trunk. \(3) Assessment: \(a) Patient will complain of mild pruritus, but will be aware that others can see the scaling and avoid them. \(b) Besides the silver scaling, the fingernails may be pitting with a yellowish discoloration. \(4) Diagnostic Tests: there is no diagnostic test for psoriasis. Diagnosis is made by observation and symptoms displayed. \(5) Medical Management: \(a) Aimed at slowing the proliferation of the skin. \(c) Topical steroids (Valisone) are used to decrease inflammation. \(d) Photochemotherapy involves the use of methoxsalen (Oxsoralen) is given orally and the patient is placed under ultraviolet light A. This is termed PUVU therapy. \(e) Methotrexate & Vitamin D may reduce epidermal proliferation. \(6) Nursing Interventions: \(a) Promote psychological wellbeing, i.e., counseling consult. Since the disease is chronic, consider the patient\'s emotional needs and encourage the patient to focus on their positive attributes. \(b) Provide for additional rest. \(c) Teach self-care regimen. d\. Systemic Lupus Erythematosus: \(1) Etiology: autoimmune disorder characterized by inflammation of almost any body part. It is chronic multisystemic inflammatory disorder that occurs when the body produces antibodies against its own cells it can affect several organ systems skin, joints, kidneys and serous membranes. \(a) found in women childbearing age 10% \(b) African American are three times more likely to be affected \(c) decreased number of T-suppressor cells \(2) Clinical Manifestation: oral ulcers, arthralgia, arthritis, vasculitis, rash, nephritis, pericarditis, peripheral neuropathies, anemia which tends to be the most common complication. \(3) Diagnostic Tests: requires extensive evaluations over months or even years. Multiple blood tests (see box 43.3) CBC, CRP, ANA, ESR, DNA antibody to name a few. \(4) Medical Management: \(a) relief of symptoms, remission of the disease, early alleviation of exacerbations and prevention of complications. \(5) Nursing Interventions: \(a) Promote psychological wellbeing, i.e., counseling consult. Since the disease is chronic, consider the patient\'s emotional needs and encourage the patient to focus on their positive attributes. \(b) Skin care to include air mattress, egg crate mattress where indicated \(c) signs of exacerbation \(d) early signs of infection \(e) stress reduction \(6) Prognosis: early treatment contributes to better prognosis \(7) Common Nursing Diagnosis: a\. Pediculosis (Lice infestation): \(1) Etiology: a parasitic disorder of the skin usually associated with poor living conditions and poor hygiene, which isn't necessarily true. \(a) head lice (pediculosis capitis) \(b) body lice (pediculosis corporis) \(c) pubic lice (pediculosis pubis) crab like appearance \(2) Clinical Manifestations: nits (eggs) or lice can be seen on the body. \(3) Assessment: \(a) Patient will complain of pruritus; tenderness and difficulty wearing clothes also noted \(b) Inspection of the skin will reveal erythematic and petechiae. \(c) Skin excoriation in the area of the lice or nits. \(4) Diagnostic Tests: physical examination and removal of the parasite. \(5) Medical Management: topical application of a pediculicide such as Permethrin or Pyrethrin's (RID) used on the affected area using medical asepsis. \(6) Nursing Interventions/ Patient Teaching: \(a) Teaching that the spread of the lice is by contact. \(c) Areas that had contact with the affected area need to be cleaned with hot water, hot dryer or dry cleaned, i.e., bed linen, furniture, carpet, stuffed animals. \(d) Control pruritus with cool compresses and corticosteroids. \(7) Patient Teaching: b\. Scabies: \(1) Etiology: \(a) Caused by the human itch mite penetrating and burrowing under the skin. \(b) Once under the skin the mite lays eggs that mature and rise to the skin Surface. \(2) Clinical Manifestations: A. Wavy, brown, threadlike lines on the body with severe pruritus and often secondary infection due to excoriation caused by scratching. B. Normally found on the hands, arms, body folds and genitalia. C. Secondary infections common due to excoriation of the area (due to pruritis) \(3) Assessment: findings of the clinical manifestations (see above). \(4) Diagnostic Tests: examination of the skin. Skin scrapping may yield the mite \(5) Management: \(a) Medical Management: 1\) Treated with crotamiton (Eurax) and a 4-8% sulfur in petrolatum solution. 2\) Sexual & other close contacts may be treated as well. b. Nursing interventions are similar to pediculosis with prevention of spread