Skin Infection and Wound Management PDF

Skin Adult Nursing 2 (NUR3003) Infections By Group 5: Asha Spence (2109860), Breanna Thomas(2206801), Kimoy Mclean(1904106), Mikaylia Oliver(2206560), Osana Mitchell(2102798), Renese Wright (2204871) & Tieanna-kay Duncan(2204201) OBJECTIVE What is Skin Types of Skin S Infe...

Skin Adult Nursing 2 (NUR3003) Infections By Group 5: Asha Spence (2109860), Breanna Thomas(2206801), Kimoy Mclean(1904106), Mikaylia Oliver(2206560), Osana Mitchell(2102798), Renese Wright (2204871) & Tieanna-kay Duncan(2204201) OBJECTIVE What is Skin Types of Skin S Infection? Infection Wound Management  What is a Skin Infection? A skin infection occurs when harmful microorganisms, such as bacteria, viruses, fungi, or parasites, invade the skin. These infections can cause various symptoms, depending on the type and severity, including redness, swelling, pain, warmth, pus, or discharge. Types of Skin Infections Bacterial Skin Infections What is a A bacterial infection is any illness or Bacterial condition caused by bacterial growth. Bacterial infections occur when bacteria Skin enters the body. Once in your body they increase in number which then causes an Infection? immune reaction in your body.  Pathophysiology Bacterial skin infections develop when bacteria enters the skin through hair follicles or small breaks in the skin. E.g. They can enter through scrapes, punctures, burns, animal or insect bites, wounds, and pre-existing skin disorders. Signs and Symptoms Irritability Fatigue Redness of the skin Fluid-filled blisters that break easily Swelling Itching  The treatment regimen used for a bacterial skin infection can vary depending on the condition, from the drainage of abscesses to the use of antibiotics. An antibiotic ointment may be used for a minor skin infection; however, antibiotics may have to be taken by mouth or given by Treatment injection for larger skin infections. If the patient has an abscess, it should be cut open by a doctor and allowed to drain properly, and any dead tissue that may be present surgically removed. Nursing Management Document the type of infection and the location of the skin lesions Assess the patient for a fever Administer antibiotics as prescribed Educate the patient about wound care Educate the patient not to touch or scratch their lesions and to wash their hands frequently Educate the patient about the infection Educate the patients caregiver on contact precautions  Nursing Diagnosis I Impaired skin integrity Disrupted body related to bacterial image related to infection as evidenced the presence of lesions secondary by lesions, redness to a bacterial skin and itching. infection. Fungal Skin Infections  Fungal infections, or mycosis, What is are diseases caused by a fungus (yeast or mold). Fungal an Fungal infections are most common on your skin or nails, but fungi Skin (plural of fungus) can also cause infections in your mouth, throat, Infection? lungs, urinary tract and many other parts of your body Types Candidiasis Ringworm Tinea versicolor/pityriasis Onychomycosi versicolor s Signs and Symptoms Itching, soreness, redness or rash in the affected area. Discolored, thick or cracked nails. Pain while eating, loss of taste or white patches in mouth or throat. A painless lump under your skin.  Pathophysiology Fungi gain access to host tissues by traumatic implantation or inhalation. The severity of disease caused by these organisms depends upon the size of the inoculum, magnitude of tissue destruction, the ability of the fungi to multiply in tissues, and the immunologic status of the host. Fungal organisms enter the skin through direct contact with contaminated surfaces, skin-to-skin transmission, or through breaks in the skin barrier.  Antifungal Medication Apply Powders Treatment Wear Open-Toed Shoes Nursing Management Administer prescribed medications Instruct the client to use a clean towel and washcloth daily Instruct the client to thoroughly dry all skin areas Encourage the client to wear clean cotton clothing Instruct the client to be careful around pets and pet objects  Nursing Diagnosis Acute Pain related to Impaired Skin inflammation and Integrity related to pruritus (itching) fungal infection as associated with fungal evidenced by skin infection as lesions, redness, and evidenced by patient itching in the reports of discomfort affected areas. and observable signs of scratching or irritation. Parasitic Skin Infections What is a Parasitic infections are any illnesses or conditions caused by Parasitic parasites living and reproducing Skin in your body. Parasites are organisms that need another Infection? living thing (a host) to get the nutrients they need to survive. Types Protozoa There are three main types of parasites that cause infections in Helminth humans: Protozoa Helminths Ectoparasites Ectoparasites Signs and Symptoms Fever Muscle aches Fatigue Nausea Vomitting Diarrhea  Pathophysiology Parasites such as mites or lice penetrate the skin barrier, typically through contact with an infected person or contaminated surface. Once they gain entry into the skin, they start to multiply and infest the affected area. Parasites feed on blood, tissue fluids, or skin cells, causing irritation, inflammation, and itching. They may lay eggs in the skin, further perpetuating the infestation.  Pathophysiology The presence of parasites in the skin triggers an immune response, leading to inflammation, redness, swelling, and sometimes the formation of papules, pustules, or nodules. Continuous scratching and rubbing of the affected area due to itching can cause abrasions, excoriations, and secondary bacterial infections, further complicating the condition.  Antiparasitic drugs Antibiotics Treatment Ointment s Nursing Management Assess the patient's signs and symptoms, medical history, exposure to parasites, and any underlying conditions that may complicate treatment. Administer prescribed medications, such as antiparasitic drugs, topical creams, or oral medications, as per the healthcare provider's orders. Assist with skin care measures to alleviate itching, inflammation, and discomfort. Educate patients about the nature of the parasitic infection, its mode of transmission, preventive measures, treatment options and the importance of adherence to prescribed medications. Educate patients on preventive measures to avoid re-  Nursing Diagnosis Impaired Skin Disrupted Body Integrity related to Image related to parasitic infections as parasitic infections as evidenced by skin evidenced by visible irritation, lesions and skin lesions and inflammation itching Allergic Skin Infections  An allergic skin infection, more What is commonly referred to as allergic contact dermatitis, is a type of skin an reaction that occurs when the skin comes into contact with an allergen. Allergic It's not a true infection caused by Skin bacteria or viruses, but rather an immune system response to Infection? something your body recognizes as harmful, even though it may not be. Types Allergic contact Irritant dermatitis contact dermatitis Signs and Symptoms Itchy Skin Flaky Skin Red, purple or darker skin at the area affected. Bumps, pimples or blisters Pus Painful, burning sensation  Pathophysiology - Immune response: The skin's immune system mistakenly identifies harmless substances as threats. · T-cell activation: Memory T-cells are generated after the first exposure, leading to a stronger, faster reaction upon re-exposure. · Inflammatory response: Inflammatory mediators are released, leading to the redness, itching, and rash associated with the condition.  Avoidance Treatment Medication (Corticosteroids, Antihistamines) Nursing Management 1. Assessment: Identify allergens, assess skin, and check for signs of infection. 2. Symptom Relief: Use topical corticosteroids, antihistamines, cool compresses, and moisturizers. 3. Education: Teach patients to avoid allergens, practice gentle skin care, and use medications properly. 4. Monitoring: Watch for complications like infections or chronic dermatitis, and refer to a dermatologist if needed. 5. Support: Offer emotional support and provide follow-up care to ensure symptom management and skin healing.  Nursing Diagnosis Impaired Skin Integrity Risk for related to Infection allergic related to reaction as impaired skin evidenced by barrier and skin irritation, exposure to inflammation, allergens. and potential infection. Viral Infections What is a Viral Viral infections are illnesses you get from tiny organisms or germs that use Infection? your cellular machinery to reproduce. Viruses replicating is what makes you sick with a viral infection. Types These include viral infections in humans: Respiratory infections Digestive system infections Viral hemorrhagic fevers Sexually transmitted infections (STIs) Exanthematous (rash- causing) infections Neurological infections Congenital infections Signs and Symptoms Flu-like symptoms: fever, head and body aches, fatigue. Upper respiratory symptoms: sore throat, cough, sneezing. Digestive symptoms: nausea, vomiting, diarrhea. Skin conditions: rashes, sores, blisters, warts.  Pathophysiology - After entry into the body, the virus binds to and enters host cell. -Virus releases genetic material and replicates/reproduces within the cell, using its machinery. -Host cells recognize viral proliferation, triggering inflammation which leads to tissue damage, cell death and organ dysfunction. Inflammatory response: Inflammatory mediators such as cytokines are released, leading to the redness, itching, and rash  Antiviral medications Convalescent plasma Treatment Post-exposure prophylaxis Nursing Management Implement droplet precautions for respiratory viruses (e.g., mask) Implement contact precautions (e.g., gloves) for skin or mucous membrane exposure Implement airborne precautions (e.g., negative pressure room) for airborne viruses Manage fever (e.g., antipyretics) Relieve pain and discomfort (e.g., analgesics) Maintain hydration and nutrition Administer antiviral medications as prescribed  Nursing Diagnosis Acute Pain Hyperthermia related to the related to host cell recognition of viral body’s proliferation which inflammatory triggers response to the inflammatory virus as response as evidenced by evidenced by facial grimacing sweating, and patient increased heart rating pain 7/10 rate and patient on pain scale. feeling warm to Wound Management  What is a Wound? A wound is an injury that damages the skin or body tissues, caused by cuts, scrapes, or burns, and can be open or closed depending on whether the skin is broken.  1.Acute wound: A wound that appears unexpectedly and heals as expected through the normal stages. 2. Chronic wound: A wound that heals slowly or doesn't progress normally, taking more than 4-6 weeks to heal. Types 3. Surgical wound: A wound resulting from a surgical of Wounds procedure, such as a cut made by a scalpel or a surgical drain. 4. Non-surgical wound: A wound, either acute or chronic, that occurs without being related to a surgical procedure. Based on Origin? Mechanical wounds Based on Origin? Chemical Wounds  Wound Management Wound management refers to the process of treating and caring for a wound to promote healing, prevent infection, and minimize complications. It involves cleaning the wound, applying dressings, and monitoring the healing process, often with the help of medications or specialized treatments depending on the wound's severity. The goal of wound management is to understand the different stages of wound healing and treat the wound accordingly.  Stages of wound healing 1. Haemostasis (seconds): Blood vessels narrow to reduce bleeding, and clots form. Management goal: Stop bleeding. 2. Inflammation (0-4 days): Immune cells clear debris and prevent infection, causing redness and swelling. Management goal: Clean the wound and prevent infection.  These stages are: 3. Proliferation (2-24 days): Connective tissue grows to repair the wound, promoting granulation. Management goal: Encourage tissue growth and protect the wound. 4. Remodelling (24 days - 1 year): New skin (epithelial tissue) forms in a moist environment to finish healing. Management goal: Protect the new tissue. Steps to take when Managing a Wound Assess the wound (type, size, depth, signs of infection). Cleanse the wound with an appropriate solution. Debride dead or infected tissue if necessary. Apply a suitable dressing to protect and promote healing. Monitor for signs of infection or complications. Maintain moisture balance in the wound. Manage pain with appropriate medications  Assessment: TIME is the clinical tool used for the systematic evaluation and documentation of wounds. It stands for Tissue, Infection or Inflammation, Moisture balance and Edges of the wound or Epithelial advancement. Tissue Epithelial tissue: Pink or pearly white, and wrinkles when touched. It forms in the final healing stage when the wound is covered by healthy skin cells. Granulating tissue: Red and moist in appearance, forms during the remodeling phase with healthy, well-vascularized tissue that bleeds easily. Slough tissue: Yellow, brown, or gray, made of Tissue Necrotic tissue: Hard, dry, and black, consisting of dead tissue that blocks wound healing. Hypergranulating tissue: Red, uneven, or granular, occurring in the proliferative phase when tissue grows excessively. Infection Infection: Infection can damage tissue and slow down the process. Infection Contamination: Microorganisms are present but do not grow or cause a response, so healing is not affected. Antimicrobials are unnecessary. Colonisation: Microorganisms grow without causing a host response, which can delay healing. Antimicrobials are not needed. Local infection: Harmful agents invade and multiply in the wound, triggering a host response that disrupts healing and may cause wound breakdown. Topical antimicrobials are required. Infection Spreading and systemic infection: Microorganisms spread through the bloodstream or lymphatic system, affecting part or all of the body, which impairs healing. Systemic treatment, including topical antimicrobials and antibiotics, is necessary to prevent sepsis. Biofilms: These are protective layers of microorganisms that form on surfaces in water or at water-air interfaces. They can cause delayed healing, reduced effectiveness of treatments, and increased inflammation or exudate.  Infection Odour: Odour can indicate infection and is categorized as follows: No odour: No noticeable smell. Slight malodour: A smell is present when the dressing is removed. Moderate malodour: A smell is noticeable upon entering the room when the dressing is removed. Strong malodour: A smell is evident upon entering the  Moisture/Exudate: Moisture/Exudate: Proper management of exudate aims to maintain the right moisture in the wound bed. Too much can cause maceration, while too little can dry out the wound. Moisture/Exudate: Serous: Clear to yellow, thin, and watery; normal during the inflammatory phase. Haemoserous: Clear to yellow with a pink tint; typical in inflammatory or proliferative phases. Sanguineous: Blood-colored; may indicate hypergranulation. Purulent: Pus-filled and thick, grey, green, or yellow; suggests infection. Haemopurulent: Blood mixed with pus; usually signals an Advancing of Edges Measure the wound's depth, length, and width with a tape measure. Advancing: Edges are pink, indicating healing. Not Advancing: Edges are raised, rolled, red, or dusky. Review wound healing stages and management goals to identify potential issues. Surrounding Skin: Check for: Cellulitis: Redness, swelling, pain, or infection. Oedema: Swelling. Advancing of Edges Pain: Pain is a key sign of wound healing issues and can arise from the disease, surgery, trauma, infection, or dressing changes. Assess pain before, during, and after dressing changes to guide wound management and dressing choices. Accurate pain assessment helps in selecting dressings that minimize discomfort, fear, and anxiety. Use both medication and non-medication methods to prepare patients for dressing changes.  Cleansing Cleaning the wound with sterile solutions to remove debris, bacteria, and dead tissue. Cleansing Solutions: Use cleansing solutions at body temperature. Potable Water: Drinkable tap water can be used, but consider the risk of contamination. Sterile Water: A safe option for cleansing. Normal Saline: Commonly used for wound care. Surfactants/Antiseptics: For biofilms or infected wounds, such as Prontosan™.  Cleansing Cleansing Technique: Avoid soaking wounds in potable water. Wash the wound separately from the rest of the body. Use scrubbing or irrigation rather than swabbing to prevent fiber shedding. Aseptic Techniques: Standard Aseptic: For simple, short dressings (