Concepts of Care for Patients With Skin Problems

Care for patient with Skin Problems Pressure Injury - Is a loss of tissue integrity Pg 438 Causes - Reduction in circulation o Bony prominence o External surface - Reduce perfusion Risk factor: - Lack of mobility, prolonged bedrest - Incontinent pt - Nutritional Level - exposure of skin to excessive moisture Such as urinary or fecal incontinence, - undernourishment, - aging skin. - Cognitive decline or dementia, decreased sensory problem - Hx of circulation or perfusion problem  o Diabetes mellitus o Peripheral vascular disease Complication:  can be very serious - Sepsis - Kidney failure - Infectious arthritis - Osteomyelitis How to take care of this pt: - Assessment who is at risk for Pressure injury!!!! o Give special attention to Bony prominences a. Heels b. Sacrum c. Elbows d. Knees e. Trochanters f. Iliac spines - Use the Braden scale pg 441 - Determine the risk level for pt o Mild, moderate or severe risk How to prevent pressure ulcer : Pg 439 peach box 1. Determine the risk level o mild , moderate, high 2. Reduce tissue pressure o Positioning the pt in ways to reduce pressure. o Use foam dressing 3. Improving pressure tolerance a. Use pillow, foam wedges b. Preserve skin integrity i. Change incontinent product regularly ii. Inspect skin 1) Stages 1 a) Nonbalanchable arrhythmia, skin with darker pigmentation. 2) Stage 2 a) Partial thickness loss., b) Wound is viable, pink or red and moist. 3) Stage 3 a) Full thickness skin loss, Skin and tissue integrity. b) Granulation tissue and rolled wound edges are often present. c) Tunneling may be present. 4) Stage 4 a) Full thickness loss of skin and tissue. b) Fascia, muscle , Ligament, cartilage, or bone. c) Obscured by eschar or sough 5) Unstageable a) Full thickness and tissue loss 6) Suspected deep tissue injury 7) Mucosal membrane pressure injury Wound Assessment: - Location, size, color, extent of tissue involvement - Looking at the exudate - Condition of surrounding tissue and pre - Be mindful to assess the wound for Hopefully to HEAL o Take measurement of the wound length, width, depth and centimeters and compare to next time dressing changing to see if its healing or not - Assess for tunneling hidden wound that extend beyond primary wound into surrounding tissue (what you cant see b/c its under the top laye of the skin) - Describe tunneling using the “CLOCK concept”  pt at 12 o’clock position and feet @ 6 o’clock position - Wound exudate: o Serosanguineous Exudate  Blood- tinged amber fluid consisting of serum and blood cells.  Normal for first 48 hour after injury.  Sudden increase in amount proceeds wound Dehiscence and wounds close by first intention. o Purulent Exudate  Creamy yellow pus Carbonization but s. coccus.  Greenish blue pus causing. Staining of dressing and accompanied by a fruity odor   Beige Pus with a fishy odor. Brownish pus w/ fecal order. Diagnostics: - Is a Culture routinely performed on a wound ? NO - Blood test for nutritional deficiencies albumin How to take care of this pt?: - Antimicrobial Dressing  o Gauze (moist): don’t use dry gauze in stage 3 ulcer, so moist the gauze then use a dry gauze on top. Wound vac will never be prescribed to the patient , o Hydrocolloid Dressing technique: - Wet to damp: putting saturated gauze w/ normal saline into the wound . when change the dressing does a debridement which helps the wound heal Diet: - Assessing the nutritional level w/ some blood test - High in ↑ protein ↑ vitamin to help the wound HEAL Negative pressure wound therapy NPWT Pg 446 - A foam sponge trim to fit and placed into the wound Assess the wound frequently to prevent wound INFECTION - Hand washing, routinely check for signs of infection, pain, tenderness, redness, warmth, looking at the drainage if it purulent Notify the dr Questions!! MULTIPLE CHOICE 1. A nurse teaches a client who has pruritus. Which statement by the client shows a need to review the information? A. “I will shower daily using a super-fatted soap.” B. “I can try taking a bath with colloidal oatmeal.” C. “I will pat my skin dry instead of rubbing it with a towel.” D. “I will be careful to keep my nails filed smoothly.” ANS: D The client with pruritus should shower only every other day, although super-fatted soap is an appropriate choice. Colloidal oatmeal baths are very soothing. Patting the skin dry avoids trauma and injury. Keeping nails filed smoothly also prevents injury. 2. A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure injury development? A. A 44 year old prescribed IV antibiotics for pneumonia B. A 26 year old who is bedridden with a fractured leg C. A 65 year old with hemiparesis and incontinence D. A 78 year old requiring assistance to ambulate with a walker ANS: C Risk factors for development of a pressure injury include lack of mobility, exposure of skin to excessive moisture (e.g., urinary or fecal incontinence), malnourishment, and aging skin. The client with hemiparesis and incontinence has two risk factors. The client with pneumonia has no identified risk factors. The other two are at lower risk if they are not very mobile, but having two risk factors is a higher risk. 3. A nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is most important to include when planning care? A. The client may have memory and cognitive issues postburn. B. Everything between the entry and exit wounds can be damaged. C. The respiratory system requires close monitoring for signs of swelling. D. Electrical burns increase the risk of developing future cancers. ANS: B As the electricity enters the body, travels through various tissues, and exits, it damages all the tissue it flows through. There may be severe internal injury that is not yet apparent. The client may have cognitive issues postburn but this is not as important as vigilant monitoring for complications. Respiratory system swelling is associated with thermal burns and smoke inhalation. Exposure to radiation increases cancer risk. 4. A nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type of dressing does the nurse use on this wound? A. Wet-to-damp saline moistened gauze B. None, the wound is left open to the air C. A transparent film D. Multi-fiber superabsorbent dressing ANS: D This pressure injury requires a superabsorbent dressing that will collect the exudate but not stick to the wound itself. A wet-to-damp gauze dressing provides mechanical removal of necrotic tissue. A draining wound would not be left open. A transparent film is a good choice for a noninfected stage 2 pressure injury. 5. A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which action would the nurse take first? A. Draw blood for albumin, prealbumin, and total protein. B. Prepare for and assist with obtaining a wound culture. C. Instruct the client to elevate the foot. D. Assess the right leg for pulses, skin color, and temperature. ANS: D A client with an ulcer on the foot would be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area. 6. A client has been brought to the emergency department after being covered in fertilizer after an explosion and fire at a warehouse. What action by the nurse is best? A. Assess the client’s airway. B. Irrigate the client’s skin. C. Brush any visible dust off the skin. D. Call poison control for guidance ANS: A With any burn client, assessing and maintaining the airway is paramount. Airway tissues can swell quickly, cutting off the airway. The fertilizer would then be brushed off before irrigation. Poison control may or may not need to be called. 7. After teaching a client who has a stage 2 pressure injury, a nurse assesses the client’s understanding. Which dietary choice by the client indicates a good understanding of the teaching? A. Green salad, a banana, whole wheat dinner roll, coffee B. Chicken breast, broccoli, baked potato, ice water C. Vegetable lasagna and green salad, iced tea D. Hamburger, fruit cup, cookie, diet pop ANS: B Successful healing of pressure injuries depends on adequate intake of calories, protein, vitamins, minerals, and water. The dinner with the chicken breast meets all these criteria. The other dinners while having some healthy items each, are not as nutritious. 8. A nurse assesses clients on a medical-surgical unit, all of whom have stage 2 or 3 pressure injuries. Which client would the nurse evaluate further for a wound infection? A. WBC 9200 mm/L3 (9.2 × 109) B. Boggy feel to granulation tissue C. Increased size after debridement D. Requesting pain medication ANS: B Wound infection may or may not occur in the presence of signs of systemic infection, but a change in the appearance, texture, color, drainage, or size of a wound (except after debridement) is indicative of possible infection. The nurse would assess the client with boggy granulation tissue further. The WBC is normal. After debridement, the wound may look larger. If the client needs a sudden increase in the amount or frequency of pain medication that would be another indicator, but there is no evidence this client has more pain than usual. 9. A nurse is teaching a client and family about self-care at home for the client’s wound infected with methicillin-resistant Staphylococcus aureus. What statement by the client indicates a need to review the information? A. “I will keep dry bandages on the wound and change them when drainage a. appears.” B. “I will shower instead of taking a bath in the bathtub each day.” C. “If the dressing is dry, I can sit or sleep anywhere in the house.” D. “I will clean exposed household surfaces with a bleach and water mixture.” ANS: C The client should not sit on upholstered furniture or sleep in the same bed as another person until the infection has cleared. The other statements show good understanding. 10. A nurse is assessing a client who has a recent diagnosis of melanoma for understanding of treatment choices. What statement by the client indicates good understanding of the information? A. “Dermabrasion or chemical peels can be done in the office.” B. “I may need lymph node resection during Mohs surgery.” C. “This needs only a small excision with local anesthetic.” D. “After surgery I will need 8 weeks of radiation therapy.” ANS: B Melanoma is usually treated with Mohs micrographic surgery, in which tissue is sectioned horizontally in layers and examined histologically, layer by layer, to assess for cancer cells. Dermabrasion and chemical peels can be used on actinic keratoses. Local anesthetic for small excisions is generally used on basal or squamous cell carcinomas. Radiation is usually not used with melanoma. 11. A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action would the nurse take? A. Request a prescription for permethrin. B. Administer an antihistamine. C. Assess the client’s airway. D. Apply gloves to minimize friction. ANS: A The client’s presentation is most likely to be scabies, a contagious mite infestation. The drugs used to treat this infestation are ivermectin and permethrin. The nurse would contact the primary care provider to request a prescription for one of the medications. Secondary interventions may include medication to decrease the itching. The client’s airway is not at risk with this skin disorder. Applying gloves will help prevent transmission. 12. A client contacts the clinic to report a life-long mole has developed a crust with occasional bleeding. What instruction by the nurse is most appropriate? A. “Take monthly photographs of it so you can document any changes.” B. “Wash daily with warm water and gentle soap to prevent infection.” C. “Keep the lesion covered with a bandage and triple antibiotic ointment.” D. “Please make an appointment to be seen here as soon as possible.” ANS: D A lesion demonstrating a change in characteristics, such as oozing, crusting, bleeding, or scaling, is suspicious for skin cancer. The nurse would instruct the client to come in for evaluation. Monthly photographs are a good way to document skin changes, but the client needs an assessment for skin cancer. The lesion can be washed and covered with a bandage and ointment, but again, the client needs an evaluation for skin cancer. 13. A nurse is teaching a client who has itchy, raised red patches covered with a silvery white scale how to care for this disorder. What statement by the client shows a need for further information? A. “At the next family reunion, I’m going to ask my relatives if they have anything a. similar.” B. “I have to make sure I keep my lesions covered, so I do not spread this to others.” C. “I must avoid large crowds and sick people while I am taking adalimumab.” D. “I will buy a good quality emollient to put on my skin each day.” ANS: B This client has plaque psoriasis which is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links so it would be correct for the client to inquire about other family members who are affects. Adalimumab is a drug used to treat psoriasis and it has a black box warning about serious infection risk and cancer risk, so the client needs to take precautions to avoid infectious individuals. Emollients help keep the plaques soft and reduce itching. 14. A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? A. Beige freckles on the backs of both hands. B. Irregular mole with multiple colors on the leg. C. Large cluster of pustules in the right axilla. D. Thick, reddened papules covered by white scales. ANS: B This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Freckles are a benign condition. Pustules could mean an infection, but it is more important to assess the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales. This is a chronic disorder and is not the priority. 15. A nurse assesses a young female client who is prescribed tazarotene. Which question should the nurse ask prior to starting this therapy? A. “Do you spend a great deal of time in the sun?” B. “Have you or any family members ever had skin cancer?” C. “Which method of contraception are you using?” D. “Do you drink alcoholic beverages?” ANS: C Tazarotene has many side effects. It is a known teratogen and can cause severe birth defects. Strict birth control measures must be used during therapy. The other questions are not directly related to this medication. 16. A nurse is assessing clients with pressure injuries. Which wound description is correctly matched to its description? A. Suspected deep tissue injury: nonblanchable deep purple or maroon. B. Stage 2: may have visible adipose tissue and slough. C. Stage 3: may have a pink or red wound bed. D. Stage 4: wound bed is obscured with eschar or slough. ANS: A A suspected deep tissue injury is characterized by persistent, nonblanchable purple or maroon discoloration. A stage 2 wound may have a pink of red would bed with granulation tissue. The stage 3 wound may have visible adipose tissue and slough. A stage 4 wound is full-thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. An unstageable wound is obscured by eschar or slough making assessment impossible. 17. A new nurse reads a client has a wound “healing by second intention” and asks what that means. Which description by the charge nurse is most accurate? A. “The wound edges have been approximated and stitched together.” B. “The wound was stapled together after an infection was cleared up.”