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UlcersSkin Integrity
Module B-102 Galbreath- Ulcers- Alterations in Skin Integrity
Question | Answer |
---|---|
Anemia | Decrease in hemoglobin |
Decreased hemoglobin=... | Decreased oxygen levels (Pt needs Iron or B12) |
Cachexia | Generalized ill health & malnutrition (Cancer, endstage renal disease(END), Coronary pulmonary disease) |
Erythemia | Redness of the skin caused by capillary congestion |
Sloughing | Separation of dead tissue from living tissue |
Debridement | Removal of foreign or dead damaged tissue |
Tissue Ischemia | Tissue not receiving adequate circulation or blood supply |
Exudate | Amount, color, consistancy, & odor of wound drainage |
hyperemia | Congestion abnormal amount of blood in a body part |
Serous | Clear watery plasma |
sanguineous | Bright red with WBC |
Serosanguineous | Pink (blood mixed with plasma) |
Purulent | thick yellow-brown & pusy |
Assess Signs & Symptoms: | heat, redness, tenderness, Blue mottled skin, Pale white skin, Pimples, Blisters, Scabbing |
Blue mottled skin indicates... | Oxygen deficit |
Pale skin indicates.. | Circulation deficit |
Assessment of a wound: | Location, Size, Stage, Color, Surrounding skin, Signs & Symptoms of Infection |
On the Braden & Norton Scale a low score indicates... | Higher risk for developing pressure ulcers |
Stage 1 Pressure Ulcer: | Little redness, with no skin breakdown |
Stage 2 Pressure Ulcer: | Partial-thickness, involving epidermis, dermis or both (abrasion, blister or shallow crater) |
Stage 3 Pressure Ulcer: | Full-thickness, subcutaneous fat may be visible |
Stage 4 Pressure Ulcer: | Full-thickness, exposed bone, tendon, or muscle. (slough or eschar may be present) |
Red areas should never be... | Massaged (possible blood clot could become dislodged) |
Protein is benifical for... | Building & healing tissue |
Lab work indicates 50 grams of protein loss due to open weeping ulcer. Nurse should... | Increase patients caloric intake, & Vitamin C |
Low Prealbumin=.... | Poor wound healing |
Prealbumin is the best measurement of... | Nutritional staus (it reflects absorbed, digested, & metabolized food) |
Psoriasis | is an inflammatory disorder characterized by abnormal proliferation of skin cells.(bright red lesion with scaly white patchy areas) |
3 Types of Dermatitis | Eczema, Contact Dermatitis, Seborreic Dermatitis |
3 Stages of Eczema: | 1st Acute Stage- red ozzing crusty rash, intense pruritus. 2nd Sub-acute- redness excoration, plaques, & puscules 3rd Chronic Stage- thick, dry, scaly, & brownish-gray in color |
Causes of Eczema.. | Family history of ashthma, hay fever, eczema, & food allergies. |
Treatment for Eczema: | Systemic antihistamines(benedril), Corticosteroids, steroids, lotions, creams, Sunscreen |
Room Temp. & humitity levels for Eczema Patients... | 68-75 Degrees, Humitity 45%-50% |
Contact Dermatitis is.. | an inflammatory condition caused by contact with a substance that triggers an allergic reaction. (Poison Ivy,Metals,Chemicals,Latex gloves) |
Contact Dermatitis Treatment: | Antihistamines(Benedril) |
Seborrheic Dermatitis is | a chronic inflammatory disease of the skin (dandruff-scalp, eyebrows, eyelids, lips, ears, sternal area, axillae, umbilicus, groin, gluteal crease, & under breast. |
Seborrheic Dermatitis appears... | as fine powdery thick crusty scales (white, yellowish, or reddish)or oily patches. |
Seborrheic Dermatitis Treatment: | Topical, Ketoconazole, Nizoral, 2-3 times per week |
Impetigo is when... | Vesicles or pustules rupture, leaving a thick crust. (Pruritus) |
Impetigo is caused by... | Group A Streptococci; Antibiotics |
Herpes Simplex | beings with itching & burning followed by vesicles that rupture & form crusts. (nose, lips, cheeks, ears, & genitalia. |
2 Types of Herpes Simplex: | Type 1: Face & upper body Type 2: Genital infections (STD's) |
Antiviral Agents: | Treats viral infections caused by Herpes Simplex & Zoster |
3 Forms of treatments with Antiviral Agents: | Topical, Oral & IV |
Antiviral Agents/Drugs: | Zovirax & Abreva, Famciclovir, Valacyclovir,& foscarnet Anelgesic & topical anesthetics (for pain) |
Herpes Zoster or (Shigles)is caused by... | the same organism that causes chickenpox (Varicella-zoster virus) |
Herpes Zoster or (Shigles)symptoms are. | Pain, itching, & sensitivity along a nerve pathway, followed by vesicles. |
Herpes Zoster lesion last... | 2 Weeks, Highly contageous |
Herpes Zoster Diagnosis: | Health history, exam, zinc smear, & cultures |
Treatment is effective for Herpes Zoster if... | Antiviral agent given within 72 hrs of onset of rash. (treated with Burrow's solution) |
Fungal Infections caused by... | fungi include ring worm, tinea pedis (athelete's foot), tinea cruris (groin), tinea capitis (scalp), & Candidiasis. |
Fungal Infection symptoms are.. | Pruritus, moist,warm tissue spread through direct or indirect contact (mouth, skin, & vagina areas) |
Topical Antifungal Agents: | Use to treat fungal infections. (Order needed to use occlusive dressing) |
Topical Antifungal Agents/Drugs: | Nystatin & Lamisil, Sprays, creams, mouthwashes or lozenges |
Oral Antifungal Agents: | Use to treat fungal infection that do not respond to topicals. Common use on nail infections; Lamisil, Nizoral, & Fulvicin P/G; Take 2 hrs after other meds with food. |
Acne is caused by... | Androgenic hormones increase sebum production & bacteria proliferates, causing sebaceous follicles to become blocked & inflammed. (Birth control,oil-based makeup, systemic corticosteroids,mentrual period, & some endocrine disorders |
Vitamin A Derivative: | Used to treat acne & decreases risk of skin cancer. |
Vitamin A Derivative/Drugs: | Retin-A |
Vitamin A Derivative: Explain importance of preventing pregnancy.. | 1 month before, during, & after therapy. Recommend 2 forms of birth control (used same time) |
Isotretinoin is a.... | teratogenic (harmful to a fetus)& also dries skin out. |
Keratolytics: | Used to treat acne & Psoriasis |
Keratolytics/Drugs: | Benzoyl peroxide, Slicylic acid, Sulfur, Coal Tar (Avoid excessive sun exposure) |
Antipsoriatics: | Use to treat Psoriasis |
Antipsoriatics/Drugs: | Anthroalin, Tar, Estar gel; Staining of skin or clothes |
Retinoid Antipsoriatic: | For severe psoriasis ONLY!! |
Retinoid Antipsoriatic/Drugs: | Soriatane |
Patient must use protection if sexually active for 3 yrs after therapy is complete... | Retinoid Antipsoriatic |
Photosensitivity Drug: | Decreases proliferatin of epidermal cells in psoriasis; Periodic blood tests needed |
Topical Antibacterial: | Used to treat skin infections; Monitor renal & GI distress & Vital signs |
Topical Antibacterial/Drugs: | Bacitracin, Polysporin Silvadene:(used to treat wound infection with serious burns) |
Scabies (Mites): | Thin red itchy lines |
Pediculosis (Lice): | Itching of Head & peri areas; wash all laundry, combs, brushes, treat entire family. |
Pediculicides & Scabicides: | Use to treat lice & Mites; Eurax & Nix |
Warts (Verruca): | Human Papillomavirus (1st small shiny lesion then becomes rough)Cut or freeze off, some topical meds. |
Staphylococcus Aureus causes what infection... | Furuncles & Carbuncles |
Furuncle (boil): | Deep inflamed nodules; apply warm compresses, & topical antibiotics |
Carbuncles: | Clustered furuncles; systemic antibiotics, incision, & drainage |
IND stands for... | Incision & drainage |
Cellulitis: | Streptococcus Pyogenes; local tenderness, redness, malaise, chills, & fever; Antibiotics |
Kaposis Carcinoma | Most common in HIV Patients |
Basal Cell Carcinoma: | Red Painless nodule with pearly borders; Excertion, radiation, topical & injected pharmacology |
Squamous Cell Carcinoma: | Scaly raised lesion with no clear margin; oral cavity |
This type of cancer is caused by over use of Alcohol/Tobacco & grows rapidly/spreads... | Squamous Cell Carcinoma |
Squamous Cell Carcinoma Treatments: | Cryotherapy, radiation, & Surgical excision |
Most serious form of Cancer; Deadly if it spreads.. | Malignant Melanoma |
This Cancer is found anywhere on the body.. | Malignant Melanoma |
Malignant Melanoma: | Irregular borders & begins as tan then enlarges & turns dark or light colors |
Malignant Melanoma Treatment: | Surgical removal, Chemotherapy, Immonotherapy |
Topical Anti-Inflammatories: | Reduces inflammation in various skin disorders (Do Not apply occlusive dressing without Order) |
Topical Anti-Inflammatories/Drugs: | Hydrocortisone, Triamcinolone, Aristocort, Fluocinolone, bio-Syn |