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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 |
Created by:
maliakaye5
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