NURS 400: Module 9: Skin Disorders

stage 1 pressure ulcer

stage 1 pressure ulcer description

-Intact skin with localized area of non-blanchable erythema (may appear differently in skin with darker pigmentation)

-May be preceded by changes in sensation, temp, or firmness

-Color changes are not purple or maroon

stage 2 pressure ulcer

stage 2 pressure ulcer description

-partial thickness loss of skin with exposed dermis

-wound bed is viable, pink/red, and moist

-may look like intact or ruptured serum-filled blister

stage 3 pressure ulcer

what is stage 3 pressure ulcer

-full-thickness skin loss with adipose visible in the ulcer

-granulation tissue and rolled wound edges are often present

-slough/eschar may be present

-subQ tissues may be damaged/necrotic

stage 4 pressure ulcer

stage 4 pressure ulcer description

-full thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone

-may have slough/eschar

-rolled edges, undermining, or tunneling may be present

unstageable and suspected deep-tissue injury

eschar covering

pressure injury interventions

-improving tissue integrity

-surgical management

-preventing infection

s/s of infection in a pressure injury

-sudden deterioration of the wound, with increase in the size or depth of the lesion

-changes in skin color or texture of the granulation tissue

-changes in quality, color, or odor of exudate

-report changes to primary HCP

-maintain safe environment

what is SJS

rare disorder of skin and mucous membranes

-cell death causes epidermis to separate from dermis

-milder form of toxic epidermal necrolysis (TEN)

etiology of SJS

-medications

-infectious causes

-delayed hypersensitive rxn

symptoms of SJS

-flu like symptoms occur several days before rash appears

-symmetric burning rash: begins on face/upper part of torso

-spreads within hours to days

what is skin like in SJS

-painful

-looks burned (peeling, blistered hives)

-lesions (cutaneous, appearance of target, red/purple coloration)

-core lesion surrounded by macular erythema later

tx in SJS

-dont cover

-stopping all non-essential meds

-fluid replacement, nutrition, wound and eye care

-pain meds, antihistamines, abx, topical steroids

-no baths

-administer morphine, clindamycin, diphenhydramine

what is cellulitis

diffuse painful inflammation of skin and subQ layers

who is most at risk for cellulitis

-athletes

-children

-men who have sex with men

-military recruits

-prisoners

-residents of LTC facilities

-IV drug users

-prior MRSA exposure

patho of cellulitis

-break in skin from injury

-most common bacteria (streptococcus/staphylococcus, MRSA)

manifestations of cellulitis

-painful, red swollen area of skin, hot, tender to touch

-fever/chills

-vesicles, bullae, plaques (with staph)

-tachycardia, hypotension, confusion, HA

-lymphadentitis and lyphangitis

cellulitis tx

abx- to kill infection and prevent sepsis

what is urticaria

-hives and welts on skin that itch

-vary in size

-may join together to form one large welt

types of urticaria

-acute hives

-chronic hives

-angioedema

what are acute hives

-may appear and go away within 24 hours

-may last for less than 6 weeks

what are chronic hives

last more than 6 weeks

what is angioedema

hives that occur deep under skin; acute episodes often involve lips, eyes, and face

s/s of urticaria

-appears as vascular rxn of skin

-characterized by sudden eruption of pale wheals or papules that cause severe itching

-some have burning/itching

presentation of urticaria

-wheals

-swellings

signs that med treatment is necessary in urticaria

-stridor

-wheezing

-other resp problems

-angioedema

tx for urticaria

-determine cause

-avoid to prevent future episodes

-OTC tx usually effective

what do we use to tx itching in urticaria

-calamine lotion

-cortisone cream

how do we dry the skin in urticaria

-topical emollients

-aluminum acetate

how do we ease discomfort in urticaria

-wet dressings

-oatmeal baths

what do ticks do in tick-bites

-blood sucking arachnids (parasites)

-embed head into skin and grow as they feed

patho of tick bites

can cause acute and chronic skin conditions

clinical manifestations of tick bites

-usual allergic rxn

-associated diseases: flu-like symptoms, rash over entire body, neck stiffness, swollen lymph nodes

lymes disease

-red bump with ringed red rash resembling bulls-eye

-fever

-HA/fatigue

-erythema migrans

etiology of squamous cell carcinoma

cumulative UV light exposure

patho of squamous cell carcinoma

-arises from damaged, unrepaired DNA in the nucleus of squamous cells of the epidermis

-UV radiation triggers cancerous keratinocyte transformation

-impaired keratinocytes extend into dermis

manifestations of squamous cell carcinoma

-Firm, smooth, or hyperkeratotic papules or plaques with ulcer in the center on sun-exposed skin

-Often presents as nonhealing sore that bleeds easily

-May present as large wart, cutaneous horn, or slow-growing, scaly, red plaque

-typically occurs in sun-exposed areas

-may also occur in body regions that are no sun exposed

types of burns

-superficial

-superficial partial thickness

-deep partial thickness

-full thickness

what are superficial burns

-reddened skin-painful

what are superficial partial thickness burns

-burned epidermis and papillary dermis

-blistering

-dermis is red and moist-painful

what is deep partial thickness burns

-damage to epidermis, papillary dermis, and reticular layer of the dermis

-injury to hair follicles

-blistering

-no pain

what is full thickness burns

-damage to epidermal, all dermal layers and structures and subQ tissue

-skin is charred and pale

-painless

-leathery skin appearance