Dermatologic Problems and Wound care

Adult Health exam 2

What are the general goals of dermatologic treatment?

Relieve itching, pain, and inflammation

Treat infection when present

Restore and maintain skin integrity

Prevent further injury or skin breakdown

Identify and eliminate triggers

Promote wound healing

What are the priority nursing responsibilities when caring for a a patient with a skin disorder?

Assess skin condition and document findings

Identify possible causes or triggers

Monitor for infection

Administer prescribed topical or systemic medications

Maintain skin cleanliness and moisture balance

Educate the patient about skin care and prevention

Monitor treatment effectiveness and adverse effects

What are the general principles of wound dressing care?

Perform hand hygiene and use appropriate infection-control precautions

Assess the wound before applying a new dressing

Cleanse as prescribed, generally using a normal saline or an appropriate wound cleanser

Maintain an appropriate moist wound environment when indicated

Protect surrounding skin from excess moisture

Avoid unnecessary trauma to healing tissue

Change dressings according to the treatment plan and drainage level

Why is maintaining a moist wound environment important?

Supports cell migration and tissue repair

Helps promote granulation and epithelialization

Prevents the wound bed from drying out

Can reduce pain and trauma during dressing changes

Excessive moisture must still be avoided because it can cause maceration

What is maceration?

Softening and breakdown of skin caused by prolonged exposure to moisture

Skin may appear white, wrinkled, and fragile

Can occur around wounds with excessive drainage or incontinence

Prevent by controlling moisture and protecting surrounding skin

What is the difference between colonization and wound infection?

Colonization: microorganisms are present but are not invading tissue or causing a clinical infection

Infection: microorganisms invade tissue and cause a host response

Signs of infection include increasing pain, warmth, swelling, redness, purulent drainage, and delayed healing

Fever or systemic symptoms may indicate spreading infection

What are signs of a wound infection?

Increased redness and warmth

Swelling

Increasing pain or tenderness

Purulent drainage

Foul odor, especially with other infection findings

Delayed healing or wound deterioration

Fever, chills, or systemic illness if infection spreads

What are important nutritional considerations for wound healing?

Adequate protein supports tissue repairs

Calories provide energy for healing

Vitamin C supports collagen formation

Zinc supports tissue repair and immune function

Adequate hydration supports circulation and tissue health

Assess for malnutrition and refer for nutritional support when eeded

What is pruritis?

The medical term for itching

Can result from dry skin, allergies, inflammation, medications, or systemic conditions

Persistent scratching can cause skin breakdown and secondary inefection

What nursing interventions help relieve pruritic?

Apply prescribed moisturizers or emollients

Use lukewarm, rather than hot water

Avoid harsh soaps and fragranced products

Keep fingernails short

Encourage loose, breathable clothing

Use prescribed antihistamines or topical corticoid steroids when appropriate

identify and eliminate triggers

What is the difference between arterial and venous ulcers?

Arterial ulcers: caused by inadequate arterial blood flow and poor tissue oxygenation

Venous ulcers: caused by venous insufficiency and increased venous pressure

Arterial ulcers are often painful dn occur on toes or pressure points

Venous ulcers commonly occur near the medial ankle and are associated with edema

What are the characteristics of an arterial ulcer?

Usually located on toes, feet, heels, or other distal areas

Often deep with a round, punched-out appearance

Wound bed may appear pale or necrotic

Minimal drainage

Surrounding skin may be cool, shiny, and hairless

Pedal pulses may be diminished or absent

Pain often worsens with leg elevation

What re priority nursing interventions fro arterial ulcers?

Assess pulses, skin temperature, color, and capillary refill

Assess pain and signs of impaired perfusion

Protect the affected limb from trauma and pressure

Avoid compression unless specifically approved after vascular evaluation

Avoid elevating the limb above the heart level if this worsens ischemic pain

Encourage smoking cessation

Collaborate with the healthcare team for vascular evaluation and possible revascularization

What are the characteristics of a venous ulcer?

Commonly located near the medial malleolus (inside ankle)

Usually shallow with irregular wound edges

Wound bed may be red and moist

Moderate to heavy drainage is common

Surrounding skin may be brown, thickened, or inflamed

Edema is common

Pedal pulses are often present, although they still need assessment

What are priority nursing interventions for venous ulcers?

Elevate legs when resting to reduce edema

Encourage walking and calf-muscle activity as tolerated

Apply prescribed compression therapy after confirming adequate arterial circulation

Provide appropriate wound care

Monitor edema, drainage, and healing

Encourage adherence to the treatment plan

Why must arterial circulation be assess before applying compression therapy?

Compression increases external pressure on the limb

If arterial circulation is already inadequate, compression can further reduce blood flow

This can worsen ischemia and cause tissue injury

Ankle-brachial index (ABI) or other vascular assessment may be used to determine whether compression is safe

What is a neuropathic ulcer?

A wound caused by loss of protective sensation, commonly associated with diabetes

Often develops on the plantar surface of the foot or over pressure points

May be surrounded by callused skin

Can be painless because of neuropathy

patients may not recognize an injury until significant tissue damage has occured

What are priority nursing interventions for neuropathic ulcers?

Assess sensation, circulation, and wound condition

Promote offloading to reduce pressure on the wound

‘Encourage daily food inspections

Teach proper footwear and avoidance of walking barefoot

Monitor blood glucose and support diabetes management

Report signs of infection promptly

Orange appropriate podiatry and wound-care follow-up

How can a nurse distinguish arterial, venous, and neuropathic ulcers?

Arterial:

Toes/feet

Often severe

Cool, shiny

Decreased

Usually low

Poor arterial flow

Venous:

Medial ankle

Aching

Brown, edematous

usually present

often heavy

Venous hypertension

Neuropathic:

Plantar foot

Often minimal

Callused

May be present or decreased

Variable

Loss of sensation/ pressure

What is a pressure injury?

Localized damage to skin and/or underlying tissue

Usually occurs over a bony prominence or beneath a medical device

Caused by sustained pressure or pressure combined with shear

Immobility, moisture, poor nutrition, and impaired sensation increase risk

What are common locations for pressure injuries?

Sacrum and coccyx

Heels

Hips and trochanters

Ankles

Elbows

Occiput

Areas beneath medical devices, such as oxygen tubing or masks

What is a Stage 1 pressure injury?

Intact skin with nonblanchable redness

Redness does not turn white when pressed

May feel warmer, cooler, firmer, softer, or more painful than surrounding skin

In darker skin tones, discoloration may be less obvious; assess changes in temperature, texture, and sensation

What is a Stage 2 pressure injury?

Partial-thickness skin loss with exposed dermis

Wound bed is viable and typically pink or red and moist

May appear as an intact or ruptures serum-filled blister

No visible adipose tissue, slough, or eschar

What is a Stage 3 pressure injury?

Full-thickness skin loss

Adipose (fat) may be visible

Granulation tissue and rolled wound edges may be present

Slough or eschar may be present if it does not obscure the depth

No exposed muscle, tendon, cartilage, or bone

What is a Stage 4 pressure injury?

Full-thickness skin and tissue loss

Exposed or directly palpable fascia, muscle, tendon, cartilage, or bone

My include undermining or tunnelingHigh risk for serious infection, including osteomyelitis

What is an unstageable pressure injury?

Full-thickness skin and tissue loss where the wound depth is obscured by slough or eschar

The actual stage cannot be determined until enough tissue is removed or the wound is otherwise visualized

Do not assume it is Stage 3 or 4 without being able to determine the depth

What is a deep tissue pressure injury?

Persistent deep red, maroon, or purple discoloration if intact or non-intact skin

May develop a blood-filled blister

Indicates damage due to underlying issue from pressure or shear

Can deteriorate rapidly

What are the priority nursing interventions for preventing pressure injuries?

Reposition regularly based on the patient’s individual risk and support surface

Offload heels and other vulnerable areas

Keep skin clean and dry

Manage incontinence and moisture

Use pressure-redistributing mattresses and cushions

Encourage adequate nutrition and hydration

Perform routine skin assessments

What should the nurse do if a patient develops a new pressure injury?

Assess and document location, stage, size, and wound characteristics

Relieve pressure immediately

Notify the appropriate healthcare provider or wound-care team

Develop an individualized wound-care and repositioning plan

Monitor for infection and further tissue damage

Never massage reddened bony prominences

What is herpes zoster (shingles)?

Reactivation of the varicella-zoster virus, the sam virus that causes chickenpox

Causes a painful, blistering rash

Usually follows a single dermatome and typically appears on tone side of the body

Can cause postherpetic neuralgia, which is persistent nerve pain after the rash resolves

What are priority nursing interventions for herpes zoster?

Administer prescribed antiviral medications, such as acyclovir or valacyclovir

Encourage treatment as early as possible, ideally within 72 hours of rash onset

Provide pain management

Keep lesions clean and covered

Avoid contact with people who are susceptible to varicella until lesions have crusted

Use appropriate isolation precautions based on whether the rash is localized to disseminated and the patient’s immune status

What isolation precautions are needed for localized versus disseminated herpes zoster?

Localized shingles is an immunocompetent patient: standard precautions; cover lesions

Disseminated shingles or shingles in an immunocompromised patient until dissemination is ruled out: airborne and contact precautions

Follow facility infection-control policy

What is herpes simplex virus (HSV)?

A viral infection that causes recurrent painful blisters or ulcers

HSV-1 commonly causes oral lesions

HSV-2 commonly causes genital lesions, although either type can affect either location

The virus remains latent and may reactivate

What are nursing interventions and patient education for herpes simplex?

Administer prescribed antiviral medications

Keep lesions clean and avoid touching or picking them

Perform hand hygiene after contact with lesions

Avoid kissing or oral contact during active oral outbreaks

Avoid sexual contact during active genital outbreaks

Explain that antivirals reduce symptoms and viral shedding but do not cure the infection

What is Stevens-Johnson syndrome (SJS)?

A rare, serious, life-threatening mucocutaneous reaction, often triggered by medications

Causes painful skin lesions, blistering, and detachment of the epidermis

Frequently involves mucous membranes, including the mouth, eyes, and genitals

Can progress rapidly

What is toxic epidural necrolysis (TEN)?

A severe form of the same disease spectrum as SJS

Causes extensive epidermal detachment

TEN involved more than 30% of body surface area

Associated with high risk of fluid loss, infection, and death

What are common medication triggers of SJS/TEN?

Certain anticonvulsants, such as carbamazepine, lamotrigine, and phenytoin

Allopurinol

Sulfonamide antibiotics

Some NSAIDs

Other medications can also trigger the reaction

What are the priority nursing interventions for suspected SJS/TEN?

Immediately stop the causative medication and notify the provider

Assess airway, breathing, and circulation

Monitor fluid and electrolyte balance

Provide wound and skin care with minimal trauma

Manage pain

Monitor for infection and sepsis

Provide eye and mucosal care

Prepare for specialized burn-unit or intensive-care management

Why is SJS/TEN treated similarly to a major burn?

Extensive skin loss damages the body’s protective barrier

Patients can lose large amounts of fluid

They are increased risk for infection and sepsis

Temperature regulation becomes impaired

Pain and nutritional needs can be significant

What are the three major types of skin cancer?

Basal cell carcinoma

Squamous cell carcinoma

Melanoma

What are the characteristics of basal cell carcinoma?

Most common type of skin cancer

Often appears as a pearly or waxy bump

May have visible blood vessels or a central ulcer

Commonly occurs on sun-exposed areas

usually grows slowly and rarely metastasizes, but can cause local tissue damage

What are characteristics of squamous cell carcinoma?

May appear as a firm, red nodule or scaly, crusty lesion

Can develop into an ulcer that does not heal

Often occurs on sun-exposed skin

Has a greater potential to metastasize than basal cell carcinoma

What are characteristics of melanoma?

Malignancy of melanocytes

Can develop from an existing mole or appear as a new lesion

May have asymmetry, irregular borders, uneven color, or evolving appearance

Can metastasize rapidly

Early recognition and treatment are critical

What are the priority nursing interventions for a patient with suspected skin cancer?

Assess and document suspicious lesions

Encourage prompt dermatology evaluation and biopsy when indicated

Teach regular skin self-examinations

Encourage sun protection and avoidance of tanning beds

Teach the ABCDE warning signs

Reinforce follow-up after treatment

What patient education helps prevent skin cancer?

Use broad spectrum SPF 30 or higher sunscreen

Reapply sunscreen approximately every two hours when outdoors and after swimming or sweating

Wear protective clothing, hats, and sunglasses

Seek shade, especially during peak UV hours

Avoid tanning beds

Examine skin regularly and report changing lesions