Alterations in Skin Integrity and Would Healing

1. Alterations in Skin Integrity and Would Healing Lisa M. Dunn MSN/Ed, RN, CCRN, CNE

2. Exemplar: Xerosis (Dryness) • A common problem among older patients • Fine flaking of the stratum corneum • Generalized pruritus • Scratching may result in secondary skin lesions, excoriations, lichenification, and infection

3. Collaborative Management • Nursing interventions aim to rehydrate the skin and relieve itching. • Bathing with moisturizing soaps, oils, and lotions may reduce dryness. • Water softens the outer skin layers; creams and lotions seal in the moisture provided by water.

4. Exemplar: Pruritus (Itching) • Pruritus is caused by stimulation of itch-specific nerve fibers at the dermal-epidermal junction. • Itching is a subjective symptom similar to pain. • “Itch-scratch-itch” cycle. • Cool sleeping environment is helpful. • Fingernails should be trimmed short. • Antihistamines. • Topical steroids.

5. The nurse is applying a topical corticosteroid to a client with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas? • Back • Axilla • Soles of the feet • Palms of the hands

7. Exemplar: Sunburn • First-degree, superficial burn • Cool baths • Soothing lotions • Antibiotic ointments for blistering and infected skin • Topical corticosteroids for pain

8. Exemplar: Urticaria (Hives) • Urticaria—presence of white or red edematous papules or plaques of varying sizes • Removal of triggering substances • Antihistamines helpful • Avoidance of overexertion, alcohol consumption, and warm environments, which can worsen symptoms

9. Exemplar: Trauma • Phases of wound healing: • Inflammatory phase • Fibroblastic or connected tissue repair phase • Maturation or remodeling phase

10. Question • The nurse manager is observing a new nursing graduate caring for a burn patient in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique? A. Using sterile sheets and linens B. Performing strict hand-washing technique C. Wearing gloves and a gown only when giving direct care to the patient. D. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

11. Process of Wound Healing

12. Process of Wound Healing (Cont’d) • First intention resulting in a thin scar • Second intention (granulation) and contraction—a deeper tissue injury or wound • Third intention (delayed closure)—high risk for infection with a resultant scar

13. Exemplar: Partial-Thickness Wounds • Involve damage to the epidermis and upper layers of the dermis • Heal by re-epithelialization within 5 to 7 days • Skin injury immediately followed by local inflammation

14. Re-epithelialization

15. Exemplar: Full-Thickness Wounds • Damage extends into the lower layers of the dermis and underlying subcutaneous tissue. • Removal of the damaged tissue results in a defect that must be filled with granulation tissue to heal. • Contraction develops in healing process. • Wound may tunnel

17. Exemplar: Pressure Ulcer • Tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period. • Mechanical forces that create ulcers: • Pressure • Friction • Shear

18. Shearing Force

19. Identification of High-Risk Patients • Mental status changes • Independent mobility • Nutritional status • Incontinence

20. Pressure-Relieving Techniques • Adequate pressure relief key to prevention of pressure ulcers • Capillary closing pressure • Pressure-relief products and devices • Positioning

21. Question • The evening nurse reviews the nursing documentation in the patient’s chart and notes that the day nurse has documented that the patient has a stage II pressure ulcer in the sacral area. Which of the following would the nurses expect to note on assessment of the patient’s sacral area? • A. Intact skin • B. Full-thickness skin loss • C. Exposed bone, tendon, or muscle • D. Partial- thickness skin loss of the dermis

22. Wound Assessment • Pressure ulcers and their features are classified and assessed in four stages: • Stage I • Stage II • Stage III • Stage IV

23. Four Stages of Pressure Ulceration

24. Wound Assessment • Location • Size • Color • Extent of tissue involvement • Cell types in the wound base and margins • Exudate • Condition of surrounding tissue • Presence of foreign bodies

26. Exemplar: Wound Contamination/Wound Infection • A wound that is exposed is always contaminated but not always infected. Contamination is the presence of organisms without any manifestations of infection. • Wound infection is contamination with pathogenic organisms to the degree that growth and spread cannot be controlled by the body’s immune defenses.

27. Nonsurgical Management • Dressings: • Mechanical débridement • Natural chemical débridement • Hydrophobic material • Hydrophilic material

28. Nonsurgical Therapy • Physical therapy • Drug therapy • Nutrition therapy • New technologies: • Electrical stimulation • Vacuum-assisted wound closure (VAC) • Hyperbaric oxygen (HBO) • Topical growth factors • Skin substitutes

30. Hyperbaric Oxygen Therapy

31. Surgical Management • Surgical débridement • Skin grafting

33. Community-Based Care • Home care management • Health teaching • Health care resources

34. Exemplar: Bacterial Infections • Folliculitis—superficial infection involving only the upper portion of the follicle • Furuncle (boil)—much deeper infection in the follicle • Cellulitis—generalized infection with either Staphylococcus or Streptococcus involving deeper connective tissue

35. Furuncle

36. Cellulitis

37. Question • The nurse is reviewing the health record of the patients scheduled to be seen at the health clinic. The nurse determines that which of the following individuals is at the greatest risk for development of an integumentary disorder? • A. An adolescent • B. An older female • C. A physical education teacher • D. An outdoor construction worker

38. Exemplar: Herpes Simplex Virus • Type 1 herpes simplex virus (HSV-1)—classic recurring cold sore • Type 2 herpes simplex virus (HSV-2)—genital herpes • Herpes zoster (shingles)

39. Herpes Simplex Virus(Cont’d) • Herpetic whitlow—a form of herpes simplex infection occurring on the fingertips of medical personnel who have come in contact with viral secretions

40. Exemplar: Herpes Zoster/Shingles • Caused by reactivation of the dormant varicella-zoster virus in patients who have previously had chickenpox. • Multiple lesions occur in a segmental distribution on the skin area innervated by the infected nerve. • Eruption lasts several weeks. • Postherpetic neuralgia occurs after lesions have resolved.

42. Exemplar: Fungal Infections (Dermatophyte) • Tinea pedis • Tinea manus • Tinea cruris • Tinea capitis • Tinea corporis • Candida albicans

43. Assessment • History • Laboratory assessment: • Tzanck smear • Swab culture • Potassium hydroxide (KOH) test

44. Interventions • Skin care with proper cleansing • Isolation Precautions • Drug therapy

45. Skin Care • Bathe daily with an antibacterial soap. • Remove any pustules or crusts gently. • Apply warm compress twice a day to furuncles or areas of cellulitis. • Apply Burow's solution to viral lesions. • Avoid excessive moisture. • Ensure optimal patient positioning.

46. Drug Therapy for Skin Disorders • Antibacterial drugs • Antifungal drugs • Anti-inflammatory drugs

47. A topical corticosteriod is prescribed for the client with dermatitis. The nurse provides instructions to the client regarding the use of the medication. Which of the following, if stated by the client, would indicate a need for further instruction? • “I need to apply the medication in a thin film.” • “I should gently rub the medication into the skin.” • “The medication will help relieve the inflammation and itching.” • “I should place a bandage over the site after applying the medication.”

48. Exemplar: Cutaneous Anthrax • Infection caused by the spores of the bacterium Bacillus anthracis • Diagnosis based on appearance of the lesions and culture or anthrax antibodies in the blood • Oral antibiotics for 60 days—ciprofloxacin or doxycycline

49. Cutaneous Anthrax

50. Exemplar: Pediculosis • Pediculosis—infestation by human lice: • Head lice—pediculosis capitis • Body lice—pediculosis corporis • Pubic or crab lice—pediculosis pubis • Pruritus most common symptom • Drugs • Laundering of clothing and bed linen