Med Surg Ch 54 & 55
Card Set Information
Med Surg Ch 54 & 55
Med Surg 54 55
Skin disorders and burns
Inflammation of the skin
characterized by itching, redness, and skin lesions with various borders and distribution patterns
Preventing dry skin
Lubricate with creams, oils, or ointments as appropriate
How is skin protected?
Lightly patting dry
avoid hot water
use sunscreen when outdoors
Its is important to teach pts that when applying a topical medication..
More is not better!
Why is topical administration preferred over systemic steroids?
Systemic steroids can cause serious side effects including adrenal suppression
What can be used to suppress dermatitis and how are they administered?
Steroids such as hydrocortisone and methylprednisolone
administered topical, intralesional, or systemic agent
Chronic inflammatory skin disorder in which the epidermal cells proliferate abnormally fast
What is the average age of onset psoriasis?
Average is 27
can begin at any age
condition can be severe if onset is in childhood
Characteristics of psoriasis
Characterized by exacerbations and remisions
aggravating factors of psoriasis
Prevention of psoriasis
Avoidance of upper respiratory infections, especially streptococcal infections
Complications of psoriasis
Psoriatic arthritis may develop
severe- fever, chills, increased cardiac output, and benign lymphadenopathy
Psoriasis is an inflammatory skin disorder that is characterized by which underlying pathology?
What information is most important for the nurse to teach patients about avoiding malignant skin lesions?
Avoid overexposure to ultraviolet rays
What action by the nurse is appropriate when caring for a pt with dermatitis?
Apply gloves to the hands at night
What factors may contribute to a pts skin breakdown other than not being turn and positioned?
Pt commonly slides down the chair
pt sits in the chair most of the day
pt is often diaphoretic
pt is incontinent of urine and stool
What instruction should the nurse provide to a Pt who is being treated for scabies?
Wash linens, towels, and clothes
A pt diagnosed with impetigo contagiosa wants to know when the disease will no longer be contagious. What will the best response be?
When all lesions are healed
When does shearing occur?
When pt slides down in bed when the head of the bed is raised, or when being pulled or repositioned without being lifted with the sheets
How do you prevent pressure ulcers?
examine and document condition of the skin daily
pat the skin dry rather than rubbing it try
avoid massage bony promises or reddened skin areas
teach pt to shift their weight every 15 minutes
turn and reposition q 2 hr
avoid elevating the head more than 30 degrees
elevate heels off the bed with pillows places lengthwise under the calf
prevent malnutrition and dehydrating by ensuring an adequate intake of protein, calories, and fluid (2500 mL of fluid each day)
What is the first sign and symptom of a pressure ulcer?
begins with a reddened area, usually over a bony prominence, that does not blanch with pressure
If a pt comes into a health care facility, what precautions should you take to "cyoa"
take photographs and document all pressure ulcers present
Describe the three-color pressure ulcer system
Black wounds - necrosis
yellow wounds - have exudate and may be infected
red wound - pink or red, healing stage
When treating a pressure ulcer, which color should you treat first?
The removal of dead or nonviable tissue from a wound to help clean up the wound and facilitate formation of granulation tissue
Types of debridement
Removal of devitalized tissue, slough, or thick, adherent eschar with a scalpel, scissors, or other sharp instrument
may be in operating room or pt room
grafting may be required
How is the stage of a pressure ulcer decided?
It is based on the depth of tissue destroyed
Describe stage I of a pressure ulcer
skin is intact
area is red but does not blanch
difficult to detect in a dark skinned person
Describe Stage 2 of a pressure ulcer
break within the skin
partial thickness skin loss of epidermis, dermis, or both
may appear as an abrasion or blister
Describe stage 3 of a pressure ulcer
full thickness skin loss, extends to subcutaneous fat but not dascia
bone,tendon, and muscle are not visible
Describe stage 4 of a pressure ulcer
full-thickness skin loss with exposed muscle, bone, or support structures such as tendons
slough or eschar may be present
undermining and tunneling
fluid consisting of serum or blood
varies in color and odors
Creamy yellow pus may indicate
Beige pus that has a fishy odor may indicate
green blue pus with a fruity odor may indicate
Brown pus with a decal odor may suggest
Granulation has what kind of appearance and texture if healthy?
budding appearance from the development of tiny new capillaries
when oral psoralen tablets are followed by exposure to UVA
temporarily inhibits DNA synthesis
pt must wear dark glasses during treatment and for the entire day after treatment