Wound Care- Derm

• HAPI


  Hospital acquired pressure injury
• Dermatologic problems


  • Wounds
• Measuring


  Length (head is 12 o'clock & feet is 6 o'clock), width (9 to 3) & depth
• Principles


  • Red = protect
  • Yellow = clean
  • Black = debride
• Debridement


  1. Autolytic: body's own digestive enzymes break down necrotic tissue

  2. Enzymatic: commercial products contain same enzymes body produces naturally

  3. Mechanical: wet to dry dressings
• Wound dressings types


  • Passive
  • Interactive
  • Active
• Categories of Dressings


  • Occlusive dressings
  • Transparent films
  • Moisture retention dressings
  • Hydrogels
  • Hydrocolloids
  • Foam dressing
  • Calcium alginates
  • Antimicrobial
  • Collagen dressings
• RULES


  • Categorization: Nurse learns about dressings by generic category
  • Selection: Nurse selects the most effective, economical and easy to use dressing
  • Change: Nurse changes the dressing based on patient, wound and assessment
  • Evolution: Dressing protocol is altered as the wound heals
  • Practice: Dressing changes should not be delegated to unlicensed personnel
• Burns


  Transfer of energy from heat source to the body. Thermal, radiation & chemical
• Goals


  • Prevention
  • Lifesaving measures for severely burned people
  • Preventing disability & disfigurement
  • Rehabilitation
• Classification


  • 1st degree = superficial partial thickness
  • 2nd degree = deep partial thickness
  • 3rd degree = full thickness
• Effects of Major Burn Injury

  • Fluid and electrolyte shifts
  • Cardiovascular effects
  • Pulmonary injury
  • Airway begins to close
  • Inhalation below the glottis
  • Carbon monoxide poisoning
  • Restrictive defects
  • Renal and GI alterations, dehydration
  • Immunologic alterations
  • Effect upon thermoregulation
• Physiologic Changes


  • Burns less than 25% TBSA = a local response
  • Burns more than 25% = local and systemic response, considered major burns
  • Systemic response = release of cytokines and other mediators into systemic circulation
  • Fluid shifts / shock result in tissue hypoperfusion and organ hypofunction
• Estimating Total Body Surface Area

  • Rule of nines
  • Lund and Browder method
  • Palm method: pt palm approximately 1%
• Ulcers


  Superficial loss of surface tissue as a result of death of cells
• Types of Ulcers


  • Arterial ulcers: Related to insufficient blood supply to the extremities
  • Venous ulcers: Due to impaired return of venous blood from the extremities to the heart
  • Neuropathic ulcers: Occur due to reduced blood supply to the nerves (often related to diabetes)
  • Pressure ulcers: Involve breakdown of the skin due to prolonged pressure, friction and shear, and insufficient blood supply
• Complications of ulcers


  • Infection
  • Gangrene
• Pressure ulcers


  Breakdown of the skin due to prolonged pressure, friction, shear, and insufficient blood supply
• Assessment


  • Assessment of skin
  • Evaluate mobility
  • Evaluate circulatory status
  • Evaluate neurologic status
  • Evaluate nutrition, hydration
  • Braden scale
• Stages


  • Stage I – Intact skin with nonblanchable erythema of a localized area, usually over a bony prominence
  • Stage II – Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, with slough
  • Stage III – Full-thickness tissue loss
  • Stage IV – Full-thickness tissue loss with exposed bone, tendon, or muscle
  • Unstageable – Ulcer is covered by slough and/or eschar and cannot be staged (depth of wound cannot be determined)
• Treatment


  • Stage I: Remove pressure. Prevent moisture, shear, friction. Promote proper nutrition, hydration
  • Stage II: Clean with sterile saline. Semipermeable occlusive dressings, hydrocolloid dressings, or wet saline dressings provide a moist healing environment
  • Stage III & IV: Debridement to remove infected area, necrotic tissues. Dressings. Topical treatment to promote granulation of tissue. Surgical interventions may be required
• Arterial ulcer


  Chronic arterial disease characterized by intermittent claudication. Small, circular, deep ulcerations on the tip of the toes or in the web spaces between the toes. Minimal exudate.
• Venous ulcer


  Caused by venous insufficiency, venous stasis – pain described as aching or heavy. Ulcerations are in the area of the medial or lateral malleolus and are typically large, pink, superficial and highly exudative, surrounding brown / purple pigmentation
• Neuropathic ulcers


  Located on plantar surface over metatarsal heads. Moderate to large exudate. Wound bed is typically red. Edges well defined.
• Interventions


  • Skin integrity: Skin care/hygiene and wound care to include bathing with warm water, avoiding dry cracking skin with moisturizers. Positioning of legs to promote circulation, avoid tight fighting stockings. Avoidance of trauma
  • Nutrition: Measures to ensure adequate nutrition. Adequate protein, vitamin C and A, iron, and zinc are especially important for wound healing. Cultural considerations and patient teaching in the dietary plan
• Skin tumors


  • Basal cell carcinoma
  • Squamous cell carcinoma
  • Malignant melanoma
  • Kaposi's sarcoma
  • Metastatic skin tumors
• ABCDE of Skin Cancer

  • Asymmetry
  • Borders
  • Color
  • Diameter
  • Evolution
• Scabies


  Itching is severe, usually about 4 weeks after contact symptoms begin
• Patient Teaching for Scabies

  • Mite frequently involves fingers and hands; contact may spread infection. Health care personnel should wear gloves when providing care until infection is ruled out
  • Take a warm, soapy bath; allow skin to cool; THOROUGHLY dry skin and apply prescription scabicide lindane, crotamiton, or 5% permethrin to the entire body, not including the face or scalp. Leave on for 12–24 hours
  • Wash clothing and bedding in hot water and dry in a hot dryer
  • Treat all contacts at the same time
  • Pruritus may continue for several weeks and does not mean retreatment is required
• Shingles


  • Herpes Zoster
  • Herpes Simplex
• Shingles Treatment


  • Antiviral acyclovir must be started within the first 72 hours to be effective, best within 24 hours
  • Goal of treatment is to treat pain and reduce or avoid complications (infection, scarring, post herpetic neuralgia and eye complications, such as blindness)
• Patient Teaching for Shingles


  • Herpes zoster: Antiviral med instructions, hand hygiene, dressings, lesion care
  • Herpes simplex: antiviral and prophylactic med instructions, spread of herpes, measures to reduce contagion of partner or child
• Psoriasis


  Chronic, noninfectious inflammatory disease of the skin in which epidermal cells are produced at an abnormally rapid rate
• Psoriasis Treatment


  • Baths to remove scales and medications
  • Biologicals- Enbrel- injection weekly alters immune function
  • Topical steroids- Clobetasol (temovate-severe)
  • Vitamin D 3 derivatives- Dovonex
  • Coal tar products T-derm, Psori gel
  • Systemic therapy- Methotrexate (chemo)
  • Photochemotherapy- UVA or UVB light without topical meds. PUVA (UVA and oral psoralens)
• Psoriasis Assessment


  Appearance of skin & coping w condition
• Psoriasis Complications


  • Infection
  • Psoriatic arthritis
• Fungal Infections


  • Tinea corporis: body
  • Tinea cruris: crotch ("jock itch")
  • Tinea pedis: foot ("athlete's foot")
• Patient Teaching for Fungal Infections


  • Instruction regarding medications, use of oral and topical agents, and shampoos
  • Instructions regarding hygiene: use clean towels and washcloths every day
  • Do not share towels, combs, etc.
  • Keep skin folds and feet dry
  • Wear clean, dry, white, cotton clothing including underwear and socks; avoid synthetic underwear, tight-fitting garments, wet bathing suits, and plastic shoes
  • Avoid excessive heat and humidity
  • Hair loss associated with tinea capitis is temporary
• Stevens-Johnson syndrome


  Severe adverse reactions to medication, after taking NSAIDs = ibuprofen, aspirin, advil, etc.
• TBSA


  Total Body Surface Area - a measurement used to estimate the severity of burn injuries, representing the percentage of the body's surface area that has been burned.