NS 303 Exam 1 Lesions, Pressure ulcers, Wounds, Asepsisrename
olanjones's version from 2016-05-26 15:50
|Primary Lesions||Primary lesions are physical changes in the skin considered to be caused directly by the disease process. Types of primary lesions are rarely specific to a single disease entity. Some are also normal variation of the skin.|
|Macule||A flat circumscribed area that is a change in the color of the skin, less than 1cm (freckle, flat mole, measles, scarlet fever)|
|Papule||Elevated, firm, circumscribed ares less than 1 cm. (wart, mole, lichen planus, skin tag)|
|Patch||flat, non-palpable, irregular shaped macule more than 1 cm in diameter. (Vitiligo, port wine stains, Mongolian spots, café-au-lait spots)|
|Plaque||Elevated firm and rough lesion with flat top surface greater than 1 cm (Psoriasis)|
|Wheal||Elevated irregular-shaped area of cutaneous edema, solid, transient, variable diameter (insect bite, urticaria, allergic reaction)|
|Nodule||Elevated, firm, circumscribed lesion…deeper in dermis than papule (melanoma, hemangioma)|
|Tumor||elevated and solid lesion may or may not be clearly demarcated, deeper in dermis. Greater than 2 cm in diameter (neoplasms, lipoma)|
|Vesicle||elevated, circumscribed, superficial, not in dermis, filled with serous fluid, less than 1 cm (herpes)|
|Bulla||vesicle greater than 1 cm (blister)|
|Pustule||elevated, superficial lesion, similar to vesicle but fill with purulent fluid (acne).|
|Cyst||elevated, circumscribed, encapsulated lesion, in dermis or subcutaneous layer, filled with liquid or semisolid material.|
|Secondary Lesions||Secondary lesions may evolve from primary lesions, or may be caused by external forces such as scratching, trauma, infection, or the healing process. The distinction between a primary and secondary lesion is not always clear.|
|Scale||Heaped up keratinized cells, flaky skin, irregular, thick or thin, dry or oily, variations in size (dry skin, eczema)|
|Lichenification||Rough, thickened epidermis secondary to persistent rubbing, itching, or skin irritation. Often on flexor surface of extremity. (chronic dermatitis)|
|Keloid||irregular-shaped scar elevated, progressively enlarging scar, grows beyond the boundaries of the wound.|
|Scar||thin to thick fibrous tissue that replaces normal tissue following injury.|
|Excoriation||loss of epidermis, linear hollowed-out crusted area (abrasion or scratch, scabies)|
|Fissure||linear crack or break from the epidermis to the dermis, may be moist or dy. (althlete’s foot, chapped hands, eczema)|
|Crust||Dried drainage or blood, slightly elevated. (scab)|
|Erosion||Loss of part of epidermis, depressed moist, glistening, follows rupture of vesicle or bulla.|
|Ulcer||loss of epidermis and dermis, concave, varies in size|
|Atrophy||thinning on skin surface and loss of skin markings (aged skin, straie)|
Vascular Skin Lesions
|Petechiae||Tiny, flat reddish purple non blanchable spots in skin less than .5 cm in diameter.|
|Purpura||flat, reddish purple, non blanchable discoloration of skin greater than .5 cm|
|Ecchymosis (bruise)||reddish purple nonblanchable spot of varying size|
|Angioma||benign tumor consisting of mass of small blood vesslels. Varies in size.|
|Capillary Hemangioma||capillaries within skin create irregular macular patch|
|Telangiectasia||Permanent dilation of preexisting small blood vessels, fine irregular red lines within skin|
|Vascular spider||small central red area with radiating spider like legs|
|Venous star||nonpalpable bluish star-shaped lesion.|
Pressure ulcers - staging
|Stage 1 pressure ulcer||first sign is blanching. Non-blanchable erythema that does not resolve within minutes of pressure relief. Epidermis intact. observable pressure-related alteration of intact skin. May include changes in |
- Skin temperature
- Tissue consistency
- Sensation (pain or itching)
Ulcer appears as defined area of persistent redness in light skin and red, blue or purple in darker skin.
|Stage 2 pressure ulcer||Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and appears clinically as an abrasion, blister/vesicle, or shallow crater. Free of eschar.|
|Stage 3 pressure ulcer||Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer manifests clinically as a deep crater with or without undermining of adjacent tissue.|
|Stage 4 pressure ulcer||Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (tendon, joint capsules). Undermining and sinus tracts may also be present.|
|RF pressure ulcers||age, debilitation of support tissue, nutrition(income), arthritis, decreased mobility, decreased nervous stimulation, obesity, wasting/FTT, decreased hygeine, connective tissue disease, poor hydration (esp. At night, and with diuretics), HTN, capillary damage, skin tears (care w/ moving and transferring|
|Braden Scale for predicting pressure sore risk||- Sensory perception (1-4) 1. Completely limited, 4. No impairment|
- Moisture (1-4) 1. Consistently moist 4. Rarely moist
- Activity (1-4) 1. Bedfast 4. Walks frequently
- Mobility (1-4) 1. Completely immobile 4. No limitation
- Nutrition (1-4) 1. Very poor 4. Excellent
- Friction and Shear (1-3) 1. Problem 4. No apparent problem
|Norton’s pressure risk assessment||- general physical condition (1-4) 1. Very bad 4. Good|
- mental state (1-4) 1. Stuporous 4. Alert
- Activity 1. Bedfast 4. Ambulatory
- mobility (1-4) 1. Immobile 4. Full
- incontinence 1. Double 4. Absent
|PUSH Tool definition||Pressure Ulcer Scale for Healing|
|PUSH Tool use||comparison of sores over time provides indication of improvement or deterioration in pressure ulcer healing|
|Terms to describe dimensions||Length X Width X Depth|
|Terms to describe exudate amount||non, light, moderate, heavy, "dime", "quarter" sized|
|Terms to describe exudate type||serous, purulent, sanguineous, serosanguineous|
|Terms to describe tissue types||closed, epithelial tissue, granulation tissue, slough, necrotic tissue, eschar|
|Healing by primary intention||edges well approximated along suture or glue line. no tissue loss, resolves.|
|Healing by secondary intention||skin lost or removed (ulcers). must heal from bottom up, tissue lost, takes longer. scarring and infection increased.|
Asepsis / Universal precautions
|Definition sterile field, basic concepts||Sterile field is free of all microorganisms. Sterile can only touch sterile. Non sterile cannot touch sterile or else sterile is now contaminated.|
|Universal Precautions||treat all patients as if they are contaminated. techniques to be used with all clients to decrease the risk of transmitting unidentified pathogens.|
|Components of Universal precautions||1. All patients must be regarded as potentially infected with blood-borne pathogens|
2. Strict hand washing must be practiced before and after each patient contact.
HANDS MUST BE WASHED IMMEDIATELY IF THEY ARE CONTAMINATED WITH BLOOD OR BODY FLUIDS
3. Gloves should be worn:
a. if soiling with blood or body fluids is anticipated,
b. for placement of intravenous lines.
c. Gloves should not be reused.
4. Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or other body fluids and if soiling with blood or body fluids is likely.
5. Masks and protective eyewear (goggles) should be worn during procedures that are likely to generate droplets or splashes of blood or other body fluids to prevent exposure of mucous membranes of the mouth, nose and eyes.
6. Articles contaminated with blood or body fluids should be discarded:
a. if disposable, in red bags labeled "infectious waste.”
b. Non-disposable items should be cleaned with a hospital approved disinfectant and sent to Central Services for sterilization.
7. Care should be taken to avoid needle-stick injuries. Used needles should not be recapped or bent; they should be placed in a prominently labeled puncture resistant container designated specially for such disposal. You may prefer to administer all drugs, via stopcock, to avoid recapping needles.
8. Blood spills should be cleaned up promptly with a solution of 5.25% sodium hypochforite diluted with Water (1:10 household bleach).
9. Health care workers who have exudative lesions or weeping dermatitis should refrain from all patient care and handling equipment until the condition is resolved.
10. To minimize the need for emergency mouth-to-mouth resuscitation, disposable mouth pieces, resuscitation bags or other ventilation devices should be available for use,
11. Pregnant health care workers should strictly adhere to precautions to minimize the risk of HIV transmission.
12. All specimens must be contained in a leak-proof plastic bag labeled ‘bio-hazard."