1. Zoya Minasyan, RN, MSN-Edu

2.  A localized injury to the skin and/or underlying tissue due to pressure with or without shear/friction Most common sites ▪ Sacrum ▪ Heels

3.  Advanced age  Anemia  Contractures  Diabetes mellitus  Elevated body temperature  Immobility  Impaired circulation  Incontinence  Low diastolic blood pressure (<60 mm Hg)  Mental deterioration Neurologic disorders  Obesity  Pain  Prolonged surgery  Vascular disease

4. Ulcers are graded or staged according to deepest level of tissue damage A pressure ulcer may also present as a blood-filled blister. Stable (dry, adherent, intact) eschar on the heels serves as “the body’s natural (biologic) cover” and should not be removed.

5.  May appear with red, blue, or purple hues in darker skin tones Intact skin with non-blanchable redness Possible indicators—Skin temperature, tissue consistency, pain

6.  Partial-thickness loss of dermis  Shallow open ulcer with red pink wound bed  Presents as an intact or ruptured serum-filled blister

7.  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia  Presents as a deep crater with possible undermining of adjacent tissue  Depth of ulcer varies by anatomic location.

8.  Full-thickness loss can extend to muscle, bone, or supporting structures.  Bone, tendon, or muscle may be visible or palpable.  Undermining and tunneling may also occur.

9.  Signs of infection  Leukocytosis  Fever  Increased ulcer size, odor, or drainage  Necrotic tissue  PainMost common complications  Recurrence  Cellulitis (is a inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin)  Chronic infection  Osteomyelitis (an infection of the bone or bone marrow)

11.  Assess pressure ulcer risk on admission and at periodic intervals based on care setting and patient’s condition.  Use risk assessment tools such as the Braden scale for systematic skin inspection.  Look for areas of skin darker (purplish, brownish, bluish) than surrounding skin.  Use natural or halogen light for accurate assessment (fluorescent light casts a blue color that can skew results).  Assess skin temperature using your hand.  An ulceration may feel warm initially, then become cooler.  Touch the skin to feel its consistency.  Boggy or edematous tissue may indicate a stage I pressure ulcer.  Ask about pain or an itchy sensation.

12.  Overall goals  No deterioration  Reduce contributing factors  Not develop an infection  Healing and no recurrence

14.  Document and describe size, stage, location, exudate, infection, pain, and tissue appearance.  Keep ulcer bed moist.  Cleanse with nontoxic solutions.  Debride.  Use adhesive membrane, ointment, or wound dressing.  Verify good nutrition.  Teach self-care and signs of breakdown.  Initiate specialty services.  Skin grafts

15. Microscopic view of the skin in longitudinal section.

16.  Structures  Epidermis  Dermis  Subcutaneous tissue

18. Irregular pigmentation and keratoses occur on sun-damaged skin on forehead.

19. Normal Physical Assessment of Integumentary System.

20.  Subjective Data  Important health information ▪ Past health history ▪ Medications ▪ Surgery or other treatments  Functional health patterns ▪ Health perception–health management pattern ▪ Nutritional-metabolic pattern ▪ Elimination pattern ▪ Activity-exercise pattern ▪ Sleep-rest pattern ▪ Cognitive-perceptual pattern ▪ Self-perception–self-concept pattern ▪ Role-relationship pattern ▪ Sexuality-reproductive pattern ▪ Coping–stress tolerance pattern ▪ Value-belief pattern

21.  Objective Data: Physical examination-Inspection, Palpation

23. Intertrigo. Rash in body folds with Candida infection.

24. Vitiligo. Total loss of pigment in the affected area.

25. Naevus of Ota. Flat gray to blue pigmentation in the upper trigeminal area, which is more common in dark-skinned individuals.

26. Traction alopecia. Hair loss in scalp due to prolonged tension from hair rollers and braiding and straightening combs.

28. Basal cell carcinoma. Rolled, well-defined border and central erosion.

29. Squamous cell carcinoma of the finger.

30. Breslow measurement of tumor thickness. A, Thin (0.08° mm) superficial spreading melanoma good prognosis. B, Thick nodular melanoma with lymph node involvement, poor prognosis.

31. Dysplastic nevus. Irregular border and color.

32. Herpes zoster (shingles) on the anterior chest, confined to one dermatome.

33. Plantar wart. A, Keratotic lesion. B, After excision.

34. Candidiasis in interdigital cleft. Occurs in workers whose constantly wet hands are not dried often.

35. Tinea unguium (onychomycosis). Fungal infection of toenails. Crumbly, discolored, and thickened nails.

36. Scabies infestation on hand.

37. Psoriasis. Characteristic inflammation and scaling.

38. Acne vulgaris. Papules and pustules.

39. Seborrheic keratoses. Deeply pigmented, rough and warty surface.

41. Fig. 24-17. Curettage. The superficial growth is removed by a gentle scoping technique.

43.  Collaborative Therapy, continued  Drug therapy ▪ Antibiotics ▪ Corticosteroids ▪ Antihistamines ▪ Topical fluorouracil ▪ Immunomodulators

44.  Diagnostic and Surgical Therapy  Skin scraping  Electrodesiccation and electrocoagulation  Curettage  Radiation therapy  Laser technology  Cryosurgery

45. Punch biopsy. A, Removal of skin for diagnostic purposes. B, Specimen obtained.

46. A, Removal of melanoma by Mohs, surgery. B, Following plastic surgery using a skin flap to repair defect.

47.  Ambulatory and Home Care  Wet dressings  Baths  Topical medications  Control of pruritus  Prevention of spread

48. Face-lift. A, Preoperative. B, Postoperative.

49.  Elective Surgery  Laser surgery  Face lift  Liposuction