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4: DERMATOLOGY GUIDELINES
knee, thought to occur from intracellular edema or
inammatory processes.
B.
Diabetic foot ulcer:
1.
Skin ulcers are usually found on the plantar surface of
the foot, most commonly occurring from trauma or plantar pressure.
INCIDENCE
A.
Diabetic foot ulcers precede more than 80% of lower
extremity amputations in the United States.
B.
The nancial burden of venous ulcers is estimated to be $2
billion per year in the United States.
C.
Up to 20% of lower extremity ulcers have been shown to
have mixed etiology disease.
PATHOGENESIS
A.
An ulcer that is found between the knees and toes consti-
tutes a lower extremity ulcer, and guidelines are based according to the etiology. Many times, lower extremity ulcers have
more than one cause. The most common etiologies are venous
insufciency, arterial insufciency, diabetic foot ulcer, and/or
pressure.
PREDISPOSING
A.
Arterial insufciency.
B.
Congestive heart failure.
C.
Coronary artery disease.
D.
Diabetes.
E.
Edema.
F.
Dyslipidemia.
G.
Obesity.
H.
Age: older than 65 years.
I.
Venous insufciency.
J.
Peripheral neuropathy.
K.
Protein calorie malnutrition.
L.
Immobility.
COMMON
A.
Lower extremity or foot pain.
B.
Bleeding.
C.
Drainage.
D.
Hyperglycemia.
SUBJECTIVE
A.
Ask the client to describe the location and onset. What do
FACTORS
COMPLAINTS
DATA
they think may have been the cause? Was the onset sudden or
gradual? How have the symptoms continued to develop?
B.
Assess if the area is pruritic or painful. Does the client note
any change in sensation?
C.
Assess for any associated drainage. Ask about the color
and if any odor is noted.
D.
Complete a drug history. Ask the client if they are taking
any steroids or anticoagulants.
E.
Has the client been treated in this location before? If so,
describe.
F.
Determine whether the client has attempted to treat this
at home. If yes, inquire about treatments that have been performed and for what period of time.
G.
Does the client have any numbness or tingling in the lower
extremities? Does the client wake up at night with pain? Do
they have any pain with ambulation? Do they have sensation
in the feet?
H.
Rule out any possible exposure to industrial or domestic
toxins or insect bites.
I.
Assess for iodine and sulfa allergies before starting
treatment.
PHYSICAL
A.
Check temperature, pulse, pulse ox, respiration, and blood
EXAMINATION
pressure.
B.
Inspect:
1.
Assess the lower extremities, feet, and metatarsals.
a.
Color of the skin:
i.
Assess skin; begin at the top of the legs, move
down the legs to the metatarsals looking for changes
in color that may exhibit signs of ischemia.
ii.
Hemosiderin staining may exhibit venous
insufciency.
2.
Inspect the ulcer.
a.
Measure length × width × depth.
i.
Undermining: Measure and note the location
using the face of a clock to document the site of undermining: 12 o’clock, 3 o’clock, 6 o’clock, or 9 o’clock.
ii.
Tunneling (destroyed tissue pathway that cre-
ates dead space underneath the skin): Measure and
note the location using the face of a clock to document the site of tunneling: 12 o’clock, 3 o’clock,
6 o’clock, or 9 o’clock.
b.
Describe the wound bed.
i.
Tissue in the wound bed:
1)
Necrotic tissue, slough tissue, granulation
tissue, or epithelial tissue. Percentage of each
together should equal 100%.
ii.
Color of the tissue (percentage to equal 100%;
e.g., 80% pink, 20% yellow):
1)
Red, pink, yellow, brown, tan, or black.
iii.
Drainage:
1)
Amount:
a)
None, scant, moderate, or copious.
2)
Color:
a)
Serous, sanguineous, purulent, yellow,
serosanguineous, or green.
iv.
Odor:
1)
Odor present: yes or no.
v.
Periwound:
1)
Intact.
2)
Not intact:
a)
Describe periwound: Note erythema,
fever, induration, maceration, excoriation,
calloused, or epiboly (rolled wound edges).
C.
Palpate:
1.
Note temperature of the skin.
2.
Assess sensation of the skin.
3.
Check capillary rell.
4.
Assess pulses in bilateral extremities.
5.
Check for edema.
DIAGNOSTIC
A.
For perfusion:
1.
2.
3.
B.
For infection:
1.
2.
TESTS
Ankle brachial index (ABI).
Arterial Doppler.
Venous Doppler.
Partial or full thickness:
a.
Wound culture and sensitivity.
Full thickness with concern of underlying structure
infection:
a.
X-ray.
WOUND CARE: PRESSURE INJURIES/ULCERS
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109
b.
MRI.
c.
Bone scan.
C.
For pathology:
1.
Wound biopsy.
D.
For medical management:
1.
Complete blood count (CBC)and basic metabolic panel.
2.
Hemoglobin A1c (Hgb A1c).
3.
Protein: protein, albumin, and prealbumin.
4.
Zinc level.
DIFFERENTIAL
A.
Vascular ulcer:
1.
Arterial/ischemic ulcer.
2.
Venous ulcer.
B.
Diabetic foot ulcer.
C.
Abscess.
D.
Atypical ulcers.
E.
Dermatologic disorder.
F.
Necrotizing fasciitis.
G.
Skin cancers.
H.
Pressure ulcer.
I.
Trauma.
J.
Pyoderma gangrenosum.
DIAGNOSES
PLAN
A.
General interventions:
1.
Vascular ulcers:
a.
Arterial ulcer:
i.
Refer to vascular surgery for assessment to
improve arterial ow.
ii.
Refer to wound care specialist.
b.
Venous ulcer:
i.
Establish arterial ow.
1)
Refer to vascular surgeon if deciency
found.
ii.
For signs and symptoms of infection, treat the
infection rst with tissue culture and sensitivity.
Treat per pharmaceutical recommendations. Treat
with silver alginate to the site for moderate drainage and silver gel to the site for scant drainage.
iii.
Once arterial ow has been established as suf-
cient and infection has been ruled out, compression therapy is the mainstay of treatment for venous
ulcers. The following are recommendations for
compression therapy:
1)
ABI: 0.8 to 1.0 full compression:
a)
Pro-fore.
b)
Apply calcium alginate to ulcer, then
wrap with an Unna Boot and cover with a
Coban wrap.
c)
Change in 3 days; if tolerating, then
change weekly.
2)
ABI: 0.6 to 0.8 light compression:
a)
Pro-fore lite.
b)
Apply calcium alginate to ulcer, then
wrap with an Unna Boot, and then cover
with a Coban wrap.
c)
Change in 3 days; if tolerating well, then
change weekly.
2.
Diabetic foot ulcer:
a.
Establish arterial ow.
i.
Refer to a vascular surgeon if deciency is found.
b.
For signs and symptoms of infection, use a sterile
Culturette to obtain a tissue culture and sensitivity rst
to assess what organism is present and to determine
sensitivities. Treat per pharmaceutical recommendations. Treat with silver alginate to the site for moderate
drainage and silver gel to the site for scant drainage.
c.
Initiate ofoading to site:
i.
Refer to an orthotist for assessment if devices
are required.
d.
Treatment options:
i.
To debride: Cleanse with normal saline (NS), apply
Santyl, and change dressing daily and as needed.
ii.
To granulate an ulcer with scant drainage:
Cleanse with NS, apply collagen dressing, cover
with a secondary dressing, and change dressing
daily and as needed.
iii.
To granulate an ulcer with moderate drain-
age: Cleanse with NS, apply calcium alginate, and
change dressing daily as needed.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Wound Care: Lower Extremity Ulcers.”
C.
Pharmaceutical therapy:
1.
If culture and sensitivity is performed, antibiotics may
be required as recommended per sensitivity.
FOLLOW-UP
A.
Follow up in 1 to 2 weeks to evaluate therapy.
B.
See the client every 1 to 2 weeks until healing well; then
the client may reduce to 2- to 4-week evaluation until complete closure.
CONSULTATION/REFERRAL
A.
Consult or refer the client to a wound care specialist when
they have the following:
1.
Extensive ulcer that you are not comfortable with.
a.
Visible bone, muscle, or tendon.
2.
Multiple medical comorbidities (especially diabetes).
3.
Did not respond to treatment of 2 to 4 weeks.
4.
Ulcer showing decline on follow-up visit.
5.
Infection present.
INDIVIDUAL
A.
Adults:
1.
2.
CONSIDERATIONS
Ischemic ulcers warrant immediate referral.
Complaints of severe pain, lack of pulse, cool digit,
or new onset of purplish/bluish discolorations to the
feet require immediate workup for arterial clot to lower
extremity.
WOUND
CARE: PRESSURE INJURIES/ULCERS
DEFINITION
A.
“A pressure injury is localized damage to the skin and
underlying soft tissue usually over a bony prominence or
related to a medical or other device. The injury can present
as intact skin or an open ulcer and may be painful. The injury
occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for
pressure and shear may also be affected by microclimate, nutrition, perfusion, co- morbidities and condition of the soft tissue”
(National Pressure Ulcer Advisory Panel [NPUAP], 2016).
INCIDENCE
A.
Acute care: 0.4% to 38%.
B.
Long-term care: 2.2% to 23.9%.
C.
Home care: 0% to 17%.
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4: DERMATOLOGY GUIDELINES
PATHOGENESIS
A.
Pressure ulcers occur when an area of tissue remains in sur-
face contact for a period of time. This contact causes occlusion of
microvascular vessels, which leads to tissue hypoxia and eventually may cause ischemia. Over time, a pressure ulcer develops.
The amount of time this takes is client-dependent and can be
altered by physical and/or environmental factors of time.
PREDISPOSING
A.
Acute illness.
B.
Fecal/urinary incontinence.
C.
Malnutrition.
D.
Weight loss.
E.
Failure or inability to ofoad:
1.
Fracture, elevation of the head of bed (HOB), lack of
FACTORS
education, or noncompliance.
2.
Chronic medical conditions.
3.
Advanced age.
4.
Medical devices.
COMMON
A.
B.
C.
SUBJECTIVE
A.
COMPLAINTS
Pain.
Bleeding.
Drainage.
DATA
Ask the client to describe the location and onset. What did
they think may have been the cause? Was the onset sudden or
gradual? How have the symptoms continued to develop?
B.
Assess if the area is itchy or painful.
C.
Assess for any associated drainage. Ask about the color
and if any odor is noted.
D.
Complete a drug history. Ask the client if they are taking
any steroids or anticoagulants.
E.
Has the client been treated in this location before? If so, ask
todescribe.
F.
Determine whether the client has attempted to treat this
problem at home. If yes, ask with what.
G.
Rule out any possible exposure to industrial or domestic
toxins or insect bites.
H.
Assess for iodine and sulfa allergies before starting
treatment.
PHYSICAL
A.
Check temperature, pulse, pulse ox, respirations, and
EXAMINATION
blood pressure.
B.
Inspect:
1.
Measure pressure ulcer: length × width × depth.
a.
Undermining: Measure and note location using the
face of a clock to document the site of undermining: 12
o’clock, 3 o’clock, 6 o’clock, or 9 o’clock.
b.
Tunneling: Measure and note location using the face
of a clock to document the site of tunneling: 12 o’clock,
3 o’clock, 6 o’clock, or 9 o’clock.
2.
Describe the wound bed.
a.
Tissue in the wound bed:
i.
Necrotic tissue, slough tissue, granulation tis-
sue, or epithelial tissue (percentage of each should
together equal 100%).
b.
Drainage:
i.
Amount:
1)
None, scant, moderate, or copious.
ii.
Color:
1)
Serous, sanguineous, purulent, yellow, sero-
sanguineous, or green.
c.
Odor.
d.
Periwound:
i.
Intact.
ii.
Not intact.
1)
Erythema, fever, induration, maceration,
excoriation, calloused, or epiboly.
DIAGNOSTIC
A.
Complete blood count.
B.
Wound culture and sensitivity.
C.
Wound biopsy.
D.
X-ray.
E.
MRI.
F.
Bone scan.
DIAGNOSIS
A.
Staging pressure injuries/ulcers
1.
TESTS
1
Deep-tissue pressure injury (DTPI):
a.
Intact or nonintact skin with persistent nonblanch-
able discoloration (purple, deep red, maroon) or epidermal separation revealing a blood-lled blister or
darkened wound bed.
b.
Changes in pain/temperature may precede changes
in skin color. Discoloration may be difcult to detect in
highly pigmented skin.
c.
DTPI may be due to intense pressure and shear
forces at the bone–muscle interface.
d.
The wound may resolve without tissue loss, or rapid
evolution may occur to reveal extent of damage.
e.
If fascia, muscle, necrotic/subcutaneous/ granulation
tissue, or other underlying structures are visible, this
is likely a full-thickness pressure injury (stage 3, 4, or
unstageable).
f.
Do not use DTPI staging to describe neuropathic,
vascular, dermatologic, or traumatic conditions.
2.
Stage 1 pressure injury:
a.
Intact skin with nonblanchable, localized erythema.
Discoloration may be difcult to detect in highly pigmented skin.
b.
Changes in sensation, temperature, or rmness may
precede visual changes.
c.
Do not use stage 1 to describe purple, deep red, or
maroon discoloration; these may indicate DTPI.
3.
Stage 2 pressure injury:
a.
Partial-thickness loss of skin with exposed dermis.
b.
The wound is moist, pink or red, viable, and may
present as an intact or ruptured serum-lled blister.
c.
Deeper tissues and adipose (fat) are not visible.
d.
Eschar, slough, and granulation tissue is not
present.
e.
Stage 2 pressure injuries are the result of adverse
microclimate or shear forces.
f.
Do not use stage 2 to describe the following:
i.
Skin tears, burns, or abrasions.
ii.
Moisture-associated skin damage (MASD),
including:
1)
Incontinence-associated dermatitis (IAD).
2)
Intertriginous dermatitis (ITD).
3)
Medical adhesive-related skin injury (MARSI).
1
Adapted from National Pressure Ulcer Advisory Panel. (2016). NPUAP pressure injury stages. Retrieved from http://www.npuap.
org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/
4.
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Stage 3 pressure injury:
a.
Full-thickness loss of skin, with visible adipose.
b.
Granulation tissue, eschar, slough, and epiboly
(rolled wound edges) may be present.
c.
Eschar and slough are present.
d.
The extent of tissue damage varies by anatomic
location; deep wounds may develop in areas of signicant adiposity.
e.
Undermining/tunneling may occur.
f.
Muscle, tendon, ligament, cartilage, fascia, and/or
bone are not exposed.
g.
Do not use stage 3 if eschar or slough obscures the
depth of tissue loss; this indicates an unstageable pressure injury.
5.
Stage 4 pressure injury:
a.
Full-thickness loss of skin and tissue.
b.
Muscle, tendon, ligament, cartilage, fascia, and/or
bone are exposed or directly palpable.
c.
Epiboly (rolled wound edges), undermining, and/
or tunneling often occur.
d.
The extent of tissue damage varies by anatomic
location.
e.
Eschar or slough may be present. If either or both
obscure the depth of tissue loss, this indicates an
unstageable pressure injury.
6.
Unstageable pressure injury:
a.
Full-thickness loss of skin and tissue.
b.
Eschar or slough obscures the extent of tissue
loss; removing these will reveal a stage 3 or 4 pressure injury.
c.
Do not soften or remove stable eschar (dry, adher-
ent, intact without erythema or uctuance) on the
heel or ischemic limb unless you have established
that client has adequate perfusion to ensure potential for wound healing.
7.
Medical device–related pressure injury:
a.
This is the result of using devices intended for diag-
nostic or therapeutic purposes.
b.
The pressure injury generally conforms to the shape
or pattern of the device.
c.
The injury should be staged using the staging system.
8.
Mucosal membrane pressure injury:
a.
Found on the mucous membranes with a history of
medical device use at the injury’s location.
b.
These ulcers cannot be staged due to the anatomy of
the tissue.
WOUND CARE: WOUNDS OF THE SKIN
4.
To granulate an ulcer with moderate drainage, cleanse
111
with NS, apply calcium alginate, and change dressing
daily as needed.
B.
Client teaching:
1.
Educate client and family regarding stage of ulcer and
treatment plan.
2.
Wound nurse should be caring for wound and educat-
ing client and family of daily/weekly care.
C.
Pharmaceutical therapy:
1.
Treatment is dependent on stage of ulcer.
FOLLOW-UP
A.
Follow up in 1 to 2 weeks to evaluate therapy.
B.
See the client every 1 to 2 weeks until healing well; then
client may reduce to 2- to 4-week evaluation until complete
closure.
CONSULTATION/REFERRAL
A.
Consult or refer the client to a wound care specialist for the
following:
1.
Extensive ulcer that you are not comfortable treating.
2.
Client with multiple medical comorbidities (especially
diabetes).
3.
Client not responding to treatment of 2 to 4 weeks.
4.
Ulcer showing decline on follow-up visit.
5.
Infection present needing alternative treatment.
INDIVIDUAL
A.
Adults:
1.
CONSIDERATIONS
Clients at end of life may develop pressure ulcers
related to the dying process, referred to as Kennedy terminal ulcers. These clients are treated for comfort.
B.
Geriatrics:
1.
Research suggests that pressure ulcers in the elderly
population (especially those suffering dementia) appear to
accelerate health deterioration, which leads to lower survival and higher mortality rates.
2.
Educate the client and surrogates that good nutrition,
fall prevention, skin care, and meticulous wound care
techniques could help reduce pressure ulcer complications
and increase survival time.
WOUND
CARE: WOUNDS OF THE SKIN
DEFINITION
A.
Wounds are breaks in the external surface of the body.
DIFFERENTIAL
A.
Pressure ulcer.
B.
Abscess.
C.
Trauma.
D.
Skin cancer.
E.
Vascular ulcer.
F.
Diabetic foot ulcers.
G.
Dermatologic disorder.
DIAGNOSES
PLAN
A.
General interventions:
1.
Identify the cause of pressure and alleviate.
2.
To debride, cleanse with normal saline (NS), apply Santyl,
and change dressing daily and as needed throughout.
3.
To granulate an ulcer with scant drainage, cleanse with
NS, apply collagen dressing, and cover with secondary
dressing, change daily as needed.
PATHOGENESIS
A.
Wounds can be caused by any one of the innumerable objects
that breach the skin. Lacerations and abrasions typically heal by
a three-stage process of clotting, inammation, and skin cell proliferation. The most common pathogens of wound infections are
Saureus and beta-hemolytic streptococcus.
PREDISPOSING
A.
Exposure to accidental or intentional injury.
B.
Accident prevention failure.
C.
High-risk behaviors.
D.
Conditions that predispose to poor wound healing:
1.
Diabetes.
2.
Corticosteroid therapy.
3.
Immunodeciency.
4.
Advanced age.
5.
Undernourishment.
6.
Comorbidities.
FACTORS
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4: DERMATOLOGY GUIDELINES
COMMON
A.
B.
C.
D.
OTHER
A.
COMPLAINTS
Bleeding.
Pain.
“Cut” in the skin integrity.
Drainage.
SIGNS AND SYMPTOMS
Signs and symptoms of infection: Deep wounds and dirty
wounds have increased risk for infection.
B.
Soft-tissue damage: Wounds with tissue necrosis have
increased risk of infection.
SUBJECTIVE
A.
Elicit the client’s description of how the wound occurred,
DATA
including where and when the injury was sustained.
B.
Ascertain how much time has elapsed until treatment. If
6 hours have elapsed, bacterial multiplication is likely.
C.
Ask if the client is currently immunized for tetanus.
D.
Complete a drug history; include any allergies to medica-
tions, anesthetics, or dressings.
E.
Ask if the client is taking any medications, especially ste-
roids or anticoagulants.
F.
Assess iodine and sulfa drug allergies before starting
treatment.
G.
Review with the client whether anything signicant in the
medical history may interfere with the healing process (e.g.,
immunodeciency).
PHYSICAL
A.
Check temperature, pulse, pulse ox, respirations, and
EXAMINATION
blood pressure.
B.
Inspect:
1.
Inspect wound.
2.
Measure size of wound: length, width, and depth.
Wounds with untidy edges may heal more slowly and
with disgurement.
3.
Assess underlying bony structures.
4.
Inspect for foreign objects.
C.
Palpate:
1.
Palpate extremities for neurovascular function and
sensation.
2.
Palpate tissue distal to the wound.
3.
Palpate lymph nodes surrounding the injured area.
D.
Perform neurologic examination:
1.
Assess motor function distal to wound.
DIAGNOSTIC
A.
Culture site of wound if suspicious for infection.
B.
Take x-ray lms for deep or crushing wounds.
DIFFERENTIAL
A.
Wound, minor.
B.
Nonaccidental self-inicted injury.
C.
Self-inicted injury.
D.
Domestic violence.
E.
Bite.
TESTS
DIAGNOSES
PLAN
A.
General interventions:
1.
Wounds that require open-wound management:
a.
Abrasions and supercial lacerations.
b.
Wounds with great amount of tissue damage.
c.
Wounds more than 6 hours old.
d.
Contaminated wounds.
e.
Large area of supercial skin denudation.
f.
Puncture wounds.
2.
For wounds that do not require sutures:
a.
Cleanse wound well with normal saline; remove all
dirt and foreign bodies.
b.
Forceful irrigation may be needed; use ne-pore
sponge (Optipore) with a surfactant such as poloxamer
188 (Shur Clens Skin Wound Cleanser). Approximate
wound edges, if possible, then apply xeroform and cover
with nonadherent dressing change Q72H and as needed.
3.
If inammation is present:
a.
Soak and wash for 15 to 20 minutes three to four
times per day. Cover with clean, dry dressing. Do not
use Steri-Strips.
4.
For wounds that require sutures:
a.
Clean with warm water and soap. Irrigate with ster-
ile saline solution.
b.
Anesthetize with 1% to 2% lidocaine (Xylocaine).
Do not use solution with epinephrine at ngertips,
nose, or ears. Probe wound for any remaining foreign
bodies. Approximate wound edges.
c.
Suture with technique appropriate to site:
i.
Skin sutures: nonabsorbable material (e.g.,
nylon, Prolene, or silk).
ii.
Subcutaneous and mucosal sutures: absorbable
material (e.g., Dexon, Vicryl, or plain or chromic gut).
iii.
Extremities: 4-0 nylon.
iv.
Soles of feet: 2-0 nylon.
d.
Cover with clean, dry dressing; change after rst
24 hours.
e.
Suture removal is based on location.
i.
Head and trunk: 5 to 7 days.
ii.
Extremities: 7 to 10 days.
iii.
Soles and palms: 7 to 10 days.
iv.
Distal extremities: 10 to 14 days.
f.
Tetanus prophylaxis (see Chapter 1, "Health
Maintenance Guidelines").
B.
Client teaching:
C.
See Client Teaching Guide for this chapter, “Wound Care:
Pressure Injuries/Ulcers.”
D.
Pharmaceutical therapy:
1.
Control pain with acetaminophen (Tylenol) as needed.
2.
Topical antibiotic ointments: bacitracin and mupirocin.
3.
Oral antibiotics for prophylaxis:
a.
Amoxicillin, clavulanic acid (Augmentin) given for
7 to 10 days:
i.
Adults: 875mg oral BID.
ii.
Adolescents: 250 to 500mg BID.
iii.
Children: 25 to 45mg/kg/d BID for 7 to 10 days;
available as 200mg/5 mL or 400mg/5 mL liquid.
b.
With penicillin allergy, use erythromycin given for 7
to 10 days:
i.
Adults: 500mg oral BID.
ii.
Adolescents: E-Mycin 250 mg QID for 7 to 10
days.
iii.
Children: EryPed 30 to 60mg/kg/d QID for 7
to 10 days; available as 200mg/5 mL or 400mg/5
mL liquid.
4.
Other alternatives: cephalexin (Keex), and cefadroxil
(Duricef), and ciprooxacin.
5.
Tetanus toxoid 0.5 mL by intramuscular injection in del-
toid, if no booster has been administered in the last 5 years.
6.
Wounds diagnosed with Methicillin-resistant S. aureus
should be treated with the following oral antibiotics:
WOUND HEALING: HIGH-PROTEIN NUTRITION
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113
a.
Trimethoprim-sulfamethoxazole (Bactrim).
b.
Minocycline or doxycycline.
c.
Clindamycin rifampin (should be used in combina-
tion with one of the previous antibiotics).
d.
Linezolid.
7.
Antibiotics not recommended due to high resistance
include the following:
a.
Beta-lactams.
b.
Fluoroquinolones.
c.
Dicloxacillin.
d.
Cephalexin.
8.
Treating the nares with Bactroban Ointment BID and
having the client use Hibiclens soap when showering will
help prevent recurrent infections.
9.
For severe cases of infection, the client requires hospi-
talization for aggressive antibiotic treatment.
FOLLOW-UP
A.
Have the client return for evaluation and dressing change
in 24 to 48 hours.
CONSULTATION/REFERRAL
A.
Refer the client to a physician for wounds of the type listed
in the following:
1.
Facial wounds.
2.
Subcutaneous tissue penetration.
3.
Functional disturbance of tendons, ligaments, vessels,
or nerves.
4.
Grossly contaminated wounds.
5.
Wounds requiring hospitalization or aggressive anti-
microbial therapy for evidence of pyogenic abscess, cellulitis, and ascending lymphangitis.
INDIVIDUAL
A.
Adults:
1.
CONSIDERATIONS
Adults with chronic conditions such as diabetes or
immune deciency or those with compromised immune
systems should be monitored closely for infection and
delayed wound healing.
B.
Geriatrics:
1.
Avoid use of nonsteroidal anti-inammatory drugs
(NSAIDs) in clients who have chronic kidney disease stage
IV or less (creatinine clearance <30mL/min).
2.
Medications commonly used in the elderly popula-
tion are associated with poor wound healing: cytotoxic
antineoplastic agents, corticosteroids, aspirin, NSAIDs,
anticoagulants, bisphosphonates, and pain medications
that contain morphine.
BIBLIOGRAPHY
Anrys, C., Van Tiggelen, H., Verhaeghe, S., Van Hecke, A., & Beeckman,
D. (2019). Independent risk factors for pressure ulcer development in
a high‐risk nursing home population receiving evidence‐based pressure ulcer prevention: Results from a study in 26 nursing homes in
Belgium. International Wound Journal, 16(2), 325–333. https://doi.
org/10.1111/iwj.13032
Au, Y., Holbrook, M., Skeens, A., Painter, J., McBurney, J., Cassata, A., &
Wang, S. C. (2019). Improving the quality of pressure ulcer management in a skilled nursing facility. International Wound Journal, 16(2),
550–555. https://doi.org/10.1111/iwj.13112
Baranoski, S., & Ayello, E. (2015). Wound care essentials: Practice principle.
Lippincott Williams, and Wilkins.
Furuya-Kanamori, L., Walker, R. M., Gillespie, B. M., Clark, J., Doi, S. A.
R., & Thalib, L. (2019). Effectiveness of different topical treatments in
the healing of pressure injuries: A network meta-analysis. Journal of
the American Medical Directors Association, 20(4), 399–407. https://doi.
org/10.1016/j.jamda.2018.10.010
Kennedy, K. (2016). Understanding the Kennedy terminal ulcer. http://
www.kennedyterminalulcer.com
National Pressure Ulcer Advisory Panel. (2016, April 13).
Pressure injury staging. http://www.npuap.org/resources/
educational-and-clinical-resources/npuap-pressure-injury-stages
National Pressure Ulcer Advisory Panel and European Pressure Ulcer
Advisory Panel. (2009). Prevention and treatment of pressure ulcers; clini-
cal practice guideline. Author.
Thakral, G., La Fontaine, J., Kim, P., Naja, B., Nichols, A., & Lavery, L. A.
(2015). Treatment options for venous leg ulcers: Effectiveness of vascular surgery, bioengineered tissue, and electrical stimulation. Advances
in Skin & Wound Care, 28(4), 164–172. https://doi.org/10.1097/01.
ASW.0000462328.60670.c3
Van Tiggelen, H., LeBlanc, K., Campbell, K., Woo, K., Baranoski, S.,
Chang, Y. Y., Dunk, A. M., Gloeckner, M., Hevia, H., Holloway, S.,
Idensohn, P., Karadağ, A., Koren, E., Kottner, J., Langemo, D., Ousey,
K., Pokorná, A., Romanelli, M., Santos, V. L. C. G., & Beeckman,
D. (2020). Standardizing the classication of skin tears: Validity
and reliability testing of the international skin tear advisory panel
Classication System in 44 countries. British Journal of Dermatology,
183(1), 146–154. https://doi.org/10.1111/bjd.18604 Epub 2019 Nov
28. PMID: 31605618; PMCID: PMC7384145
Weller, C. D., Team, V., Ivory, J. D., Crawford, K., & Gethin, G. (2019).
ABPI reporting and compression recommendations in global clinical practice guidelines on venous leg ulcer management: A scoping
review. International Wound Journal, 16(2), 406–419. https://doi.org/
10.1111/iwj.13048
Yapp, J. H., Raja Ahmad, R. M. K., Ahmad, S. A., Mahmud, R.,
Mohtarrudin, N., Mohamad Yusof, L., Rahim, E. A., Ahmad, S.
A., & Abu Bakar, M. Z. (2019). Determining weight‐bearing tissue condition using peak reactive hyperemia response trend and
ultrasonographic features: Implications for pressure ulcer prevention. Wound Repair & Regeneration, 27(3), 225–234. https://doi.org/
10.1111/wrr.12698
WOUND
A.
HEALING: HIGH-PROTEIN NUTRITION
Nutrition is an essential component in the healing of any
wounds. Protein, carbohydrates, fats, vitamins, minerals,
and amino acid needs are increased for tissue repair. Table
4.3 summarizes the recommended amount of protein intake
needed under different circumstances for tissue repair.
1.
Consult with a dietitian for medical nutrition therapy
(MNT).
2.
Evaluate protein intake.
3.
Evaluate the client’s weight.
a.
Obtain serial weights; use the same scales.
b.
Use diet diary or 24-hour recall.
c.
The dietary and weight history is used to determine
additional needs.
d.
Excessive protein potentially leads to dehydration.
4.
Perform laboratory tests.
a.
Complete blood complete.
b.
Basic metabolic panel (BMP).
c.
Protein: albumin, total protein, and prealbumin.
d.
Renal: blood urea nitrogen (BUN) and creatinine.
5.
Evaluate wound stage/healing.
6.
Supplemental protein may be required.
a.
Sources of protein:
i.
Whole eggs are considered the “gold standard”
protein.
ii.
Meat: red and white meat.
iii.
Fish.
Liver.
iv.
v.
Dairy: milk, cheese, and yogurt.
vi.
Soybeans.
vii.
Legumes.
viii.
Seeds.
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TABLE
4: DERMATOLOGY GUIDELINES
4.3 RECOMMENDED PROTEIN NEEDS PER DAY FOR WOUND HEALING
Elderly: baseline protein needs 1.0–1.2 g/kg body weight/d
Healthy adults 0.8–1.0 g/kg body weight/d
Large burns 1.5–3.0 g/kg body weight/d (varies by extent of the burn)
Post surgery 1.0–1.5 g/kg body weight/d (varies by extent of the surgery)
Pressure injuries/ulcers 1.0–2.0 g/kg body weight/d
ix.
Nuts.
x.
Grains.
b.
Encourage meals and snacking, double portions
of meat and eggs, commercial supplements, and
INCIDENCE
A.
Xerosis occurs in 48% to 98% of clients with atopic
dermatitis.
B.
It occurs more frequently in elderly clients.
fluids.
i.
Eat ve to six smaller meals throughout the day.
ii.
Keep ready-to-eat meals and snacks.
iii.
Drink shake-type beverages that contain pro-
tein, vitamins, and minerals.
iv.
Add protein powder to drinks.
c.
Consider appetite stimulants.
d.
Enteral nutrition should be considered if oral food
and uid intake is not adequate.
OTHER
CONSIDERATIONS
A.
The elderly have multiple risk factors for intake of insuf-
cient protein for wound healing.
1.
Financial:
a.
Expense of high-protein foods.
b.
Expense of oral supplemental nutrition drinks.
2.
Difculty chewing:
a.
Dental problems.
b.
Loose-tting dentures.
c.
Edentulous.
3.
Assistive needs:
a.
Inability to prepare foods.
b.
Need to have a caregiver feed the elderly person.
c.
Given inadequate time to consume food if being fed.
4.
Dysphagia.
5.
Anorexia.
6.
Fatigue.
7.
Psychosocial:
a.
Depression.
b.
Loneliness.
B.
Consultation with a dietitian for MNT, wound care spe-
cialist, social worker, occupational therapist, and behavioral
health evaluations is advised.
BIBLIOGRAPHY
Au, Y., Holbrook, M., Skeens, A., Painter, J., McBurney, J., Cassata, A., &
Wang, S. C. (2019). Improving the quality of pressure ulcer management in a skilled nursing facility. International Wound Journal, 16(2),
550–555. https://doi.org/10.1111/iwj.13112
Baranoski, S., & Ayello, E. (2015). Wound care essentials: Practice principle.
Lippincott Williams, and Wilkins.
PATHOGENESIS
A.
Dry skin may ssure, appear shiny and cracked, and leave
subsequent inammatory changes.
PREDISPOSING
A.
Frequent bathing with hot water and harsh soaps.
B.
Cold air.
C.
Low humidity.
D.
Central heating or cooling.
E.
Alcohol use.
F.
Poor nutrition.
G.
Cholesterol-lowering drugs.
H.
Systemic disease manifested by thyroid, renal, or hepatic
FACTORS
disease, anemia, diabetes, or malignancy.
COMMON
A.
OTHER
A.
COMPLAINTS
Dry, rough skin, especially on legs.
SIGNS AND SYMPTOMS
Pruritic, scaling skin, particularly on legs, with cracks
and/or ssures.
B.
Pruritus may be associated with systemic disorders or
other infections. Itching of scabies is particularly intense at
night.
C.
Plaques 2 to 5 cm in diameter.
D.
Erythema.
E.
Wheal-and-are response typical of urticaria.
SUBJECTIVE
A.
Obtain the client’s description of the onset of symptoms
DATA
and whether it was sudden or gradual.
B.
Ask the client to identify any discomfort. Ask if the skin is
itchy or painful.
C.
Assess lesions for any associated discharge (blood or pus).
D.
Determine whether the client has recently ingested any
new medicines (antibiotics, cholesterol-lowering medications,
or other drugs), alcohol, or new foods.
E.
Ask the client about use of any topical medications.
F.
Identify any preceding systemic symptoms (fever, sore
throat, anorexia, or vaginal discharge).
G.
Ask the client about bathing in hot water and if they are
bathing regularly.
H.
Review the client’s full medication history for comorbid
XEROSIS
(WINTER ITCH)
conditions.
DEFINITION
A.
Xerosis, often called “winter itch,” is characterized by a
dry skin.
PHYSICAL
A.
Inspect:
EXAMINATION
1.
Inspect skin for lesions, noting texture of skin.
B.
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Palpate:
1.
Palpate abdomen for masses and hepatosplenomegaly.
2.
Palpate lymph nodes.
DIAGNOSTIC
A.
There are no diagnostic tests for xerosis.
DIFFERENTIAL
A.
Scabies.
B.
Atopic dermatitis.
TESTS
DIAGNOSES
PLAN
A.
General interventions:
1.
Hydrate and lubricate the skin.
2.
Assess for and treat secondary infection.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Xerosis (Winter Itch).”
1.
Avoid alkaline soaps: Use Dove, Basis, mild soap, or
soap substitutes such as Cetaphil or Aquaphor.
C.
Pharmaceutical therapy:
1.
Apply emollient cream or lotion (Sarna, Lac-Hydrin, or
Eucerin).
2.
Use over-the-counter skin lubricants (petroleum jelly,
mineral oil, or cold cream).
3.
Use topical corticosteroid.
a.
Triamcinolone 0.025% two to four times daily or
0.1% two to three times daily; apply sparingly.
b.
Hydrocortisone 1% or 2.5% two to four times daily;
apply thin lm; avoid the face.
4.
Systemic antihistamine is used to control pruritus,
such as diphenhydramine (Benadryl) 25 to 50mg every 4
to 6 hours as needed.
XEROSIS (WINTER ITCH)
115
FOLLOW-UP
A.
Follow-up as indicated until resolved.
CONSULTATION/REFERRAL
A.
Consult or refer the client to a dermatologist if no improve-
ment is seen.
INDIVIDUAL
A.
Pediatrics:
1.
CONSIDERATIONS
Avoid corticosteroid preparation or use low-potency
corticosteroid only.
B.
Geriatrics:
1.
Monitor the client for possible skin breakdown and/or
ulceration.
2.
Xerosis is common among the elderly population.
Several nonpharmacologic treatments to consider before
using topical hydrocortisone would include increasing
home environment humidity, avoiding excessive bathing
and bath oils, encouraging oatmeal baths, and using emollient ointment (e.g., Aquaphor or Eucerin) and ceramide
lotions (e.g., AmLactin) to smooth cracked rough skin and
decrease pruritus.
BIBLIOGRAPHY
Anderson de Oliveira Cruz, R., Palhano, D. B., & Costa, M. M. L.
(2019). Nursing care for skin xerosis in elderly. Journal of Nursing
UFPE/Revista de Enfermagem UFPE, 13(3), 875–878. https://
doi-org.proxy.library.vanderbilt.edu/10.5205/1981-8963v13i03a237348p875-878-2019
Mekić, S., Jacobs, L. C., Gunn, D. A., Mayes, A. E., Ikram, M. A., Pardo,
L. M., & Nijsten, T. (2019). Prevalence and determinants for xerosis
cutis in the middle-aged and elderly population: A cross-sectional
study. Journal of the American Academy of Dermatology, 81(4), 963.
https://doi-org.proxy.library.vanderbilt.edu/10.1016/j.jaad.
2018.12.038
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CLIENT
TEACHING GUIDE
ACNE ROSACEA
PROBLEM
bumps. The blood vessels may be more prominent on the face, causing the skin to appear reddened.
CAUSE
redness of the skin.
PREVENTION/CARE
A.
Avoid rubbing or massaging the face as it can irritate the skin.
B.
Avoid alcoholic beverages.
C.
Avoid using harsh soaps/creams on the face, including cosmetics that irritate the skin.
D.
Wash face with a mild soap daily, such as Cetaphil or Purpose soap. Other suggested daily cleansers are sulfa-based cleans-
ers (Rosanil) or benzoyl peroxide cleansers.
E.
Protect the skin when outdoors by wearing protective clothing, as well as hats and others to cover the face. Use sunscreen
with sun protection factor (SPF) 30 or a zinc-based ointment, such as zinc oxide, on the skin for protection.
F.
You may be prescribed an antibiotic by mouth or an antibiotic cream/gel to place on the skin. Use medications as prescribed
by your provider.
G.
Avoid using steroid creams on your face unless prescribed by your provider.
H.
If your skin condition begins to affect your eyes, you need to notify your provider immediately. Do not apply any medications
or creams on your eyes unless prescribed by your provider.
Acne
rosacea is a skin condition that affects primarily the nose and face, causing redness, ushing, pimples, and
The
cause is not known but is thought to be due to the blood vessels in the face being too active, causing ushing and
TREATMENT
A.
Use antibiotics/medications as prescribed by your provider.
B.
Wash face with mild cleanser daily.
Activity:
PLAN
As tolerated. No limitations in physical activity.
Diet:
A.
Drink plenty of uids daily.
B.
Avoid alcoholic beverages.
Medications:
You
or Your Child Has Been Prescribed:
You
Need to Take:
You
Need to Notify the Office If:
A.
You have a reaction to any of the medications or cleansers prescribed.
B.
Rash appears on your eyes or other new places.
C.
Symptoms worsen or new signs or symptoms present before your next follow-up appointment.
D.
Other:
Phone:
RESOURCE
ww.rosacea.org
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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