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Presentation on theme: "INTEGUMENTARY OBJECTIVES 1-11"— Presentation transcript:

Integumentary system is made up of: Skin, accessory structures, and subcutaneous tissues Body covering separating internal environment from external environment Barrier against pathogens, most chemical, and injury to inner structures. Is an organ, the largest 2 layers; epidermis and the dermis

2 EPIDERMIS Stratified,squamous epithelial tissue
AVASCULAR; nourishment from DERMIS Thickest on palms of hands, soles of feet Innermost layer is STRATUM GERMANITIVUM Mitosis occurs to produce NEW epidermal cells. Usually occurs at constant rate, but increased pressure produces increased production to form calluses.

3 New cells in the EPIDERMIS produce KERATIN
Keratin is a waterproofing protein, prevents loss of water as well as prevents entry of excess H2O. When die and slough off, also removes pathogens As new cells get pushed to surface of epidermis, they die, become the STRATUM CORNEUM, OUTERMOST LAYER Loss of large portions of this layer greatly increase risks for infection and dehydration

4 MELANOCYTES,cells in the lower EPIDERMIS, produce the protein MELANIN
MELANOCYTES,cells in the lower EPIDERMIS, produce the protein MELANIN. Amounts produced are genetically determined. Melanin is what gives color to skin and hair. Exposing melanin to UV rays causes an increase in production. Melanin is incorporated in to the epidermal cells, making them darker before they die. Tanning is a direct result of this process. Melanin is important in that it acts as a pigment barrier to exposure from UV rays and thereby, protects the str. germanitivum from mutational changes that can lead to extensive skin damage and cancerous lesions.

5 Langerhans cells, a type of MACROPHAGE, are located in BOTH the epidermis and the dermis. They act to present ANTIGENS to the HELPER T CELLS; a first line barrier to invasion through the skin by pathogens

6 DERMIS Made up of fibrous connective tissue
Cells are called FIBROBLASTS They produce THE PROTEIN FIBERS OF COLLAGEN and ELASTIN,which support the skin and allow for some skin stretching and recoil THE DERMIS ALSO CONTAINS the hair and nail follicles, GLANDS, NERVE ENDINGS AND BLOOD SUPPLY. THE blood CAPILLARIES are found in the PAPILLARY layer of the dermis

7 HAIR Developes in FOLLICLES located in the EPIDERMAL structures.
The hair root is a group of cells that undergo mitosis to produce the hair shaft Cells die AFTER producing KERATIN and incorporating MELANIN Eyelashes,eyebrows,keep dust and sweat out of eyes. Nostril hair filters air entering nasal cavities.Hair on head, not sparse body hair, provides for thermal regulation

8 NAILS Follicles found at ends of fingers and toes
Growth similar to growth of hair, starts in the layer of DERMIS Mitosis in nail root, produces new cells containing keratin. Dead cells form the visible nail Protect ends of digits from mechanical injury

9 RECEPTORS SENSORY RECPTORS for the cutaneous senses are located in the DERMIS. FREE nerve endings are receptors for heat, cold and pain ENCAPSULATED nerve endings are for touch and pressure Sensitivity is = to # of nerve endings present

10 Sebaceous glands and sudoriferous glands
Sebaceous gland ducts open into hair follicles or directly onto surface of skin Sebum (a lipid substance) is secreted Inhibits growth of some bacteria and drying of skin and hair Sudoriferous glands are SWEAT GLANDS 2 kinds: APOCRINE (modified scent glands),and ECCRINE (sweat is secreted onto skin surface) APOCRINE found in axilla and genital areas. Activated by stress and emotions.

11 ECCRINE throughout dermis, but more numerous on face, palms, soles; activated by high temperatures or exercise. Effective cooling mechanism MODIFIED sweat glands or CERUMINOUS glands are located in the dermis of ear canals Prevents drying of outer surfaces of ear canal

12 BLOOD VESSELS In the dermis, they serve to provide nourishment.
ARTERIOLES are involved in body temp. maintenance Increased body heat results in vasodilatation, increased blood flow and loss of body heat to air or clothing Decreased body temp results in vasoconstriction with <blood flow and <loss of body heat

13 SUBCUTANEOUS TISSUE Located BETWEEN dermis and muscles
Made up of areolar connective tissue and adipose tissue Contains numerous WBCs (fights pathogens invading through the skin) Adipose tissue cushions some bones, provides for some insulation,but MOST IMPORTANTLY, provides for STORAGE OF FATS for energy needs

Cell division in the epidermis slows. Fibroblasts in the dermis die, don’t regenerate Hair and skin much thinner Collagen/elastin fibers deteriorate Sebaceous and sweat glands decrease activity

15 Skin frail and dry Less subcutaneous fat Temperature regulation labile in hot or cold weather; more sensitive to changes Melanocytes die, hair goes to gray

16 NURSING ASSESSMENT Skin problems are common complaints May be only complaint or may be a manifestation of underlying systemic condition/psychological stress Visibly communicates the clients’ health WHATSUP questions INSPECTION AND PALPATION Phys. Assessment includes skin,hair nails,scalp, and mucus membranes.Client must be fully disrobed but draped for privacy

17 Well lit and warm room Nl skin is intact, warm, smooth, dry, well hydrated, with firm skin turgor. Surface is flexible and soft Know color ranges Know developmental changes Inspect for color, moisture,lesions,edema, breaks in skin integrity, vascular markings, turgor, and cleanliness

18 COLOR obj. #6 Factors include temp of client, O2 level, blood flow, exposure to UV rays, positioning, genetic differences Pallor; a decrease in color due to vasoconstriction, decreased blood flow or < HgB BEST ASSESSED ON FACE, CONJUNCTIVA, NAILBEDS AND LIPS

19 Erythema; reddish discoloration, also may indicate circulatory changes due to vasodilation, incr. blood flow to skin from fever or inflammation BEST ASSESSED ON FACE OR AREA OF TRAUMA/RASH Jaundice (yellow-orange) may occur as result of liver disease. BEST ASSESSED IN SCLERA OF THE EYE

20 Cyanosis; bluish discoloration
Cardiac, pulmonary or perfusion problem BEST ASSESSED LIPS, NAILBEDS, CONJUNCTIVA, PALMS People of mediterranean descent, may have nl bluish on lips coloration Brown coloration due to increased melanin prod. Could be from chr. exposure to sun or due to pregnancy or PVD BEST ASSESSED FACE, AREOLA, NIPPLES, AND AREAS EXPOSED TO SUN

21 LESIONS obj. #7 Any change or injury to tissue
Assessment may help determine cause of skin disorder Class. As primary; secondary PRIMARY represent initial reaction to a disease process SECONDARY lesions are the changes that take place in the primary lesion from infection, scratching, trauma or various disease stages

22 PRIMARY LESIONS Macule; flat, non-palpable, usually smaller than 1cm; freckle Papule; palpable, solid raised lesion; wart, ringworm;1cm or less Nodule; solid raised lesion, larger and deep; fibroma Vesicle; small fluid filled blister type lesion; 1cm; chicken pox

23 Bulla; larger fluid filled blister;>1cm, burns
Pustule; sm. elevation of skin, vesicle or bulla that contains lymph or pus; impetigo/acne Wheal; round transient elevation of the skin caused by dermal edema; white in the center and red in the periphery; hives, insect bites Plaque; PATCH, solid or raised lesion on skin OR mucus membrane >1cm in diameter; psoriasis Cyst; CLOSED SACK OR POUCH; contains solid, semi-solid or liquid material; sebaceous cyst

24 SECONDARY LESIONS Scales Crusts Excoriations Fissures Ulcers
Lichenification scar

25 configurations Discrete Grouped Confluent Linear Annular Polycyclic
Arciform reticular

26 NOTE: Color Size in cm Location Distribution Configuration (pattern) Exudate (amt., color, odor, any other s/s) Read how lesions may present in peoples of color

27 Check levels of hydration
Dryness, moisture, scales and flakes Moisture within skin folds Should normally be smooth and dry

28 PALPATION OBJ.#8 Utilized in conjunction with INSPECTION
Dorsum of hand for temp. Palpate lesions with fingertips to deter. Size, contour, consistency Note level of discomfort with palpation Wear gloves Turgor/texture Back of forearm, over sternum (best for elderly) Tenting with gradual return= poss. Dehydr., aging

29 Vascular marking Normal Abnormal (petechiae, ecchymosis)
Petechiae sm. Purplish hemorrhagic spots <0.5cm Seen best on dark skinned persons on conjunctiva and oral mucosa Ecchymosis is a bruise; coloration changes

30 edema Dependent edema; part of body at lowest point; feet , ankles, sacrum Often relieved with elevation and repositioning, elastic stockings, medications Brawny edema Pre-tibial edema

31 Edema Occurs due to build up of fluid in the tissues Skin becomes stretched, taut and shiney Location, distribution and color are determined and documented If unilateral, compare to other side Measure to track progression or regression

32 When suspect edema, palpate for tenderness, mobility, and consistency
Pressure from finger/thumb 5sec. leaves indentation (pitting edema) Classified by depth 1+=1mm depth or “trace” edema 2+= 2mm or small amt. edema 3+=moderate edema 4+ large amount of edema

33 hair Hair distribution is palpated Quantity, thickness, and texture
Note any areas of ALOPECIA Terminal hair is hair of scalp, eyebrows, axillae, pubic areas in both sexes and facial and chest hair with men VELLUS hairs are soft downey covering body Normally has uniform distribution

34 Scalp hair can be thick, thin, coarse, shiney, curly, straight
Describe distribution and cleanliness

35 NAILS Reflect general health
Color, shape, texture, thickness, any abnormalities Normally pink, smooth, hard, slightly convex (160 degree) with firm base Elderly: yellowish-gray, thickening, ridges Brown or black pigm. between nail and nail base In persons of color is nl

36 Abnl findings include clubbing (poss. Hypoxia)
Spoon nails (concave)(koilonchia); poss. Anemia Thick nails; (poss. Fungal infection) Observe for redness, swelling, tenderness Beaus’ lines Splinter hemorrhages paronychia

37 Diagnostic tests obj.#9 Cultures to show presence of bacteria, fungi, viruses fungi: specimen in 10% KOH; remains at room temp until sent to lab viral: fluid gently expressed from intact vesicle with sterile swab, special culture tube MUST BE KEPT ON ICE until sent to lab ASAP See box 50-2 for instr. On wound cultures

38 Skin biopsy Indicated for deeper infection
Eval. For dx and/or efficacy of current tx Excision of small piece of tissue Punch bx: plug of tissue for full thickness specimen Incisional bx: deep incision with scalpel ALWAYS REQUIRES CLOSURE WITH SUTURE Shave bx removes area of skin just above rest of skin

39 All bx require sterile field/technique
Prepare client Most painful part is ususally injection of local anesthetic

40 WOODS’ LIGHT is use of UV rays to detect fluorescent substances in hair and skin that are present during certain diseases such as tinea capitis (ringworm) Hand held black light in darkened room

41 Skin testing Patch and scratch when allergic dermatitis is suspected
Done by dermatolgist on uninvolved skin/upper back, arms, must be shaved SCRATCH; superficial scratch or prick with allergen; IMMEDIATE REACTION Wheal= + reaction MUST HAVE RESUSCITATION EQUIP AVAIL.

42 PATCH test: delayed hypersensitivity
Develops in 48-96h Allergens applied under occlusive tape patches Review procedure Final reading in 2-5 days

43 Therapeutic measures obj.#10
Wet compresses for acute, weeping, crusted, inflammatory, ulcerative lesions Decrease inflammation, cleanse and dry the wound To continue drainage from the area Can be ordered as sterile or clean procedures Cool tap H2O, Burrows, normal saline, magnesium sulfate applied q3-4 h for 15-20min Not prescribed for more than 72h/skin too dry or macerated. For cool compr. Reapply q 5-10min

44 Balneotherapy: therapeutic baths
Medicate large areas of skin, remove old medications, debridement, relieve itching and inflammation Lasts for 15-30min. Bathmats are important Water/saline for weeping, oozing, and erythematous lesions

45 Colloidal baths for wide area of lesions, to dry and relieve itching
Medicated tar baths for chronic eczema and psoriasis Need WELL VENTILATED ROOM To increase hydration of skin after bath, use lubricating agent applied to damp skin An EMOLLIENT is used for LUBRICATION AND TO RELIEVE ITCHING

46 Topical medications Include lotions, ointments, creams, gels, pastes, intralesional therapy May need systemic medications as well Review how and why each type of medication is used and how applied. Powders should not be used with clients with respiratory or traches

47 DRESSINGS Used to enhance absorption of topical meds, promote retention of moisture, prevent evaporation of medication, reduce pain and itching Occlusive drsg; to seal wound; airtight plastic film placed over topical agent Tube gauze, cotton socks, gloves, etc. Medication may be impregnated within drsg (chordran tape Review nursing care plan for client with occlusive drsg (50-3)pg 946 Applied ONLY to wound area, not healthy skin

48 Transparent dressings, (Opsite,Tegaderm)
Hydrocolloid protect areas exposed to pressure, and treat ulcers in beginning stages Gels, pastes, granules to fill in deep wounds/ulcers to promote granulation and healing

Moh’s chemosurgery technique; method of excising tumors of the skin, done in layers until entire tumor removed. Insures complete removal of the tumor. Helpful in tx of basal cell cancers (pg 1375 Tabers)

50 Cryosurgery; use of extremely cold probes to destroy unwanted, or cancerous or infected tissues (508,T.) Photochemotherapy; use of light and chemical together to treat certain conditions such as psoriasis or cutaneous T-cell lymphoma

FIRST INTENTION; SECOND INTENTION AND THIRD INTENTION Edges approximated and closed with sutures= 1st intent; minimal scarring. 2nd intent=wound left open to heal by granulation; scarring may be extensive 3rd intent=infected site may be left open/reopened until all signs of infection are gone, then surgically closed

Assess site minimum 3x day (4h x3) Assess for dead tissue, maceration, exudates, Cleanse, pat dry Apply agent and occlusive drsg REMOVE for 12h out of 24h Assess/eval forprogression/regression


54 PRESSURE ULCERS OBJ.#12-14 SORE CAUSED BY PROLONGED PRESSURE AGAINST SKIN in one position Weight of body compresses capillaries against a solid object, especially over bony prominences Results in tissue anoxia Start to develop in 20-40min.if pressure not relieved

55 Assess at risk client Use Braden scale or similar scale Assess labs for low serum albumin, anemia, level of immobility and incontinence

56 Other causes include tight splints, casts, traction
At risk are the immobile, decreased sensation, decreased circulation, decreased neurological function Mechanical forces are friction, shear and pressure. When pressure to the skin is greater than the capillary bed pressure, there is impairment of cellular metabolism with decreased blood supply to cells causing tissue ischemia. The reduction in blood flow causes BLANCHING.(LOSS OF COLOR)

57 “FRICTION” rubbing of skin surface with an external mechanical force
“FRICTION” rubbing of skin surface with an external mechanical the effect of sheet burns. “SHEARING”occurs when pt slides down or is pulled up without lifting buttocks. Skin and subcut. tissues remain stationary; fat, muscle and bone shift in direction of body’s movement Damage occurs deep in tissues

58 Prolonged pressure occurs in the elderly due to nl skin changes
The obese, because fat cells are poorly vascularized, the thin, because there is little padding over prominences, and those with impaired peripheral circulation

59 Signs and symptoms Pain at ulcer site
Freq. assess at common sites: sacrum, heels, elbows, lateral malleoli, greater trochanters, ischial tuberosities Describe according to “3” color system “blackened” tissue=necrosis ‘yellow” color and with exudates=infection present “red”wounds are pink/red and are in the healing stages

60 Treat worst color first
Dead tissue must be removed first or healing will not take place

61 Interventions obj.#13 Box 51-1avoid use of soap and water on dry skin
Clean and dry between toes Perineal cleansers Moisturizing agents without alcohol Avoid areas of pressure,don’t massage areas of redness Assess for areas of redness, if stage 1, initiate turn/position schedules

62 Short fingernails Use of pillows, pads to maintain good body alignment. Use of specialty mattresses, pads to decrease pressure Encourage activity. Continue to assess skin and position Teach patient to shift weight q15min. When lying or sitting If immobile, needs freq. active/passive ROM Provide high protein, vitamin rich diet Braden scale to assess for risk

63 Heels should not rest on bed
Avoid source of any pressure behind calves if using pillows to elevate heels Use protectors to alleviate pressure on vulnerable sites NEVER USE A “DONUT” Avoid allowing skin surfaces to rub together Use trapeze, draw sheets to move pt in bed

64 Complications are wound infections, progression to a deeper, larger wound

65 DIAGNOSTIC TESTS All considered to be colonized with bacteria( bacteria present); wound not necessarily “infected” Cleansing and mech. debridement can prevent progression to infection Swab cultures; cultures for sensitivity done to identify causative agent from suspected infected sites Must determine between infection and bacterial colonization. If wound is healing by 2nd intention, will be colonized by flora on skin and in environment. If growth exceeds local tissue defenses, then becomes a true infaction

66 When ulcer not healing, invasive/non-invasive blood supply studies are recommended
Wound biopsies may be obtained in the case of large, extensive wounds Medical treatment varies with size, depth and stage of ulcer, pt condition. ALL PRESSURE MUST BE REMOVED FOR HEALING TO OCCUR, cleanliness maintained Debridement, cleansing and wound drsg. To provide moist, healing environment

67 Debridement: removal of non-viable tissue from the wound
Non-surgical means: mechanical, enzymatic, autolytic Mech.; scissors/forceps; dextranomer beads; whirlpool baths; wet to dry saline gauze

68 Results in non-selective debridement
Usually very painful; pt needs premed Enzymatic proteolytic agent; selectively digests necrotic tissue. Requires very careful application. Will digest living tissue also Autolytic; use of synthetic dressing; a moisture retentive drsg. Eschar is self digested due to enzyme action. NOT USED FOR INFECTED WOUNDS

69 SURGICAL debridement removal by scalpel, of devitalized tissue, thick adherent eschar.
May need a graft to close wound, espec. For full thickness ulcer or loss of joint funct involves a donor site Needs continual assess for pain during procedure

70 Wound cleansing Should be cleansed with whirlpool or shower head/irrigation with between 4-15lbs per sq. inch(psi) Less than 4psi does not effectively cleanse. Greater than 15psi may damage good tissue If wound debris or light layer of eschar present, use 30ml syringe with 18g needle/250ml of NS This pressure will also remove bacteria

71 If wound healing and tissue is red ( sign of new granulation tissue), use 30-60ml NEEDLELESS syringe to prevent trauma to new fragile tissue. After cleansing/dbr. Apply occlusive drg Wounds need moist env, minimal bacterial colonization and a healing temp; takes 12h to occur.if freq removed, may not reach healing temp Infected wounds are NOT covered with occlusive

72 Wound dressings Vary according to size, location, depth, stage of ulcer Commonly used materials; hydrogel, polyurethane, hydocolloid wafers, biologic agents, alginates and cotton gauze Use hypoallergenic tape to secure PRESSURE MUST BE KEPT OFF OF ULCER

73 Nursing assessment Ongoing assessment
Recognize causative factors and any impediments to healing Wound measurements including depth Probe gently with q-tip to detect and measure tunneling

74 Wound staging 1; skin intact but red and does NOT blanch; may have warmth, hardness and deeper tissue damage 2; break in skin with PARTIAL THICKNESS LOSS OF EPIDERMIS/DERMIS. Appears as a shallow crater, abrasion, or a blister

75 3; full thickness skin loss that extends to the subcutaneous tissue, BUT NOT THE FASCIA. There may be undermining of adjacent tissue. Looks like a deep crater, may have eschar 4; full thickness loss with damage into the muscle, bone, other support structures. May have undermining and sinus tracts

76 Assess the wound exudate
Will be serosanguiness or may be purulent Purulent may have color and odor depending on the infecting agent Yellow = staph Beige and fishy=proteus Green-blue /fruity=pseudomonas Brown/fecal=bacteroides

77 Assess for granulation
Should be pink/red and slightly spongey Assess ulcer min. q24h; color , size, exudate Assess pt temp Provide wound care/sterile technique Assess pt for pain/can pt sleep, eat

78 Inflammatory skin problems dermatitis obj15-17
Char. by itching, redness, lesions of varying sizes and distribution Often caused by exposure to allergens, irritants,: can be precipitated by emotional stress and genetic factors Eczema ( non-specific term) and dermatitis used interchangeably

79 Contact dermatitis: acute/chronic
Caused by DIRECT CONTACT WITH IRRITATING SUBSTANCE; SOAP, MEDICINE Allergic: contact with an allergen resulting in A CELL MEDIATED IMMUNE RESPONSE Atopic: chronic, inherited, assoc with asthma. Lesions often become lichenified and hyperpigmented

80 Seborrheic: chronic inflammatory, see seborrhea,excessive production of sebaceous secretions ( scalp face, axilla, genitocrural areas), greasy scales,yellow or pink-yellow crusts Assoc. with emot. Stress, often a genetic pre-disposition

81 3 types are common Atopic, contact, seborreic Chronic, usually respond to tx, but recur See preventive measures Present as dry flakey scales, yellow crusts, fissures, macules, papules Worsen with continued irritation and exposure to offending agents

82 Dx based on hx, s/s, clinical findings.
Review table 51-1 Tx based upon s/s Control itching, pain, decrease inflammation, control or prevent crust formations, prevent further skin damage, infection

83 Measures to control s/s are:
Use of antihistamines, anti-puretics and analgesics to control itching and pain Use of steroids topically, intralesionally or systemically to control inflammation Topical is preferred as systemic use over the long term can cause side effects and adrenal suppression Read page 325 in Davis 10th edit. For s/e to corticosteroids

84 Use “whatsup for nsg assess
Use “whatsup for nsg assess. Be sure to include assessment for altered body image Review your NANDA dx; impaired skin integrity, disturbed body image, and defic. Knowledge related to disease and tx Goals of tx to keep skin intact, or improve, prevent infect., maintain comfort

85 Give me at least 10 questions with rationales from whatsup, 50-1
Display an accepting attitude Teaching for how to apply medications, robin How are you able to measure your goals for effectiveness of tx Controlled or in remission, itching or discomfort minimal, able to socialize, pt able to describe and demonstrate self care

86 Psoriasis Chr. Inflammatory disorder in which the EPIDERMAL CELLS proliferate abnormally fast. Ordinarily takes 27 days. With psoriasis, takes only 4-5 The abnl keratin forms loosly adherent scales on reddened base Exacerbations/remissions Cause unknown, but has large familial component

87 Onset can be any age with 27y being the average
Severe if starts in childhood Sun /humidity may suppress Strep pharyngitis, stress, hormonal changes, weather, skin trauma and meds ( antimalarials, beta blockers and lithium) may exacerbate

88 No known true prevention, but avoid stress, meds, trauma, resp
No known true prevention, but avoid stress, meds, trauma, resp. infections if poss. s/s vary with type of psoriasis Lesions usually are red papules that join to form plaques with DISTINCT BORDERS silvery scales form on untreated lesions Most affected areas are: ELBOWS, KNEES, SCALP, UMBILICUS, GENITALS May see nail involvement, dry, brittle hair

89 Complications may include secondary infections, psoriatic arthritis
Systemic s/s and lymphadenopathy Tests would depend on severity Usually done on phys. Findings Testing done to dx a concurrent disease or secondary infect.

90 Anthralin, a strong irritant, may be used with salicylic acid as a paste.
Can cause a chemical burn, not on for >2h Used with tar and UV light under close medical supervision UVB (short wave) and UVA (long wave) amount of exposure dtermined by pts condit., pigmentation and susceptibility

91 Occlusive drsgs enhance penetration of meds
Keratolytics enhance effects of salicylic acid to loosen, remove scales Tars are usually prescribed along with steroids. Tars act to slow cell division in the epidermal layers Never use occlusive drsgs with tars

92 Must WEAR EYE GUARDS during tx
PUVA tx is oral Psoralen used in conjunct with UVA tx. This tx temporarily inhibits DNA synthesis Pt MUST WEAR DARK GLASSES DURING TX AND FOR ENTIRE DAY AFTER TX. Longterm effects are unknown. Possible incr. risk of skin cancers, premature aging and actinic keratosis

93 Observe pt closely for redness, tenderness, edema and eye changes
Depending upon pt condition, initial and f/u eye exams, skin bx, urinalysis and blood work may be ordered Antimetabolites..a last resort Methotrexate most common agent, can lead to hepatotoxicity. Liver bx and labs are routinely done prior to tx. Contraindicated in persons with any liver, renal or bone marrow disease

94 Nursing care would be the same as for any pt with a dermatitis, but be sure to emphasize freq. periods of rest to enhance the antimitotic effects of the medications

95 Usually females pred. In males, often have Rhinophyma (enlarged, redenned/purplish nose
Heat/cold, spicey foods Avoid temp. extremes/alcohol/stress


97 Rosacea Chronic acneform disorder of face
Increased reactions of capillaries to heat Often exists with acne Often cause of significant facial cosmetic disfigurement Age 30-50y

Impetigo contagiosa Common , infectious, inflammatory skin disorder Strep or staph Pools, pets, dirt fingernails, contaminated materials, or secondary to scrapes, cuts, etc.

99 Primary infection appears on exposed areas, extrem
Primary infection appears on exposed areas, extrem., hands, face , neck, skin folds OOZING, THIN ROOFED VESICLE that grows rapidly and produces a HONEY COLORED CRUST; EASILY REMOVED, replaced with new ones Heal in 1-2wks if allowed to dry


TOPICALANTIBIOTICS AFTER REMOVAL OF CRUSTS Gentle washing with mild soap and warm water to remove crusts Antipyretics Clean hands/nails, mitts, GOOD HYGIENE REMAIN HOME UNTIL ALL LESIONS ARE HEALED Observe for 6-7 weeks for s/s glomerular nephritis

102 HERPES SIMPLEX common viral infection
Hsv1 and hsv2 HSV-1 occurs above the waist, typical cold sore on mouth HSV-2 occurs below the waist and causes genital herpes Primary infection occurs thru direct contact, respiratory droplet or exposure to fluid filled vesicles

103 Lies dormant in nerve ganglia near the spinal cord…immune system can’t destroy it. At this time, pt has no s/s, may first present with pain , itching, burning at site of breakout Recurrence is spontaneous; stress, lowered immune, fatigue, injury Secondary lesion may be single or as a group of vesicles or pustueles on an erythematous base Crusts form, dry, heal in approx. 1 wk

104 LESIONS ARE CONTAGIOUS for 2-4 days before dry crusts form
Can be red lesions without vesicles Virus sheds Avoid contact with a known infected lesion during the blistering phase can prevent the primary infection Attacks diminish with age..contagious until scabs form

105 If herpes simples is present in the vagina at childbirth, the newborn may be infected and develop meningoencephalitis or panvisceral infection If rub lesion and rub eyes, can develop HSV infection in eyes, possible blindness, brain infection

106 Culture provides definite dx
Usual dx based on s/s, hx NO COMPLETE CURE Topical acyclovir drug of choice to tx primary lesions to suppress multiplication of vesicles.DOES NOT WORK ON SECONDARY LESIONS. Oral acyclovir may be recommended for severe or freq. attacks.; people who are immunocompr. Creams. Ointments may be prescribed to speed drying, healing..may need addit. Of oral antibiotics

107 Nursing education of pt is PRIMARY IMPORTANCE; INSTRUCTION ON HOW TO AVOID INFECTION, WHEN IT IS CONTAGIOUS, AND how to prevent spreading to other body parts

108 Furuncles and carbuncles
Furncle; small tender boil; occurs deep in one or more hair follicles, spreads to dermis Usually caused by Staph Areas of excessive perspiration, friction and irritation Yellow, black or whitehead Pain, tenderness, erythema, surrounding cellulitis, poss. lymphadenopathy

109 Carbuncle; extension of furuncle
Abscess of skin and subcutan. Tissue Where skin is thick, non-elastic, fibrous Upper back, back of neck, buttocks Fevers , pain, leukocytosis, collapse Debilitated clients and diabetics

110 Furuncles can progress to carbuncles
Systemic infection Can spread infection to others (staph) Scarring can occur, may require I&D, and systemic antibiotics

Use antibacterial soaps to cleanse/ointment Surg. I&d Cover lesion with DSD DOUBLE BAG ALL SOILED DRESSINGS Analgesia/antipyretics Bed rest advised with carbuncles/or furuncles located in the perineal/anal areas (Forniers’ gangrene) Cleans living area and equipment daily, laundry after each use Strict hand washing

Different virus than HSV This is caused by Varicella zoster, thought to be identical to virus causing chickenpox Presents as acute, inflammatory and infectious outbreak of painful vesicles on erythematous base. Out break occurs along the dermatone(s) of one or more cutaneous sensory nerves Usually unilateral

113 Thought to be a reactivation of latent zoster virus
Incubation 7-21 days Vesicles appear in 3-4 days Eruption generally occurs posteriorly and progresses anteriorly and peripherally along the dermatone Duration can vary from 10days to 5+ weeks

114 Occurs most commonly in elderly
Or immune suppressed, immun-suppr. Agents or with malignancies, injuries to spine or cranial nerves Avoid contagion by avoiding contact with person with this disease. Contagion possible a few days before eruption of vesicles and until dry

115 May present with vesicles and plaques
Irritation, itching, fever, malaise May be very painful, pain likely to increase with age of pt and remain after healing in the elderly Condition referred to as hyperesthesia; any measures to increase comfort should be used; cold compresses

116 Dx by clinical presentation and assoc. s/s
Dx by clinical presentation and assoc. s/s. may do cultures for suspected secondary infection If in more than two dermatones, pt will need isolation room in hospital Some evidence can be airborn

117 complications Post herpetic neuralgia
Persistent dermatomal pain, can last for months and years. Can have severe negative impact on quality of life Opthalmic herpes zoster affects 5th cranial nerve; serious complication, can lose sight, hearing loss, facial paralysis, vertigo Full thickness skin necrosis and systemic viremia Can cause chickenpox in others

118 Treatment Aimed towards controlling s/s and preventing complications. Should start within 72h Acyclovir, topical, oral, IV may be used at initial outbreak, early stages as well as Famciclovir and Valacyclovir Doesn’t cure, but helps suppress the viral outbreak Analgesics for pain; of limited value, corticosteroids to reduce pain, but NOT with opthalmic involvement. Topicals, tricyclics, anticonvulsants Antihistamines, antibiotics, medicated baths

119 Only reliable way to differentiate from HSV is culture, serum PCR/IFA
Use of new vaccine, Zostavax in people age 60 and younger

120 FUNGAL INFECTIONS DERMATOPHYTOSIS a fungal infection of the skin that occurs when there is a break in skin integrity in the presence of warmth and moisture. Occurs with direct contact with infected humans ,animals or objects TINEA IS THE OPERATIVE NOUN. The second name stands for the body site affected

121 TINEA pedis(athletes foot), common.
Chronic plantar scaling, acute vesicular, and interdigital Chronic plantar scaling in fold lines, itching not usually present Acute vesic. Eruption of tiny painful itching blisters Interdigital, common form, erosion, scaling, fissuring in toe webs, painful, burning, itchy with offensive odor

122 Chronic planatr treated with keratolytics, topical antifungals
Chronic planatr treated with keratolytics, topical antifungals. NOT CURATIVE ACUTE SOAKS OR BATHS 2-3X DAY TO DRY BLISTERS astringent paint applied to unroofed blisters Interdigital treated with combinations antifungals, antibiotics and foot soaks with Burrows

123 Pt teaching important Feet dry, avoid plastic/rubbersoled shoes Water shoes in public showers Cotton socks to absorb perspiration

124 Tinea capitas; ringworm of scalp
Contagious; loss of hair in children Presents as scattered round red scaly patches, may have small pustules Brittle hair at site, breaks off, mild itching and kerion inflammation

125 Treat with systemic antifungals because of high relapse rate with just topicals
Highly contagious Teach med side effects, never share combs, headgear, pillows, brushes Check pets for s/s of infection

126 Tinea corporis; ringworm of body
Erythematous macule that progresses to rings of vesicles, alone or in groups, on exposed areas of body, may be intensely itchy Infected pets are freq. source Topical/oral antifungals, topical steroids Keep skin dry, wear cotton

127 Tinea cruris (jock itch)
Ringworm of groin may extend to inner thighs and buttocks. Often present along with tinea pedis Small scaly patch, then sharply demarcated plaque with elevated scaly or vesicular borders May be intensely itchy

128 Teach to avoid heat, moisture, friction
Topical anitfungals; spread beyond lesion borders Oral antifungals/steroids may be needed to control/cure Remember to discuss possible med side effects, short and long term with client

129 Tinea unguium (onychomycosis) fungal infection of fingernails and toenails
Usually lifelong Yellow thickening of nailplate, crumbly debris; nail plates become separated, eventually nail is destroyed

130 Topicals usually not effective
May need nail avulsion (removal) High rate of relapse

131 CELLULITIS Inflammation of skin cells and or cellular or connective tissue from a generalized infection with Staph or Strep Result of skin trauma or secondary infection of an ope wound, or may have no immediately known cause Most freq. occurs in lower extremities Good hygiene and prevention of cross contamination

132 Presents with warmth, pain, edema, erythema, tenderness, fever locally and progresses rapidlyif not treated C&S of pustule or lesions to identify organism. May need blood cultures if bacteremia suspected Always be aware of your patient’s immune status

133 Topical and oral or IV antibiotics
Get good hx; recent trauma?, abnl temp, v/s Use of good hand hygiene at all times for you and the patient, wash linens and clothes Much CA-MRSA now

Occurs freq. on upper back, face, shoulders, whereever there are numerous hair follicles Multifocal causes, often hormonal Sebaceous glands under endocrine system control; androgens

135 Stimulation of glands causes more sebum to be produced
This with grad. Obstr. Of pilosebaceous ducts with debris, leads to inflammation and rupture of seb. Gl. This leads to greater infl., formation of pustules, nodules and cysts

136 Hereditary factors, stress, strong soaps contribute
NOT RELATED TO CHOCOLATE, DIET, CLEANLINESS Can occur regardless of interventions Initial lesions are comeodones, closed whiteheads, lead to open lesions with blackheads, lipids and melanin pigments

137 Effective topical agents; benzol peroxide, an anticiotic, erythromycin and tetracycline(teeth)to kill bacteria in follicles Vitamin A acid (retin-A to loosen pore plugs and prevent new form. Antibiotics usually reserved for severe cases, espec Retin-A must be closely monitored Must be tested to be sure not pregnant, use 2 forms of birthcontrol 1 mo before, during and after

138 Parasitic disorders infestations
Infestation by lice Pediculosis capitas,corporis, pubis Bite skin and feed on human blood Leave eggs and excrement Causes intense itching Lice are oval and 2mm in length

139 P. capitas, female lays eggs(nits) close to scalp hair and behind ears
Silvery white Transmitted dy direct contact with infested organisms or objects(fomites) Most common in children and people with long hair May not be itchy

140 P.corporis; body lice that lay eggs in seams of clothing, then pierce skin
Neck, trunk thighs Intense itching, excoriations P. pubic(crabs) usually in genital area, but can be hairs of chest, axilla,eyelashes, beard Often thru sexual contact,less often infested bed linen Intensely itchy

141 Prevent by avoiding contact with infested persons/objects
Don’t share equip.,routine washing of clothing

142 Secondary infections/impetigo, boils
Mrsa Parallel linear scratches,Hyperemia, hyperpigmentation Can be vectors for rickettsial diseases Through hx and exam, may also want to test for STDs Pediculocides/nix Complications with other meds

143 Goal to kill the parasites and mechanically remove nits
Use of pediculocides ie permethrin or pyrethrum are commonly used Some lice may exhibit resistance “NIX” or permethrin active for approx. 1wk, kills adult lice immediately and nits as they hatch

144 Rid, A-200 pyrinate must be re-applied in one week
Physostigmine opthal. Oint to eyebrows, lashes, no other meds

145 Nursing care; give full instructions on the medications used, possible side effects, how, when and where the medication is used and for how long. How to remove nits How to remove lice from body, hair and linens Children out of school until adequately treated

146 SCABIES Contagious and caused by Sarcoptes scabiei
Intimate or prolonged contact with infected clothing, bedding, animals Mites burrow into superficial layers of skin; show as short, wavy brown or blacklines. Most contagious at this time, but pt may be asymptomatic

147 s/s may not appear for 4 wks
Mites live for 24h only without human contact All infected Persons and animals need to have tx at same time Linen and clothing washed, but furniture does not require cleaning

148 s/s = itching and rash, espec. At night
s/s = itching and rash, espec. At night. Itching starts 1mo after infestation and may continue for days and weeks after tx Signs may be concentrated in webs of fingers, axilla, wrist folds, groin, genitals, excoriations from scratching On penis, groin

149 Hypersensitivity to mite can result in crusted lesions, infection
Dx confirmed by superficial shaving of a lesion and microscopic eval. For mites, eggs or feces

150 Topical scabicides are used for disinfection
Entire body, neck to feet and folds, left on for 8-12h, then washed off. One tx usually suffic. If not re-infected Caution pt that itching may return after tx until the allergic reaction subsides Dead mites remain in theepidermis until exfoliated

151 PEMPHIGUS Acute or chronic serious skin disease characterized by the development of large bullae on normal skin and mucus membranes, usually affects older poulation When they rupture, leave open, raw, painful, eroded, oozing partial thickness wounds, that form crusts Originates in the oral mucosa and spreads to the trunk, involving large areas of body

152 May also experience pain, burning, itching and may develop foul smell
Interferes with chewing, talking, swallowing, pt miserable Likely to develop a secondary bacterial infection..high mortality rate with this disease

153 Dx by +Nikolski’s sign (sloughing or blistering of nl skin when pressure applied)
Bx will reveal acantholysis (separation of epidermal cells from each other

154 Medical Tx consists of trying to control s/s and infection, body fluid and protein losses, promote healing Corticosteroids in large doses, cytotoxic agents, analgesics, antipyretics Needs high protein/high calorie diets to maintain nutrition and fluid replacement

155 Nursing care Educate pt on effects and side effects of medications
Maintain I&O, body wt, b/p Potassium permanganate baths to cleanse, disinfect and remove odors. Thoroughly dissolve these crystals Offer fluids, provide appropriate psycho-social support

156 At risk for alterations in self image
At risk for nutritional deficits At risk for infections At risk for alterations in fluid/electrolyte balance At risk for medication side effects of steroids At risk for alterations in comfort At risk for grief reaction/mortality

157 BURNS pages ; in PEDS Wounds caused by energy transfer from a heat source to body tissue, causing tissue damage Infants under age 2 and adults over age 60 have highest mortality rates Heat denatures proteins and interrupts blood supply 3 zones of tissue damage EPIDERMIS; hyperemia; no interruption of blood supply; no cell death; area least affected by heat

158 DERMIS; stasis injury; temp. incr
DERMIS; stasis injury; temp. incr. on tissue edema; vasoconstriction, sludging of red blood cells; red, + blanching; fragile area prone to necrosis/infection SUBCUTANEOUS TISSUE; coagulation injury; irreversible cell death; white/gray; no blanching

159 Damage related to: temperature of agent, type of agent, length of exposure, conductivity of tissue, thickness of tissue involved Loss of large areas of skin= loss of protective functions, impaired temp. regulation, possible infection, loss of fluids, sensory deficits, impaired skin regeneration, impaired secretory/excretory function

160 Alterations in skin function affects most all body systems
Increased capillary permeability leads to leakage of plasma and proteins into tissues; leads to edema and loss of intravascular volume (HYPOVOLEMIA) Evaporative water loss, greater than 4-15x nl Incr. metabolism= incr. water loss thru resp. system

161 Cardiac funct. ; decre. output, that worsens due to lower circ
Cardiac funct.; decre.output, that worsens due to lower circ. Plasma vol. As plasma leaks into interstitial tissues,for first 48h, leads to severe hypovolemia; if untreated, hypovolemic shock. At risk for 72h after burn. Must have fluid replacement. There is an increase in Hct., and red blood cell destruction; decreases platelet function (pg 367)intravenous fluids as ordered, check urinary output, likely will require indwelling catheter

162 Increased metabolic demands; body maintains high metabolic rate for healing
Severe catabolism (breakdown of body tissues and cellular structures) results in neg. nitrogen balance, wt. loss, and decre. Wound healing Stress triggers elevated catecholamine levels (epinepherine, norepinepherine) which causes elevated glucagon levels and hyperglycemia

163 GI problems ie. Gastric dilation, Curling’s ulcer (peptic ulcer from stress), paralytic ileus, and superior mesenteric artery syndrome (intestinal angina from occlusion) Acute renal insufficiency Electrical burns can result in tubular necrosis as a result of myoglobin casts (muscle damage)

164 Pulmonary effects mostly related to smoke inhalation, and very common in burns to face and chest. Hyperventilation in proportion to severity of burn Incr. O2 consumption. Rapid swelling/edema of the respiratory passages, hoarse voice. Elevate head of bed to 30 degrees, continuous assessment, provide O2, prepare pt for intubation if nec. Immune system severely compromised from loss of substantial portion of skin barrier and first line defense macrophages.

165 Common burns Thermal/steam/scalds Radiation Chemical; acids or alkali, cancause skin and pulmonary burns; dry chemicals must be brushed off Flames Contact Electrical; more serious than appears; lightening in excess of 50,000 degrees; may present with feathery, branching appearance

166 Burn classifications Partial thickness (1st-2nd degree)
Superficial; comprised of epidermis, poss. Papillae of dermis Bright red to pink, blanches, fluid filled blisters, glistening, moist Very sensitive to air , temp. and touch Heals in 7-10 days

167 MINOR BURNS 15% of TBSA NOT involving face , hands, genitalia or Full thickness burn less than 2% of TBSA

168 Partial thickness (deep; 2nd degr.);
Appendage usually involved ½-7/8 dermis Blisters may be present Pink, light red, white, blanchable Exposed nerve endings 14-21 days for healing May need grafting to prevent scars

169 MODERATE BURNS 15-25% of TBSA or Full thickness burns that are 10% of TBSA

170 Full thickness (3-4th degree)
Epidermis down thru bone 3rd degr. Involves entire dermis and portions of subcutaneous tissue, fatty tissue showing Red, Snow white , gray, brown, leathery, dry Nerve endings destroyed, no pain unless close to lesser degree burns Needs grafting

171 MAJOR BURNS Partial thickness burn greater than 25% of TBSA or Full thickness burn involving greater than 10% of TBSA or involving face, hands, feet or genitalia

172 sizing Done by rule of “nines” or Lund and Browder chart
Figure 51-11, see difference in adult and child configurations on “nines” This formula NOT accurate in formulating burn percentages for children, so note differences

173 Common labs ordered Dx thru clinical manifestations and hx
labs: CBC,BUN, fasting glucose, electrolytes, ABGs, pulse oximetry Blood protein; albumin Urinalysis; specific gravity Ekg Bronchoscopy Pulm. Funct, (spirometer, lung vol, diffusion capacity(body’s ability to extract O2 from lungs)

174 Emergent phase onset of injury to completion of fluid resuscitation
BURNING PROCESS MUST BE STOPPED/REMOVE VICTOM FROM SOURCE OF BURN. and airway patency ,breathing, and circulation assured Assess percentage and depth of burns (#2) Clothing must be removed and jewelry (#1) Wound is cooled with tepid water only if TBSA is 10% or less, however,lavage for 20min. Needed for chemical burns.dry chemicals must be brushed off. Use precautions Person covered with sterile or clean sheet to decrease shivering/contamination

175 DO NOT APPLY ICE Assist in wound debridement/medicate for pain prior to txs

176 Assess for hypovolemia (decreased B/P, incr. HR, and respirations)
Monitor ABGs, and carboxyhemoglobin levels

177 Initiate intravenous access, USUALLY LACTATED Ringers, 0
Initiate intravenous access, USUALLY LACTATED Ringers, 0.9% saline or plasma Possible need for TPN Monitor v/s; CLOSE, ACCURATE I&O Maintain NPO Insert indwelling catheter Administer pain medication as prescribed Administer Tetanus toxoid as prescribed Monitor extr for any circumferential burns

178 Check extremities for any circumferential burns
Check extremities for any circumferential burns. Will act like a tourniquet, causing compartment syndrome/respiratory insufficiency. Pt will need an escharotomy; incision thru eschar and superficial fat. Common sites are extremities, trunk and chest

179 Patients, especially children, may quickly become hypervolemic (within 24-96h) even to having pulmonary edema

180 Sterile technique/hand washing
Prevent infection/sepsis

181 Stage 2 (acute) from start of diuresis to near completion of wound closure
Goals are wound closure No infections Minimum scarring/lack of contracture Maintainance of comfort Adequate nutrit support

182 Dialy wound cleansing and debridement
MEDICATE FOR PAIN Hubbard tank or showering for cleansing Debridement; mech. Chemical, surgical or combination

183 Dressings Open or closed, biologic or synthetic or combo
Open involves topical agent no dressing Closed involves occlusive drsg over the wound

184 Limit bulk No skin surface to surface; donut gauze around ear Base drsgs on wound size, absorption needs, protection and type of debridement being done Wrap extremities DISTAL TO PROXIMAL ELEVATE ALL AFFECTED EXTREMITIES ABOVE LEVEL OF HEART

These dressings may be used as donor site dressings; to manage a partial thickness burn and cover a clean, excised wound before autografting Assist with wound healing and stimulate epithelialization

186 Synthetic dressings Are used in management of partial thickness burns and donor sites More available, less costly, easier to store than biologics Variety of materials and sizes Rarely contain antimicrobial agents

187 Biologic and synthetic dressings are TEMPORARY wound coverings for clean partial- thickness AND full thickness injuries Maintain wound surface until healing occurs, a donor site is available or wound is ready for autografting

188 SKIN GRAFTING Autograft is skin graft from the PATIENT’S unburned skin to be placed on clean excised burn site 2 types; STSG ( ) and FTSG ( ) inches in thickness STSG includes epidermis and part of dermis FTSG includes epidermis and entire DERMAL AREA

189 STSG may be applied as a sheet graft or meshed graft
Sheet graft used primarily for cosmetic effect; face, chest, breasts , or hands, placed on as a full sheet Meshed graft, tiny splits, looks like fishnet; allows skin to expand times its original size Allows for coverage of large area with small piece of skin. Good for extensive burn areas Graft take or revascularization in 3-5 days

190 Disadvantages include:
Prone to chronic breakdown More likely to hypertrophy More likely to contract

191 FTSG can be sheet grafts or pedicle flaps
Used over areas of muscle mass, soft tissue loss, hands feet, eyelids Pedicle attached to blood supply and area to area in need of grafting Pedicle not used for extensive wounds; not as popular as free skin grafts

192 FTSGs allows more elasticity over joints
Soft, pliable May allow hair regrowth Provides good color match Less hyperpigmentation Donor sites take longer to heal Requires split-thickness graft to heal or closure from wound edges

193 Promoting factors Adequate hemostasis Anatomic location of graft
Smooth contour Non-joints Graft well secured Immobilization of graft area Good nutitional status

194 Inhibiting factors Infection Necrotic skin
Location on perineum, axilla, buttocks Poor quality donor skin Poor nutritional status Bleeding Mechanical trauma Shock+

195 DONOR SITES Donor sites are considered to be PARTIAL THICKNESS WOUNDS
Try to get healed in days, but many variables affect this time-table Nursing considerations include promoting comfort, preventing trauma and infection Outer dressing to apply pressure to maintain homeostasis remains in place 1-2 days. Dry exposure may require avoidance of pressure, and a heat lamp wts, KEPT 2 FEET AWAY FROM SITE. Loose separating gauze is trimmed



198 MEDICATIONS USED Silver sulfadiazine: buttered on, covered with a light dressing 1-2x day Broad spectrum, low toxicity, Can still have burning sensation can be used with/wo dressings Intermediate penetration of eschar Leukopenia (fever, sore throat, cough) Thrombocytopenia (easy bruising, unusual bleeding)

199 Sulfamylon: buttered on 3-4x day
Broad spectrum, rapid deep penetration of eschar, excreted rapidly Causes pain with application Pulmonary toxicity, metabolic acidosis, may inhibit wound healing With any sulfa med, may have adverse reaction, Stevens- Johnson syndrome,MUST MAINTAIN ADEQUATE FLUID INTAKE

200 Silver Nitrate solution: wet dressing change BID, resoak q2h; broad spectrum, nonallergenic, low toxicity, inexpensive, won’t interfere with healing Poor penetration of eschar; ineffective on established wound infections

201 Bacitration: buttered on q4-6h
No pain, odorless, softens eschar, but..poor penetration of eschar. Ineffective on established wound infections Gentamicin: apply gently 3-4x day Broad spec., covered or left open Ototoxic, nephrotoxic, pain with application

202 Nitofurazone: THIN LAYER dierectly on wound or impregnate gauze
Nitofurazone: THIN LAYER dierectly on wound or impregnate gauze. Change drsg. BID, Broad spec., bacteriocidal PAINFUL APLLICATION May support overgrowth of fungus and/or Pseudomonas

203 STAGE 3 from wound closure to return of optimum function on all levels
Rehabilitation therapy STARTS IN ACUTE PHASE CONTINUES THRU REHAB Reconstructive can take many years 2 major nsg considerations; the most comfortable position is the position of CONTRACTURE and the burn site will contin. to shorten until it meets an opposing force

Exercise program within 24-48h Use of splinting devices for positioning and stretching ie pressure garment Great psychosocial effect Important to return to abilities of preburn level. Requires work of many disciplines and the patient

205 Nursing process Assessment includes: medical hx, known allergies, current medications if any, Extent, depth, burn agent, duration of contact, location of pain, level of pain, associated injuries Determine first aid needs Additional losses, how burn ocurred

206 Nursing diagnosis Primary are: Impaired skin integrity
Impaired gas exchange Deficient fluid volume Ineffective tissue perfusion Imbalanced nutrition Activity intolerance Selfcare deficit Disturbed body image Ineffective coping

207 Deficient fluid volume
Check urine output/replacement 50ml/h in adults; HR AT NL TO 100BPM, stable body wt Wt daily Record I&O, insert indwelling catheter Assess for s/s hypovolemia(<b/p,tachycardic,tachypneic, thirsty, restless, disoriented) Monitor/review labs (electrolytes and CBC) Assess urine specific gravity and for hemochromogens(indicate renal tubular necrosis)

208 Administer osmotic diuretics
Assess gi funct.for paralytic ileus Maintain nasogastric tube/tube patency

209 Impaired gas exchange related
To upper airway edema, carbon monoxide poisoning, edema of capillary aveolar membranes Goal: pt will have patent airway; CO level< 10%, clear lung sounds, PAO mmhg; PACO mmHg, alert and aware No s/s stridor, nasal flaring, retractions

210 Pain related to burns or graft donor sites
Pt will have good pain control as evidenced by verbal and non-verbal cues Does pt verbalize this, how many hours of sleep in 24h, does he/she feel rested

211 Risk for sepsis related to wound infection
Pt will not develop a wound infection Healthy granulation tissue? Unhealed, open area with <10 colonies of bacteria Donor sites free of infection? Did graft take Nl temp/nl WBC?

212 Skin lesions Non-cancerous Premalignant malignant

213 Benign include: cysts, seborrheic keratosis, keloids, pigmented nevi,which must be watched for change in color or moles>1cm, size, inflammation, itching, oozing, bleeding, varigated colors(bluish), irregular borders, warts, hemangiomas

214 Malignant lesions Basal cell carcinoma arises from basal cell layer of epidermis Most common type Sun exposed areas on body Rolled waxy edge, depressed center, can be pearly, crusting and ulceration Rarely metastatic, but can be locally invasive/disfiguring

215 Squamous cell ca., also from epidermis and sun exposed areas of skin and the mucus membranes
Lower lip, neck, tongue, head and dorsa of hands, poss. develops on preexisting lesion (actinic keratosis) Single crusted, scaled, eroded papule, nodule or plaque, fragile, prone to oozing, bleeding Highly invasive with mets

216 Malignant melanoma Malignant growth of pigment cells Highly metastatic/high mortality rate Can occur anywhere on body Many arise out of pre existing moles or nevi

217 Three types: Lentigo maligna; slow growing dark macule on exposed skin surfaces (face of elderly pts) irreg. borders, brown, black, tan. Prognosis good if treated early Superficial spreading; most common type, can occur anywhere on body espec of elderly; slightly elevated plaque with irreg border, varies in color, may bleed or ooze

218 Eventually develops into a nodule
Prognosis is poor at this stage Nodular melanoma appears suddenly Spherical papule or nodule on skin or in a mole Color blue-black, blue gray, reddish-blue Fragile, bleeds easily Mets occurs rapidly, least favorable prognosis

219 prevention Prevention is primary
Limit or avoid direct exposure to UV rays, sun (10a-2p), tanning booths Wear sunblock 15 or> Protective clothing Self examination weekly/monthly See md for suspicious lesions or changes. Have moles or nevi in areas of constant friction removed Fair skinned people, and/or those with a lot of moles, freckles be more cautious, less melanin protection

220 Preliminary based on presentation of lesion
Definitive from biopsy; further testing done if +


222 Miliaria rubra Prickly heat Pinsized erythematous papules
Sweat glands, folds Itching Prevention No bundling Tepid baths

223 Diaper rash Rash from ammonia Burning erythematous rash
Must consider yeast Primary is prevention Expose to air Avoid baby powders Wash and dry thoroughly

224 C. albicans Causative agent for thrush and some “diaper rash”
If mother has vaginitis Milk curds Antibiotic therapy Mycostatin/nystatin q6h, thin layer Cleanliness/open to air as much as possible

225 impetigo Superficial bacterial infection In newborn/staph aureus
Older child group A beta-hemolytic strep Newborn presents as bullous(blisters) Older child non-bullous Highly infectious Follow skin/contact precautions

226 Gown and gloves Infant needs to be segregated from others Appears on face, spreads, crusts and drainage are contagious Soak off crusts, follow with Bacitracin/neosporin Careful handwashing Older child treated in home with careful teaching of caregivers

227 Very itchy, trim nails Medical treatment can be Peniciilen or erythromycin for ten days
Daily wash off crusts,/bactroban ****If older child and organism is strep, infection can be rheumatic fever or acute glomeruloephritis*****

228 Acute infantile eczema
Atopic dermatitis often as a result of reaction to an irritant Common first year of life, after 3mos Uncommon in breastfed babies Hereditary predisposition Hypersensitivity in deep skin layers to protein or protein like allergens

229 Allergens may be inhaled, ingested, absorbed thru direct contact
House dust,mites, egg white , wool Infants may develop hay fever or asthma later in life

230 Starts on cheeks, spreads to extensor surfaces of arms and legs, then entire trunk
Initially red skin, then papule and vesicle formation INTENSE ITCHING causing weeping and crusting, may quickly become infected by strep or staph

231 Common allergens are foods; egg whites, cows milk, wheats, orange juice, tomato juice
Inhalants, dust , pollens, animal dander Materials; wools, nylons, plastic

232 Dx, by process of elimination
Elimination diet/ assess often for s/s malnutrition Serious condition eczema vaccinatum High mortality rate Avoid herpes infection/exposure Severe pain and illness

233 Treatment may include oral antibiotics, antihistamines, sedatives
Cortisone creams only if there is no infection, wet soaks (colloidal), tepid water, emollients Parents are exhausted, frustrated Usually clears by age 2

234 Nursing diagnoses Impaired skin integrity
Disturbed sleep patterns(itching/discomfort) Imbalanced nutrition (elimination diet) Risk for infection Deficient knowledge of caregivers

235 goals Preserve skin integrity Maintain comfort Maintain good nutrition
Prevent infection Increase family/caregiver knowledge

236 What are the interventions available to implement goals?
Cover skin, prevent scratching, wet dressings, don’t allow to dry Weighing daily**** Aseptic technique/avoid hospitalization Read labels carefully Instruct caregivers/ provide support/referrals to community services Small papule on scalp;spreads

237 Griseofulvin drug of choice. Compliance difficult due to tx of 3mos
Corporis lesions on body Usually from infected dog or cat Miconazole, clotrimazole T. pedis, hygiene, meds, white socks T. cruris

238 Fungal infections (pg 406)
Tinea, fungal infection living in outer layers of hair, skin, nails Ringworm of scalp, tinea capitis/tonsurans Transmitted person to person Microsporum canis/animal to child Hair brittle and breaks off easily

239 Parasitic infections Pediculosis and scabies Suck blood of hosts
Capitis, corporis, pubis Human to human Severe itching Kwell shampoo for at least 4min, rinse, dry, dip comb in warm white vinegar Wash all in hot wter and dry in hot dryer

240 Dryclean non-washables
Seal in plastic bags for 2 weeks to break cycle All in contact days, treat

241 Drugs affecting skin TERMS
Antiseptic: chemicals applied to living tissue to kill pathogens that may harm the host Disinfectants: chemicals used to kill organisms present on objects Bacteriostatic: halts or slows growth without killing off entire population Bactericidal: will kill bacteria, not fungus, spores or viruses

242 Types of drugs I. Topical anti-infectives Topical antibiotics
Topical antifungals Topical antivirals II.Topical antiseptics and germicides III.Topical corticosteroids IV.Topical antipsoriatics V.Topical enzymes VI.Keratolytics VII.Topical local anesthetics

243 Topical antibiotics Exert direct local effect on specific organisms
Can be bacteriostatic/bactericidal Used to prevent superficial infections in minor breaks in skin integrity

244 Bacitracin; 1-5x day G-myticin; 1-5xday Emgel; 2x day Neomycin; 1-3x day Thin layers All have significant side effects

245 antifungals Interrupts the continued growth of a fungus after long period of use Used for jock itch, athletes foot, ringworm, candidal infections of skin, vagina and mucus membranes Fungizone (amphetericin B), Miconozole (Micatin), ciclopirox olamine (Loprox) Econazole(spectazole)

246 Tolnaftate (tinactin), Nystatin (Nilsat and Mycostatin)

247 antivirals 2 available are acyclovir (Zovirax) and penciclovir (Denavir) inhibit viral replication Acyclovir for initial outbreaks of genital herpes and for Herpes simplex viral infections in immunocompromised clients Penciclovir only for HSV 1( Herpes labalis adults

248 Adverse reactions of topicals
Can cause hypersensitivity reaction Superinfection (overgrowth of organisms not affected by med) Topical antibiotics are category C for pregnant women..used cautiously during pregnancy and lactation Topical antivirals are Cat. B, still used with caution Topical antifungals unknown except for Spectazole (cat. C) and ciclopirox (penlac)(cat. B)

249 Topical antiseptics/germicides
Exact action not known; affect a variety of organisms Efficacy may depend on strength, concentration and length of exposure with skin or mucus membrane Used to reduce numbers of bacteria on skin surfaces Benzalkonium,chlorhexidine, Iodine

250 Have few adverse reactions unless individual has an allergy
Contraindicated if known hypersens otherwise, no significant reasons to avoid use

251 Topical corticosteroids
Vary in potency, vehicle for delivery, and area of skin to which it is applied Exert a local anti-inflammatory effect Useful in relieving itching, redness and swelling from psoriasis, dermatitis, rashes, eczema, insect bites, first and second degree burns May cause same symptoms supposed to relieve

252 Don’t give with known hypersensitivity
Not for use as monotherapy in bacterial skin infections or viral infections Limit or avoid use on face, eyes Preg. Category C

253 Topical antipsoriatics
Drugs help to remove plaques Anthralin (Anthra-derm) and calcipotriene ( Dovonex) Don’t give with known hypers. Category C

254 Topical enzymes Aids in removal of necrotic tissue by reducing proteins into simpler tissue (proteolytic action) Responders may be second/third degree burns, pressure ulcers and ulcers of PVD Collagenase/Santyl Low incidence of adverse reactions Not for use in wounds where nerves are exposed or wounds connect with a body cavity. Cat. B, may be inactivated by detergents and antiseptics

255 keratolytics Acts to remove excess growth of the epidermis
Warts, calluses, corns, and seborrheic keratosis Salicylic acid, diclofenac (solaraze) and Actinex, salicylic acid often in OTC preparations Usually well tolerated

256 Don’t give with known hypersen.
Not used on moles, warts with hair, genital or facial warts, warts on mucus membranes or infected skin Not for longterm use in diabetics, clients with impaired circulation or infants Cat. C

257 Topical local anesthetics
Temporarily inhibit conduction of impulses from sensory nerve fibers Relieve itching, burning and pain Can be used with caution on mucus membranes Lanacane, nupercainal, Xylocaine Occas. local irritation noted Contraind. With known hypers. And with certain class 1 antiarrhy meds

258 Nursing process Pre-administration assessment consists of visual and palpation, describe using appropriate terminology Ongoing assessment of site every application; checking for changes or adverse reactions Apply nursing diagnoses Planning for expected outcomes

259 Implementation to promote an optimal response to therapy
Allow for time to verbalize concerns or ask questions Assure condition improves, if true

260 Topical antiinfectives
Cleanse skin with soap and warm water Apply medication thin layer, liberally Either cover or leave exposed Avoid eye area

261 Topical antiseptics and germicides
Instill or apply as directed Occlusive dressing only if ordered All containers must be clearly labeled and dated, more advisable not to leave on bedside table, espec. With elderly or confused pt Educate pt to any special effects of med, iodine may stain, etc

262 Topical corticosteroids
Wash site with soap/water unless otherwise directed Applied sparingly. If to have occlusive drsg, apply while skin still moist, cover with plastic wrap

263 Topical enzymes to remove dead tissue
Certain skin wounds may require special preparation, Area is washed or cleansed Med applied as dir If bleeding occurs, d/c and rept Avoid application to healthy tissue

264 Topical antipsoriatics
Apply only to prescribed areas Assess for intensified irritation Educate pt on s/e and limitation to sunlight exposure

265 Topical anesthetics Advise pt of numbness which can last an hour or so If used on mucus membranes, advise no food for at least I hr, may have impaired swallow



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