Integumentary

Question 1

What are the manifestations of candidiasis?

Answer 1

Found in moist areas of the skin surface
white exudate
peeling inflamed areas that bleed easily
pruritic

Question 2

What are the nursing actions for candidiasis?

Answer 2

admin topical antifungal ointment
-miconazole
-nystatin

Question 3

What are the manifestations of Impetigo?

Answer 3

Reddish macule becomes vesicular w/ crust
erupts easily, leaving moist erosion on the skin, secretions dry, forming crusts
honey-colored crust

Question 4

What are the nursing interventions for impetigo?

Answer 4

Admin topical bactericidal or triple antibiotic ointment
oral or parenteral antibiotics for severe cases
assist in preventing the child from itching/touching the affected area

Question 5

What infection control measures should be taken to control impetigo?

Answer 5

HIGHLY contagious
give the pt their own washcloths
do not share towels
wash on hot w/ bleach

Question 6

What should you educate your patient on with impetigo?

Answer 6

Hand washing!!
do not pick at crusts
avoid sharing clothing, hats, combs, brushes, towels

Question 7

What are the clinical manifestations of pediculosis capitis? (head lice)

Answer 7

intense itching
nits (white specks) on the hair shaft
small, red bumps on the scalp

Question 8

What are the nursing actions for head lice?

Answer 8

use 1% permethrin shampoo
teach on removal process

Question 9

What infection control measures should be taken with lice?

Answer 9

do not share personal items (combs, brushes, hair ties, hair clips)
do not share hats

Question 10

What should you educate your patient on with lice?

Answer 10

Remove nits w/ a fine-tooth nit comb, repeat in 7 days after shampoo tx
wash clothing and bedding in hot water w/ detergent bag items that cannot be washed into tightly sealed bags for 14 days
place items in a hot dryer for 20 min

Question 11

What are the manifestations of diaper dermatitis?

Answer 11

bright red rash that extends gradually
fiery red & scaly areas on the scrotum, penis, & labia
pimples, blisters, ulcers, large bumps or pus-filled sores
smaller red patches that blend together
can be yeast: greater moisture w/ white exudate present (candidiasis)

Question 12

What are the nursing interventions & teaching for diaper rash?

Answer 12

promptly remove the soiled diaper
clean the perineal area w/ a non-irritating cleanser
expose the affected area to the air to air dry
use superabsorbent disposable diapers to reduce skin exposure
apply a skin barrier such as zinc oxide, petrolatum ointment, aluminum acetate solution
- must be clean before applying
- do not wash it off w/ each diaper change
encourage frequent diaper changes
diaper rash can be a sign of neglect
do not use corticosteroid ointments

Question 13

What are the clinical manifestations for acne?

Answer 13

lesions (comedones) are open (blackheads) or closed (whiteheads)
most common on the face, neck, back & chest
p.acne can lead to inflammation manifesting as papules, pustules, nodules or cysts

Question 14

What are the nursing actions for acne?

Answer 14

apply warm compresses
determine if the pt is sexually active before beginning isotretinoin
monitor for behavioral changes & s/sx of depression or suicidal ideation in pts taking isotretinoin

Question 15

What should you teach your patient about acne?

Answer 15

gently wash their face
encourage a balanced, healthy diet; sleep, rest & daily exercise; frequent shampooing
do not pick or squeeze comedones
assist in coping w/ new body-image changes
wear protective clothing & sunscreen, avoid tanning beds
reinforce the need for follow-up & monitoring of chol and triglycerides in pts taking isotretinoin
reinforce the need to take oral contraceptives

Question 16

What are the adverse effects of isotretinoin?

Answer 16

dry skin & mucous membranes
dry eyes
decrease night vision
HA
Photosensitive
elevated chol & triglycerides
depression
SI or violent behaviors

Question 17

Who is contraindicated for isotretinoin?

Answer 17

women of childbearing age who are not taking birth control
- if sexually active, must use 2 forms of contraception for 1 month before, during, & 1 month after treatment

Question 18

What is lyme disease?

Answer 18

tick infected w/ borrelia burgdorferi

Question 19

When are the 3 stages of manifestions for lyme disease?

Answer 19

Stage 1: 3-30 days after the bite
Stage 2: 3-10 weeks after the bite
Stage 3: 2-12 months after the bite

Question 20

What are the stage 1 manifestations of Lyme disease

Answer 20

erythema migrans at site
chills, fever, itching, HA, fainting, stiffneck, muscle weakness
bull’s eye rash at the site of the bite

Question 21

What are the stage 2 manifestations of lyme disease?

Answer 21

systemic involvement begins
- neurologic, cardiac, & musculoskeletal
paralysis or weakness in the face, muscle pain, swelling in large joints (knees), fever, fatigue, splenomegaly

Question 22

What are the stage 3 manifestations of lyme disease?

Answer 22

systemic involvement is advanced
- musculoskeletal pain that includes the muscles, tendons, bursae & synovia
possible arthritis, deafness, cardiac comps & encephalopathy
abnormal muscle movement & weakness, numbness & tingling, speech problems

Question 23

What are the nursing actions for lyme disease?

Answer 23

observe the pt for 30 days after bite
single dose antibiotics for pts who meet criteria
2-3 week course for pts w/ confirmed case
doxycycline for kids 8 yrs & older
amoxicillin or cefuroxime for children under 8 years
cefuroxime for kids w/ penicillin allergy

Question 24

How do you prevent future bits?

Answer 24

avoid tall grass
use insect repellant
avoid contact w/ insects
avoid wood piles
inspect & treat pets, carpet, furniture
avoid flowery prints & bright clothing
avoid perfume & colognes

Question 25

What is the priority for burns?

Answer 25

stop the burn
prevent infection
maintain homeostasis & body temp
fluid replacement
manage pain

Question 26

What defines a 3rd-degree burn/full-thickness burn?

Answer 26

damage to the entire epidermis & dermis and possible damage to the subq tissue
nerve endings, hair follicles & sweat glands are destroyed

Question 27

What are the expected findings of a 3rd-degree burn/full-thickness burn?

Answer 27

red to tan, black, brown or waxy white in color
dry, leathery appearance
no blanching
possibly not painful at first but as it heals, pain sensation returns

Question 28

How long does it take for a 3rd-degree burn to heal?

Answer 28

weeks to months
scarring is present
grafting is required

Question 29

What are the expected findings of a 4th-degree burn?

Answer 29

color variable
no pain is present
exposed bone and muscle

Question 30

What is a thermal burn?

Answer 30

occurs when there is exposure to flames, hot surfaces, or hot liquids
occurs w/ burns to the face & lips
damage occurs to the tracheobronchial tree after inhalation of heated gases and toxic chemicals produced during combustion
can be delayed 24 to 48 hours

Question 31

What are the expected findings of a thermal burn?

Answer 31

wheezing
increased secretions
hoarseness
wet rales in the lungs
singed nasal hairs
laryngeal edema
carbonaceous secretions

Question 32

What are the nursing interventions for minor burns?

Answer 32

STOP the burn: apply cool tepid water (NO ICE)
AVOID using greasy lotion or butter on the burn
cover burn w/ clean cloth to prevent contamination
cleanse w/ mild soap & tepid water, antimicrobial ointment, apply dressing, provide analgesia

Question 33

What should you check and why with burn patients?

Answer 33

Immunization status because they will need a tetanus shot if it has been >5 years since the last one

Question 34

What are the nursing interventions for major burns?

Answer 34

minor burn interventions too
maintain airway & vent (humidified @ 100%)
replace fluids
manage pain
prevent infection
monitor for s/sx of septic shock
increase protein & calories for tissue healing
increase vit. A, C and zinc
body-image change coping

Question 35

What findings should be reported with burn patients?

Answer 35

septic shock
infection