Integumentary Flashcards
What are the manifestations of candidiasis?
Found in moist areas of the skin surface
white exudate
peeling inflamed areas that bleed easily
pruritic
What are the nursing actions for candidiasis?
admin topical antifungal ointment
-miconazole
-nystatin
What are the manifestations of Impetigo?
Reddish macule becomes vesicular w/ crust
erupts easily, leaving moist erosion on the skin, secretions dry, forming crusts
honey-colored crust
What are the nursing interventions for impetigo?
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
What infection control measures should be taken to control impetigo?
HIGHLY contagious
give the pt their own washcloths
do not share towels
wash on hot w/ bleach
What should you educate your patient on with impetigo?
Hand washing!!
do not pick at crusts
avoid sharing clothing, hats, combs, brushes, towels
What are the clinical manifestations of pediculosis capitis? (head lice)
intense itching
nits (white specks) on the hair shaft
small, red bumps on the scalp
What are the nursing actions for head lice?
use 1% permethrin shampoo
teach on removal process
What infection control measures should be taken with lice?
do not share personal items (combs, brushes, hair ties, hair clips)
do not share hats
What should you educate your patient on with lice?
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
What are the manifestations of diaper dermatitis?
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)
What are the nursing interventions & teaching for diaper rash?
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
What are the clinical manifestations for acne?
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
What are the nursing actions for acne?
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
What should you teach your patient about acne?
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
What are the adverse effects of isotretinoin?
dry skin & mucous membranes
dry eyes
decrease night vision
HA
Photosensitive
elevated chol & triglycerides
depression
SI or violent behaviors
Who is contraindicated for isotretinoin?
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
What is lyme disease?
tick infected w/ borrelia burgdorferi
When are the 3 stages of manifestions for lyme disease?
Stage 1: 3-30 days after the bite
Stage 2: 3-10 weeks after the bite
Stage 3: 2-12 months after the bite
What are the stage 1 manifestations of Lyme disease
erythema migrans at site
chills, fever, itching, HA, fainting, stiffneck, muscle weakness
bull’s eye rash at the site of the bite
What are the stage 2 manifestations of lyme disease?
systemic involvement begins
- neurologic, cardiac, & musculoskeletal
paralysis or weakness in the face, muscle pain, swelling in large joints (knees), fever, fatigue, splenomegaly
What are the stage 3 manifestations of lyme disease?
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
What are the nursing actions for lyme disease?
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
How do you prevent future bits?
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
What is the priority for burns?
stop the burn
prevent infection
maintain homeostasis & body temp
fluid replacement
manage pain
What defines a 3rd-degree burn/full-thickness burn?
damage to the entire epidermis & dermis and possible damage to the subq tissue
nerve endings, hair follicles & sweat glands are destroyed
What are the expected findings of a 3rd-degree burn/full-thickness burn?
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
How long does it take for a 3rd-degree burn to heal?
weeks to months
scarring is present
grafting is required
What are the expected findings of a 4th-degree burn?
color variable
no pain is present
exposed bone and muscle
What is a thermal burn?
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
What are the expected findings of a thermal burn?
wheezing
increased secretions
hoarseness
wet rales in the lungs
singed nasal hairs
laryngeal edema
carbonaceous secretions
What are the nursing interventions for minor burns?
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
What should you check and why with burn patients?
Immunization status because they will need a tetanus shot if it has been >5 years since the last one
What are the nursing interventions for major burns?
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
What findings should be reported with burn patients?
septic shock
infection
