Integumentary Flashcards
Interventions for pressure ulcer
Recommended interventions for a client at risk for developing a pressure ulcer include the following:
▪ Utilize standardized assessments to evaluate a client’s risk for a pressure ulcer.
▪ Ensure that nutritional goals are being met by providing adequate fluid and protein in the diet.
▪ Keep the head of the bed at 30 degrees or less to prevent shearing.
▪ Offload bony prominences using foam or pillows. Reposition the client at least every two hours.
▪ Do not use any products comprised of plastic and avoid using donut pillows.
▪ Moisturize the skin with products containing zinc oxide.
▪ Do not massage reddened areas.
Deep-Partial Thickness wound
Wounds that appear moist and pale white with sluggish capillary refill are classified as deep-partial.
full thickness wound
Full-thickness burns involve the destruction of the epidermis and the entire dermis, as well as possible damage to the subcutaneous layer, muscle, and bone. Eschar is found on the skin and appears leathery.
Superficial-partial burn
Superficial-partial burns are characterized by blister formation, exudation, and collections of tissue fluid.
Superficial wound
Superficial burns are characterized by the redness of the skin. It involves only the epidermal layer of the skin.
Rabies
Rabies is a serious infection caused by a virus. The virus is transmitted to humans by the saliva of an infected mammal introduced through a bite or skin abrasion. Common animals infected with rabies include raccoons, skunks, bats, and foxes. After an animal bite, the nurse should thoroughly irrigate the wound with soap and water. This is an essential step in preventing the virus’s transmission and other pathogens. Any client bitten by a wild animal is assumed to be exposed to rabies. Rabies may be fatal if not prevented through immunoglobulin, and manifestations of this infection include flu-like symptoms, seizures, hallucinations, and hypersalivation.
sequence for bedwash
the inner canthus of the eyes should be washed first, followed by the outer canthus of the eyes. Once the eyes have been cleansed in this manner, the UAP may then move on to the remainder of the face.
To reduce the risk of infection, always perform hygiene measures while moving from cleanest to less clean or dirty areas.
This often requires you to change gloves and perform hand hygiene during care activities.
Begin with the inner canthus and move to the outer canthus.
Bathing the eye from inner to outer canthus prevents secretions from entering the nasolacrimal duct.
When washing a client’s eyes, use plain warm water, as soap irritates the eyes.
Use different sections of the washcloth or mitt for each eye to avoid transmission of any infection.
Any rough patches may need to be soaked prior to removal.
Gently, but thoroughly, dry the eyes as pressure can cause internal injury.
Parkland Formula
The Parkland formula is a guide to determining the 24-hour fluid replacement following a major thermal burn. The phases of fluid replacement include the first eight hours and the remaining sixteen.
The client’s weight in kilograms will be multiplied by the total body surface area burned, then multiplied by 4 mL
After the 24-hour fluid total is determined, it should be divided by two (for the two phases)
The first eight hours begin at the time of injury - not hospitalization.
Deduct any fluids given pre-hospital
A central line is preferred to deliver this fluid
Lactated Ringer’s is commonly used as the fluid of choice because it may mitigate metabolic acidosis.
Urine output is monitored closely to determine if the client is responding to treatment (0.5mL/kg/hr)
The nurse should also monitor the mean arterial pressure (MAP) to determine if the client is responding (goal is > 65 mm Hg)
The nurse is caring for a client who sustained full-thickness burns to their entire torso and back. The nurse plans to take which priority action?
When caring for a client with a significant thermal burn (greater than 10% TBSA), the priority is assessing respiratory status. Smoke inhalation injuries and carbon monoxide poisoning are immediate concerns that must be addressed.
The emergent (resuscitation) phase of a burn injury begins at the onset of injury and continues for about 24. The type of burn determines the type of care along with the percentage of body surface affected. The priorities of care during the emergent phase include:
Securing the airway
Supporting circulation and perfusion through volume repletion
Maintaining body temperature
Providing adequate pain control
Rendering emotional support
Scleroderma
Scleroderma is a medical condition that causes fibrosis to the connective tissue. This multisystem disorder causes many clinical manifestations, including skin thickening and hardening (taut and shiny), vasospasms of the digits, arthritis, muscle stiffness, significant fatigue, dysphagia, esophageal reflux, and an insult to the kidneys that may lead to renal failure.✓ Scleroderma is a progressive multisystem disorder
✓ This disorder commonly impacts women and causes an array of symptoms
✓ Major manifestations include thickening of the skin, joint pain, contractures, vasospasm in the fingers, dysphagia, renal insufficiency, and pulmonary hypertension
✓ The treatment goal is to put the disease into remission via immunomodulators with corticosteroids commonly used
✓ Nursing care is supportive of mitigating symptoms, including applying skin moisturizers, good oral hygiene, and managing esophageal reflux
Isotrenitoin for Acne
Acne vulgaris is a cutaneous disorder characterized by inflammation of the pilosebaceous unit. The severity of this disorder varies, and moderate to severe forms of acne vulgaris may benefit from topical or oral antibiotics (doxycycline). Isotretinoin may also be utilized as it has demonstrated its ability to shrink the sebaceous glands.
➢ This medication is highly teratogenic, and the client should be counseled on reliable contraception.
➢ A negative pregnancy test is required before the start of treatment.
➢ Laboratory monitoring of the client’s liver function tests and triglycerides is essential. This medication may cause liver injury and raise triglyceride levels.
➢ Clients will need to complete an iPLEDGE program before they may obtain the prescription. This ensures safety while they take the medication.
Physiological process that occurs in the body following a burn?
✓ After a burn injury, the body undergoes significant hormonal changes.
✓ The sympathetic nervous system is activated, releasing stress hormones such as cortisol and catecholamines, including epinephrine and norepinephrine.
✓ These hormones help the body respond to stress and increase blood glucose levels.
✓ According to a study published in the Journal of Burn Care and Research, cortisol levels can increase up to 5-10 times the normal range within hours of a burn injury.
✓ Epinephrine and norepinephrine levels increase significantly, which can lead to tachycardia and hypertension .
✓ There is also an increase in antidiuretic hormone (ADH), which helps to retain water and sodium in the body.
✓ The renin-angiotensin-aldosterone system is activated, increasing aldosterone, which helps retain sodium and water and conserve potassium.
Onychia
Onychia is characterized by inflammation of the nail fold resulting from either injury or infection.
Whereas, paronychia refers to infection of the proximal nail folds. Infection of the nail folds can occur by the introduction of bacteria into nail folds through small wounds. The nurse should document and report this condition.
Onychomychosis
Onychomycosis is a fungus infection of the nails that causes the nails to look thick, discolored, and crumbling
Onychomadesis
Onychomadesis is the falling off and the separation of the nails from the nail bed
