Integumentary Flashcards
Common Skin Disorders: Assessment
▫ Present health status
▫ Past medical history
▫ Inspection of the entire skin for color and lesions
▫ Palpate skin for temperature, texture, moisture, and turgor
Common Skin Disorders
• Most treated by self-care at home • Focus of treatment is identifying, modifying, or eliminating precipitating factors • Diagnosis ▫ Culture ▫ Skin scrapings ▫ Biopsy ▫ Ultrasound tests
Infections/ Infestations: Assessment
▫ History of contact
▫ Living conditions
▫ Chronic illnesses
▫ Inspect skin, hair, mucous membranes Note location, appearance, and size of lesions
Infections/ Infestations
- Treatment focused on identifying causative agent
- Administer medication to kill bacteria or eradicate the organism
- Prevent secondary infection
- Environmental surveillance and control
Infections/ Infestations: Treatment
• Parasitic infestations
▫ Topical agents to kill the parasite
• Complementary therapy
▫ Tea tree oil
Infections/ Infestations: Treatment
• Bacterial infections
▫ Antibiotics—topically or systemically
• Fungal infections
▫ Antifungal agents—topically or systemically
• Viral infections
▫ Antiviral agents
▫ Medications to relieve pain and pruritis
Infections/ Infestations: Nursing Care
- Acute Pain
- Disturbed Sleep Pattern
- Risk for Infection
Atopic Dermatitis
- Corticosteroids
- Antihistamines
- Antibiotics
- Dietary
- Lifestyle adaptations
Psoriasis
- Tar soaps
- Photo therapy
- Topical agents
- Systemic Agents
Common Skin Disorders
• Pruritis - medications and treatments ▫ Antihistamines ▫ Tranquilizers—stress related to pruritis ▫ Antibiotics ▫ Topical steroids ▫ Therapeutic baths
Common Skin Disorders
Complimentary therapy
▫ Aloe
▫ Goldenseal
▫ Peppermint oil
Common Skin Disorders: Nursing Care
• Impaired Skin Integrity ▫ Strategies to relieve itching ▫ Therapeutic baths • Disturbed Body Image ▫ Trusting relationship ▫ Self-perception ▫ Involvement of family • Deficient Knowledge ▫ Medication administration
Pressure Ulcers
- Goal is prevention
- Laboratory tests to determine infection
- Topical and systemic antibiotics
- Surgical debridement
- Specialty dressings and beds
Pressure Ulcers: Assessment
▫ Identify patients at risk
▫ Describe appearance
▫ Measure size and depth
▫ Braden Skin Assessment
Skin Breakdown
- Altered nutrition less than body requirements
- Incontinence
- Chronic illness
Pressure Ulcers: Nursing Care
• Risk for Impaired Skin Integrity ▫ Minimize risk ▫ Conduct systematic inspection ▫ Keep skin clean and manage incontinence ▫ Minimize environmental factors ▫ Minimize friction and shearing forces
Pressure Ulcers: Nursing Care
▫ Maintain adequate nutritional intake ▫ Maintain activity level ▫ Teach client to shift weight ▫ Use positioning devices, pillows ▫ Keep head of bed at lowest position ▫ Use specialty devices
Skin Disorders: Teaching
- Supportive role
- Report complications of treatments
- Proper medication administration
- Care to facilitate healing and eliminate spread of infection
- Dressing changes and direct care of skin lesions
- Nutrition
- Environmental control
- Prevention of pressure ulcers in clients cared for at home
Phases of Burn Management
- Prehospital Care
- Emergent (Resuscitative)
- Acute
- Rehabilitative
Prehospital Care
• Remove the person from the source of the burn and stop the burning process
• The caregiver must be protected from becoming part of the incident
• Electrical Injuries
- Remove client from contact of source
• Chemical Injuries
- Brush solid particles off the skin - Water lavage
Prehospital Care
• Small Thermal Burns
- Cover with clean, cool, tap water- dampened towel
• Large Thermal Burns
- Airway, breathing, and circulation
• Wound Care
- Do not immerse in cool water or pack with ice
- Wrap in clean, dry sheet or blanket - Remove burned clothing
Emergent Phase
- Emergent phase is the period of time required to resolve the immediate problems resulting from burn injury
- From burn onset to 5 or more days
- Usually lasts 24-48 hours
- The phase begins with fluid loss and edema formation and continues until fluid mobilization and diuresis begin
Emergent Phase Nursing and Collaborative Management: Airway Management
- Early nasotracheal or endotracheal intubation
- Escharotomies of the chest wall
- Fibre-optic bronchoscopy
- Humidified air and 100% oxygen
Emergent Phase Nursing and Collaborative Management: Fluid Therapy
- Two large-bore IV lines
- A cut down is a final measure
- Parkland (Baxter) formula for fluid replacement
- Colloidal solutions
Emergent Phase Nursing and Collaborative Management: Wound Care
- Cleansing • Can be done in a hydrotherapy tub, cart shower, shower, or bed - Debridement • May need to be done in the OR • Loose necrotic skin is removed
Emergent Phase Nursing and Collaborative Management: Wound Care
- Immersion in a tank or Shower
• Open method
• Burn is covered with a topical antibiotic with no dressing over the wound
• Multiple dressing changes
• Sterile gauze dressings are laid over a topical antibiotic
• The dressings may be changed from 2 - 3 times every 24 hours, to once every 3 days
Wound Management
• Splints used to prevent contractures
• Uniform pressure garments
▫ Reduces hypertrophic scarring
▫ May be required to wear for 6 months to 1 year postgraft
Emergent Phase Nursing and Collaborative Management: Wound Care
- Allograft or homograft skin
• Commonly used
• Rejection eventually occurs
Emergent Phase Nursing and Collaborative Management: Other Care Measures
Facial care
- Hands and arms should be extended and elevated on pillows or slings
- Ears should be kept free of pressure
• No use of pillows
• Performed by the open method
- Eye care for corneal burns
• Done with slightly warmed physiological saline rinses as often as every hour
Emergent Phase Nursing and Collaborative Management: Other Care Measures
- Head can be elevated using a donut roll
- Perineum must be kept as clean and dry as possible
- Routine lab tests
- Early ROM exercises
Emergent Phase Nursing and Collaborative Management: Drug Therapy
- Analgesics and sedatives • morphine • meperidine (Demerol) • haloperidol (Haldol) • lorazepam (Ativan) • midazolam (Versed)
Emergent Phase Nursing and Collaborative Management: Drug Therapy
Tetanus immunization - Given routinely to all burn clients - Antimicrobial agents Topical agents - silver sulfadiazine (Silvadene) - bacitracin Systemic agents not usually used
Emergent Phase Nursing and Collaborative Management: Nutritional Therapy
- Fluid replacement takes priority over nutritional needs
- When bowel sounds return at 48-72 hours, oral intake can be initiated beginning with clear liquids
Emergent Phase Nursing and Collaborative Management: Nutritional Therapy
Hypermetabolic state
• Resting metabolic expenditure may be increased by 50% to 100% above normal
• Core temperature is elevated
• Caloric needs are about 5000 kcal/day
Acute Phase
- The acute phase begins with the mobilization of extracellular fluid and subsequent diuresis
- The acute phase is concluded when the burned area is completely covered by skin grafts or when the wounds are healed
Acute Phase Nursing and Collaborative Management: Wound Care
- Daily observation
- Assessment
- Cleansing
- Debridement
Acute Phase Nursing and Collaborative Management: Wound Care
Appropriate coverage of the graft:
- Fine-mesh gauze next to the graft followed by middle and outer dressings
- Sheet skin grafts must be kept free of blebs
Acute Phase Nursing and Collaborative Management: Excision and Grafting
- Eschar is removed down to the subcutaneous tissue or fascia
Acute Phase Nursing and Collaborative Management: Excision and Grafting
Artificial Skin
- Life-threatening full-thickness or deep partial-thickness wounds where conventional autograft is not available or advisable
Acute Phase Nursing and Collaborative Management: Pain management; Non- pharmacological strategies
Pain Management - Opioid every 1 - 3 hours for pain - Several drugs in combination - Morphine with haloperidol Non-pharmacologic strategies - Relaxation tapes - Visualization, guided imagery - Biofeedback - Meditation
Acute Phase Nursing and Collaborative Management: Physical and Occupational Therapy
- Exercise during and after hydrotherapy
- Passive and active ROM
- Splints should be custom-fitted
Acute Phase Nursing and Collaborative Management: Nutritional Therapy
- Calculation of caloric needs by dietitian
- High-protein, high-carb foods
- Diet supplements
- Clients should be weighed on a regular basis
Acute Phase Nursing and Collaborative Management: Psychosocial Care
- Social worker
- Nursing staff
- Pastoral care
Rehabilitation Phase
The rehabilitation phase is defined as beginning when the client’s burn wounds are covered with skin or healed and the client is able to resume a level of self care activity
Rehabilitation Phase Nursing and Collaborative Management
- Both client and family actively learn how to care for healing wounds
- An emollient water-based cream should be used
- Cosmetic surgery is often needed following major burns
Rehabilitation Phase Nursing and Collaborative Management
- Role of exercise cannot be overemphasized
- Constant encouragement and reassurance
- Address spiritual and cultural needs
- Maintain a high-calorie, high- protein diet
- Occupational therapy
Emotional Needs of the Client and Family
- Family members need to understand the importance of re establishing the client’s independence
- Encourage the family to participate as team
- Early psychiatric intervention
- Issue of sexuality must be met with honesty
- Family and client support groups
Special Needs of the Nursing Staff
- The nurse cares for clients who, at times, may be unpleasant, hostile, apprehensive, and frustrated
- Nurses new to burn nursing often find it difficult to cope
Skin Cancer: Treatment
Treatment focuses on removal of malignant tissue • Surgery • Chemotherapy • Immunotherapy • Radiation therapy • Biological therapies
Skin Cancer: Diagnosis
▫ Microscopic exam and tissue biopsies
▫ Liver function tests
▫ Chest x-rays
▫ Microstaging
Skin Cancer: Assessment, Past Medical History
Assessment Present health status - Change in mole, wart, birthmark, scar - Exposure - Other Past medical history - Skin cancer or family history - Geographic residence - Serious sunburn
Skin Cancer: Assessment
▫ Inspection and palpation of skin lesions
▫ Measure and document location
▫ Monitor report results
Melanoma
Precursor lesion is a dysplastic nevi (mole)
Change in the color or size of a nevus occurs in 70% of people diagnosed with melanoma
▫ A asymmetry
▫ B border irregularity
▫ C color variation
▫ D diameter greater than 6 mm
Treatment
Surgery - Sentinel lymph node biopsy Biological therapy Radiation therapy Immunotherapy Chemotherapy Clinical Trials
Non Melanoma
Basal Cell - Surgical excision - Mohs Surgery - Curettage & electrodesication Squamous Cell - Mohs Sugery - Topical chemotherapy
Skin Cancer: Nursing Care
- Anxiety
- Impaired Skin Integrity
- Hopelessness
Skin Cancer Health Promotion
Environmental hazards Sun exposure Education about sun safety - Sunscreen SPF 15+ - Hats with wide brims or flaps - Danger of burn on overcast days - Potential dangers of tanning beds
