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Nursing Theory IV > Integumentary > Flashcards

Integumentary Flashcards

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1
Q

Common Skin Disorders: Assessment

A

▫ Present health status
▫ Past medical history
▫ Inspection of the entire skin for color and lesions
▫ Palpate skin for temperature, texture, moisture, and turgor

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2
Q

Common Skin Disorders

A 
• Most treated by self-care at home
• Focus of treatment is identifying, modifying, or eliminating precipitating factors 
• Diagnosis
▫ Culture
▫ Skin scrapings
▫ Biopsy
▫ Ultrasound tests
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3
Q

Infections/ Infestations: Assessment

A

▫ History of contact
▫ Living conditions
▫ Chronic illnesses
▫ Inspect skin, hair, mucous membranes  Note location, appearance, and size of lesions

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4
Q

Infections/ Infestations

A
  • Treatment focused on identifying causative agent
  • Administer medication to kill bacteria or eradicate the organism
  • Prevent secondary infection
  • Environmental surveillance and control
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5
Q

Infections/ Infestations: Treatment

A

• Parasitic infestations
▫ Topical agents to kill the parasite
• Complementary therapy
▫ Tea tree oil

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6
Q

Infections/ Infestations: Treatment

A

• Bacterial infections
▫ Antibiotics—topically or systemically
• Fungal infections
▫ Antifungal agents—topically or systemically
• Viral infections
▫ Antiviral agents
▫ Medications to relieve pain and pruritis

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7
Q

Infections/ Infestations: Nursing Care

A
  • Acute Pain
  • Disturbed Sleep Pattern
  • Risk for Infection
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8
Q

Atopic Dermatitis

A
  • Corticosteroids
  • Antihistamines
  • Antibiotics
  • Dietary
  • Lifestyle adaptations
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9
Q

Psoriasis

A
  • Tar soaps
  • Photo therapy
  • Topical agents
  • Systemic Agents
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10
Q

Common Skin Disorders

A 
• Pruritis - medications and treatments 
▫ Antihistamines
▫ Tranquilizers—stress related to pruritis
▫ Antibiotics
▫ Topical steroids
▫ Therapeutic baths
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11
Q

Common Skin Disorders

A

Complimentary therapy
▫ Aloe
▫ Goldenseal
▫ Peppermint oil

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12
Q

Common Skin Disorders: Nursing Care

A 
• Impaired Skin Integrity
▫ Strategies to relieve itching 
▫ Therapeutic baths
• Disturbed Body Image 
▫ Trusting relationship
▫ Self-perception
▫ Involvement of family
• Deficient Knowledge
▫ Medication administration
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13
Q

Pressure Ulcers

A
  • Goal is prevention
  • Laboratory tests to determine infection
  • Topical and systemic antibiotics
  • Surgical debridement
  • Specialty dressings and beds
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14
Q

Pressure Ulcers: Assessment

A

▫ Identify patients at risk
▫ Describe appearance
▫ Measure size and depth
▫ Braden Skin Assessment

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15
Q

Skin Breakdown

A
  • Altered nutrition less than body requirements
  • Incontinence
  • Chronic illness
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16
Q

Pressure Ulcers: Nursing Care

A 
• Risk for Impaired Skin Integrity 
▫ Minimize risk
▫ Conduct systematic inspection
▫ Keep skin clean and manage incontinence 
▫ Minimize environmental factors
▫ Minimize friction and shearing forces
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17
Q

Pressure Ulcers: Nursing Care

A 
▫ 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
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18
Q

Skin Disorders: Teaching

A
  • 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
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19
Q

Phases of Burn Management

A
  • Prehospital Care
  • Emergent (Resuscitative)
  • Acute
  • Rehabilitative
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20
Q

Prehospital Care

A

• 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

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21
Q

Prehospital Care

A

• 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

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22
Q

Emergent Phase

A
  • 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
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23
Q

Emergent Phase Nursing and Collaborative Management: Airway Management

A
  • Early nasotracheal or endotracheal intubation
  • Escharotomies of the chest wall
  • Fibre-optic bronchoscopy
  • Humidified air and 100% oxygen
24
Q

Emergent Phase Nursing and Collaborative Management: Fluid Therapy

A
  • Two large-bore IV lines
  • A cut down is a final measure
  • Parkland (Baxter) formula for fluid replacement
  • Colloidal solutions
25
Q

Emergent Phase Nursing and Collaborative Management: Wound Care

A 
- 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
26
Q

Emergent Phase Nursing and Collaborative Management: Wound Care

A
  • 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
27
Q

Wound Management

A

• Splints used to prevent contractures
• Uniform pressure garments
▫ Reduces hypertrophic scarring
▫ May be required to wear for 6 months to 1 year postgraft

28
Q

Emergent Phase Nursing and Collaborative Management: Wound Care

A
  • Allograft or homograft skin
    • Commonly used
    • Rejection eventually occurs
29
Q

Emergent Phase Nursing and Collaborative Management: Other Care Measures

A

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

30
Q

Emergent Phase Nursing and Collaborative Management: Other Care Measures

A
  • Head can be elevated using a donut roll
  • Perineum must be kept as clean and dry as possible
  • Routine lab tests
  • Early ROM exercises
31
Q

Emergent Phase Nursing and Collaborative Management: Drug Therapy

A 
- Analgesics and sedatives
• morphine
• meperidine (Demerol) 
• haloperidol (Haldol)
• lorazepam (Ativan)
• midazolam (Versed)
32
Q

Emergent Phase Nursing and Collaborative Management: Drug Therapy

A 
Tetanus immunization
- Given routinely to all burn clients
- Antimicrobial agents
Topical agents
- silver sulfadiazine (Silvadene)
- bacitracin
Systemic agents not usually used
33
Q

Emergent Phase Nursing and Collaborative Management: Nutritional Therapy

A
  • Fluid replacement takes priority over nutritional needs

- When bowel sounds return at 48-72 hours, oral intake can be initiated beginning with clear liquids

34
Q

Emergent Phase Nursing and Collaborative Management: Nutritional Therapy

A

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

35
Q

Acute Phase

A
  • 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
36
Q

Acute Phase Nursing and Collaborative Management: Wound Care

A
  • Daily observation
  • Assessment
  • Cleansing
  • Debridement
37
Q

Acute Phase Nursing and Collaborative Management: Wound Care

A

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
38
Q

Acute Phase Nursing and Collaborative Management: Excision and Grafting

A
  • Eschar is removed down to the subcutaneous tissue or fascia
39
Q

Acute Phase Nursing and Collaborative Management: Excision and Grafting

A

Artificial Skin
- Life-threatening full-thickness or deep partial-thickness wounds where conventional autograft is not available or advisable

40
Q

Acute Phase Nursing and Collaborative Management: Pain management; Non- pharmacological strategies

A 
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
41
Q

Acute Phase Nursing and Collaborative Management: Physical and Occupational Therapy

A
  • Exercise during and after hydrotherapy
  • Passive and active ROM
  • Splints should be custom-fitted
42
Q

Acute Phase Nursing and Collaborative Management: Nutritional Therapy

A
  • Calculation of caloric needs by dietitian
  • High-protein, high-carb foods
  • Diet supplements
  • Clients should be weighed on a regular basis
43
Q

Acute Phase Nursing and Collaborative Management: Psychosocial Care

A
  • Social worker
  • Nursing staff
  • Pastoral care
44
Q

Rehabilitation Phase

A

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

45
Q

Rehabilitation Phase Nursing and Collaborative Management

A
  • 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
46
Q

Rehabilitation Phase Nursing and Collaborative Management

A
  • Role of exercise cannot be overemphasized
  • Constant encouragement and reassurance
  • Address spiritual and cultural needs
  • Maintain a high-calorie, high- protein diet
  • Occupational therapy
47
Q

Emotional Needs of the Client and Family

A
  • 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
48
Q

Special Needs of the Nursing Staff

A
  • 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
49
Q

Skin Cancer: Treatment

A 
Treatment focuses on removal of malignant tissue
• Surgery
• Chemotherapy
• Immunotherapy
• Radiation therapy
• Biological therapies
50
Q

Skin Cancer: Diagnosis

A

▫ Microscopic exam and tissue biopsies
▫ Liver function tests
▫ Chest x-rays
▫ Microstaging

51
Q

Skin Cancer: Assessment, Past Medical History

A 
Assessment
Present health status
- Change in mole, wart, birthmark, scar
- Exposure
- Other
Past medical history
- Skin cancer or family history
- Geographic residence
- Serious sunburn
52
Q

Skin Cancer: Assessment

A

▫ Inspection and palpation of skin lesions
▫ Measure and document location
▫ Monitor report results

53
Q

Melanoma

A

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

54
Q

Treatment

A 
Surgery
- Sentinel lymph node biopsy
Biological therapy
Radiation therapy
Immunotherapy
Chemotherapy
Clinical Trials
55
Q

Non Melanoma

A 
Basal Cell
- Surgical excision
- Mohs Surgery
- Curettage & electrodesication
Squamous Cell
- Mohs Sugery
- Topical chemotherapy
56
Q

Skin Cancer: Nursing Care

A
  • Anxiety
  • Impaired Skin Integrity
  • Hopelessness
57
Q

Skin Cancer Health Promotion

A 
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

Nursing Theory IV (12 decks)

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