Integumentary Flashcards
Types of Exudate from Wounds
Serous: clear or straw colored (normal)
Serosanguineous: pink colored (normal part of healing)
Sanguineous: red from trauma, occurs with wound cleansing (abnormal)
Hemorrhaging: blood leaking from vessels, emergency (abnormal)
Purulent: yellow gray or green due to infection
Normal Bacterial Flora
gram positive and gram negative staph
pseudomonas
streptococcus
**obtain cultures before stating antibiotic therapy then start broad spectrum till cultures return
Candida albicans Patho
yeast infection and thrush
Candida albicans S/S
red irritated skin. itching. stinging sensation. red and white patches in mouth.
Candida albicans Care
keep skin folds clean and dry. inspect skin folds and turn and reposition. keep skin and linen clean and dry. frequent mouth care. tepid food and fluids. antifungal meds.
Herpes Zoster (Shingles) Patho
reactivation of varicella (chicken pox) from dorsal root ganglia during immunocompromised condition
Herpes Zoster (Shingles) S/S
unilateral clustered skin vesicles along peripheral sensory nerves on trunk thorax or face. fever. burning. pain. paresthesia. pruritus.
Herpes Zoster (Shingles) Care
Tzanck smear and culture to verify. isolate client. contact precautions. check for infection. neurovascular and 7th cranial nerve checks (could lead to Bell’s palsy). cool environment. prevent scratching or rubbing. wear lightweight loose cotton clothes and avoid wool. astringent compresses. keep skin clean. topical treatment and antivirals w/in 3 days. shingles vaccine (60 years of age or older)
MRSA Patho
skin or wound infected with antibiotic resisty
MRSA Diagnosis
culture and sensitivity test of skin or wound confirms MRSA and leads to proper antibiotic selection.
MRSA Care
CONTAGIOUS AND SPREAD BY CONTACT. contact precautions. check for signs of further infection or organ damage. give antibiotics
Erysipelas and Cellutitis Patho
Erysipelas: acute superficial rapidly spreading inflammation of dermis that enters via abrasion, bite, trauma, wound.
Cellulitis: infection of dermis and hypodermis
Erysipelas and Cellutitis S/S
pain. tender. red. warm. edema. fever
Erysipelas and Cellutitis Care
rest of affected area. warm compress. antibacterial dressings ointments or gels. culture then antibiotics
Poison Ivy Patho
dermatitis that develops from contact with urushiol
Poison Ivy S/S
papulovesicular lesions. pruritus
Poison Ivy Care
cleanse skin ASAP. apply cool wet compress for itching. apply topical products for itching and discomfort. topical or oral glucocorticoids. calamine lotion. aluminum acetate compress. oatmeal baths.
Spider Bites
place ice on the area. antiseptics and antibiotics. remove tarantula hairs using sticky tape to pull hairs from skin and then irrigate skin. saline irrigation used for eye exposures. elevate and immobilize extremity. tetanus prophylaxis. CONTACT POISON CONTROL ASAP.
Bee and Wasps Stings
quick removal of stinger. ice pack. do not use tweezers due to risk f punching venom sac (gently brush off). emergency care is needed if allergic. carry epi pen (2 if possible) CONTACT POISON CONTROL ASAP.
Snake Bites
move to safe area ASAP and rest. immobilize extremity and keep lower than level of heart. remove constrictive clothes and jewelry. keep pt warm. no caffeine or etoh. use constricting bacd proximal to wound to slow venom circulation. monitor circulation and loosen band if edema occurs. no sucking on wound. no ice. go to emergency room when pt will get antivenom. do not transport snake with pt unless in sealed container. CONTACT POISON CONTROL ASAP.
Frostbite Patho
tissue and blood vessel damage from prolonged exposure to cold
Frostbite S/S
1st degree: white plaque surrounded by ring of hyperemia and edema
2nd degree: large, clear fluid filled blisters with partial thick skin necrosis
3rd degree: small hemorrhagic blisters, eschar formation of hypodermis requiring debridement
4th degree: no blisters. no edema. full thickness necrosis. tissue loss down to muscle and bone. gangrene. amputation.
Frostbite Care
warm with warm water or towels at 104-107 degrees. handle gently and immobilize. no dry heat. no rubbing or massage. pain meds. no compression. loose nonadherent sterile dressings. watch for compartment syndrome. tetanus. antibiotics. debridement.
Actinic Keratoses Patho
lesions from chronic exposure to the sun
Actinic Keratoses S/S
rough scaly red brown lesions. premalignant with slow progression to squamous cell carcinoma.
Actinic Keratoses Care
excision. cryotherapy. curettage (remove tissue by scraping). laser therapy.
Actinic Keratoses Meds
Fuorouracil. Aminolevulinic acid. Diclofenac sodium gel. Imiquimod cream. Ingenol mebutate.
Basal Cell Carcinoma
waxy nodule with pearly borders. papule red central crater. metastasis is rare
Squamous Cell Carcinoma
oozing bleeding crusting lesion. potential to metastasize. larger tumors = higher risk for metastasis.
Melanoma
irregular circular bordered lesion with hues of tan black or blue. rapid infiltration into tissue. highly metastatic.
ABCDE of Melanoma
Asymmetrical Border Color Diameter Evolving
Care for Patient with Skin Cancer
teach risk factors and prevention. monthly skin self assessments. monitor lesions that do not heal or that change. have moles or lesions that irritating removed. avoid contact with chemicals. avoid overexposure to sun. wear layered clothes. use sunscreen. avoid sun between 10am-4pm.
Psoriasis Patho
chronic noninfectious skin inflammation with keratin formation and psoratic patches
Psoriasis Causes
stress. trauma. infection. hormone changes. autoimmune reaction. climate change.
Psoriasis S/S
pruritus. shedding silvery white scales on raised red round plaque. yellow discoloration pitting and thickened nails. joint inflammation.
Psoriasis Meds
phototherapy. coal tar. steroids. cyclosporine. methotrexate. tazarotene.
Psoriasis Care
emotional support. no OTC meds. no scratching. keep skin lubricated. report s/s of infection. reduce stress.
Care for Acne
skin cleansing methods. no scrubbing. only use prescribed topical agents. oral or topical meds. do not squeeze prick or pick. use products labeled noncomedogenic and water based cosmetics. no oil based products. ISOTRETINOIN: HIGHLY TERTOGENIC AND CAN CAUSE FETAL ABNORMALITIES. FOLLOW STRICT RULES OF IPLEDGE PROGRAM. CHECK TRIGYLCERIDE LEVELS BEFORE AND DO NOT TAKE WITH VIT. A
Stevens-Johnson Syndrome
medication induced skin reaction from antibiotics, NAIDS, antiseizure meds. common in people with autoimmune compromise
Stevens-Johnson Syndrome S/S
vesicles erosion and crust on skin. systemic reactions involving respiratory system, renal system and eyes (can cause blindness). can be fatal. flulike s/s.
Stevens-Johnson Syndrome Care
discontinue antibiotics. give steroids and supportive therapy.
Risk Factors for Pressure Ulcers
skin pressure skin shearing and friction immobility malnutrition incontinence decreased sensory perception
Stage 1 Pressure Ulcer
skin in tact. red. does NOT blanch. painful firm soft warmer or cooler than surrounding tissue
Stage 2 Pressure Ulcer
skin NOT intact. partial thickness skin loss of dermis. shallow open ulcer with red pink wound bed or intact or ruptured blister.
Stage 3 Pressure Ulcer
full thickness skin loss through dermis and tissue. slough. subcutaneous tissue is visible. undermining and tunneling may or may not be present.
Stage 4 Pressure Ulcer
full thickness skin loss with exposed bone tendon or muscle. slough. eschar. undermining and tunneling.
Deep Tissue Injury Pressure Ulcer
ischemic subcutaneous tissue under intact skin. purple or maroon. painful firm or boggy.
Unstageable Pressure Ulcer
full thickness tissue loss where wound bed is covered by slough and eschar. can not determine depth or stage until slough or eschar is removed.
Care for Patients with Pressure Ulcers
AVOID DIRECT MASSAGE!! prevention is key. frequent skin assessments. keep skin dry and sheet wrinkle free. check pt and change pads frequently if patient is incontinent. creams and lotions to lubricate skin. skin barrier ointments. turn and reposition q 2hrs in bed and q 1 hr in chair. passive ROM. document and record location and size. if patient is admitted with pressure ulcer make sure to document every detail. serosanguineous exudate is expected for 1st 48 hours. purulent exudate = culture.
Priority Nursing Actions for Burns
maintain airway.
give oxygen
obtain vital signs
start IV and give IVF to prevent hypovolemic shock
elevate extremities
keep pt warm with sterile linen and place NPO
insert foley cath to carefully monitor urine output (needs to be 30 ml/kg/hr)
then complete assessment
stay with client and monitor closely
tetanus prophylaxis
Rule of Nines
front of head 4.5 back of head 4.5 check 18 back 18 front of arm 4.5 back of arm 4.5 front of leg 9 back of leg 9
Superficial Thickness Burn
injury to epidermis. blood supply still intact. pink to red. no blisters. skin blanches. painful. tingling sensation. pain eased by cooling. discomfort for 48 hrs. no scaring. no skin grafts
Superficial Partial Thickness Burn
deeper into dermis. blood supply is reduced. large blisters. edema. red to red base. broken epidermis with wet shiny and weeping skin. painful. sensitive to cold air. heals in 10-21 days with NO scarring. minor pigment changes. may need graft.
Deep Partial Thickness Burn
NO blisters. red and dry with white areas. may or may not blanch. moderate edema. 3-6 weeks to heal. scars present. may need graft.
Full Thickness Burn
would will NOT heal on own. may need graft. dry hard leathery eschar which has to be removed before healing can begin. waxy white deep red yellow brown or black. edema under eschar. reduced or absent sensation. scarring and wound contractures.
Deep Full Thickness Burn
involves skin tissues muscle bone and tendons. black. no sensation. hard inelastic eschar. no pain because nerve endings have been destroyed. grafts required
Smoke Inhalation S/S
facial burns. erythema. swelling of oropharynx and nasopharynx. singed nasal hairs. flaring nostrils. stridor wheezing and dyspnea. hoarse voice. carbonaceous sputum and cough. tachycardia.
Smoke Inhalation Care
AIRWAY IS PRIORITY
Carbon Monoxide Poisoning
oxygen displace and carbon monoxide binds to hemoglobin to form carboxyhemoglobin leading to tissue hypoxia
Carbon Monoxide Poisoning Care
can lead to upper airway obstruction during first 24-48 hrs. immediate intubation if obstruction occurs.
General Burn Patho
increased capillary permeability allows plasma to seep into tissues causing generalized edema and decrease circulating intravascular blood volume. when this occurs there is a decrease in organ perfusion. heart rate increase. cardiac output decreased. blood pressure drops. at first hyponatremia and hyperkalemia occur. blood is shunted from kidneys causing oliguria. body then reabsorbs fluid and diuresis occurs. GI blood is diminished leading to ileus and GI dysfunction. depressed immune system leading to increased risk of sepsis and infection. can lead to hypovolemic shock and death due to fluids deplacing in tissue and not circulating.
Resuscitation/Emergent Phase of Burns
begins at the time of injury and ends with restoration of normal capillary permeability. remove patient from source of injury. assess ABCs. conserve body heat. cover burns with sterile or clean cloth. remove jewelry and clothes. insert IV. maintain airway with 100% O2. intubation if needed. assess lungs. ABGs and carboxyhemoglobin levels. duration is 48-72 hrs. includes prehospital and emergency department care. goal is to maintain airway give IVF to prevent hypovolemic shock and preserve vital organs
Resuscitative Phase of Burns
begins with initiation of fluids and ends when capillary integrity returns to normal levels and fluid shifts have decreased. fluid given is based on weight and extent of burn. (calculate from time of injury not from time of hospital arrival). goal is to prevent shock by maintaining circulating volume and organ perfusion
Acute Phase of Burns
begins when pt is hemodynamically stable capillary permeability is restored and diuresis begins. 48-72 hours after time of injury. focus on infection control wound care wound closure nutrition pain management and PT. emphasis on restorative therapy. phase continues till wound closes.
Rehab Phase of Burns
extends beyond hospitalization. goal is that pt gains independence and function.
Parkland Burn Formula
4ml/kg/percent of total burn
Best Way to Check Cardiac Output and Tissue Perfusion for Burn Patient
Urine Output (30-50ml/hr)
Care for Burn Patients
airway. O2. IV and IVF. assess lungs. ABGs and carboxyhemoglobin. HOB 30 degrees with facial burns. monitor for pulmonary edema and fluid overload. EKG monitoring. assess for infection. protective isolation. strict hand washing. sterile sheets and linen. clip body hair around wound. daily weight. expect 15-20 lb weight gain in 1st 72 hrs. monitor pH and gastric output for stress ulcer. antacids and antiulcer meds. bowel sounds for ileus and check abdominal distention. check stools for blood. cap refill and pulses. keep room warm. special mattress. pain management. NO IM OR SUBQ MEDS DUE TO FLUID SHIFT. IV MEDS ONLY!! increase to 5000+ calories.
Escharotomy
relieve constriction and pressure. improves circulation. may be needed on thorax to improve breathing.
Fasciotomy
performed if tissue perfusion does NOT return after escharotomy. in operating room with general anesthesia.
Burn Wound Care
cleansing. debridement. hydrotherapy. wound coverings. autografting.
Autografting
surgical removal of pt’s unburned skin that is then applied to burn area
Autografting Care
immobilized 3-7 days post op. elevate graft to prevent shearing and movement. keep site free from pressure. no weight bearing. use q tip to remove exudate. monitor for foul smelling drainage increase WBC hematomas and fluid build up. no fabric softeners or harsh detergents. lubricated with prescription. protect against sun.
Xenograft or Heterograft
animal tissue
Alograft or Homograft
donated human tissue
Amniotic Membranes Wound Cover
from human placenta
Cultered Skin for Wound Cover
made in lab
Artificial Skin for Wound Cover
bovine hide and shark cartilage
Pediculosis (Lice) Locations
occipital area.behind ears. nape of neck. eyebrows and eyelashes.
Pediculosis (Lice) Care
wash everything in hot water dry for 20 mins. seal toys for 2 weeks.
Scabies S/S
pruritic papular rash burrows under skin
(fine gray red lines) transmitted via contact
Scabies Care
topical cream. lindane shampoo (do not use for kids <2). sabicide permethrin: on skin within 30 after bath and then leave on for 8-14hrs. handwashing. hot water and high heat for laundry. antiitch cream. antibiotics.
Atopic Dermatitis (Eczema)
chronic inflammatory skin disease. dry scaly skin
Atopic Dermatitis (Eczema) Care
moisturizer. topical steroids. immunosuppressants. avoid sunlight. wash hands before and after topical meds and make sure to wear gloves. place meds on back, palms, feet
Sunscreen Rules
organic sunscreen absorbs UV light. inorganic sunscreen reflects and scatters UV light. use at least SPF 15. apply 30 mins before sun exposure and reapply q 2-3 hrs.
Burn Products
SILVER SULFADIAZINE: broad spectrum. prevent sepsis. does not cause acidosis. 1/16 film and keep covered at all times. causes rash itching blue green gray skin discoloration leukopenia and nephritis. check CBC WBC and report leukopenia to MD
MAFENIDE ACETATE: water soluble cream. reduce bacteria. check ABGs and electrolytes. causes local pain and rash. adverse effect is bone marrow depression, anemia, and metabolic acidosis (watcher for hyperventilation). keep covered at all times. report to MD if pt hyperventilates, acidosis develops
Fluid Used During Fluid Resusitation of Burn
lactated ringer because it is isotonic and contains electrolytes that will maintain circulatory volume.
