Integumentary Disorders of the Adult Client Flashcards
Burn
Cell destruction of the layers of the skin caused by heat, friction, electricity, radiation, or chemicals.
Carbon monoxide poisoning
Carbon monoxide is a colorless, odorless, and tasteless gas that has an affinity for hemoglobin 200 times greater than that of oxygen. Poising occurs from the inhalation of carbon monoxide. Oxygen molecules are displaced and carbon monoxide reversibly binds to hemoglobin to form carboxyhemoglobin. Tissue hypoxia results.
Deep full-thickness burn
Injury extends beyond the skin into underlying fascia and tissues, and muscle, bone, and tendons are damaged. Appears black and sensation is completely absent. Eschar is hard and inelastic; lack of pain due to nerve endings destruction. Healing is months with grafts required.
Deep partial-thickness burn
Injury extends deep into the dermis.
No blisters; Wound surface is red and dry with white areas in deeper part; May or may not blanch; moderate edema. Can convert to full-thickness burn if tissue damage increases with infection, hypoxia, or ischemia.
Heals 3-6 weeks; scar formation and skin grafting may be needed.
Full-thickness burn
Involves injury and destruction of the epidermis and the dermis. Will not heal by reepithelialiazation; grafting may be needed. Dry, hard, leathery eschar; waxy white, deep red, yellow, brown or black; edema; sensation is reduced. Healing weeks-months. Burn requires removal of eschar. Scarring.
Herpes zoster (shingles)
An acute viral infection of the nerve structure caused by varicella-zoster. Herpes zoster is contagious to individuals who never had chickenpox and have not been vaccinated against the disease.
Pressure ulcer
Area of tissue damage that occurs as a result of skin and underlying soft tissue compression from pressure between a surface and a bony prominence.
Shingles
Same as the herpes zoster infection. An acute viral infection of the nerve structure caused by varicella-zoster. Herpes zoster is contagious to individuals who never had chickenpox and have not been vaccinated against the disease.
Skin cancer
A malignant lesion of the skin that may or may not metastasize.
Smoke inhalation injury
Respiratory injury that occurs due to inhalation of products of combustion during a fire.
Superficial partial-thickness burn
Involves injury that extends into the dermis; blood supply reduces.
Large blisters; edema; mottled pink to red base, broke epidermis with wet, shiny, weeping surface. Painful and sensitive to cold air. Heals 10-21 days with no scarring, but may have pigment changes. Grafts may be used if healing process is prolonged.
Superficial-thickness burn
Involves injury to the epidermis; blood supply to the dermis still intact.
Mild-severe erythema (pink to red), no blisters.
Skin blanches with pressure; pain is eased by cooling. Discomfort last 48 hours, healing occurs in 3-6 days. No scarring.
The skin is the largest ______ of the body.
sensory organ
Layers of the skin
- Epidermis
- Dermis
- Hypodermis (subcutaneous fat)
Epidermal appendages
- Nails
- Hair
- Glands (Sebaceous & Sweat)
Normal bacterial flora
- Gram-positive and gram-negative staphylococci
- Pseudomonas sp.
- Streptococcus sp.
A pH of _____ halts the growth of bacteria
4.2-5.6
Risk Factors for Integumentary Disorders
- Exposure to chemical and environmental pollutants
- Exposure to radiation
- Race and age
- Exposure to sun or indoor tanning
- Lack of personal hygiene habits
- Harsh soaps
- Medication (long-term use of glucocorticoid and herbals)
- Nutritional deficits
- Infection
- Repeated injury and irritation
- Genetics predisposition
- Systemic illnesses
Phases of Wound Healing
- Inflammatory
- Fibroblastic
- Maturation
Inflammatory Phase
Begins at time of injury and lasts 3-5 days;
Local edema, pain, redness, and heat.
Fibroblastic Phase
Begins the 4th day after injury and last 2-4 weeks;
Scar tissue forms and granulation tissue forms in the tissue bed.
Maturation Phase
Begins as early as 3 weeks after the injury and may last 1 year;
Scar tissue becomes thinner and is firm and inelastic on palpation.
Healing by intention - First Intention
Wound edges are approximated and held in place (ex. with sutures) until healing occurs; wound if easily closed and dead space is eliminated.
Healing by intention - Second Intention
Occurs with injuries or wounds that have tissue loss and require gradual filling in of the dead space with connective tissue.
Healing by intention - Third Intention
Involves delayed primary closure and occurs with wounds that are intentionally left open for several days for irrigation or removal of debris and exudates; once debris has been removed and inflammation resolves, the wound is closed by first intention.
Types of Exudate from Wounds
- Serous
- Serosanguineous
- Sanguineous
- Hemorrhaging
- Purulent
Serous
Clear or straw colored; Occurs as a normal part of the healing process.
Serosanguineous
Pink colored due to the presence of a small amount of blood cells mixed with serous drainage. Normal part of the healing process.
Sanguineous
Red drainage from trauma to a blood vessel; May occur with wound cleansing or other trauma to wound bed; Is uncommon in wounds.
Hemorrhaging
Frank blood from a leaking blood vessel; may required emergency treatment to control bleeding; Is an abnormal wound exudate.
Purulent
Yellow, gray, or green drainage due to infection in the wound.
Skin Biopsy
The collection of a small piece of skin tissue by punch, excisional, or shave.
Skin/wound cultures
A small skin culture obtained with a sterile applicator and culture tube. Scraping, punch biopsy and collecting fluid.
Wood’s light examination
Skin is viewed under ultraviolet light through a special glass (Wood’s glass) to identify superficial infections of the skin. Need room darkened.
Diascopy
Technique allows clearer inspection of lesions by eliminating the erythema caused by increased blood flow to the area. A glass is pressed over the lesion, causing blanching and revealing the lesion more clearly.
Candida albicans
Superficial fungal infection of the skin and mucous membranes (Yeast infection, or thrush).
Common areas: mouth, perineum, vagina, axilla, under breasts.
Risk factors: immunosuppression, cancer clients, long-term antibiotics, diabetes, obesity.
Candida albicans - Assessment Findings
- Skin: red, irritated - itches and stings
2. Mucous membranes: red and whitish patches
Candida albicans - Interventions
- Keep skin fold areas clean and dry
- Inspect skin folds frequently, reposition, bed linens clean and dry
- mouth care
- Food and fluids that are tepid in temp and nonirritating to mucous membranes
- antifungal medications
Herpes Zoster (Shingles)
Varicella-zoster; Occurs is a segmental distribution on the skin along the infected nerve. Diagnosed by visual exam and by Tzanck smear and viral culture.
Herpes Zoster (Shingles)- the dormant virus is located in the…
dorsal nerve root ganglia of the sensory cranial and spinal nerve.
Herpes simplex virus is another type of virus with Type 1 infection causes ___ and Type 2 causes ____.
cold sore; genital herpes
Herpes Zoster (Shingles) - Assessment Findings
- Unilaterally clustered skin vesicles along peripheral sensory nerves on the trunk, thorax, or face.
- Fever, malaise
- Burning and pain
- Paresthesia
- Pruritus
Zostavax vaccine
for Shingles; recommended for adults 60 years of age and older to reduce the risk of occurrence and the associated long-term pain.
Methicillin-Resistant Staphylococcus aureus (MRSA)
Health care associated infection; Skin or wound becomes infected with MRSA. Infection can range from mild to severe and can present as folliculitis or furuncles. If MRSA infects the blood, sepsis, organ damage, and death can occur.
Folliculitis
superficial infection of the follicle caused by Staphylococcus and presents as a raised red rash and pustules; furuncles are also caused by Staphylococcus and occur deep in the follicle, presenting very painful large raised bumps that may or may not have a pustule.
Erysipelas
An acute, superficial, rapidly spreading inflammation of the dermis and lymphatics caused by group A Streptococcus, which enters the tissue via an abrasion, bite, trauma, or wound.
Cellulitis
An infection of the dermis and underlying hypodermis; the causative organism is usually group A Streptococcus or Staphylococcs aureus.
Erysipelas and Cellulitis - Assessment Findings
- Pain and tenderness
- Erythema and warmth
- Edema
- Fever
Erysipelas and Cellulitis - Interventions
- Promote rest of affected area
- Apply warm compress to promote circulation and decrease discomfort, erythema and edema.
- Antibacterial dressings, ointments, or gels
- Antibiotics, obtain a culture prior to initiation
Frostbite
Damage to tissues and blood vessels as a result of prolonged exposure to cod. Fingers, toes, face, nose and ears often are affected.
First-degree Frostbite
White plaque surrounded by a ring of hyperemia and edema.
Second-degree Frostbite
Large, clear fluid-filled blisters with partial-thickness skin necrosis.
Third-degree Frostbite
Formation of small hemorrhagic blisters, usually followed by eschar formation involving the hypodermis requiring debridement.
Fourth-degree Frostbite
No blisters or edema; full-thickness necrosis with visible tissue loss extending into muscle and bone, which may result in gangrene. Amputation may be required.
Frostbite - Interventions
- Rewarm at 104-107.6 or 40-42 to thaw frozen part
- Never rub
- Rewarming may be painful
- Avoid compression
- Monitor for compartment syndrome
- Tetanus prophylaxis
- Debridement of necrotic tissue; amputation if needed
Actinic Keratosis
Caused by chronic exposure to the sun and appear as rough, scaly, red, or brown lesions that are usually found on the face, scalp, arms, and backs of the hands.
Lesions can progress to squamous cell carcinoma.
Tx: medications, excision, cryotherapy, curettage, laser therapy.
Skin Cancer
A malignant lesion of the skin, which may or may not metastasize. Diagnosed by skin biopsy.
Types of Skin Cancer
- Basal cell
- Squamous cell
- Melanoma
Basal Cell Cancer
arises from the basal cells contained in the epidermis; metastasis is rare but underlying tissue destruction can progress to organ tissue.
Squamous Cell Cancer
is a tumor of the epidermal keratinocytes and can infiltrate surrounding structures and metastasize to lymph nodes.
Melanoma Cancer
May occur any place on the body (birthmarks or new moles); highly metastatic to the brain, lungs, bone, liver. Survival depends on early diagnosis and treatment.
Psoriasis
A chronic, noninfectious skin inflammation involving keratin synthesis that results in psoriatic patches. A break in skin integrity can lead to an infection in the affected area.
Psoriasis vulgaris the most common.
Keobner phenomenon
is the development of psoriatic lesions at a site of injury, such as a scratched or sunburned area.
Psoriasis - Assessment findings
- Pruritus
- Shedding: silvery, white scales on a raised, reddened, round plaque on scalp, knees, elbows, extensor areas of arms, legs and sacral regions.
- Yellow discoloration, pitting, thickening nails
- Joint inflammation with psoriatic arthritis
Stevens-Johnson Syndrome
A drug-induce skin reaction that occurs through an immunological response.
May cause vesicles, erosions, crusts on the skin, when sever may affect respiratory, renal, eyes (blindness). Most common in cancer pts who are receiving chemo or immunotherapy.
Toxic epidermal necrolysis (TEN)
Drug-induced skin reaction that results in diffuse erythema and large blister formation on the skin and mucous membranes
Stevens-Johnson Syndrome Treatments
- Discontinuation of medication causing the syndrome.
2. antibiotics, corticosteroids and supportive therapy may be needed.
Pressure ulcer
An impairment of skin integrity; can occur anywhere on body.
Actions to Take in the Emergency Department for a Client with a Burn Injury
- Assess airway patency
- Administer O2 as prescribed
- Obtain vital signs
- Initiate IV line; begin fluids as prescribed to prevent hypovolemic shock
- Elevate the extremities if no fractures are obvious
- Keep pt warm and on NPO
Burns of the head, neck and chest are associated with
pulmonary complications
Burns of the face are associated with
corneal abrasion
Burns of the ear are associated with
auricular chondritis
Hands and joints burns require
intensive therapy to prevent disability
Circumferential burns of the extremities produce
a tourniquet-like effect and lead to vascular compromise (compartment syndrome)
Circumferential thorax burns lead to
inadequate chest wall expansion and pulmonary insufficiency.
Smoke inhalation injury- Assessment Findings
- Facial burns
- Erythema
- Swelling of oropharynx and nasopharynx
- Singed nasal hair
- Flaring nostrils
- Stridor, wheezing, dyspnea
- Hoarse voice
- Sooty (carbonaceous) sputum and cough
- Tachycardia
- Agitation and anxiety
Direct thermal heat injury
Can occur to the lower airways by the inhalation of steam or explosive gases or the aspiration of scalding liquids.
Can occur to the upper airways, which appear erythematous and edematous, with mucosal blisters and ulcerations. Mucosal edema can lead to upper airway obstructions, especially during the 1st 24-48 hrs.
Pathophysiology of Burns
A. Vasoactive substances released and cause an increase in capillary permeability allowing plasma to seep into surrounding tissues.
B. Injury to vessels increase capillary permeability.
C. Body edema; decrease circulating intravascular blood volume.
D. Fluid loss; decrease in organ perfusion.
E. HR increases, Q decreases, BP drops.
F. Hyponatremia and hyperkalemia
G. Hct increases as plasma loss
H. pulmonary hypertensions
Poison Ivy, Poison Oak and Poison Sumac
A dermatitis that develops from contact with urushiol from poison ivy, oak, or sumac plant.
Assessment: Papulovesicular lesions & sever pruritus.
Brown recluse spider Bites
cause skin lesion, a necrotic wound, or systemic effects from the toxin. Apply ice and topical antiseptics and antibiotics if infected.
Black widow spider Bites
causes a small red papule; venom causes neurotoxicity.
Apply ice to inhibit the action of the neurotoxicity; Systemic toxicity may require supportive therapy in hospital.
Tarantulas Bites
causes swelling, redness, numbness, lymph inflammation, pain at site.
They launch their hairs which need to be removed asap, irrigate skin, elevate and immobilize extremity to reduce pain and swelling, antihistamines and corticosteroids may be prescribed.
Scorpion stings
cause local pain, inflammation, mild systemic reactions that are treated with analgesics, wound care and supportive therapy.
Bark scorpion can inflict severe and fatal systemic response and an antivenom is administer, ER asap.
For spider bites, scorpion bites, or other stings or bites, the ____ should be contacted asap to determine the best initial management.
Poison Control Center
Frostbite
is damage to the tissues and blood vessels as a result of prolonged exposure to cold.
Possible causes for Psoriasis disorder
Stress, trauma, infection, hormonal changes, obesity, an autoimmune reaction, climate changes, genetic predisposition.
Resuscitation/emergent phase (Burn injury management)
- Prehospital care (remove victim from source of the burn; assess ABCs; assess associated trauma- inhalation injury; converse body heat, cover burns with sterile/clean cloths; remove jewelry/clothing; insert IV; transport to ER).
- ED care is continuation of care administered at the scene.
- a) Major burn - treat life-threatening conditions, 100% O2 administered, monitor for respiratory distress, assess blister and erythema, lung sounds, monitor arterial blood gases and carboxyhemoglobin level; NPO; Foley to monitor output at 30-50 mL/hour, pain medication.
b) pain meds, oral analgesics, tetanus prophylaxis, wound care.
Resuscitative Phase (Burn injury management)
- Fluid resuscitation (maintain urine output of 30-50 mL/hr; if hbg and hct levels decrease or if urine output exceeds 50 mL/hr, the rate of Iv fluid administration may be decreased.
Urine output is the most reliable and most sensitive noninvasive assessment parameter for…
cardiac output and tissue perfusion.
Escharotomy
A lengthwise incision is made through the burn eschar to relieve constriction and pressure and to improve circulation. Is performed for circulatory compromise caused by circumferential burns.
Fasciotomy
An incision is made extending through the subcutaneous tissue and fascia. Done if adequate tissue perfusion does not return following an escharotomy.
Debridement
Removal of eschar or necrotic tissue to prevent bacterial proliferation under the eschar and to promote wound healing.
Mechanical Debridement
Performed during hydrotherapy; use of washcloths or sponges to cleanse and debride and the use of scissors and forceps to life and trim aware loose eschar. Painful and may cause bleeding.
Enzymatic Debridement
Application of topical enzyme agents directly to the wound; the agent digests collagen in necrotic tissue.
Surgical Debridement
Excision of eschar or necrotic tissue via a surgical procedure in the OR.
Tangential Technique Debridement
Very thin layers of the necrotic burn surface are excised until bleeding occurs (bleeding indicates that a healthy dermis or subcutaneous fat has been reached).
Fascial Technique Debridement
Burn wound excised to the level of superficial fascia; usually reserved for very deep and extensive burns.
Autografts are immobilized following surgery for…
3-7 days to allow time to adhere and attach to the wound bed.
Care of the graft site
- Elevate and immobilize the site
- Keep the site free from pressure
- Avoid weight-bearing
- monitor for infection
- lubricate the healing skin
- protect from sunlight
Rehabilitative phase of Burn injury managemtn
Is the final phase of burn care.
Goals: promote wound healing; minimize deformities; increase strength and function; provide emotional support.
Poison Ivy Treatment - Treatment of lesions includes…
calamine lotion and other products that soothe lesions, Burrow’s solution compresses, Domeboro solution, and/or Aveeno baths to relieve discomfort.
Poison Ivy Treatment - Topical corticosteroids are effective to…
prevent or relieve inflammation, especially when used before blister formation.
Poison Ivy Treatment - ___ may be prescribed for severe reactions and a ___ may be prescribed.
oral corticosteroids;
sedative such as diphenhydramine (Benadryl).
Poison Ivy Treatment Products
- Bentoquatam - for preventive use (Ivy Block)
- Calamine lotion (Caladryl lotion)
- Hydrocortisone (Ivy Soothe, Ivy Stat)
- Isopropanol; cetyl alcohol (Ivy Cleanse)
- Zine acetate; isopropanol (Ivy Dry)
- Zine acetate; isopropanol; benzyl alcohol (Ivy Super Dry).
Atopic Dermatitis
A chronic inflammatory skin disease that is also known as eczema and is characterized by dry and scaly skin.
Medications to Treat Atopic Dermatitis
- Moisturizer
- Topical glucocorticoids
- Systemic immunosuppressants
Systemic immunosuppressants for Atopic Dermatitis
- Methotrexate
- Cyclosporine (Sandimmune)
- Azathioprine (Imuran)
- Oral glucocorticoids
Topical Immunosuppressants for Atopic Dermatitis
- Tacrolimus (Protopic)
- Pimecrolimus 1% (Elidel)
Side effects: redness, burning, itching, sensitive to sunlight.
Tacrolimus increases the risk of ____ in children.
varicella-zoster infection
Tacrolimus may cause __ and __.
skin cancer and lymphoma.
Topical Glucocorticoids
Anti-inflammatory, antipruritic, and vasoconstrictive actions.
Topical Glucocorticoids - Contraindications
- Sensitivity to corticosteroids
- Current systemic fungal, viral, or bacterial infection.
- Current complications r/t to glucocorticoid therapy.
Topical Glucocorticoids - Local side/adverse effects
- Burning, dryness, irritation, itching
- Skin atrophy
- thinning of skin, striae, purpura, telangiectasia
- Acneiform eruption
- Hypopignmentation
- Overgrowth of bacterial, fungi, and viruses.
Topical Glucocorticoids - Systemic side/adverse effects
- Growth retardation in children
- Adrenal suppression
- Cushing’s syndrome
- Striae, skin atrophy
- Ocular effects (glaucoma and cataracts)
Topical Glucocorticoids - Interventions
- Monitor plasma cortisol levels
- Wash area before application to increase med penetration.
- Apply think film, rubbing gently.
- avoid dry dressing
- report signs of adverse effects
Medications to Treat Actinic Keratosis
- Aminolevulinic acid (Levulan Kerastick)
- Diclofenac sodium 3% gel (Solaraze)
- Fluorouracil (Carac, Efudex, Fluoroplex)
- Imiquimod 5% cream (Aldara)
