Integumentary Problems Flashcards
1
Q
Anatomy and Physiology
A
- skin is the largest sensory organ and weights about 4kg (9lb).
- acts as the first line of defense, protects underlying tissues and organs, and receives stimuli from the external environment (touch, pressure, pain, and temp); relays information to the CNS.
- regulates normal body temp, excretes salt, water, and organic wastes; protects body from excessive water loss.
- synthesizes vit D3, which converts to calcitriol, for normal calcium metabolism; stores nutrients.
- layers: epidermis, dermis, hypodermis (subcutaneous fat).
- epidermal appendages: nails, hair, glands (sebaceous and sweat).
- normal bacteria flora: gram-positive and negative staphylococci, pseudomonas, streptococcus.
- a pH of 4.2 to 5.6 halts bacteria growth.
2
Q
Risk Factors for Integumentary Problems
A
- exposure to chemical and environmental pollutants
- exposure to radiation
- race and age
- exposure to the sun or use of indoor tanning
- lack of personal hygiene habits
- use of harsh soaps or other harsh products
- some medications (such as long-term glucocorticoid or herbal preparations)
- nutritional deficiencies
- moderate to severe emotional stress
- infection, with injured areas (potential entry points)
- repeated injury and irritation
- genetic predisposition
- systemic illness
3
Q
Phases of wound healing
A
- inflammatory: begins at the time of injury and lasts 3-5 days; local edema, pain, redness, and warmth.
- fibroblastic: begins the 4th day after injury and lasts 2-4 weeks; scar tissue forms and granulation tissue forms in the tissue bed.
- maturation: begins as early as 3 weeks after injury and may last for 1 year; scar tissue becomes thinner and is firm and inelastic on palpation.
4
Q
Wound healing by intention
A
- 1st intention: wound edges are approximated and held in place (sutures) until healing occurs; wound is easily closed and dead space is eliminated.
- 2nd intention: occurs with injuries or wounds that have tissue loss and require gradual filling in of the dead space with connective tissue.
- 3rd intention: involves delayed primary closure and occurs with wounds that are intentionally left open for several days for irrigating or removal of debris and exudates; once debris has been removed and inflammation resolves, the wound is closed by 1st intention.
5
Q
Types of exudate from wounds
A
- serous: clear or straw colored, occurs as a normal part of the healing process.
- serosanguineous: pink colored due to blood cells mixed with serous; normal part of the process.
- sanguineous: red drainage from trauma to a blood vessel; abnormal finding.
- hemorrhaging: frank blood from a leaking blood vessel; may require emergency treatment; abnormal.
- purulent: yellow, gray, or green drainage due to infection in the wound.
6
Q
Diagnostic tests: skin biopsy
A
- collection of a small piece of skin tissue.
- methods: punch, excisional, and shave.
- preop: informed consent, cleanse site as prescribed.
- postop: place specimen in appropriate container and send to lab; surgically aseptic technique for dressing; assess site for bleeding and infection; instruct to keep dressing in place for at least 8hs and then clean daily and use ATB ointment as prescribed (sutures are usually removed 7-10 days after).
7
Q
Diagnostic tests: skin/wound cultures
A
- small skin culture sample is obtained with a sterile applicator and appropriate type of tube (bacterial or viral)
- methods: scraping, punch biopsy, and collecting fluid (local anesthesia may be used)
- nasal swab is also commonly done to determine previous exposure to certain types of bacteria.
- postop: viral culture is placed immediately on ice.
8
Q
Diagnostic tests: Wood’s light examination
A
- skin is viewed under ultraviolet light through a special glass (Wood’s glass) to identify superficial infections.
- preprocedure: explain and reassure that the light is not harmful to the skin or eyes; darken the room.
9
Q
Diagnostic tests: Diascopy
A
- technique allows clearer inspection of lesions by eliminating the erythema caused by increased blood flow to the area.
- a glass slide is pressed over the lesion, causing blanching and revealing the lesion more clearly.
10
Q
Candida Albicans
A
- superficial fungal infection of the skin and mucous membranes.
- also known as yeast infection (oral) or thrush.
- risk factors: immunosuppression, long-term ATB therapy, DM, and obesity.
- common areas: skin folds, perineum, vagina, axilla, and under the breasts.
- assessment: skin red and irritated (itches and stings); mucous membranes of the mouth shows red and whitish patches.
- interventions: keep skin clean and dry; turn and reposition client frequently; provide frequent mouth care; provide foods and fluids that are tepid in temp and nonirritating; antifungal meds may be prescribed.
11
Q
Herpes Zoster (shingles): description
A
- can occur during any immunocompromised state in a client with a history of chickenpox; cause by reactivation of the varicella zoster virus.
- dormant virus is located in the dorsal nerve root ganglia of the sensory cranial and spinal nerves.
- eruptions occur in a segmental distribution on the skin area along the infected nerve and show up after several days of discomfort in the area.
- diagnosis is determined by visual examination and by Tzanck smear to verify and a viral culture to identify the organism.
- postherpetic neuralgia (severe pain) can remain after the lesions resolve.
- is contagious to individuals who never had chickenpox and who have not been vaccinated against the disease.
- herpes simplex virus is another type of virus; type 1 infection typically causes a cold sore (usually on the lip) and type 2 causes genital herpes typically below the waist (both types are contagious and may be present together).
12
Q
Herpes Zoster (shingles): assessment and interventions
A
- assessment: unilaterally clustered skin vesicles along peripheral sensory nerves on the trunk, thorax, or face; fever, malaise, burning and pain, paresthesia, and puritus.
- interventions: isolate the client (standard and contact precautions as long as vesicles are present); assess for signs and symptoms of infection and necrosis; assess neurovascular status and 7th cranial nerve function (Bell’s palsy is a complication); keep environment cool (warmth and touch aggravate the pain); prevent client from scratching and rubbing; instruct to wear loose and light clothing; keep skin clean; topical and antiviral meds may be prescribed; vaccination for shingles is recommended for adults 50 years or older.
13
Q
Methicillin-Resistent Staphylococcus aureus (MRSA)
A
- can be community or hospital acquired.
- infection can range from mild to severe and can present as folliculitis or furuncles.
- folliculitis is a superficial infection of the follicle and presents as a raised red rash and pustules.
- furuncles occur deep in the follicle, presenting as very painful large, raised bumps that may or may not have a pustule.
- if MRSA infects the blood, sepsis, organ damage, and death can occur.
- assessment: culture and sensitivity test of the skin or wound confirms the infection.
- interventions: standard and contact precautions, monitor the client for signs of systemic or organ damage, adm ATB as prescribed.
14
Q
Erysipelas and Cellulitis
A
- Erysipelas is 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 wounds.
- Cellulitis is an infection of the dermis and underlying hypodermis caused usually by group A Streptococcus or Staphylococcus aureus.
- assessment: pain, tenderness, erythema, warmth, edema, fever.
- interventions: promote rest of affected area; apply warm compresses (promote circulation and decrease discomfort, erythema, and edema); apply ATB dressing, ointments, or gels as prescribed; adm ATB and obtain cultures as prescribed.
15
Q
Poison Ivy, Poison Oak, and Poison Sumac
A
- a dermatitis that develops from contact with urushiol from poison ivy, oak, or sumac plants.
- assessment: papulovesicular lesions, severe puritus.
- interventions: cleanse the skin immediately; apply cool, wet compresses or topical products to relieve the itching; topical or oral glucocorticoids may be prescribed for severe reactions.
16
Q
Spider Bites
A
- almost all types of spider bites are venomous and most are not harmful, but bites from brown recluse, black widow, and tarantulas can produce toxic reactions.
- tetanus prophylaxis should be current because spider bites can be contaminated with tetanus spores.
- Brown recluse: can cause skin lesion, a necrotic wound, or systemic effects from the toxin (loxoscelism); application of ice decreases enzyme activity and limits tissue necrosis (should be done immediately and intermittently for up to 4 days after the bite); topical antiseptics and ATB may be necessary (if becomes infected).
- Black widow: bite causes a small red papule; venom causes neurotoxicity; ice is applied immediately to inhibit the action of the neurotoxin; systemic toxicity can occur, and the victim may require supportive therapy in the hospital.
- Tarantulas: bite causes swelling, redness, numbness, lymph inflammation, and pain; it launches its barbed hairs (which can penetrate the skin and eyes) producing a severe inflammatory reaction; hairs are removed ASAP, using sticky tape and then is thoroughly irrigated (for eyes use saline); involved extremity is elevated and immobilized to reduce pain and swelling; antihistamines and topical or systemic corticosteroids may be prescribed; tetanus prophylaxis is necessary.
17
Q
Scorpion Stings
A
- inject venom through a stinging apparatus on their tail.
- cause local pain, inflammation, and mild systemic reactions that are treated with analgesics,wound care, and supportive treatment.
- bark scorpion can inflict a severe and potential fatal systemic response (specially children and elderly); venom is neurotoxic and the victim should be taken to the ED immediately (an antivenom is adm).
18
Q
Bees and Wasps
A
- usually cause a wheal and flare reaction.
- emergency care involves quick removal of the stinger (tweezers are not used because there is a risk of pinching the venom sac) and application of an ice pack
- if victim is allergic, a severe reaction can occur and these individuals should carry an IM epinephrine autoinjector.
19
Q
Snake bites
A
- some snakes are venomous and can cause a serious systemic reaction.
- victim should be immediately removed to a safe area away from the snake and should rest to decrease venom circulation; extremity is immobilized and kept bellow the level of the heart.
- constricting clothing and jewelry are removed before swelling occurs.
- victim is kept warm and is not allowed to consume caffeinated or alcoholic beverages, which may speed absorption of the venom.
- a constricting band may be applied proximal to the wound to slow venom circulation (monitor and loosen band if edema occurs).
- wound is NOT incised or sucked to remove the venom; ice is NOT applied to the wound.
- emergency care in hospital is required; an antivenom may be adm.
- snake should not be transported with the victim for identification purposes unless it can be safely placed in a sealed container during transportation.
- Poison Control Center should be contacted ASAP to determine best initial management.
20
Q
Frostbite
A
- is damage to tissues and blood vessels as a result of prolonged exposure to cold.
- 1st-degree: involves white plaque surrounded by a ring of hyperemia and edema.
- 2nd-degree: large, clear fluid-filled blisters with partial-thickness skin necrosis.
- 3rd-degree: involves the formation of small hemorrhagic blisters, usually followed by eschar formation involving the hypodermis requiring debridement.
- 4th-degree: no blisters or edema; full thickness necrosis with visible tissue loss extending into the muscle and bone, which may result in gangrene; amputation may be required.
- interventions: rewarm the affected part with warm water bath or towels at 40-42C (104-107.6F); avoid using dry heat and never rub or massage the area (handle gently and immobilize); apply loose and nonadherent sterile dressings (avoid compression); monitor for signs of compartment syndrome; tetanus prophylaxis is necessary and topical and systemic ATB may be prescribed; debridement of necrotic tissue may be needed or amputation if gangrene develops.
21
Q
Actinic Keratoses
A
- 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 are considered premalignant, and there is risk for slow progression to squamous cell carcinoma.
- treatment includes meds, excision, cryotherapy, curettage, and laser therapy.
22
Q
Skin Cancer: description and types
A
- is a malignant lesion, which may metastasize.
- over exposure to the sun is a primary cause; other causes include chronic skin damage from repeated injury and irritation such as tanning and use of tanning beds, genetic predisposition, ionizing radiation, light-skinned race, age older than 60y, an outdoor occupation, and exposure to chemical carcinogens.
- diagnosis is confirmed by skin biopsy.
Types - Base cell: arises from the basal cells contained in the epidermis; metastasis is rare, but underlying tissue destruction can progress to organ tissue.
- Squamous cell: is a tumor of the epidermal keratinocytes and can infiltrate surrounding structures and metastasize to lymph nodes.
- Melanoma: may occur any place on the body, especially where birthmarks or new moles are apparent; it is highly metastatic to the brain, lungs, bone, and liver, with survival depending on early diagnosis and treatment.
23
Q
Skin Cancer: assessment and interventions
A
Assessment:
- change in color, size, or shape of preexisting lesion; pruritus and local soreness.
Interventions:
- instruct risk factors and preventive measures.
- monthly skin assessment to monitor lesions that do not heal or that change characteristics.
- management may include surgical (cryosurgery, curettage and electrodessication) or nonsurgical interventions.
24
Q
Psoriasis
A
- a chronic, noninfectious skin inflammation occuring with remissions and an autoimmune reactions; a genetic predisposition may also be a cause.
- may be exacerbated by the use of certain meds and some individuals develop arthritis.
- Koebner phenomenon is the development of psoriatic lesions at a site of injury (prompt cleansing may prevent or lessen).
- the goal of therapy is to reduce cell proliferation and inflammation, and the type of therapy prescribed depends on the extent of the disease and client’s response.
- assessment: pruritus, shedding, yellow discoloration, pitting, and thickening of the nails, joint inflammation.
- interventions: emotional support, instruct in the use of prescribed meds, avoid over-the-counter meds, keep skin lubricated, wear light cotton clothing and reduce stress.
25
Acne Vulgaris: description and interventions
- chronic skin disorder that usually begins in puberty and is more common in males; oily skin and a genetic predisposition may be contributing factors.
- lesions develop on the face, neck, chest, shoulders, and back.
- requires active treatment for control until it resolves.
- types of lesions: comedones, pustules, papules, and nodules.
- exact cause is unknown but may include androgenic influence on sebaceous glands, increased sebum production, and proliferation of Propionibacterium, organism that converts sebum into irritant fatty acids.
- interventions: instruct skin-cleansing and using only prescribed topical agents; not to squeeze, prick, or pick at lesions; use products labeled non-comedogenic and cosmetics that are water based, and avoid products with excessive oil base.
26
Acne Vulgaris: assessment
- closed comedones are whiteheads and noninflamed lesions that develop as follicles enlarge, with the retention of horny cells.
- open comedones are blackheads that result from continuing accumulation of horny cells and sebum, which dilates the follicles.
- pustules and papules result as the inflammatory process progresses.
- nodules result from total disintengration of a comedone and subsequent collapse of the follicle.
- deep scaring can result from nodules.
27
Stevens-Johnson Syndrome
- a medication-induced skin reaction that occurs through an immunological response.
- common meds: ATB (especially sulfonamides), antiseizure meds, and nonsteroidal antiinflammatory drugs (NSAIDs).
- similar to toxic epidermal necrolysis, another medication-induced skin reaction that results in diffuse erythema and large blister formation on the skin and mucous membranes.
- may be mild or severe, and may cause vesicles, erosions, and crusts on the skin; if severe, systemic reaction occur that involve the respiratory system, renal system, and eyes (resulting in blindness), and it can be fatal.
- initial manifestation include flu-like symptoms and erythema of the skin and mucous membranes; serious systemic symptoms and complications occur when the ulcerations involve the larynx, bronchi, and esopgagus.
- most commonly occurs in clients who have impaired immune systems.
- treatment icludes immediate discontinuation of the med, ATB, corticosteroids, and supportive therapy.
28
Pressure injury: description and interventions
- is an impairment of skin integrity and can occur anywhere on the body.
- tissue damage results when the skin and underlying tissue are compressed between a bony prominence and an external surface for an extended period.
- tissue compression restricts blood flow to the skin, which can result in tissue ischemia, inflammation, and necrosis; once a pressure injury forms, it is difficult to heal.
- prevention is a major role for the nurse.
- risk factors: skin pressure, skin shearing and friction, immobility, malnutrition, incontinence, decreased sensory perception.
- Interventions: identify clients at risk and institute measures to prevent; perform frequent skin assessment; keep skin dry and use creams and lotions to lubricate the skin; turn and reposition the immobile client every 2h or more and provide passive and range-of-motion exercises; if injury present, record location, size and characteristics.
- treatment include wound dressing and debridement; skin graft may be necessary.
29
Assessment and Stages of Pressure Injuries
- Stage 1: skin is intact and does not blanch with external pressure; area may be painful, firm, soft, warmer, or cooler compered with adjacent tissue.
- Stage 2: skin is not intact; partial-thickness skin loss of the dermis occurs; presents as a shallow open ulceration with a red-pink wound bed or as intact or open/ruptured serum-filled blister.
- Stage 3: full-thickness skin loss extends into the dermis and subcutaneous tissues, and slough may be present; subcutaneous tissue may be visible; undermining and tunneling may be present.
- Stage 4: Full-thickness skin loss is present with exposed bone, tendon, or muscle; slough or eschar may be present; undermining and tunneling may develop.
- Suspected deep-tissue injury: ischemic subcutaneous tissue injury under intact skin; appears purple or maroon colored; may be painful, firm, or boggy.
- Unstageable: full thickness tissue loss in which the wound bed is covered by slough and/or eschar; the true depth, and therefore stage, of the wound cannot be determined until the slough and/or eschar is removed to visualize the wound bed.
30
Types of dressing and mechanisms of action for pressure injuries
- Stage 1: none, transparent or hydrocolloid dressing. Slow resolution within 7-10 days.
- Stage 2: composite film, hydrocolloid dressing, hydrogel. Heals through reepithelialization.
- Stage 3: hydrocolloid, hydrogel covered with foam dressing, gauze, growth factors. Heals through granulation and reepithelialization.
- Stage 4: hydrogel covered with foam dressing, calcium alginate, gauze. Heals through granulation, reepithelialization, and scar tissue development.
- Unstageable: adherent film, gauze with a prescribed solution, enzymes, none. Eschar loosens and lifts at the edges as healing occurs; surgical debridement may be necessary.
31
Types of Dressings: Alginate
- provides hemostasis, debridement, absorption, and protection.
- can be used as packing for deep wounds and for infected wounds.
- requires a secondary dressing for securing.
- changes should be done when dressing is saturated (every 3-5 days) or more frequently.
32
Types of Dressings: Biological
- provides protection and debridement after eschar removal.
- may be used for dormant and nonhealing wounds that do not respond to other topical therapies.
- may be used for burns or before pigskin and cadaver skin grafts.
- conforms to uneven wound surfaces
- reduces pain
- requires a secondary dressing for securing.
- topical growth factors should be changed daily.
- skin substitutes: the need for dressing change varies.
33
Types of Dressings: Cotton gauze
- continuous dry dressing provides absorption and protection.
- continuous wet dressing provides protection, a means for the delivery of topical treatment, and debridement.
- wet to damp dressing provides atraumatic mechanical debridement.
- may be painful on removal.
- clean base: change every 12-24h.
- necrotic base: every 4-6h.
34
Types of Dressings: Foam
- provides absorption, protection, insulation, and debridement.
- conforms to uneven wound surfaces.
- requires a secondary dressing for securing.
- change dressing when is saturated or more frequently; can remain for a maximum of 7 days.
35
Types of Dressings: Hydrocolloidal
- provides absorption, protection, and debridement.
- is waterproof and painless on removal.
- clean base: change on leakage of exudates.
- necrotic base: change every 24h.
36
Types of Dressings: Hydrogel
- provides absorption, protection, and debridement.
- conducive to use with topical agents.
- conforms to uneven wound surfaces but allows only partial wound visualization.
- requires a secondary dressing for securing.
- can promote the growth of Pseudomonas and other microorganisms.
- clean base: change every 24h.
- necrotic base: change every 6-8h.
37
Types of Dressings: Adhesive transparent film
- provides protection for partial-thickness lesion and debridement and serves as a secondary (cover) dressing.
- provides good wound visualization.
- is waterproof and reduces pain.
- use is limited to superficial lesions.
- is nonabsorbent, adheres to normal and healing tissue.
- dressing may be difficult to apply.
- clean base: change on leakage of exudates.
- necrotic base: change every 24h.
38
Other treatments for Pressure Injury
- electrical stimulation: increases blood vessel growth and stimulates granulation.
- vacuum-assisted wound closure: removes infectious material from the wound and promotes granulation.
- hyperbaric oxygen therapy: adm of oxygen under high pressure raises tissue oxygen concentration.
- topical growth factors: biologically active substances that stimulate cell growth.
