Integumentary System Flashcards
Top layer of skin
Epidermis
Second layer of skin that contains connective tissue and appendages such as hair follicles, sweat glands, and sebaceous glands
Dermis
Layer of skin beneath the dermis that contains adipose or fat tissue
Hypodermis
Wound healing
Primary intention: wound is closed or approximated using sutures, staples, or glue
Secondary intention: wound is left open to heal through granulation, contraction, and epithelialization
Tertiary intention: intentionally leave wound open to debride necrotic tissue or wait for inflammation to subside, then close it at a later time
Factors that can delay wound healing
Older age, decreased immune function, impaired nutrition (protein), impaired circulation, smoking, diabetes
Inflammatory phase of wound healing
Hemostasis — vasoconstriction, platelet aggregation, formation of clot
Proliferate phase of wound healing
Consists of epithelialization, granulation, contraction — open wound will fill with granulation tissue consisting of collagen, wound edges will contract or get smaller, resurfacing of wound with new skin cells
Maturation/remodeling phase of wound healing
Collagen produced during proliferative phase is replaced with new, stronger collagen (may take over 1 year)
Pressure injury risk factors
Impaired nutrition, reduced sensation, excess, moisture, immobility, impaired oxygenation, and friction and shear forces
Scales used for assessment of increased risk of skin breakdown
Norton and Braden
Patients with a score less than or equal to ___ with the Norton scale, or a score less than or equal to ___ with the Braden scale at increased risk for skin breakdown
14; 18
Stage I pressure injury
- Damage to the epidermis
- skin intact non-blanchable erythema
Stage II pressure injury
- damage to the epidermis and dermis
- wound with partial thickness, skin loss, base of wound is usually red and moist
- May also present as serous-filled blister
Stage III pressure injury
- damage extends to the subcutaneous tissue
- full-thickness skin loss with visible adipose tissue
- undermining or tunneling may be present
Stage IV pressure injury
- Full-thickness skin loss with exposure of bone, tendon, or muscle
- may have undermining or tunneling present
Unstageable pressure injury
Necrotic tissue that covers wound base (slough or eschar) preventing staging
Deep tissue injury
- damage that occurs at the bone-muscle interface
- intact or non-intact skin with a deep purple or maroon discoloration
- may also present as blood-filled blister
Nursing care for pressure injuries
Ensure patient is on specialty mattress that provides pressure redistribution, turn and reposition frequently (q2h), keep HOB under 30 degrees, NEVER massage bony prominences, ensure patient is receiving adequate nutrition (protein intake)
Wound culture nursing care
Obtain prior to administration of antibiotics, clean wound with NS, swab and area of viable tissue in wound bed for about 5 sec, do NOT touch skin surface when placing swab in tube
Inflammation of a hair follicle that presents as a small, erythematous pustule
Folliculitis
Infection of multiple hair follicles as well as the adjacent tissue presenting as large, erythematous pus-filled nodule
Furuncle
Bacterial infection of deep tissue that can’t be life-threatening if left untreated
Cellulitis
Symptoms of cellulitis
Erythema, warmth, pain, and swelling in the affected area, fever, malaise
Cellulitis treatment
Systemic antibiotics, IV antibiotics
Tinea infections
- ringworm
- tinea capitus (on head)
- tinea corporis (on body)
- tinea cruris (jock itch)
- tinea pedis (athletes foot)
S/S of tinea infection
Pruritis, red scaly cracked skin, ring-shaped rash, hair loss
Tinea infection diagnosis and treatment
Dx: clinical examination, KOH test
Tx: oral or topical antifungals agents, selenium sulfate shampoo w/ oral antifungal for tinea capitus
Tinea infection patient education
Keep skin clean and dry, avoid sharing personal items, avoid walking barefoot through locker rooms or public showers
Candidiasis risk factors
Antibiotic therapy, immunosuppression, corticosteroids, diabetes, pregnancy
S/S of candidiasis
Red, irritated skin with burning and itching, oral — white patches in mouth and throat
Candidiasis patient education
Keep skin clean and dry, vaginal candidiasis — wear cotton underwear, avoid tight clothing, inhaled corticosteroids — rinse mouth after administration
What type of fungal infection is spread through contact with people, pets, or contaminated objects?
Dermatophytosis (tinea infections)
Examples of candidiasis infections
Thrush, vaginal yeast infection
How is HSV-1 spread?
Contact with contaminated saliva
How is HSV-2 spread?
Sexual contact
Symptoms of HSV
Painful vesicular lesions or ulcers (on mouth for HSV-1 and gentials for HSV-2), pain, burning, tingling precede appearance of vesicles, fever, malaise
HSV patient teaching
Safe sex (condoms), abstain for sex when lesions are present
Viral disease caused by reactivation of the varicella-zoster virus (chicken-pox)
Herpes-Zoster
S/S of herpes-zoster
- Prior to lesions: Abnormal skin sensations (burning), fever, malaise
- painful, unilateral vesicular rash that runs along a dermatome (one side of face or one side of torso)
Shingles nursing consideration
Place patient on airborne and contact precautions until lesions have crusted over
Complication of shingles
Postherpetic neuralgia — pain that lasts months or years after disappearance of rash; vaccine is available to prevent shingles! Recommended for adults over age of 50**
Rash caused by direct contact with irritant or allergen resulting in an inflammatory response
Contact dermatitis
Things that can cause contact dermatitis
Soaps, detergents, cosmetics, certain metals
Treatment of contact dermatitis
Avoid trigger, administer steroid cream and antihistamines
Chronic inflammatory disease that causes dryness, erythema, pruritis, and crusting of skin
Atopic dermatitis (Eczema)
Eczema treatment
Moisturizes, identifying and avoiding triggers, topical steroids, antihistamines
Eczema patient education
Shower in LUKE-WARM water, apply emollient right after shower to trap moisture in skin, avoid scratching skin (increases risk for skin damage and infection)
Development of waxy, flaky plaques and scales on areas of body that have a large number of sebaceous glands (scalp, etc.)
Seborrheic Dermatitis
Chronic autoimmune inflammatory skin disease that causes the development of thick, red patches with silver scales
Psoriasis
S/S of psoriasis
Scaly patches, pitting or crumbling nails
treatment of psoriasis
Topical steroids, salicylic acid, coal tar, immunosuppressants such as methotrexate, UV light therapy (for severe psoriasis)
Coal tar patient education
May stain skin, hair, and clothing
UV light therapy for severe psoriasis
- provide eye protection for patient
- psoralen med may be given to increase skin sensitivity to UV light which enhances effects of therapy
- NOTE: this therapy increases risk for skin cancer
Emergent phase of burns
- begins at time of injury and lasts 24-48 hours
- focus: maintain airway, provide fluid resuscitation, preserving organ function
Acute phase of burns
- begins once fluid resuscitation is complete and ends with wound closure
- Focus: infection control, wound healing, nutrition, mobility
Rehabilitative phase of burns
- begins when there is wound closure until patient achieves maximal function
- focus: psychosocial adjustment and prevention of contractures; reconstructive procedures
Emergent phase nursing interventions
Stop burning process, maintain airway, administer oxygen as ordered, assess for signs of inhalation injury (singed eyebrows or nasal hair, sooty sputum), provide IV fluid resuscitation using large bore catheter to prevent hypovolemia, IV opioid analgesics, keep patient warm and NPO, insert NG tube and catheter, administer tetanus vaccine
Rule of nines for burn assessment
- entire head: 9% (4.5% anterior and posterior)
- entire trunk: 36% (18% anterior and posterior)
- each upper extremity: 9% (4.5% anterior and posterior)
- each lower extremity: 18% (9% anterior and posterior)
- perineum: 1%
Superficial of first degree burn
- limited to epidermis
- skin pink or red in color
- mild edema, but NO blisters
- ex: sunburn
Superficial partial-thickness or second-degree burn
- damage to upper layer of dermis
- red or pink color, mild to moderate edema, presence of blisters
Deep partial-thickness burn (still second-degree)
- damage extends deep into dermis
- red or white color, moderate edema, soft dry eschar
Full-thickness or third degree burn
- damage extends into subcutaneous tissue
- severe edema, NO blisters, hard inelastic eschar
- nerve endings have been destroyed, patient may not have pain
Deep full-thickness burn or fourth degree burn
- damage extends beyond the subcutaneous tissue into the muscle, tendon, or bone
- black with hard, inelastic eschar, NO edema or blisters, NO pain at affected area d/t destroyed nerve endings
Parkland formula for fluid resuscitation for burns
Amount of fluid needed in first 24 hr = 4 mL LR x weight (kg) x % body burned (using rule of nines)
NOTE: half the amount of fluid is given in the first 8 hours, and the other half of the fluid is administered over the next 16 hours
Nursing care for acute phase of burn
Provide wound care using a septic technique, elevated and immobilize area following skin graft surgery and monitor for signs of infection, administer antibiotics as ordered, take measures to prevent infection, assist with passive and active ROM to prevent contractures, ensure adequate nutrition (require additional calories and proteins to facilitate healing — may require TPN)
Key antibiotics for burns
- silver sulfadiazine: key side effect is transient neutropenia
- mafenide acetate: penetrates eschar, risk for metabolic acidosis
Tick-transmitted bacterial infection that causes local inflammation and infection, but left untreated can spread to other organs of the body and cause systemic complications
Lyme disease
Lyme disease prevention
Wear long sleeves and pants, closed shoes and hat when going into wooded areas, treat clothing with tick-repellant, check body for ticks when going back inside, check pets as well
First stage of Lyme disease
Ring-shaped bulls eye lesion (erythema migrans) is often but not always present, flu-like symptoms
Stage II of Lyme disease
- occurs 3-12 weeks after initial infection
- palpitations, arrythmias, dyspnea, facial paralysis, nerve pain and numbness
Stage III of Lyme disease
- late stage; occurs months or years after initial infection
- complications: arthritis, cognitive impairment, other neurological symptoms
Lyme disease diagnosis
Positive ELISA test, confirmed with western blot test
Lyme disease treatment
Antibiotics such as doxycycline, analgesics such as NSAIDs
Permethrin is used to treat
Head lice (pediculosis)
Prevention of head lice reinfestation
Wash clothes and linens in hot water, place items that cannot be washed in tightly sealed bag for 2 weeks, other household members should be checked and treated
S/S of scabies
Intense pruritis, pimple-like rash, presence of burrows (gray-white lines)
5% permethrin is used to treat
Scabies
5% permethrin for treatment of scabies education
Apply head to toe, leave on for extended tome (8-14 hrs), reapply one week later
S/S of Steven’s Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
Flu-like symptoms followed by painful blistering and peeling of skin typically beginning on face and chest
Treatment of SJS and TEN
D/C causative agent, fluid resuscitation, Oxygen therapy, analgesics, corticosteroids, intubation and mechanical ventilation, admittance to burn unit
SJS and TEN nursing care
Maintain body temp, provide wound care using non-adherent dressings
Causes of SJS and TEN
Abnormal immune response triggered by certain meds (anticonvulsants, allopurinol, suflonamides)
